OITE & ABOS Orthopedic Board MCQs: Fracture & Nerve

About This Board Review Set

This is Part 190 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Two distinct learning modes are available:

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

Topics Covered in Part 190

This module focuses heavily on: Deformity, Fracture, Nerve.

Sample Questions from This Set

Sample Question 1: Figure 46 shows the MRI scan of a patient who has a mass in the calf that has been fluctuating in size. Radiographs are negative. Which of the following procedures will most quickly aid in confirming the diagnosis?...

Sample Question 2: Figures A-C are images of a 37-year-old man who presents with isolated muscle atrophy due to a compressed nerve. Which of the following sequences correctly describes the pathway of this nerve through the brachial plexus, before it innervate...

Sample Question 3: A 53-year-old man is involved in a motor vehicle collision and sustains the closed distal femur fracture seen in Figures 54a and 54b. A precontoured distal femoral locking plate is selected for fixation. A locking construct should be used t...

Sample Question 4: -Posterior cruciate insufficiency diagnosed using the quadriceps active test is confirmed with tibial translation...

Sample Question 5: A 17-year-old girl with a history of Scheuermann's kyphosis has a fixed thoracic deformity of 80 degrees. There was no correction of her deformity on supine hyperextension radiographs. What is the most appropriate treatment? 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

Figure 46 shows the MRI scan of a patient who has a mass in the calf that has been fluctuating in size. Radiographs are negative. Which of the following procedures will most quickly aid in confirming the diagnosis?

Explanation

DISCUSSION: The bright signal on the T2-weighted MRI scan suggests fluid. The multiloculated appearance in proximity to the proximal tibiofibular joint suggests that the most likely diagnosis is a ganglion. They typically increase and decrease in size and can be diagnosed by the classic gelatinous fluid obtained through needle aspiration.
REFERENCES: Bianchi S, Abdelwahab IF, Kenan S, Zwass A, Ricci G, Palomba G: Intramuscular ganglia arising from the superior tibiofibular joint: CT and MR evaluation. Skeletal Radiol 1995;24:253-256.
Feldman F, Singson RD, Staron RB: Magnetic resonance imaging of para-articular and ectopic ganglia. Skeletal Radiol 1989;18:353-358.

Question 2

Figures A-C are images of a 37-year-old man who presents with isolated muscle atrophy due to a compressed nerve. Which of the following sequences correctly describes the pathway of this nerve through the brachial plexus, before it innervates the affected muscles?

Explanation

Figures A-C shows atrophy of teres minor and deltoid due to compression of the axillary nerve. The correct pathway of the axillary nerve within the brachial plexus is, C5-C6 nerve roots; upper trunk, posterior division, posterior cord.
Quadrilateral space syndrome is a condition defined by axillary nerve, +/- posterior humeral circumflex artery compression in the quadrilateral space. It most commonly affects the dominant shoulder in overhead movement athletes (e.g. basketball players) or other throwing athletes. Physical examination may reveal weakness with the arm positioned in abduction and external rotation. In situations of long-standing compression, there may also be atrophy of the teres minor and deltoid muscle.
Chafik et al. dissected thirty-one cadaveric human shoulders to describe the neuromuscular anatomy of teres minor. They showed that the primary nerve branch to teres minor travelled in a fascial sling 44 mm medial to the muscular insertion. This
area may be the potential site of greatest compression and tethering of this nerve in patients with isolated teres minor atrophy.
Friend et al. performed a cadaveric dissection of nine shoulder specimens to look at the anatomical variability in course, length and branching pattern of both the teres minor nerve and the axillary nerve. These were compared to a case-based study of these two male patients with isolated atrophy of teres minor. They concluded that there is no good anatomical predictor of nerve compression outside the quadrilateral space as there is considerable anatomical variation in its origin and course, as well as potential site of compression.
Figure A-C are MRI images that show atrophy of the teres minor muscle and possibly deltoid muscle. The rotator cuff muscles are labeled in Illustration A. The teres minor muscle is labeled in Illustration B. Illustration C shows a diagram of the brachial plexus.
Incorrect
1:
This
describes
the
musculocutaneous
nerve.
3:
This
describes
the
suprascapular
nerve.
4:
This
describes
the
long thoracic
nerve.

Question 3

A 53-year-old man is involved in a motor vehicle collision and sustains the closed distal femur fracture seen in Figures 54a and 54b. A precontoured distal femoral locking plate is selected for fixation. A locking construct should be used to A B

Explanation

DISCUSSION
This patient has a comminuted distal femur fracture. A fixed-angle device such as a locking plate is preferred to confer angular stability to the construct and prevent varus collapse. The strategy to promote union of the fracture is to provide a low-strain environment to allow bone healing. Strain is determined by the amount of motion over the length of a fracture. In the case of a noncomminuted fracture, the fracture surfaces can be compressed and rigid fixation applied to abolish strain and promote primary bone healing without callus. In the case of a comminuted fracture, the preferred fixation strategy
focuses on distributing motion along the length of the fracture to provide a low-strain environment that will promote secondary bone healing and callus formation.
RECOMMENDED READINGS
Gardner MJ, Evans JM, Dunbar RP. Failure of fracture plate fixation. J Am Acad Orthop Surg. 2009 Oct;17(10):647-57. Review. PubMed PMID: 19794222.View Abstract at PubMed
Lujan TJ, Henderson CE, Madey SM, Fitzpatrick DC, Marsh JL, Bottlang M. Locked plating of distal femur fractures leads to inconsistent and asymmetric callus formation. J Orthop Trauma. 2010 Mar;24(3):156-62. doi: 10.1097/BOT.0b013e3181be6720. PubMed PMID:

Question 4

Posterior cruciate insufficiency diagnosed using the quadriceps active test is confirmed with tibial translation

Explanation

In the quadriceps active drawer test, with the subject supine, the leg is relaxed and supported with the knee flexed 70 to 90 degrees. The examiner must adequately support the patient’s thigh so that the subject’s muscles are completely relaxed. The patient is then asked to perform a gentle quadriceps contraction without extending the knee. In the normal knee in 90 degrees of flexion, the patellar ligament is already slightly posterior, and contraction of the quadriceps does not result in an anterior shift of the tibia. However if the PCL is ruptured, the tibia sags into a posteriorly subluxed position, and the patellar ligament is then directed anteriorly. In this situation, contraction of the quadriceps muscle in the posterior cruciate deficient knee results in an anterior shift of the tibia 2mm or more. The examiner can visualize this anterior shift of the tibia with the knee is 90 degrees of flexion.

Question 5

A 17-year-old girl with a history of Scheuermann's kyphosis has a fixed thoracic deformity of 80 degrees. There was no correction of her deformity on supine hyperextension radiographs. What is the most appropriate treatment? Review Topic

Explanation

The Smith-Petersen osteotomy is most appropriate for long, sweeping, global kyphosis, such as Scheuermann's kyphosis. It can achieve approximately 10 degrees of correction in the sagittal plane at each spinal level at which it is performed. The pedicle subtraction osteotomy is the preferred osteotomy for patients with ankylosing spondylitis, who have a sagittal plane imbalance. It can achieve approximately 30 degrees to 40 degrees of correction in the sagittal plane at each spinal level at which it is performed. Vertebral column resections are extensive procedures, thus they are most appropriately applied to pathologies with sharp angular kyphosis, anterior fusions, and when maximal visualization and decompression of the spinal cord is required. Sagittal curves were reduced an average of 50 degrees, with a lumbosacral deformity treated via vertebral column resection. Anterior arthrodesis alone will not provide sufficient correction and stabilization of the deformity. Posterior arthrodesis alone, while providing stabilization, will not correct the fixed deformity.

Question 6

Following a radial nerve neurapraxia at or above the elbow, return of muscle function can be expected to start at the brachioradialis and return along which of the following progressions?

Explanation

DISCUSSION: Following a radial nerve neurapraxia above the elbow, muscle recovery can be expected in a predictable pattern. Although variations will occur, the return of function or reinnervation usually occurs in the following order: brachioradialis, extensor carpi radialis longus, supinator, extensor carpi radialis brevis, extensor carpi ulnaris, extensor digitorum comminus, extensor digiti minimi, extensor indicis proprious, extensor pollicis longus, abductor pollicis longus, and extensor pollicis brevis.
REFERENCES: Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System. Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ,

Ciba-Geigy, 1991, vol 8, p 53.
Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA,

Harper and Row, 1982, vol 3, pp 428-429.

Question 7

A 14-year-old girl reports hip pain that is exacerbated by weight bearing. A radiograph and biopsy specimen are shown in Figures 16a and 16b. The best course of management should be

Explanation

DISCUSSION: The patient has a unicameral bone cyst. Because the subtrochanteric part of the femur is a high-stress region, the treatment of choice is bone curettage and grafting.
REFERENCES: Azouz EM, Karamitsos C, Reed MH, Baker L, Kozlowski K, Hoeffel JC: Types and complications of femoral neck fractures in children. Pediatr Radiol 1993;23:415-420.
Hecht AC, Gebhardt MC: Diagnosis and treatment of unicameral and aneurysmal bone cysts in children. Curr Opin Pediatr 1998;10:87-94.

Question 8

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared to a standard parapatellar approach, what is the expected outcome?

Explanation

DISCUSSION
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

RESPONSES FOR QUESTIONS 58 THROUGH 62
Nerve palsy
Skin necrosis
Flexion instability
Patellar instability
Anterior knee pain
Malalignment
Total knee arthroplasty (TKA) is performed to address each condition shown in Figures 58 through 62b. Which complication is most commonly associated with each image?

Question 9

During treatment of rupture of the subscapularis tendon with associated biceps instability, treatment of the biceps tendon should include which of the following?

Explanation

DISCUSSION: With subscapularis tendon ruptures that have biceps tendon pathology, treatment with tenodesis or tenotomy has improved clinical results. Subluxation or dislocation of the biceps tendon is common with subscapularis rupture. Dislocation of the biceps can occur either beneath the tendon, within the tendon, or extra-articularly. In all cases, the restraints to medial translations of the biceps have been disrupted. Attempts at recentering the biceps have not been successful, and clinical results appear to be improved when tenodesis or tenotomy is employed in the treatment of the unstable biceps associated with subscapularis tears.
REFERENCES: Edwards TB, Walch G, Sirvenaux F, et al: Repair of tears of the subscapularis: Surgical technique. J Bone Joint Surg Am 2006;88:1-10.
Deutsch A, Altchek DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.
Edwards TB, Walch G, Sirveaux F, et al: Repair of tears of the subscapularis. J Bone Joint Surg Am 2005;87:725-730.

Question 10

A 7-year-old sustains the isolated injury shown in Figures A and B. On physical examination there is no evidence of soft tissue compromise and he is able to make an okay sign, give a thumbs up sign and cross his fingers. Which treatment will minimize complications? Review Topic

Explanation

This patient has sustained an extension type supracondylar fracture (Gartland Type 3). The optimal treatment is closed reduction and a percutaneous pinning construct using laterally based pins.
Supracondylar fractures are common pediatric elbow injuries. Extension type injuries account for 95-98% of all cases. Non-displaced injuries may be treated conservatively. Displaced fractures are treated with closed reduction and percutaneous pinning. Use of laterally divergent pin constructs avoids risk of ulnar nerve injury, while maintaining satisfactory fracture alignment.
Slobogean et al. retrospectively reviewed pediatric supracondylar fractures to identify if there was an increased risk of ulnar nerve injury with crossed pin configurations. They found a higher incidence of ulnar nerve injury with crossed pinning constructs. For every 28 crossed pin constructs, there was one ulnar nerve injury identified.
Woratanarat et al. retrospectively reviewed supracondylar fractures to identify differences in the outcomes between lateral pinning versus crossed pinning constructs. No difference was found for loss of fixation or development of late deformity between the two groups. Crossed pin constructs were associated with a 4.3 times higher risk of iatrogenic ulnar nerve injury.
Omid et al. review pediatric supracondaylar humerus fractures. They note that lateral pinning is as stable as crossed pinning when appropriately spread-out at the fracture line. This also avoids the risk of ulnar nerve injury.
Figures A and B show AP and lateral radiographs of a pediatric supracondylar fracture. This would be classified as a Gartland Type 3.
Incorrect Answers:

Question 11

A B Figures 82a and 82b are the clinical photograph and radiograph of a 60-year-old man with a 30-year history of diabetes complicated by borderline chronic renal failure, heart failure controlled by medication, and bilateral lower extremity neuropathy. He is currently wheelchair bound because of his cardiopulmonary limitations, but uses his legs for transfers. He has had a progressive left ankle deformity that has progressed to the point at which he cannot use his leg for pivot transfers. He is adamant that something should be done to improve his living situation. Which surgical option can best achieve his goal of using the leg for transfers?

Explanation

DISCUSSION
The indications for surgery in a Charcot joint are an unbraceable deformity or recurrent ulceration despite use of adequate bracing. Any significant varus/valgus deformity of the ankle or hindfoot (as in this patient) is unbraceable, whereas midfoot Charcot deformities usually can be treated nonsurgically. The goal of surgery is to provide a stable aligned foot and ankle to permit activities and reduce risk for recurrent ulceration. This does not mean that there has to be a radiographic fusion because many patients with diabetes achieve a stable nonunion without pain. The only surgical construct that will provide long-term inherent stability and alignment in this situation is use of a hindfoot fusion rod. It provides better stability and purchase than screw fixation and can be left in indefinitely (unlike an external fixator).
RECOMMENDED READINGS
Dalla Paola L, Volpe A, Varotto D, Postorino A, Brocco E, Senesi A, Merico M, De Vido D, Da Ros R, Assaloni R. Use of a retrograde nail for ankle arthrodesis in Charcot neuroarthropathy: a limb salvage procedure. Foot Ankle Int. 2007 Sep;28(9):967-70. PubMed PMID: 17880869. View Abstract at PubMed
Pinzur MS. Benchmark analysis of diabetic patients with neuropathic (Charcot) foot deformity. Foot Ankle Int. 1999 Sep;20(9):564-7. PubMed PMID: 10509683. View Abstract at PubMed Pinzur M. Surgical versus accommodative treatment for Charcot arthropathy of the midfoot. Foot Ankle Int. 2004 Aug;25(8):545-9. PubMed PMID: 15363375. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 83 THROUGH 87

Figures 83a and 83b are the clinical photographs of a 42-year-old woman with a BMI of 31 who has had a 1-year history of right heel pain.
A

Question 12

A 32-year-old man is brought to the emergency department after being involved in an MVC. He is found to have a closed left femoral shaft fracture (Figures A and B) and a Glasgow Coma Scale (GCS) score of 13. A CT scan of the head is performed and demonstrates no significant bleeding. He has no other injuries and is hemodynamically stable. Which of the following statements is true?

Explanation

Early stabilization of femur fractures in patients with concomitant head injuries has been found to have no increased risk of worsening neurologic outcomes.
Treatment of patients with a closed head injury and a femoral fracture remains controversial but recent data suggests that intramedullary nails done acutely
leads to decreased pulmonary complications, decreased thromboembolic events, improved rehabilitation, decreased length of stay and cost of hospitalization, and improved GCS scores on discharge. However, it is important to note that intraoperative hypotension should be avoided in these patients, as it has been associated with worsening outcomes following acute intramedullary nailing of the femur.
Starr et al. performed a retrospective study to determine if the timing of treatment of femur fractures in patients with an associated head injury had an effect on the risk of pulmonary and CNS complications. They found that delaying fracture stabilization (> 24 hours) made pulmonary complications 45 times more likely, while early fracture stabilization had no effect on the risk of CNS complications.
McKee et al. performed a retrospective case-control study to determine the effect of early intramedullary nailing of femoral shaft fractures on the neurologic outcome of patients with multiple injuries and a concomitant head injury. They found no significant differences between the two groups in terms of early mortality, length of hospital/ICU stay, level of neurologic disability, or results of cognitive testing. Their results support the continued early intramedullary nailing of femoral fractures for patients with a concomitant head injury.
Richards et al. performed a retrospective study evaluating lactate levels before reamed intramedullary nailing (IMN) of femur fractures treated with early fixation (< 24 hours) and its effects on pulmonary complications (defined as mechanical ventilation lasting ≥ 5 days). They found that a median admission lactate of 3.7 mmol/L was associated with duration of mechanical ventilation ≥ 5 days, whereas a median preoperative lactate of 2.8 mmol/L was not.
Figures A and B are radiographs demonstrating a transverse femoral shaft fracture.
Incorrect Answers:
OrthoCash 2020

Question 13

A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals no other injuries. Radiographs are shown in Figures 35a and 35b. Initial management of this fracture should consist of

Explanation

DISCUSSION: The radiographs show a minimally displaced fracture of the tibial eminence, which is classified as a McKeever type II injury. In a number of studies, it has been found that most of these fractures will reduce with extension of the knee. This is often made easier with evacuation of the hemarthrosis. The position of knee immobilization is controversial, with some authors preferring full extension and others preferring 20 degrees of flexion. Flexion to 90 degrees will further displace the fragment. If the fragment does not reduce or if the patient has a McKeever type III or IV injury, reduction and internal fixation are required. This can be done with either an open or an arthroscopic procedure. Excision of the fragment is not indicated.
REFERENCES: Meyers MH, McKeever FM: Fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.
Wiley JJ, Baxter MP: Tibial spine fractures in children. Clin Orthop 1990;255:54-60
Janarv PM, Westblad P, Johansson C, Hirsch G: Long-term follow-up of anterior tibial spine fractures in children. J Pediatr Orthop 1995;15:63-68.
Kuhn JE, Sailer MJ, Sterett WI, Hawkins RJ: Arthroscopic technique for the treatment of tibial spine fractures in the skeletally immature patient. J Ortho Tech 1995;3:7-12.

Question 14

A 35-year-old woman who runs long distance has had posterior calf tenderness for the past 3 months. A clinical photograph is shown in Figure 10a, and MRI scans are shown in Figures 10b and 10c. Management at this point should consist of

Explanation

DISCUSSION: The initial treatment for peritendinitis should consist of calf stretching in an eccentric mode and physical therapy. In a recent study, this treatment has been found superior to surgical debridement in nonextensive peritendinitis and pantendinitis. A non-weight-bearing cast, while useful in reducing inflammation, will result in calf atrophy and poorly organized collagen repair. Cortisone is contraindicated because of the danger of tendon damage. Tendon debridement at this stage is not indicated.
REFERENCES: Alfredson H, Pietila T, Jansson P, Lorentzon R: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360-366.
Angermann P, Hougaard D: Chronic Achilles tendinopathy in athletic individuals: Results of nonsurgical treatment. Foot Ankle Int 1999;20:304-306.

Question 15

A patient sustains an injury to the pelvis as a result of high-energy trauma. A radiographic and clinical assessment is performed. A lateral view of the pelvis will best identify

Explanation

Radiographic assessment of the pelvis is an essential part of the initial evaluation of trauma patients. In addition to an AP radiograph, 40-degree caudal (inlet) and 40-degree cephalad (outlet) views are obtained. The caudal/inlet view is useful for detecting the integrity of the pelvic ring because it shows the sacroiliac joints and the sacrum, which can help detect either sacroiliac dislocations or sacral fractures and their displacement in the anterior-posterior plane. The outlet view detects superior or inferior displacement and sagittal plane flexion or rotation of the pelvis. A lateral radiograph of the sacrum identifies transverse fractures of the sacrum and coccyx and the degree of their displacement. A lateral view should be obtained in instances of bilateral sacral fractures and U-shaped sacral fractures in which there are bilateral vertical fractures through the sacral foramina that connect with a transverse fracture line between the second or third sacral segments. Some patients with these fractures have sacral fracture-dislocations with spinopelvic dissociation and a high incidence of neurologic injuries. The lateral view discloses the extent of displacement of the upper sacral segment (usually S2 forward on S3) and the resultant kyphotic deformity.

Question 16

The so-called high ankle sprain from an external rotation mechanism of injury typically involves injury to which of the following structures?

Explanation

DISCUSSION: Ankle sprains most commonly involve injury to the lateral collateral ligaments of the ankle (anterior talofibular, posterior talofibular, and calcaneofibular) from an inversion mechanism of injury. A different entity has been more recently described that involves an external rotation mechanism of injury that widens the ankle mortise and disrupts the anterior inferior tibiofibular ligament. Deltoid ligament and extensor retinaculum injuries do occur, although infrequently, and involve eversion and extreme plantar flexion mechanisms, respectively.
REFERENCES: Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, p 182.
Kaye RA: Stabilization of ankle syndesmosis injuries with a syndesmosis screw. Foot Ankle 1989;9:290-293.
Baxter DE: The Foot and Ankle in Sports. St Louis, MO, Mosby-Year Book, 1995, p 30.
Pfeffer GB (ed): Chronic Ankle Pain in the Athlete. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 11.

Question 17

Closed-chain exercise differs from open-chain exercise in which of the following ways?

Explanation

DISCUSSION: Closed-chain exercise requires the distal portion of the extremity to be fixed. It is more commonly used in lower extremity exercise, and movement is produced by co-contraction of muscles. Joint compression is increased, and multiple joints are involved with closed-chain exercise. In open-chain exercise, the distal portion of the extremity is free.
REFERENCES: Braddom RL (ed): Physical Medicine and Rehabilitation, ed 2. Philadelphia, PA, Saunders, 2000, pp 975-976.
Childs DC, Irrang JJ: The language of exercise and rehabilitation, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 1, p 329.

Question 18

A 68-year-old man underwent a primary total hip arthroplasty 2 years ago for a femoral neck fracture. His early postoperative course was unremarkable, but he notes some aching in the thigh since surgery. His symptoms have gotten worse over the last year, such that he now has activity-related thigh pain that limits his walking ability. An AP hip radiograph is shown in Figure 9. What is the most appropriate surgical management?

Explanation

DISCUSSION: The radiograph shows a loose femoral component with failure of osseous integration.
There is a reactive radiolucent line around the fiber mesh portion of the implant, hypertrophy of the bone under the collar, and a pedestal formation at the distal tip of the implant, all of which indicate failure of bone ingrowth. If
bone ingrowth had occurred, there would be stress shielding of bone under the collar.
REFERENCES: Engh CA, Massin P, Suthers KE: Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop Relat Res 1990;257:107-128.
Lieberman JR, Huo MH, Schneider R, et al: Evaluation of painful hip arthroplasties: Are technetium bone scans necessary? J Bone Joint Surg Br 1993;75:475-478.
Vresilovic EJ, Hozack WJ, Rothman RH: Radiographic assessment of cementless femoral components: Correlation with intraoperative mechanical stability. J Arthroplasty 1994;9:137-141.

Question 19

An 8-year-old boy sustains injuries to his head, abdomen, and left lower extremity after being struck by a truck. In the emergency department, his mental status deteriorates and he is intubated after assessment reveals a Glasgow Coma Scale score of 3; the score subsequently improves to 10. A CT scan reveals a right parietal intracranial hemorrhage, and an abdominal ultrasound reveals free fluid. Prior to an emergency laparotomy, the swollen left thigh is evaluated. Radiographs reveal a transverse fracture of the mid-diaphysis. Management of the fracture should consist of

Explanation

DISCUSSION: The prognosis for a young patient with a head injury is more favorable compared to that for adults. Full neurologic recovery generally occurs. Spasticity may occur within a few days after injury, which can lead to fracture displacement if immediate spica casting or traction is used. Early surgical stabilization will reduce problems with shortening and malunion and will facilitate transportation of the child for diagnostic tests. Surgery may be performed when it is best for the patient, either on the day of injury or later if time is needed for stabilization. In this patient, the fracture is ideally suited to stabilization using flexible intramedullary nails. Heinrich and associates’ report of 78 diaphyseal femur fractures stabilized with flexible intramedullary nails included 14 patients with an associated closed head injury. All fractures healed, and there were no major complications.
REFERENCES: Tolo VT: Management of the multiply injured child, in Rockwood CA, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996,

pp 83-95.
Heinrich SD, Drvaric DM, Darr K, MacEwen GD: The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails: A prospective analysis. J Pediatr Orthop 1994;14:501-507.

Question 20

A 40-year-old man reports an enlarging soft-tissue mass in his right shoulder. Based on the MRI scan and biopsy specimens shown in Figures 40a through 40c, what is the most likely diagnosis?

Explanation

DISCUSSION: Nodular fasciitis is a pseudosarcomatous, self-limiting reactive process composed of fibroblasts and myofibroblasts. Most patients give a history of a rapidly growing mass that has been present for only a few weeks. Many have pain associated with the mass and can recall a specific traumatic event predating the presence of the lesion. It can occur at any age but is most commonly seen in adults who are 20 to 40 years of age. Histologically, the lesion is composed of predominantly plump, immature-appearing fibroblasts that bear a close resemblance to the fibroblasts found in granulation tissue. Characteristically, the fibroblasts

are arranged in short, irregular bundles and fascicles and are adjacent to collagen and reticulin. The lesions can appear to be more myxoid or more fibrotic in nature and this correlates to the duration of symptoms. The lesions with a short duration of symptoms have a more myxoid appearance in contrast to those of longer duration characterized by hyaline fibrosis.
REFERENCES: Weiss SW, Goldblum JR, Enzinger FM: Enzinger and Weiss’s Soft Tissue Tumors, ed 4. Philadelphia, PA, Elsevier, 2001, pp 250-266.
Wang XL, De Schepper AM, Vanhoenacker F, et al: Nodular fasciitis: Correlation of MRI findings and histopathology. Skeletal Radiol 2002;31;155-161.

Question 21

Which of the following changes to heart rate, blood pressure, and bulbocavernosus reflex are typical of spinal shock?

Explanation

DISCUSSION: The term ‘spinal shock’ applies to all phenomena surrounding physiologic or anatomic transection of the spinal cord that results in temporary loss or depression of all or most spinal reflex activity below the level of the injury. Hypotension and bradycardia caused by loss of sympathetic tone is a possible complication, depending on the level of the lesion. The mechanism of injury that causes spinal shock is usually traumatic in origin and occurs immediately, but spinal shock has been described with mechanisms of injury that progress over several hours. Spinal cord reflex arcs immediately above the level of injury also may be depressed severely on the basis of the Schiff-Sherrington phenomenon. The end of the spinal shock phase of spinal cord injury is signaled by the return of elicitable abnormal cutaneospinal or muscle spindle reflex arcs. Autonomic reflex arcs involving relay to secondary ganglionic neurons outside the spinal cord may be affected variably during spinal shock, and their return after spinal shock abates is variable. The returning spinal cord reflex arcs below the level of injury are irrevocably altered and are the substrate on which rehabilitation efforts are based.
REFERENCE: Ditunno JF, Little JW, Tessler A, et al: Spinal shock revisited: A four-phase model. Spinal Cord 2004;42:383-395.

Question 22

Figures 11a and 11b show the radiographs of a 50-year-old man who was struck by a car. Treatment should consist of

Explanation

DISCUSSION: The patient has a displaced femoral neck fracture. Although the treatment remains controversial, most clinicians advocate either a closed or open reduction in younger active patients. Achieving an anatomic reduction is necessary to avoid loss of reduction, nonunion, or osteonecrosis. An acceptable reduction may have up to 15° of valgus angulation and 10° of posterior angulation. Parallel multiple screws or pins are the most common method of internal fixation. Prosthetic replacement is generally reserved for older and less active individuals.
REFERENCES: Callaghan JJ, Dennis DA, Paprosky WG, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 97-108.
Asnis SE, Wanek-Sgaglione L: Intracapsular fractures of the femoral neck: Results of cannulated screw fixation. J Bone Joint Surg 1994;76A:1793-1803.

Question 23

The primary effect of deep freezing on musculoskeletal allografts is a reduction of

Explanation

Deep freezing alters biological and immunological properties. Many investigators have shown that frozen bone is less immunogenic than fresh bone and freeze-dried is even less. Freezing does increase shelf-life but has no effect on strength, stiffness, or risk of HIV.

Question 24

A 28-year-old woman who is training for the New York Marathon reports pain in the posteromedial aspect of her right ankle. Examination reveals tenderness just posterior to the medial malleolus. Radiographs are normal. An MRI scan is shown in Figure 3. What is the most likely diagnosis?

Explanation

DISCUSSION: Any of the above conditions is credible with a limited history. The MRI scan unequivocally shows the stress fracture in the distal tibia. Most tibial stress fractures can be managed with rest and immobilization.
REFERENCES: Boden BP, Osbahr DC: High risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.
Lee JK, Yao L: Stress fractures: MR imaging. Radiology 1988;169:217-220.

Question 25

Figure 45 shows the lateral radiograph of a 19-year-old swimmer who has had back pain for the past 2 months. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has a pars interarticularis defect of L5 without apparent listhesis. The other diagnoses are not present.
REFERENCES: Papanicolaou N, Wilkinson RH, Emmans JB, Treves S, Micheli LJ: Bone scintigraphy and radiography in young athletes with low back pain. Am J Roentgenol 1985;145:1039-1044.
Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 291-302.

Question 26

A 30-year-old man landed on his shoulder in a fall off his mountain bike. An AP radiograph and CT scan are shown in Figures 34a and 34b. Management should consist of

Explanation

DISCUSSION: The radiograph shows a valgus impacted four-part fracture. The humeral head is deeply depressed into the metaphysis but is still articulating with the glenoid as seen on the CT scan. Unlike a “classic” four-part fracture in which the head is dislocated out of the glenoid and devoid of any soft-tissue attachments (high risk of osteonecrosis), this valgus impacted head will have a medial soft-tissue hinge with a lower risk of osteonecrosis. It is most amenable to open reduction and internal fixation with minimal soft-tissue stripping techniques. Bone grafting may be necessary on occasion. Nonsurgical management for displaced proximal humeral fractures generally results in a poor outcome. This patient does not have a humeral head defect. A hemiarthroplasty is not indicated.
REFERENCES: Jakob RP, Miniaci A, Anson PS, et al: Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br 1991;73:295-298.
Resch H, Povacz P, Frohlich R, et al: Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Br 1997;79:295-300.

Question 27

What is the most common organism found following a nail puncture wound through tennis shoes in a host without immunocompromise?

Explanation

DISCUSSION: The association of a nail puncture wound with a gram-negative infection (Pseudomonas aeruginosa) has been attributed to the local environmental factors in shoes. Osteomyelitis is rare, occurring only in about 1% of patients. Tetanus prophylaxis should be given if it is not up to date. While the remaining organisms listed are periodically involved, they are more common in patients who are immunocompromised or who have diabetes mellitus. Therefore, obtaining a culture of the infected wound is appropriate in such individuals because of the multifactorial nature of the infection.
REFERENCES: Green NE, Bruno J III: Pseudomonas infections of the foot after puncture wounds. South Med J 1980;73:146-149.
Riegler HF, Routson GW: Complications of deep puncture wounds of the foot. J Trauma 1979;19:18-22.

Question 28

What is the most common cause for late revision (> 2 years post op) total knee arthroplasty? i. Infection

Explanation

DISCUSSION: There are multiple causes for failure of total knee arthroplasty, and more than one may exist at the same time. Sharkey and associates reviewed a series of revision total knee arthroplasties, and found that polyethylene failure was the most common cause of failure followed closely by component loosening. The most common cause of early failure (< 2 years post op) was infection. Instability and malalignment are both complications of surgical technique, and if these categories are combined, they would be the most common cause of all total knee failures.
REFERENCE: Sharkey PF, Hozack WJ, Rothman RH, et al: Insall Award paper: Why are total knee arthroplasties failing today? Clin Orthop Relat Res 2002;404:7-13.

Figure 59a Figure 59b

Question 29

In an effort to reduce costs, a limited MRI sequence is planned to detect a possible occult hip fracture. What is the anticipated fracture signal?

Explanation

DISCUSSION: At present, radiologists perform multiple MRI images to rule out all possible diagnoses. The ability to specify the anticipated changes on MRI should become more important as a means of reducing costs. MRI is sensitive to changes in free water (or hemorrhage) and thus this will appear dark on T₁ and bright on T₂.
REFERENCES: Miller MD: Review of Orthopaedics, ed 3. Philadelphia PA, WB Saunders, 2000, p 116.
Guanche CA, Kozin SH, Levy AS, et al: The use of MRI in the diagnosis of occult hip fractures in the elderly: A preliminary review. Orthopedics 1994;17:327-330.

Question 30

A 60-year-old woman has a mass in the right scapula. Figures 25a and 25b show a CT scan and a biopsy specimen. The cells are lymphocyte common antigen positive, Ewing’s specific antigen (CD99) negative, and keratin negative. What is the next step in management?

Explanation

DISCUSSION: The clinical history, CT scan, and histology are most consistent with a lymphoma of bone. An important part of the staging is bone marrow aspiration and biopsy. The other studies listed are not indicated. Lymphoma of bone, when localized, is usually treated with chemotherapy and radiation therapy and has excellent survival rates. Widespread lymphoma has a worse prognosis.
REFERENCES: Finiewicz K, van Biesen K: Non-Hodgkins lymphoma, in Golomb H, Vokes E (eds): Oncologic Therapies, ed 2. Berlin, Germany, Springer, 2003, pp 295-318.
Lems P, Primus G, Anastas J, Doherty D, Montag AG, Peabody TD, Simon MA: Oncologic outcomes of primary lymphoma of bone in adults. Clin Orthop 2003;415:90-97.

Question 31

Which of the following surgical devices employed for stabilization of the sternoclavicular joint is associated with the highest incidence of life-threatening complications?

Explanation

DISCUSSION: Numerous reports have documented serious complications including death from migration of intact or broken Kirschner wires or Steinmann pins into hilar structures such as the heart, pulmonary artery, and the aorta.
REFERENCES: Gilot GJ, Wirth MA, Rockwood CA: Injuries to the sternoclavicular joint, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott, Williams and Wilkins, 2006, vol 2, pp 1373-1374.
Lyons FA, Rockwood CA Jr: Migration of pins used in operations of the shoulder. J Bone Joint Surg Am 1990;72:1262-1267.

Question 32

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

Explanation

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

Question 33

A 30-year-old woman has had pain in her right leg for the past 6 months. A lytic lesion is noted in the anterior cortex of the midtibia, extending 5 cm in length without a soft-tissue mass. A radiograph and a biopsy specimen are shown in Figures 35a and 35b. What is the preferred treatment?

Explanation

DISCUSSION: In an adult with an anterior cortical tibial lesion, this is the classic histologic appearance and anatomic location for an adamantinoma. The histology reveals areas of epithelial cells (in a glandular pattern) within a fibrous stroma. The epithelial cells are shown in nests. They would stain positively for keratin. Adamantinoma is a rare malignant bone tumor with a propensity for late metastasis. It has a high incidence of local recurrence unless resected with a wide margin. Chemotherapy and radiation therapy are not helpful in the treatment of this disease. Amputation generally is not necessary because a diaphyseal resection is usually possible.
REFERENCES: McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 263.
Moon NF, Mori H: Adamantinoma of the appendicular skeleton: Updated. Clin Orthop Relat Res 1986;204:215-237.

Question 34

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

Explanation

An isolated avulsion of the lesser tuberosity occurs very rarely and usually is found in 12- and 13-year-old adolescents. The MRI scans reveal a tear of the humeral attachment of the inferior glenohumeral ligament, a so-called HAGL lesion. This injury to the inferior glenohumeral ligament occurs much less commonly than the classic Bankart lesion (anterior inferior labral tear). A tear of the subscapularis occurs with a similar mechanism of injury but generally occurs in older individuals.

Question 35

A 17-year-old girl has multidirectional instability of the shoulder. What is the most appropriate initial management?

Explanation

DISCUSSION: Multidirectional instability of the shoulder is defined as symptomatic instability in two or more directions (anterior, posterior) but must include a component of inferior instability. Initial treatment should always include physical therapy and instruction in a home exercise program that emphasizes periscapular and rotator cuff strengthening to improve the dynamic stability of the glenohumeral joint. Immobilization has not been shown to be effective. Open capsular shift and arthroscopic capsular plication remain the surgical options when appropriate nonsurgical management fails (typically a minimum of 6 months of dedicated therapy and home program). Thermal capsulorrhaphy remains controversial but is not recommended by many clinicians because of reported complications including recurrent instability, axillary nerve injury, chondrolysis, and capsular injury.
REFERENCES: Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908.
D’Alessandro DF, Bradley JP, Fleischli JE, et al: Prospective evaluation of thermal capsulorrhaphy for shoulder instability: Indications and results, two- to five-year follow-up.

Am J Sports Med 2004;32:21-33.
Levine WN, Clark AM Jr, D’Alessandro DF, et al: Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability: A report of two cases. J Bone Joint Surg Am 2005;87:616-621.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 278-279.

Question 36

A 25-year-old man has an isolated flexor digitorum profundus laceration just proximal to the distal interphalangeal (DIP) flexion crease of his ring finger. The tendon ends are trimmed, removing 10 mm from each end (secondary to fraying) and the tendon repaired. Four months later, he reports limited finger motion of the long, ring, and small fingers. He cannot fully extend his wrist and all joints of the 3 fingers simultaneously. He has full passive flexion but cannot actively completely close his fingers into a fist. What is the most likely cause?

Explanation

EXPLANATION:
If a single flexor digitorum profundus (FDP) tendon is debrided more than 1 cm prior to repair, the tendon is advanced too far distally, essentially shortening the musculotendon unit. The finger will likely develop a flexion posture. Because of the common muscle belly and interconnections of the profundi, the long and small fingers adjacent to the injured finger will be affected because of loss of some of their normal proximal excursion. The result is an inability of the adjacent fingers to completely flex. This condition, known as quadrigia, is named after the Roman chariot driver who held control of the reins of 4 horses, forcing them to move as 1. Quadrigia occurs when the FDP tendon is advanced too far distally, when a tendon graft is too short, or when the profundus is sutured over the end of an amputated digit. Intrinsic muscles of the hand flex the metacarpophalangeal (MP) joints and extend the PIP joint. Intrinsic tightness causes decreased PIP flexion when the MP joint is in extension. The lumbrical muscle modulates tension on the flexor profundus tendon. When a tendon graft to repair the profundus tendon is too long, a lumbrical plus deformity occurs. This is a paradoxical PIP extension as the finger is flexed. Disruption of the tendon
repair causes limited flexion of the injured finger.

Question 37

Which of the following is a contraindication to laminoplasty in a patient with cervical spondylotic myelopathy?

Explanation

DISCUSSION: Laminoplasty or any posterior decompressive procedure is contraindicated in patients with cervical spondylotic myelopathy and cervical kyphosis. The residual kyphotic posture of the cervical spine results in persistent spinal cord compression. The other choices are not contraindications for laminoplasty. Concomitant cervical radiculopathy can be addressed at the time of laminoplasty with a keyhole foraminotomy.
REFERENCES: Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-247.

Question 38

When a patient has recurrent anterior shoulder instability, a bony glenoid reconstructive procedure should be considered in which clinical setting?

Explanation

HAGL lesions may initially be treated without surgery. Recurrent instability in the setting of a HAGL lesion may be treated with a soft-tissue repair. A non-engaging or non-tracking Hill-Sachs lesion may be treated with an anterior soft-tissue (Bankart) repair. A tracking or engaging lesion may be treated with a bony glenoid procedure or a soft-tissue procedure plus remplissage. An ALPSA lesion may be treated with a soft-tissue procedure unless it is associated with a glenoid bony defect >25%. A glenoid bony defect >25% is associated with substantially higher recurrence than defects <20%, and consideration for bony glenoid reconstruction is advised. Consideration of bone augmentation procedures with less severe glenoid bone loss may be considered
in collision athletes.

Question 39

Figure 36a shows the current radiograph of a 65-year-old woman who slipped and fell. History reveals that prior to the fall she was actively functioning without pain. Figure 36b shows a radiograph obtained 1 year ago. Based on the fracture pattern, the failure is most likely related to

Explanation

DISCUSSION: The radiograph shows a fracture distal to the prosthesis in a stable, apparently well-fixed prosthetic stem. The well-fixed prosthesis-bone composite is stiff, creating a modulus mismatch between the proximal and distal femur. Therefore, the risk of fracture, particularly in osteoporotic bone, is increased at this level. Revision of the stem to a longer construct is unnecessary, and standard plate and screw fixation has been shown to yield union rates of greater than 90%. Nonsurgical treatment of fractures distal to the tip of the prosthesis results in high nonunion rates, reported to be from 25% to 42%.
REFERENCES: Johansson JE, McBroom R, Barrington TW, Hunter GA: Fracture of the ipsilateral femur in patients with total hip replacement. J Bone Joint Surg Am 1981;63:1435-1442.
Bethea JS III, DeAndrade JR, Fleming LL, Lindenbaum SD, Welch RB: Proximal femoral fractures following total hip arthroplasty. Clin Orthop 1982;170:95-106.
Garbuz DS, Masri BA, Duncan CP: Periprosthetic fractures of the femur: Principles of prevention and management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 237-242.

Question 40

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

Explanation

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

Question 41

A 68-year-old woman with metastatic breast carcinoma is seen in the emergency department. She appears lethargic, and she reports abdominal pain, nausea, and constipation. An EKG reveals a shortened QT interval. The only physical finding on examination is diffuse hyporeflexia. What is the most appropriate step in management?

Explanation

DISCUSSION: Intravenous fluid administration is the best first step to treat the hypercalcemia of malignancy. Many of these patients are dehydrated, and the increased serum calcium impairs the ability of the kidney to concentrate the urine. The decreased glomerular filtration rate secondary to the hypovolemia also leads to increased tubular resorption of calcium. The establishment of normovolemia will help promote increased urinary excretion of calcium. Lasix can also be used to help promote calciuria. Mithramycin is an antibiotic derived from Streptomyces plicatus. It is part of a group of drugs referred to as chromomycin antibiotics and is the only one of this group used clinically in the United States. It is rarely used in cancer chemotherapy because of its toxicity. A number of drug-related deaths have occurred from the use of mithramycin. Its use is now limited to the treatment of hypercalcemia associated with malignancy where it is used in lower dosage than that used for the treatment of tumors. Methotrexate has no role in the treatment of hypercalcemia of malignancy. While intravenous bisphosphonates are helpful in slowing progression of metastases and may help lower cerum calcium, they are not appropriate in the emergent treatment of hypercalcemia in the metastatic cancer patient.
REFERENCE: Stewart AF: Clinical practice: Hypercalcemia associated with cancer. N Engl J of Med 2005;352:373-379.

Question 42

Free flap coverage for severe trauma to the upper extremity has the fewest complications when performed within what time period after injury?

Explanation

DISCUSSION: Flap necrosis and infection rates are lowest if free flap coverage is performed within 72 hours of injury. Delays beyond 72 hours are associated with a higher rate of complications.
REFERENCES: Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-292.
Manske PR (ed): Hand Surgery Update. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 31-37.

Question 43

A 14-year-old girl reports bilateral patellofemoral symptoms. Based on the radiograph and MRI scans shown in Figures 23a through 23d, what is the next most appropriate step in management of the lesion?

Explanation

DISCUSSION: A periosteal desmoid lesion is a tumor simulator. It is characterized by a bone irregularity along the posteromedial aspect of the distal femur at the insertion of the adductor magnus or the origin of the gastrocnemius muscle. It most commonly occurs in patients who are age 10 to 15 years. The lesions are asymptomatic, with no palpable mass, pain, or swelling. They are frequently an incidental finding when radiographs are obtained for nonspecific symptoms or trauma about the knee. Following recognition of the characteristic imaging findings, observation is the management of choice.
REFERENCES: Dunham WK, Marcus NW, Enneking WF, et al: Developmental defects of the distal femoral metaphysis. J Bone Joint Surg Am 1980;62:801-806.
Verdonk PC, Verstraete K, Verdonk R: Distal femoral cortical irregularity in a 13-year old boy: A case report. Acta Orthop Belg 2003;69:377-381.

Question 44

A 40-year-old man with a history of Legg-Calve-Perthes disease underwent a right hip resurfacing 3 years ago with no perioperative complications. Hip pain has developed gradually during the last 4 months. Radiographs show no evidence of fixation loosening or any adverse changes at the femoral neck. No periarticular osteolysis is evident. A large intra-articular and intrapelvic pseudotumor has developed. What predominant histological feature(s) is/are present in such a lesion?

Explanation

DISCUSSION:
Controversy persists over what exactly is the best approach to managing patients with metal-on-metal (MOM) hip arthroplasties. All patients with painful MOM hip arthroplasties should be examined for fixation loosening, wear/osteolysis, and infection—no differently than patients without MOM hip arthroplasties. It is recommended to obtain serum trace element levels. If the levels are high, cross-sectional imaging should be obtained to determine whether any pseudotumor or tissue necrosis is present around the hip arthroplasty. Hip aspiration should be considered if concern for infection exists. Adverse tissue reaction has been identified to occur around MOM hip arthroplasties. The predominant histologic feature is tissue necrosis with infiltration of lymphocytes and plasma cells.

Question 45

A 12-year-old girl who plays softball has chronic lateral hindfoot aching pain that is aggravated by weight-bearing activity. She reports that the pain has recurred after initial improvement with cast immobilization, and it continues to limit her overall level of activity. Radiographs are seen in Figures 40a through 40c. What is the most appropriate surgical treatment? Review Topic

Explanation

Spine MRI
Standing radiographs of the bilateral feet
Gastrocnemius stretching and nightime use of ankle foot orthosis
Gastrocnemius stretching and use of UCBL orthotic when ambulating
Gastrocnemius stretching
The patient is presenting with bilateral flexible pes planovalgus (or flexbile flatfoot). The most appropriate treatment in patients with a tight heel cord and no pain is gastrocnemius stretching
A flexible flatfoot in a child typically resolves spontaneously. Radiographs are typically indicated when there is pain to rule out other conditions. Treatment for patients without pain includes observation and gastrocnemius stretching. If there is pain, soft arch support or a more rigid UCBL can be used, but orthotics do not change the natural history. In patients with continued tightness in the heel cord despite aggressive stretching, gastrocnemius lengthening may be necessary.
Mosca reviews the management of flexible flatfeet in children and adolescents. He reports that there is no compelling evidence that an arch can be created with use of
orthotics. He proposes the following algorithm: patients with asymptomatic flatfeet are observed; symptomatic flatfeet with tight heel cords undergoing stretching until they become asymptomatic; symptomatic flatfeet with tight heel cords that do not respond to stretching (rare cases) are considered for surgery.
Figure A shows a young a patient with bilateral flatfeet when standing. Incorrect Answers:
abnormalities can seen in patients with cavovarus deformity Answer 2: Radiographs are indicated when there is pain to rule out other conditions. Answer 3: Ankle foot orthoses are not used for pes planovalgus Answer 4: UCBL would be indicated if the patient was having pain.
(SBQ13PE.42) Submuscular bridge plating is appropriate treatment for which of the following? Review Topic
A 2-month-old female with displaced, spiral, mid-diaphyseal femur fracture
A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with
<2cm shortening
A 7-year old boy with a transverse, non-comminuted mid-diaphyseal femur fracture
A 7-year-old boy with a highly comminuted mid-diaphyseal femur fracture
A 15-year-old girl with a displaced butterfly fragmented mid-diaphyseal femur fracture
Submuscular bridge plating is appropriate for length-unstable femur fractures in skeletally immature patients ages 6 years and older.
Traditional plating of diaphyseal femur fractures in children has been abandoned due to the large incision and significant periosteal stripping involved. Submuscular plating with limited incisions and percutaneously applied fixation is a more biologically friendly way to achieve rigid internal fixation in length-unstable fracture patterns. External fixation is another acceptable option for these fractures. Locked plating, on the other hand, provides an 'internal external fixator,' avoids pin site issues and allows rapid mobilization while providing a biologically favorable environment for healing.
Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. They concluded that there was insufficient evidence regarding submuscular bridge plating to include it in the guideline.
Flynn et al. review the management of pediatric femoral shaft fractures. The note that
the narrow indications for plating of pediatric femoral fractures are open fractures, multiple trauma, head injury or compartment syndrome in patients less than 12 years old. Plating allows rigid fixation with readily available equipment and allows for rapid mobilization.
Hedequist et al. present a Technical Tricks paper in which they detail their surgical technique for submuscular bridge plating. They recommend this fixation strategy for patients between age 6 and skeletal maturity with comminuted diaphyseal femur fractures that are not easily treated by other methods.
Illustration A shows a preoperative and postoperative radiograph of a comminuted pediatric femur fracture treated with submuscular plating.
Incorrect answers:
(SBQ13PE.88) A 12-month-old boy attends a government regulated childcare center. His parents are called after a fall. Non-accidental trauma has been ruled out. On physical examination the right elbow is swollen and tender. He is unwilling to allow you to move the arm. Radiographs of the elbow are shown in Figure A. What is the orthopaedic management of this injury? Review Topic

Observation only
Elbow sling for 3 to 4 weeks
Rigid elbow immobilisation for 4 to 5 weeks
Admit for 24-48 hours for continuous intracompartmental pressure measurements
Operative fixation with percutaneous pinning PREFERRED RESPONSE 5
This patient presents with a distal humeral physeal separation. The most appropriate treatment would be closed reduction with internal fixation with percutaneous pins.
Displaced distal humerus physeal separation is typically seen in children under the age of 3 and has a high association with child abuse. The diagnosis can be a difficult as radiographs of a distal humeral physeal separation may be subtle. Often, radiographs show no obvious fracture, but can appear like an elbow dislocation since the secondary ossification centers have not yet developed. MRI or arthrogram can be used to aid in diagnosis.
Shrader et al. reviewed pediatric supracondylar fractures and pediatric physeal elbow fractures. They state the key to diagnosis of distal humerus physeal separation is the assessment is the radial head–capitellum relationship. These injuries should be fixed with closed reduction and smooth wire pinning. An elbow arthrogram may be considered intraoperatively for these patients because of the difficulty visualizing the distal humeral anatomy in children so young.
Skaggs et al. reviewed the diagnosis and management of pediatric elbow fractures. He states that child abuse should be suspected in all cases of elbow fracture when the child is less than 3 years of age and/or the injury pattern occur from a shearing mechanism. The displacement of physeal elbow fractures is almost always posteromedial.
Figure A shows AP and lateral radiographs with posteromedial displacement of the radial and ulnar shafts relative to the distal humerus. This is consistent with distal humeral physeal separation.
Incorrect Answers:

Question 46

What ligament is the primary restraint to applied valgus loading of the knee?

Explanation

DISCUSSION: The superficial portion of the MCL contributes 57% and 78% of medial stability at 5 degrees and 25 degrees of knee flexion, respectively. The deep MCL and posteromedial capsule act as secondary restraints at full knee extension. The anterior cruciate ligament and PCL also provide secondary resistance to valgus loads.
REFERENCE: Garrett WE, Speer KP, Kirkendall DT (eds): Principles & Practice of Orthopaedic Sports Medicine. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, p 767.

Question 47

An 18-year-old hockey player sustains an acute anterior shoulder dislocation that requires manual reduction. At arthroscopy, the lesion shown in Figure 24 will be observed in what percent of patients?

Explanation

DISCUSSION: The clinical photograph shows an acute capsulolabral avulsion from the anterior glenoid, also referred to as a Perthes-Bankart lesion. In patients who sustain an acute dislocation that requires a manual reduction, this pathologic lesion is observed with high frequency. In several research studies, it has been visualized in 80% to 95% of patients at arthroscopy.
REFERENCES: Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306-311.
Baker CL, Uribe JW, Whitman C: Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med 1990;18:25-28.

Question 48

Figures 1a and 1b are the recent radiographs of an 82-year-old man with rheumatoid arthritis who underwent total knee arthroplasty (TKA) 18 years ago. These radiographs reveal osteolysis with loosening of the tibial component. Aspiration and laboratory study findings for infection are negative. During the revision TKA, treatment of tibial bone loss should consist of

Explanation

DISCUSSION

Video 1 for reference
For severe tibial defects (Anderson Orthopaedic Research Institute [AORI] types 2 and 3), metaphyseal fixation is necessary to achieve construct fixation during revision TKA. Metaphyseal fixation may be achieved with cement, structural allograft, or conical metallic implants. The major concerns regarding structural allograft are graft resorption and mechanical failure and technical issues related to fashioning the graft and obtaining a good host-allograft interface. In a systematic review, porous metal cones were associated with a decreased loosening rate in AORI 2 and 3 defects compared to structural allografts. Metallic trabecular metal cones and metaphyseal porous coated sleeves provide a stable construct with which to support the tibial component during revision TKA. Clinical results with these devices include good metaphyseal fixation for severe tibial bone defects.

Question 49

A neurologic injury at T11-L2 with loss of bowel and bladder control is best described as what syndrome?

Explanation

DISCUSSION: Conus medullaris syndrome describes isolated loss of bowel and bladder function, usually at T12-L1 but can include T11-L2. In central cord syndrome, lower extremity motor function is better than upper extremity function. Cauda equina syndrome generally involves injury at the lumbar levels, with some degree of lower extremity motor loss. Posterior cord syndrome is characterized by preservation of motor function below the level of injury and position/vibratory sensory loss. In anterior cord syndrome, the lower extremity findings include loss of light touch, sharp/dull, and temperature sensations below the level of injury, as well as motor function.
REFERENCES: Apple DF Jr: Spinal cord injury rehabilitation, in Rothman RH, Simeone FA (eds): The Spine, ed 3. Philadelphia, PA, WB Saunders, 1992, Chapter 31.
Weisberg LA: Neurologic localization: Lesions below foramen magnum, in Weisberg LA, Strub RL, Garcia CA (eds): Adult Neurology, ed 2. St. Louis, MO, Mosby, 1993.

Question 50

A 9-month-old nonambulatory girl is seen in the emergency department with a fracture of her right forearm. The mother says she fell from the changing table yesterday and continues to cry and not use her right arm. Radiographs are shown in Figure 31. Treatment should consist of which of the following? Review Topic

Explanation

The occurrence of a forearm fracture in a 9-month-old child has a greater than 50% chance that the injury is due to child abuse. It is mandatory to report this to child protective services unless there is some compelling reason that it is definitely not child abuse. In addition, a skeletal survey should be requested to look for other injuries. A bone scan would show other injuries, but a skeletal survey is a more
efficient way to evaluate for other fractures. A MRI of the brain is not indicated unless fundoscopic examination reveals an abnormality.

Question 51

Which of the following methods most reliably detects mechanical loosening of the hip?

Explanation

DISCUSSION: Mechanical loosening of the hip is best revealed by serial radiographs of the prosthetic joint. None of the other methods of evaluation is considered reliable in diagnosing mechanical loosening.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 455-492.
Miniaci A, Bailey WH, Bourne RB, McLaren AC, Rorabeck CH: Analysis of radionuclide arthrograms, radiographic arthrograms, and sequential plain radiographs in the assessment of painful hip arthroplasty. J Arthroplasty 1990;5:143-149.

Question 52

A 25-year-old man has had an insidious onset of left hip pain over the past 11 months. A radiograph, coronal MRI scan, and histopathologic specimens are seen in Figures 2a through 2d. What is the most likely diagnosis?

Explanation

DISCUSSION: Ewing’s sarcoma is the second most common primary sarcoma of bone in children and young adults. It is a malignant round cell tumor with uncertain histogenesis. Sheets of uniform small round blue cells with a high nuclear-to-cytoplasm ratio and the absence of osteoid formation differentiate this histologic diagnosis from the other conditions. Immunohistochemical staining and molecular diagnostic studies are useful to verify the diagnosis.
REFERENCE: Sucato DJ, Rougraff B, McGrath BE, et al: Ewing’s sarcoma of the pelvis: Long-term survival and functional outcome. Clin Orthop 2000;373:193-201.

Question 53

A 25-year-old man injured his dominant shoulder after falling on his outstretched arm 4 months ago. Examination reveals that he cannot lift his arm above 90 degrees, and he has pronounced medial scapular winging. Management should consist of

Explanation

DISCUSSION: Serratus anterior palsy or long thoracic nerve palsy is usually caused by traction injury to the nerve, blunt injury, or iatrogenic injury. The palsy results in winging of the scapula and medial rotation of the inferior pole of the scapula. A patient with this injury will usually recover in 12 to 18 months. Initial treatment should include observation and shoulder strengthening exercises. Nerve exploration with repair has not proven beneficial in changing the outcome. Many orthopaedic surgeons favor using a split pectoralis major transfer for symptomatic patients. Electrodiagnostic studies are helpful in confirming the diagnosis.
REFERENCES: Post M: Pectoralis major transfer for winging of the scapula. J Shoulder Elbow Surg 1995;4:1-9.
Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325.

Question 54

-A 42-year-old patient with a right distal radius fracture underwent open reduction and internal fixation. To reduce the likelihood of complex regional pain syndrome, the most appropriate medication is

Explanation

Question 55

An 8-year-old boy has had pain and swelling around the right knee for the past 4 weeks. He recalls bumping it about 4 weeks ago. He has no pain in other joints, and denies any fevers, chills, or other symptoms. A radiograph is shown in Figure 13. Laboratory studies show a WBC count of 9,700/mm P 3 P , an erythrocyte sedimentation rate of 18 mm/h, and a C-reactive protein level of 3.7 mg/L. What is the next most appropriate step in management?

Explanation

DISCUSSION: The history and laboratory findings are consistent with osteomyelitis of the patella. The radiograph reveals bone destruction in the patella; therefore, the next most appropriate step is open biopsy and debridement of the site. Aspiration of the knee joint may be needed to rule out septic arthritis prior to patellar debridement. With this amount of bone destruction, surgical debridement is helpful to obtain cultures and to remove necrotic material. Administering antibiotics without any prior culture increases the risk of negative cultures later and a potentially incorrect choice of antibiotic. A neoplasm should be included in the differential. It would be inappropriate to initiate chemotherapy and radiation therapy without a biopsy-confirmed diagnosis. A bone scan is likely to demonstrate uptake, but radiographs have already localized the abnormality to the patella.
REFERENCES: Morrisy RT: Bone and joint sepsis, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 466-470.
Dormans JP, Drummond DS: Pediatric hematogenous osteomyelitis: New trends in presentation, diagnosis, and treatment. J Am Acad Orthop Surg 1994;2:333-341.

Question 56

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

Explanation

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

Question 57

Figures 1 through 3 are the weight-bearing radiograph and MRI scans of a 27-year-old man who twisted his knee coming down awkwardly from a lay-up during a basketball game. He felt a sharp stabbing pain in the posterior aspect of his knee at the time of the injury. Physical examination reveals a trace effusion, full range of motion but pain with hyperflexion >90° degrees and tenderness over the affected joint line. What is the most appropriate treatment at this time?

Explanation

The MRI scan shows a posterior horn medial meniscus root avulsion with bony edema at the tibial root insertion. The radiograph shows no significant degenerative changes. If left untreated, posterior meniscal
root tears lead to progressive degenerative changes as a result of the altered tibiofemoral contact pressures and areas. Nonsurgical treatment including injections, physical therapy, and unloader braces are more appropriate in the older patient with pre-existing advanced degenerative changes.

Question 58

What is the most appropriate treatment for a chordoma involving the sacrum?

Explanation

DISCUSSION: Chordomas are very radio- and chemotherapy resistant; therefore, en bloc resection with a negative margin is the preferred treatment. Lesions at or below S3 can be resected without compromising pelvis stability, and continence usually is maintained. The mean survival rate for patients with sacral chordomas is approximately 7 years. Patients with chordoma of the mobile (cervical, thoracic, or lumbar) spine have a mean survival rate of approximately 5 years. This difference is most likely the result of an earlier diagnosis.
REFERENCES: Fardin DF, Garfin SR, Abitbol J, et al (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 123-133.
Stener B, Gunterberg B: High amputation of the sacrum for extirpation of tumors: Principles and technique. Spine 1978;3:351-366.
Stener B: Resection of the sacrum for tumors. Chir Organi Mov 1990;75:S108-S110.

Question 59

Which of the following bones is most frequently involved in stress fractures in athletes? Review Topic

Explanation

The tibia is the most frequent stress fracture location in most series in both athletes and modern military training. The anterior midshaft region of the tibia may be at higher risk secondary to tensile forces and a relative paucity of blood supply.

Question 60

Based on the findings seen at C5-6 in Figure 30, the most likely deficit for this patient will be weakness of the

Explanation

DISCUSSION: A herniated cervical disk at C5-6 causes a C6 radiculopathy. There are eight cervical nerve roots and seven cervical vertebrae, and C8 exits between the C7 and T1 vertebrae. The C6 nerve root typically innervates the biceps and wrist extensor. The deltoid is predominantly innervated by C5. The wrist flexor and triceps are predominantly innervated by C7. Grip strength is predominantly a function of C8.
REFERENCE: Hoppenfeld S: Evaluation of nerve root lesions involving the upper extremity, in Orthopaedic Neurology. Philadelphia, PA, JB Lippincott, 1977, pp 7-23.

Question 61

In overhead athletic activities, the kinetic chain generates what percentage of force from the leg and trunk segments of the chain?

Explanation

DISCUSSION: The leg and trunk provide a stable base for arm motion, supply rotational momentum for force generation, and generate 50% to 55% of the total force and kinetic energy in the tennis serve.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 47.
McClure PW, Michener LA, Sennett BJ, et al: Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg 2001;10:269-277.
Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 2003;19:641-661.

Question 62

A 2-year-old child has marked hypotonia and depressed reflexes. History reveals that the child was normal at birth and developed normally for the first year. The child also began to ambulate, but lost this ability during the next 6 months. Laboratory studies show a creatine phosphokinase level that is within the normal range. DNA testing confirms a deletion in the survival motor neuron (SMN) gene. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has spinal muscular atrophy, type 2. This type is intermediate in severity between the Werdnig-Hoffmann type (type 1) and the Kugelberg-Welander type

(type 3). It normally manifests itself between the ages of 3 and 15 months. Survival until adolescence is common. All three types of spinal muscular atrophy have been linked to the SMN gene at the 5q12.2-13.3 locus. DNA testing is available and is preferred to muscle biopsy because it is less invasive and more definitive.
REFERENCES: Biros I, Forrest S: Spinal muscular atrophy: Untangling the knot? J Med Genet 1999;36:1-8.
Zerres K, Wirth B, Rudnik-Schoneborn S: Spinal muscular atrophy: Clinical and genetic correlations. Neuromuscul Disord 1997;7:202-207.

Question 63

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

Explanation

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

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

Question 64

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

Explanation

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.

Question 65

Figures 1 and 2 show the clinical photograph and ultrasonography image obtained from an 8-month-old boy who has a 2-month history of a well-circumscribed mass in the palm, just proximal to the palmar digital crease of the index finger. The mass has not changed in size and does not seem to cause pain. What is the best next step in treatment?

Explanation

EXPLANATION:
The history, clinical photograph, and ultrasonography evaluation point to a diagnosis of ganglion cyst. The likelihood of resolution of ganglion cysts without intervention in pediatric patients ranges from 66-79%. Therefore the most appropriate treatment at this time is observation. Because the diagnosis is confirmed with the information provided, excisional biopsy and further imaging are not necessary.

Question 66

A 38-year-old man who is an avid runner reports a several month history of right hip pain. Based on the radiograph and cross-sectional CT scan shown in Figures 33a and 33b, what is the most likely diagnosis for the lesions seen on the femoral neck?

Explanation

DISCUSSION: Synovial herniation pits or Pitt’s pits are tumor simulators and are incidentally identified on radiographs obtained for either pain or trauma. The main diagnostic pitfall with this lesion is mistakenly identifying it as an osteoid osteoma. Accurate diagnosis is achieved by knowledge of the location and the characteristic imaging appearance. These are common lesions in individuals with femoroacetabular impingement.
REFERENCES: Pitt MJ, Graham AR, Shipman JH, et al: Herniation pit of the femoral neck. Am J Roentgenol 1982;138:1115-1121.
Daenen B, Preidler KW, Padmanabhan S, et al: Symptomatic herniation pits of the femoral neck: Anatomic and clinical study. Am J Roentgenol 1997;168:149-153.

Question 67

Consider the theoretic articulation shown in Figure 11 as femoral and tibial components of a total knee prosthesis in which the components fit like a “roller in trough.” Which of the following best describes the articulation?

Explanation

DISCUSSION: The theoretic total knee components will resist anteroposterior motion by making the femoral component “climb the walls” of the tibial component. As drawn, there is no constraint to medial-lateral translation. The cylinder is not rounded on the edges, so varus-valgus motion will impart load from the cylinder to the trough over a small area, thus having a high contact stress.
REFERENCE: Alicea J: Scoring systems and their validation for the arthritic knee, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 3. Philadelphia, PA, Churchill Livingstone, 2001, vol 2, pp 1507-1515.

Question 68

Which of the following procedures is not part of the routine evaluation of a patient with suspected metastatic disease to bone?

Explanation

DISCUSSION: The work-up for a patient with an unknown primary lesion that is metastatic to bone includes a search for the primary tumor and other sites of metastasis. This involves conducting a thorough history and physical examination, appropriate laboratory studies, bone scan, chest radiograph, and CT of the chest, abdomen, and pelvis. In women, a mammogram may be indicated. CT of the brain is not necessary in the early stages of a metastatic work-up.
REFERENCES: Simon MA, Bartucci EJ: The search for the primary tumor in patients with skeletal metastases of unknown origin. Cancer 1986;58:1088-1095.
Frassica FJ, Gitelis S, Sim FH: Metastic bone disease: General principles, pathophysiology, evaluation, and biopsy. Instr Course Lect 1992;41:293-300.

Question 69

below show the radiographs obtained from a year-old woman with a 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 70

A 25-year-old athletic woman has a 16-week history of left lower-extremity radiating pain in an S1 distribution. MR images obtained by her family physician reveal a large L5-S1 paracentral disk herniation impinging on the left S1 nerve root. You suggest a left-sided L5-S1 microdiskectomy and tell her that when comparing tubular diskectomy and open procedures

Explanation

DISCUSSION
Several comparative studies have reported no difference in functional outcomes between tubular diskectomy and microsurgical lumbar diskectomy. A recent systematic review by Kamper and associates in which conventional microdiskectomy and minimally invasive approaches were compared revealed that there was no difference between the procedures in terms of clinical outcomes, complication risk, or rate of revision surgery.
RECOMMENDED READINGS
Kamper SJ, Ostelo RW, Rubinstein SM, Nellensteijn JM, Peul WC, Arts MP, van Tulder MW. Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis. Eur Spine J. 2014 May;23(5):1021-43. doi: 10.1007/s00586-013-3161-2. Epub 2014 Jan 18.
PubMed PMID: 24442183.View Abstract at PubMed
Dasenbrock HH, Juraschek SP, Schultz LR, Witham TF, Sciubba DM, Wolinsky JP, Gokaslan ZL, Bydon A. The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials. J Neurosurg Spine. 2012 May;16(5):452-62. doi: 10.3171/2012.1.SPINE11404. Epub 2012 Mar 9. PubMed PMID:

Question 71

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 72

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 73

Figure 9 shows a cross-sectional view of the spinal cord at the lower cervical level. Injury to the structure indicated by the black arrow will lead to what neurologic deficit?

Explanation

DISCUSSION: The arrow is pointing to the posterior columns of the spinal cord that transmit position sense, vibratory sense, and proprioception. There are no motor tracts in the posterior columns.
REFERENCES: Bohlman H, Ducker T, Levine A: Spine trauma in adults, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 911.
Northrup B: Evaluation and early treatment of acute injuries to the spine and spinal cord, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, p 545.

Question 74

Which of the following is considered an advantage of the tibial inlay fixation compared to transtibial tunnel technique when used in posterior cruciate ligament reconstruction? Review Topic

Explanation

One of the most difficult aspects of posterior cruciate ligament reconstruction is placement of the tibial tunnel and passing of the graft through this tunnel. The tibial inlay technique requires a posteromedial approach to the tibia whereby the graft is directly fixed to the posterior aspect of the tibia. This obviates the need for a tibial tunnel. This technique has never been shown to be less invasive, more cosmetic, or require decreased surgical time. It has also never been shown in a published level I study to have superior clinical results. However, it does eliminate the need for the 90-degree critical "killer" turn and passing of the tibial graft through the tibial tunnel which may lead to graft failure.

Question 75

A patient in the recovery room has weakness of the extensor hallucis longus and tibialis anterior muscles following a total knee replacement. Initial management should consist of

Explanation

Operative exploration and decompression of the peroneal nerve-Five patients were treated by operative exploration and decompression of the peroneal nerve for peroneal nerve palsy complicating total knee arthroplasty (TKA). All patients had failed to demonstrate improvement in the peroneal nerve function despite extended conservative care. The procedure was performed five to 45 months after the index TKA. Patients were evaluated and graded preoperatively and postoperatively using the Modified Nerve Palsy Scale of Weber, Daube, and Coventry. All patients demonstrated improved nerve function. Four of five patients had full peroneal nerve recovery. All patients were able to discontinue their ankle-foot orthoses.
This is a rare
complication of TKA, and when conservative nonoperative measures do not lead to sufficient improvement in nerve function, consideration may be given to operative decompression of the peroneal nerve.

Question 76

A 46-year-old male construction worker has right hip pain that has failed to respond to nonsurgical management. His body mass index (BMI) is 32, he is 6’2” tall, and he has no other medical comorbidities. AP and lateral radiographs of the right hip are shown in Figures 23a and 23b. The patient inquires about his suitability for metal-on-metal hip resurfacing. The patient should be educated that he is at higher risk for failure secondary to which of the following?

Explanation

DISCUSSION: This young patient has osteonecrosis of the femoral head with a large area of collapse.
The results of hip resurfacing arthroplasty have been reported to be best in young, male patients who are younger than 55 years of age with a diagnosis of osteoarthritis. Although some authors advocate metal- on-metal hip resurfacing as an option for patients with osteonecrosis of the femoral head, in this particular patient, given the size of the necrotic segment, he would be at higher risk for failure and a conventional total hip arthroplasty would be a more conservative option. As the acetabulum is resurfaced in metal- on-metal hip resurfacing, the secondary changes of the acetabulum are not an issue and his BMI is in an acceptable range for the procedure.
REFERENCES: Mont MA, Ragland PS, Etienne G, et al: Hip resurfacing arthroplasty. J Am Acad Orthop Surg 2006;14:454-463.
Revell MP, McBryde CW, Bhatnagar S, et al: Metal-on-metal hip resurfacing in osteonecrosis of the femoral head. J Bone Joint Surg Am 2006;88:98-103.
Buergi ML, Walter WL: Hip resurfacing arthroplasty: The Australian experience. J Arthroplasty 2007;22:61-65. Question 24
A 31-year-old woman had disabling right knee pain. An arthroscopic assessment reveals chondromalacia of both the lateral femoral condyle and tibial plateau. The standing femorotibial axis measures 10 degrees of valgus. The
optimum treatment of this condition should include
distal femoral varus osteotomy.
osteoarticular transplant to the lateral femoral condyle.
unicondylar arthroplasty.
high tibial osteotomy.
Fulkerson tibial tubercle transfer. PREFERRED RESPONSE: 1
DISCUSSION: The long-term outcome of a distal femoral varus osteotomy has been quite favorable and should remain the primary choice for this young active woman. Sharma and associates have shown that a 5-degree valgus malalignment has a five-fold chance of progressing at least one grade within 18 months, making a corrective osteotomy the most important surgical maneuver.
REFERENCES: Sharma L, Song J, Felson DT, et al: The role of knee alignment in disease progression and function decline in knee osteoarthritis. JAMA 2001 ;286:188-195.
Murray PB, Rand JA: Symptomatic valgus knee: The surgical options. J Am Acad Orthop Surg 1993; 1:19.

Figure 25a Figure 25b Figure 25c

Question 77

A 21-year-old basketball player inverts his foot during practice. Examination reveals obvious deformity of the hindfoot with a prominence of the talar head dorsolaterally and medial displacement of the forefoot. A radiograph is shown in Figure 17. What is the most likely obstacle to closed reduction?

Explanation

DISCUSSION: The patient has a medial subtalar dislocation. These injuries should be reduced as soon as possible to minimize risk to the skin. Most often, this can be done easily, and further radiographic evaluation then can be performed as necessary. On rare occasions, closed reduction is not possible because of fractures of the articular surface of the talus, navicular, interposed extensor digitorum brevis, or transverse fibers of the cruciate crural ligament. The posterior tibial tendon is the most common obstruction to closed reduction in lateral subtalar dislocations, which are less common than medial dislocations. The majority of both injuries can be managed by closed reduction and immobilization.
REFERENCES: Mulroy RD: The tibialis posterior tendon as an obstacle to reduction of a lateral anterior subtalar dislocation. J Bone Joint Surg Am 1953;37:859-863.
Heckman JD: Fractures and dislocations of the foot, in Rockwood CA, Green DP, Bucholz RW (eds): Fractures in Adults. Philadelphia, PA, JB Lippincott, 1991, pp 2093-2100.
Saltzman C, Marsh JL: Hindfoot dislocations: When are they not benign? J Am Acad Orthop Surg 1997;5:192-198.

Question 78

A 37-year-old man who works in a factory has isolated, lateral unicompartmental pain about his knee with activities. Nonsurgical management has failed to provide relief. The radiograph shown in Figure 45 reveals a tibiofemoral angle of approximately 15 degrees which is clinically correctable to neutral. What is the best surgical option in this patient?

Explanation

DISCUSSION: Patients with a valgus alignment about the knee can have lateral compartment arthritis. Similar to a high tibial osteotomy, a supracondylar femoral osteotomy is indicated in younger patients who have a more active lifestyle and isolated unicompartmental disease. In this young patient who works in a factory and has a valgus knee, a medial closing wedge supracondylar femoral osteotomy is the treatment of choice. The role of arthroplasty is limited in younger patients.
REFERENCES: Mathews J, Cobb AG, Richardson S, et al: Distal femoral osteotomy for lateral compartment osteoarthritis of the knee. Orthopedics 1998;21:437-440.
Cameron HU, Botsford DJ, Park YS: Prognostic factors in the outcome of supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee. Can J Surg 1997;40:114-118.

Question 79

A 67-year-old woman has a painful, arthritic proximal interphalangeal (PIP) joint, and nonsurgical measures have failed to improve the pain. What implant and joint replacement approach combination has been demonstrated to have the lowest rate of revision surgery?

Explanation

EXPLANATION:
A recent systematic review compared silicone replacement, pyrocarbon replacement, and surface replacement arthroplasty for PIP arthritis. Silicone arthroplasty through a volar approach showed the greatest gains in arc of motion and had the lowest rate of revision surgeries. The rates of revision surgeries from low to high for each type of arthroplasty were 6% for silicone volar, 10% for silicone lateral, 11%
Surface replacement arthroplasty through a volar
for silicone dorsal, 18% for surface replacement dorsal, and 37% for surface replacement volar. Revision surgeries include implant replacement (to silicone or maintaining the surface replacement), arthrodesis, explantation, amputation, and other procedures.
approach showed the highest revision rate, the worst gain in arc of motion, and the greatest extension lag. However, substantial pain relief and higher satisfaction still were reported after surface replacement arthroplasty, regardless of the complications.

Question 80

Demyelination diseases as multiple sclerosis and Guillain-Barre $ create neurologic symptoms by

Explanation

These diseases cause demyelinated regions of the axon and thus have a higher capacitance and lower membrane resistance (opposite of normal) and thus affects an action potential’s saltatory propagation. When an action potential is propagate down a myelinated axon and reaches a demyelinated region its conduction becomes slowed or may even stop. This loss of conduction had effects on behavior.

Question 81

A 19-year-old college student reports a 1-week history of wrist pain following an intramural rugby match. A PA radiograph is shown in Figure 6. He denies any prior wrist injury. What is the best course of action?

Explanation

DISCUSSION: The patient has a scaphoid fracture involving the proximal pole. Surgical treatment is recommended for such fractures because of the prolonged period of cast immobilization necessary and the increased risk of delayed union, nonunion, and/or osteonecrosis with nonsurgical management. A cannulated compression screw, inserted in the central scaphoid via a dorsal approach, is biomechanically advantageous and provides greater stability for fracture healing than Kirschner wires. Recently, good outcomes have been reported with arthroscopic-assisted percutaneous fixation of nondisplaced or minimally displaced scaphoid fractures.
REFERENCES: Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210.
Chan KW, McAdams TR: Central screw placement in percutaneous screw scaphoid fixation: A cadaveric comparison of proximal and distal techniques. J Hand Surg Am 2004;29:74-79.
Bedi A, Jebson PJ, Hayden RJ, et al: Internal fixation of acute non-displaced scaphoid waist fractures via a limited dorsal approach: An assessment or radiographic and functional outcomes. J Hand Surg Am 2007;32:326-333.
McCallister WV, Knight J, Kaliappan R, et al: Central placement of the screw in simulated fractures of the scaphoid waist: A biomechanical study. J Bone Joint Surg Am 2003;85:72-77.

Question 82

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

Explanation

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

Question 83

A new composite material is being evaluated for potential use as a prosthetic ligament. In measuring the tensile strength of this material, why is it important to consider and accurately control the loading rate?

Explanation

Ligaments are viscoelastic, meaning that their deformation under load depends not only on the magnitude of the load but also on the rate of loading. Under higher load rates (faster loading), natural ligaments are stiffer and stronger. Therefore, it is important in such an experiment to apply a loading rate that is physiologically relevant, ie, that represents typical or worst case activities. Creep refers to deformation of a viscoelastic material over time under constant load. Stress relaxation refers to a decrease in stress over time under a constant displacement.

Question 84

A 28-year-old professional dancer reports a 3-month history of progressive pain in the posterior aspect of the left ankle. Her symptoms are worse when she assumes the en pointe position. Examination reveals tenderness to palpation at the posterolateral aspect of the ankle posterior to the peroneal tendons which is made worse with passive plantar flexion. There is no nodularity, fluctuance, or tenderness of the Achilles tendon. The neurovascular examination is unremarkable. A lateral radiograph and MRI scan are shown in Figures 16a and 16b, respectively. Management should consist of

Explanation

DISCUSSION: The imaging studies reveal findings typical of the os trigonum syndrome. This condition results from inflammation between the os trigonum and the adjacent talus. The symptoms of posterior ankle pain are exacerbated by plantar flexion, which stresses the fibrous union between these two bones. Definitive management of the high-level athlete involves excision of the os trigonum from a medial approach, although arthroscopic excision has also been described. The os trigonum is not an intra-articular structure; therefore, ankle arthroscopy is neither diagnostic nor therapeutic.
REFERENCES: Abramowitz Y, Wollstein R, Barzilay Y, et al: Outcome of resection of a symptomatic os trigonum. J Bone Joint Surg Am 2003;85:1051-1057.
Mouhsine E, Crevoisier X, Leyvraz P, et al: Post-traumatic overload or acute syndrome of the os trigonum: A possible cause of posterior ankle impingement. Knee Surg Sports Traumatol Arthrosc 2004;12:250-253.
Wredmark T, Carlstedt CA, Bauer H, et al: Os trigonum syndrome: A clinical entity in ballet dancers. Foot Ankle 1991;11:404-406.

Question 85

A 17-year-old patient sustained a closed calcaneal fracture when he jumped off of a roof 2 years ago, and he underwent nonsurgical management at the time of injury. The patient now reports lateral hindfoot pain that is worse with weight-bearing activities. Anti-inflammatory drugs and orthoses have failed to provide relief. Coronal and sagittal CT scans are shown in Figures 36a and 36b. What is the best course of action?

Explanation

DISCUSSION: The CT scans show evidence of a lateral wall blowout and malunion without significant arthrosis of the subtalar joint. In a young patient, it is preferable to avoid a fusion and allow residual motion by performing an exostectomy that decompresses the lateral subtalar joint and peroneal tendons.
REFERENCES: Chandler JT, Bonar SK, Anderson RB, et al: Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures. Foot Ankle Int 1999;20:18-24.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, p 52.

Question 86

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

Explanation

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

Question 87

A 23-year-old woman has had vague left knee pain for the past 6 months. A radiograph and CT scan are shown in Figures 50a and 50b. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographic appearance of the lesion emanating from the posterior cortex of the left distal femur is consistent with a surface bone-producing lesion; therefore, the most likely diagnosis is a parosteal osteosarcoma. In an osteochondroma, the cortex and medullary cavity of the lesion are in continuity with that of the native bone. A dedifferentiated chondrosarcoma has histologic components of a high-grade sarcoma plus a benign or low-grade malignant cartilage tumor. Tumoral calcinosis is characterized by amorphous calcium in the soft tissues and does not emanate from the bone itself. While often confused with parosteal osteosarcoma, myositis ossificans is usually more mature at the periphery of the lesion rather than the center. In addition, myositis ossificans does not involve the underlying cortex but remains separate from the bone.
REFERENCES: Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 185-196.
Okada K, Frassica FJ, Sim FH, Beabout JW, Bond JR, Unni KK: Parosteal osteosarcoma. A clinicopathological study. J Bone Joint Surg Am 1994;76:366-378.

Question 88

A 45-year-old construction worker sees a surgeon 23 days after sustaining an eccentric injury to his dominant right elbow. An MRI demonstrates a distal biceps tendon rupture with 5 cm of proximal retraction. In the operating room, the surgeon encounters good tissue quality but finds that primary repair can only be performed with the elbow hyperflexed to 70°. What is the best next step?

Explanation

Distal biceps ruptures, although relatively less common in comparison with other upper extremity tendon injuries, still garner considerable attention in the orthopaedic literature. The mechanism of injury typically results from an eccentric extension load to a flexed elbow. A biceps-deficient arm can result in up to 40% loss of supination strength and up to 80% loss of supination endurance. A delay in diagnosis can compromise the ability to reduce the tendon back to its anatomic insertion without having to hyperflex the elbow. Current literature confirms the ability to safely proceed with primary repair even with the elbow flexed up to 100° without fear of developing a flexion contracture. With time, patients can anticipate restoration of full elbow extension. An interposition graft should be used for a poor residual tendon quality stump <4 cm in length and in cases of delay to surgery of >6 weeks. Biceps to brachialis tendon transfer does not restore supination
strength. Isolated debridement of the distal tendon would not be an appropriate treatment.

Question 89

A 73-year-old man reports increasing back and lower extremity pain. A bone scan is shown in Figure 31. What is the most likely diagnosis?

Explanation

DISCUSSION: The bone scan reveals lesions throughout the skeleton. The patient’s age, gender, and pain pattern are consistent with metastatic prostate cancer. Multiple myeloma typically does not have enough osteoblastic activity to produce this bone scan. The patient’s age is not consistent with metastatic neuroblastoma (a pediatric disease). Polyostotic fibrous dysplasia may involve multiple active lesions in younger patients but does not have such a widespread distribution of lesions. Hodgkin’s lymphoma can involve bone, but the widespread discrete appearance on this bone scan is most consistent with metastatic prostate cancer. In a patient with widespread bone metastases from prostate cancer, bisphosphonates may play a critical role in treatment by decreasing pain and the number of fractures.
REFERENCES: Roudier MP, Vesselle H, True LD, Higano CS, Ott SM, King SH, Vessella RL: Bone histology at autopsy and matched bone scintigraphy findings in patients with hormone refractory prostate cancer: The effect of bisphosphonate therapy on bone scintigraphy results. Clin Exp Metastasis 2003;20:171-180.
Sartor O: Radioisotopic treatment of bone pain from metastatic prostate cancer. Curr Oncol Rep 2003;5:258-262.

Question 90

A 37-year-old laborer falls 12 feet and sustains a comminuted tibial plafond fracture. Three years after treatment using standard techniques, what will be the most likely outcome?

Explanation

DISCUSSION: Two recent studies by Pollak and associates and Marsh and associates have focused on function after high-energy tibial plafond fractures. Findings are unfavorable even when anatomic reduction is performed in the best centers and patients are provided excellent rehabilitation. Function improves up to 2 years after injury, but even basic walking skills remain adversely affected. Virtually all patients have long-term adverse general health effects compared to their gender and age-matched peers. Posttraumatic degenerative arthritis is present in most ankles. Patients should be told early about the long-term prognosis, and early vocational/psychological counseling should be given. Despite these adverse outcomes, only a minority of patients require fusion or arthroplasty.
REFERENCES: Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.
Marsh JL, Weigel DP, Dirschl DR: Tibial plafond fractures: How do these ankles function over time? J Bone Joint Surg Am 2003;85:287-295.

Question 91

Which of the following factors is most likely to predispose a patient to dislocation of the patellar component following total knee arthoplasty?

Explanation

The experimental data for this answer came from Anouchi et al The Effects of Axial Rotational Alignment of the Femoral Component on Knee Stability and Patellar Tracking in Total Knee Arthroplasty Demonstrated on Autopsy Specimens. This study looked at knee stability, patellar tracking, and patellofemoral contact points with the femoral component positioned in 5 degrees internal, 5 degrees external, and neutral alignment in relation to the posterior femoral condyles. Total knee arthroplasty was performed on four cadavaric specimens without lateral release.
Internally rotating the femoral component produced abnormal laxity seen at 30, 60, and 90 degrees of flexion. There was no gapping noted in the neutral or externally rotated specimens.
The normal pattern for patellar tracking was a gentle curve with maximal deflection at 15 and 60 degrees of flexion. The maximal medial displacement were lowest for the externally rotated specimens.
Although contact areas could not be quantitatively measured accurately, the contact areas were more evenly distributed between the medial and lateral sides of the patella in the externally rotated specimens than they were in either the internally rotated or neutral specimens.
You have to be careful interpreting this data at least in reference to knee stability. In this study a perpendicular tibial cut was made. The normal tibia has a 30 degree varus slope and thus more bone is resected from the lateral surface. External rotation of the femoral component compensates for this.
No tests were done with lateral placement of the femoral component or medial placement of the patellar component.

Question 92

Which of the following structures is most vulnerable during a medial sesamoidectomy of the hallux?

Explanation

DISCUSSION: The plantar-medial cutaneous nerve is at risk with the surgical approach to the medial sesamoid. It is found directly underlying an incision made at the junction of the glabrous skin of the hallux and must be identified before the approach can proceed. Transection will result in a painful neuroma that impinges on the plantar-medial surface of the toe and cause problems with shoe wear. The only other structure that lies near the surgical field is the abductor hallucis tendon which lies dorsal to the incision.
REFERENCE: Sarrafian SK: Anatomy of the Foot and Ankle, Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993, p 377.

Question 93

What root is most commonly involved with a segmental root level palsy after laminoplasty?

Explanation

DISCUSSION: The postoperative incidence of C5 root palsy after laminoplasty ranges from 5% to 12%. Other roots also may be affected. The palsies tend to be motor dominant, although sensory dysfunction and radicular pain are also possible. The palsy may arise during the immediate postoperative period or up to 20 days later. C5 may be preferentially involved because it is at the apex of the cervical lordosis. Recovery usually occurs over weeks to months.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-249.
Uematsu Y, Tokuhashi Y, Matsuzaki H: Radiculopathy after laminoplasty of the cervical spine. Spine 1998;23:2057-2062.

Question 94

Figure below depicts the radiograph obtained from a 52-year-old woman who has leg-length inequality and chronic, activity-related buttock discomfort. This problem has been lifelong, but it is getting worse and increasingly causing back pain. What is the best current technique for total hip arthroplasty?

Explanation

DISCUSSION:
A high hip center is not recommended for Crowe type IV hips because of the lack of acetabular bone and altered hip biomechanics. An anatomic center is a better option but necessitates a technique to address the tight soft-tissue envelope. A trochanteric osteotomy with progressive femoral shortening has been described but can be prone to trochanter nonunion. Iliofemoral lengthening prior to surgery has been described but may not be tolerated by all patients. A shortening subtrochanteric osteotomy avoids trochanter nonunion and allows adjustment of femoral anteversion. Fixation of the osteotomy can include a stem with distal rotational control, plate fixation, a step versus oblique cut, or strut grafts.

Question 95

A 61-year-old man with a body mass index of 31 had a 6-month gradual onset of right medial knee pain. Examination revealed a small effusion, stable ligaments, a normally tracking patella, and mild medial joint line tenderness. Standing radiographs show mild medial joint space narrowing. Effective treatment at this stage of early medial compartmental osteoarthritis includes

Explanation

DISCUSSION:
According to the 2008 AAOS Clinical Practice Guideline, Treatment of Osteoarthritis of the Knee (Nonarthroplasty), level 1 evidence confirms that weight loss and exercise benefit patients with knee osteoarthritis. The other responses have either inclusive evidence (a valgus-directing brace) or no evidence to support their use (glucosamine 1,500 mg/day and chondroitin sulfate 800 mg/day as well as
arthroscopic debridement and lavage).

Question 96

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 97

Treatment should now include

Explanation

Postoperative vertebral subluxation with pain, restricted movement, and further neural compression does occur following extensive decompressive laminectomy. Resection of posterior elements has been regarded as benign, and some degree of forward slipping is not always associated with an increase in pain. Postoperative instability appears to be predominantly related to extenuating circumstances, such as a primary neural disorder, rheumatoid arthritis, degenerative spondylolisthesis, or recurrent severe trauma after decompression. An analysis of 182 patients with extensive decompression involving at least one part of one facet joint showed that in thirteen of them progressive spondylolisthesis developed postoperatively. Three of the patients had been treated for a herniated disc and ten, for degenerative spondylolisthesis. When subluxation did occur, it was within the first few weeks after operation and progressed for as long as two years. All patients with progression were older than fifty-two-years and were in more pain than those whom subluxation did not occur. An extensive review of 6000 patients in whom a wide resection was performed, including hemifacetectomy and either a total facetectomy or removal of the pars interarticularis, or both, found that only 2 percent of those patients required fusion or instability. An admonition was given by that author not to remove facet joints or pars interarticularis areas in patients who are less than thirty-years old, since these patients are most susceptible to postoperative instability. Older individuals with advanced degenerative changes at the level of the disc, as well as posteriorily, tolerate extensive laminectomy better. When the disc is maximally narrowed, no further settling of the space is possible and marginal osteophytes enhance stability.
Extensive laminectomy in patients with degenerative spondylolisthesis does result in postoperative instability. In the study by White and Wiltse, further subluxation did occur in 66 percent of patients who were operated on for degenerative spondylolisthesis , whereas it was observed in only 2 percent of the spondylolisthesis or disc patients who did not have
spondylolisthesis postoperatively. The extent of decompression and facet removal must be limited in the patient with degenerative spondylolisthesis or a fusion of the transverse processes included as part of the treatment. Internal fixation devices have been used in these circumstances to prevent further subluxation while the fusion is consolidating. Wiltse outlined some guidelines for spinal fusion in spinal stenosis: (1) the patient who is less than sixty years old and had degenerative spondylolisthesis with a total loss of posterior stability due to removal of the articular processes (a one-level fusion of the transverse processes); (2) the patient who is less than fifty-five and had a midline decompression for degenerative spondylolisthesis with facet preservation; and
(3) the patient who is less than fifty years old with isthmic spondylolisthesis, if the posterior elements have been removed. Simple degenerative spinal stenosis seldom requires a fusion, even if all posterior stability has been lost. The problem with obtaining a successful spinal fusion is real and conditions are less than optimum in these instances.

Question 98

Metal-on-metal lumbar disk arthroplasty devices may generate cobalt and chromium ions into the serum of patients after implantation into the lumbar spine. Which of the following statements best represents the levels of the serum ion levels in these patients? Review Topic

Explanation

According to two studies looking at patients with a cobalt-chrome metal-on-metal lumbar disk arthroplasty, serum ion levels in these patients were similar to values measured in patients with total hip arthroplasty metal-on-metal prostheses.

Question 99

A 75-year-old man has persistent radial sided hand and wrist pain. Radiographs demonstrate severe scaphotrapezial trapezoidal arthritis. His basal joint is unaffected. His pain has failed to improve with bracing, activity modification, and image-guided corticosteroid injection. He has elected surgical treatment. What longterm complication can arise from a distal scaphoid resection?

Explanation

EXPLANATION:
Resection of the distal pole of the scaphoid eliminates the arthritic contact at the scaphotrapeziotrapezoid joint; however, it functionally shortens the scaphoid. Theoretically, the lunate is at equilibrium between the extension moment of the capitate and the triquetrum and the flexion moment of the scaphoid. Shortening the scaphoid allows the extension moment of the triquetrum to predominate, pulling the lunate into extension and creating a DISI deformity. Concomitant capsulodesis or interposition is recommended by some authors to prevent this complication.

Question 100

-Figures 156a and 156b are the radiographs of a 38-year-old man with diabetes mellitus who fell 8 feet from a ladder and sustained an isolated closed injury of his leg. Examination revealed swollen but soft compartments. His neurovascular examination was unremarkable. A damage-control fixator was initially applied, and his soft-tissue envelope is now amenable to further intervention. What is the most appropriate treatment?

Explanation

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Open biopsy
Needle aspiration
Arthroscopy
CT
Arthrography

Correct Answer: Needle aspiration

Explanation:

Question 2:

Options:

C5-C7 nerve roots; upper/middle trunks; anterior division; lateral cord
C5-C6 nerve roots; upper trunk; posterior division; posterior cord
C5-C6 nerve roots; upper trunk
C5-C7 nerve roots
C8-T1 nerve root; lower trunk; anterior division; medial cord

Correct Answer: C8-T1 nerve root; lower trunk; anterior division; medial cord

Explanation:

Question 3:

Options:

- make the construct as rigid as possible and minimize strain to promote primary bone healing.
- make the construct as rigid as possible and provide a high-strain environment to promote primary bone healing.
- provide a fixed-angle construct and bridge the area of comminution to minimize strain and promote secondary bone healing.
- provide a fixed-angle construct and bridge the area of comminution to provide a high-strain environment and promote secondary bone healing.

Correct Answer: - provide a fixed-angle construct and bridge the area of comminution to minimize strain and promote secondary bone healing.

Explanation:

DISCUSSION
This patient has a comminuted distal femur fracture. A fixed-angle device such as a locking plate is preferred to confer angular stability to the construct and prevent varus collapse. The strategy to promote union of the fracture is to provide a low-strain environment to allow bone healing. Strain is determined by the amount of motion over the length of a fracture. In the case of a noncomminuted fracture, the fracture surfaces can be compressed and rigid fixation applied to abolish strain and promote primary bone healing without callus. In the case of a comminuted fracture, the preferred fixation strategy
focuses on distributing motion along the length of the fracture to provide a low-strain environment that will promote secondary bone healing and callus formation.
RECOMMENDED READINGS
Gardner MJ, Evans JM, Dunbar RP. Failure of fracture plate fixation. J Am Acad Orthop Surg. 2009 Oct;17(10):647-57. Review. PubMed PMID: 19794222.
View Abstract at PubMed
Lujan TJ, Henderson CE, Madey SM, Fitzpatrick DC, Marsh JL, Bottlang M. Locked plating of distal femur fractures leads to inconsistent and asymmetric callus formation. J Orthop Trauma. 2010 Mar;24(3):156-62. doi: 10.1097/BOT.0b013e3181be6720. PubMed PMID:

Question 4:

- Posterior cruciate insufficiency diagnosed using the quadriceps active test is confirmed with tibial translation

Options:

Anteriorly at 20 to 30 degrees of flexion
Anteriorly at 70 to 90 degrees of flexion
Posteriorly at 20 to 30 degrees of flexion
Posteriorly at 70 to 90 degrees of flexion
Anteriorly with the knee in full flexion

Correct Answer: Anteriorly at 70 to 90 degrees of flexion

Explanation:

Question 5:

Options:

Posterior arthrodesis
Anterior interbody arthrodesis
Smith-Petersen osteotomies with posterior arthrodesis
Vertebral column resection with posterior arthrodesis
Pedicle subtraction osteotomy with posterior arthrodesis

Correct Answer: Smith-Petersen osteotomies with posterior arthrodesis

Explanation:

Question 6:

Following a radial nerve neurapraxia at or above the elbow, return of muscle function can be expected to start at the brachioradialis and return along which of the following progressions?

Options:

Extensor carpi radialis brevis, extensor carpi radialis longus, extensor digitorum comminus, extensor indicis proprious
Extensor carpi radialis brevis, extensor carpi radialis longus, extensor indicis proprious, extensor digitorum comminus
Extensor carpi radialis longus, extensor carpi radialis brevis, extensor indicis proprious, extensor digitorum comminus
Extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum comminus, extensor indicis proprious
Extensor carpi radialis longus, extensor digitorum comminus, extensor carpi radialis brevis, extensor indicis proprious

Correct Answer: Extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum comminus, extensor indicis proprious

Explanation:

DISCUSSION: Following a radial nerve neurapraxia above the elbow, muscle recovery can be expected in a predictable pattern. Although variations will occur, the return of function or reinnervation usually occurs in the following order: brachioradialis, extensor carpi radialis longus, supinator, extensor carpi radialis brevis, extensor carpi ulnaris, extensor digitorum comminus, extensor digiti minimi, extensor indicis proprious, extensor pollicis longus, abductor pollicis longus, and extensor pollicis brevis.
REFERENCES: Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System. Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ,
Ciba-Geigy, 1991, vol 8, p 53.
Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA,
Harper and Row, 1982, vol 3, pp 428-429.

Question 7:

A 14-year-old girl reports hip pain that is exacerbated by weight bearing. A radiograph and biopsy specimen are shown in Figures 16a and 16b. The best course of management should be

Options:

a steroid injection.
curettage and bone grafting.
radiation therapy.
observation.
internal fixation without a bone graft.

Correct Answer: curettage and bone grafting.

Explanation:

Question 8:

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared to a standard parapatellar approach, what is the expected outcome?

Options:

Improvement in range of motion
Reduction in range of motion
Increase in extensor mechanism lag
No differences in motion and strength

Correct Answer: No differences in motion and strength

Explanation:

DISCUSSION
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.
RESPONSES FOR QUESTIONS 58 THROUGH 62
Nerve palsy
Skin necrosis
Flexion instability
Patellar instability
Anterior knee pain
Malalignment
Total knee arthroplasty (TKA) is performed to address each condition shown in Figures 58 through 62b. Which complication is most commonly associated with each image?

Question 9:

During treatment of rupture of the subscapularis tendon with associated biceps instability, treatment of the biceps tendon should include which of the following?

Options:

Tenosynovectomy
Recentering
Deepening of the bicipital groove
Tenodesis or tenotomy
Lysis of sheath adhesion

Correct Answer: Tenodesis or tenotomy

Explanation:

DISCUSSION: With subscapularis tendon ruptures that have biceps tendon pathology, treatment with tenodesis or tenotomy has improved clinical results. Subluxation or dislocation of the biceps tendon is common with subscapularis rupture. Dislocation of the biceps can occur either beneath the tendon, within the tendon, or extra-articularly. In all cases, the restraints to medial translations of the biceps have been disrupted. Attempts at recentering the biceps have not been successful, and clinical results appear to be improved when tenodesis or tenotomy is employed in the treatment of the unstable biceps associated with subscapularis tears.
REFERENCES: Edwards TB, Walch G, Sirvenaux F, et al: Repair of tears of the subscapularis: Surgical technique. J Bone Joint Surg Am 2006;88:1-10.
Deutsch A, Altchek DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.
Edwards TB, Walch G, Sirveaux F, et al: Repair of tears of the subscapularis. J Bone Joint Surg Am 2005;87:725-730.

Question 10:

Options:

Observation alone
Closed reduction with casting in > 90 degrees of flexion
Closed reduction with casting at 90 degrees of flexion
Closed reduction and a percutaneous pinning construct using laterally based pins
Closed reduction and a percutaneous pinning construct using crossed pins

Correct Answer: Observation alone

Explanation:

Question 11:

Options:

Local debridement of the ankle with long-term bracing
Attempted fusion using a multiplanar external fixation
Attempted fusion using an intramedullary rod
Attempted fusion using screw fixation

Correct Answer: Attempted fusion using an intramedullary rod

Explanation:

DISCUSSION
The indications for surgery in a Charcot joint are an unbraceable deformity or recurrent ulceration despite use of adequate bracing. Any significant varus/valgus deformity of the ankle or hindfoot (as in this patient) is unbraceable, whereas midfoot Charcot deformities usually can be treated nonsurgically. The goal of surgery is to provide a stable aligned foot and ankle to permit activities and reduce risk for recurrent ulceration. This does not mean that there has to be a radiographic fusion because many patients with diabetes achieve a stable nonunion without pain. The only surgical construct that will provide long-term inherent stability and alignment in this situation is use of a hindfoot fusion rod. It provides better stability and purchase than screw fixation and can be left in indefinitely (unlike an external fixator).
RECOMMENDED READINGS
Dalla Paola L, Volpe A, Varotto D, Postorino A, Brocco E, Senesi A, Merico M, De Vido D, Da Ros R, Assaloni R. Use of a retrograde nail for ankle arthrodesis in Charcot neuroarthropathy: a limb salvage procedure. Foot Ankle Int. 2007 Sep;28(9):967-70. PubMed PMID: 17880869.
View
Abstract at PubMed
Pinzur MS. Benchmark analysis of diabetic patients with neuropathic (Charcot) foot deformity. Foot Ankle Int. 1999 Sep;20(9):564-7. PubMed PMID: 10509683.
View Abstract at PubMed
Pinzur M. Surgical versus accommodative treatment for Charcot arthropathy of the midfoot. Foot Ankle Int. 2004 Aug;25(8):545-9. PubMed PMID: 15363375.
View
Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 83 THROUGH 87
Figures 83a and 83b are the clinical photographs of a 42-year-old woman with a BMI of 31 who has had a 1-year history of right heel pain.
A
B

Question 12:

Options:

Early stabilization of the patient's femur fracture places him at risk for increased pulmonary complications
Surgical intervention should be delayed due to the patient's head injury
Damage control orthopaedics (DCO) using external fixation is indicated for this patient
Early stabilization of the patient's femur fracture does not place the patient at increased risk for worsening neurologic outcomes
A concomitant chest injury would always be a contraindication to early fixation of the patient's femur fracture

Correct Answer: A concomitant chest injury would always be a contraindication to early fixation of the patient's femur fracture

Explanation:

Question 13:

Options:

open reduction and internal fixation.
arthroscopic reduction and internal fixation.
closed reduction following evacuation of the hemarthrosis and casting in extension if reduction is adequate.
closed reduction and casting in 90 degrees of flexion.
excision of the fragment.

Correct Answer: closed reduction following evacuation of the hemarthrosis and casting in extension if reduction is adequate.

Explanation:

Question 14:

Options:

a non-weight-bearing cast for 4 weeks.
eccentric calf stretching and physical therapy.
a cortisone injection.
tendon debridement.
tendon debridement and augmentation.

Correct Answer: eccentric calf stretching and physical therapy.

Explanation:

Question 15:

A patient sustains an injury to the pelvis as a result of high-energy trauma. A radiographic and clinical assessment is performed. A lateral view of the pelvis will best identify

Options:

pubic symphysis diastasis.
sagittal plane pelvic rotation.
sacroiliac diastasis.
spinopelvic dissociation.
a vertical transforaminal sacral fracture.

Correct Answer: spinopelvic dissociation.

Explanation:

Question 16:

The so-called high ankle sprain from an external rotation mechanism of injury typically involves injury to which of the following structures?

Options:

Posterior talofibular ligament
Deltoid ligament
Anterior inferior tibiofibular ligament
Calcaneofibular ligament
Extensor retinaculum

Correct Answer: Anterior inferior tibiofibular ligament

Explanation:

Question 17:

Closed-chain exercise differs from open-chain exercise in which of the following ways?

Options:

Distal portion of the extremity is free during exercise
More commonly used in upper extremity exercise
Predictable movement is produced by co-contraction of muscles
Joint compression is decreased
Usually involves a single joint

Correct Answer: Predictable movement is produced by co-contraction of muscles

Explanation:

Question 18:

Options:

No surgery is indicated
Revision of the acetabular component
Revision of the femoral component
Psoas tendon tenotomy
Strut grafting of the femur to stiffen the bone near the tip of the implant

Correct Answer: Revision of the femoral component

Explanation:

Question 19:

Options:

immediate application of a hip spica cast.
insertion of a distal femoral traction pin and placement into 90-90 traction.
closed reduction and stabilization using retrograde flexible intramedullary nails.
insertion of an antegrade reamed interlocking intramedullary nail.
closed reduction and transcutaneous pin fixation supplemented by a long leg cast.

Correct Answer: closed reduction and stabilization using retrograde flexible intramedullary nails.

Explanation:

DISCUSSION: The prognosis for a young patient with a head injury is more favorable compared to that for adults. Full neurologic recovery generally occurs. Spasticity may occur within a few days after injury, which can lead to fracture displacement if immediate spica casting or traction is used. Early surgical stabilization will reduce problems with shortening and malunion and will facilitate transportation of the child for diagnostic tests. Surgery may be performed when it is best for the patient, either on the day of injury or later if time is needed for stabilization. In this patient, the fracture is ideally suited to stabilization using flexible intramedullary nails. Heinrich and associates’ report of 78 diaphyseal femur fractures stabilized with flexible intramedullary nails included 14 patients with an associated closed head injury. All fractures healed, and there were no major complications.
REFERENCES: Tolo VT: Management of the multiply injured child, in Rockwood CA, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996,
pp 83-95.
Heinrich SD, Drvaric DM, Darr K, MacEwen GD: The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails: A prospective analysis. J Pediatr Orthop 1994;14:501-507.

Question 20:

A 40-year-old man reports an enlarging soft-tissue mass in his right shoulder. Based on the MRI scan and biopsy specimens shown in Figures 40a through 40c, what is the most likely diagnosis?

Options:

Nodular fasciitis
Fibrosarcoma
Intramuscular hemangioma
Schwannoma
Rhabdomyoma

Correct Answer: Nodular fasciitis

Explanation:

DISCUSSION: Nodular fasciitis is a pseudosarcomatous, self-limiting reactive process composed of fibroblasts and myofibroblasts. Most patients give a history of a rapidly growing mass that has been present for only a few weeks. Many have pain associated with the mass and can recall a specific traumatic event predating the presence of the lesion. It can occur at any age but is most commonly seen in adults who are 20 to 40 years of age. Histologically, the lesion is composed of predominantly plump, immature-appearing fibroblasts that bear a close resemblance to the fibroblasts found in granulation tissue. Characteristically, the fibroblasts
are arranged in short, irregular bundles and fascicles and are adjacent to collagen and reticulin. The lesions can appear to be more myxoid or more fibrotic in nature and this correlates to the duration of symptoms. The lesions with a short duration of symptoms have a more myxoid appearance in contrast to those of longer duration characterized by hyaline fibrosis.
REFERENCES: Weiss SW, Goldblum JR, Enzinger FM: Enzinger and Weiss’s Soft Tissue Tumors, ed 4. Philadelphia, PA, Elsevier, 2001, pp 250-266.
Wang XL, De Schepper AM, Vanhoenacker F, et al: Nodular fasciitis: Correlation of MRI findings and histopathology. Skeletal Radiol 2002;31;155-161.

Question 21:

Which of the following changes to heart rate, blood pressure, and bulbocavernosus reflex are typical of spinal shock?

Options:

Tachycardia, hypertension, intact bulbocavernosus reflex
Tachycardia, hypotension, intact bulbocavernosus reflex
Tachycardia, hypotension, absent bulbocavernosus reflex
Bradycardia, hypotension, absent bulbocavernosus reflex
Bradycardia, hyperthermia, intact bulbocavernosus reflex

Correct Answer: Bradycardia, hypotension, absent bulbocavernosus reflex

Explanation:

Question 22:

Figures 11a and 11b show the radiographs of a 50-year-old man who was struck by a car. Treatment should consist of

Options:

cemented bipolar hemiarthroplasty.
cementless bipolar hemiarthroplasty.
hybrid total hip arthroplasty.
cementless total hip arthroplasty.
open reduction and internal fixation.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 23:

- The primary effect of deep freezing on musculoskeletal allografts is a reduction of

Options:

Strength
Stiffness
Shelf life
Antigenicity
Risk of HIV transmission

Correct Answer: Antigenicity

Explanation:

Question 24:

Options:

Posterior tibial tendinitis
Osteoid osteoma
Posterior ankle impingement
Tibial stress fracture
Flexor hallucis longus tendinitis

Correct Answer: Tibial stress fracture

Explanation:

Question 25:

Figure 45 shows the lateral radiograph of a 19-year-old swimmer who has had back pain for the past 2 months. What is the most likely diagnosis?

Options:

Disk degeneration
Limbus fracture
Degenerative retrolisthesis of L4-5
Spondylolysis
Osteoid osteoma

Correct Answer: Spondylolysis

Explanation:

Question 26:

A 30-year-old man landed on his shoulder in a fall off his mountain bike. An AP radiograph and CT scan are shown in Figures 34a and 34b. Management should consist of

Options:

immobilization in a sling and swathe.
open reduction and internal fixation.
humeral arthroplasty.
subscapularis transfer into the humeral head articular defect.
a hanging cast.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 27:

What is the most common organism found following a nail puncture wound through tennis shoes in a host without immunocompromise?

Options:

Methicillin-resistant Staphylococcus aureus
Escherichia coli
Enterobacter
Pseudomonas aeruginosa
Klebsiella pneumoniae

Correct Answer: Pseudomonas aeruginosa

Explanation:

Question 28:

What is the most common cause for late revision (> 2 years post op) total knee arthroplasty? i. Infection

Options:

Polyethylene wear
Instability
Patellar complications
Malalignment

Correct Answer: Instability

Explanation:

Question 29:

In an effort to reduce costs, a limited MRI sequence is planned to detect a possible occult hip fracture. What is the anticipated fracture signal?

Options:

Bright on T 1 and T 2
Dark on T 1 and T 2
Dark on T 1 , bright on T 2
Bright on T 1 , dark on T 2
Enhancement by gadolinium

Correct Answer: Dark on T 1 , bright on T 2

Explanation:

DISCUSSION: At present, radiologists perform multiple MRI images to rule out all possible diagnoses. The ability to specify the anticipated changes on MRI should become more important as a means of reducing costs. MRI is sensitive to changes in free water (or hemorrhage) and thus this will appear dark on T
1
and bright on T
2
.
REFERENCES: Miller MD: Review of Orthopaedics, ed 3. Philadelphia PA, WB Saunders, 2000, p 116.
Guanche CA, Kozin SH, Levy AS, et al: The use of MRI in the diagnosis of occult hip fractures in the elderly: A preliminary review. Orthopedics 1994;17:327-330.

Question 30:

Options:

Skeletal survey
PET scan
Indium-labeled WBC scan
Bone marrow aspiration and biopsy
Mammography

Correct Answer: Bone marrow aspiration and biopsy

Explanation:

Question 31:

Which of the following surgical devices employed for stabilization of the sternoclavicular joint is associated with the highest incidence of life-threatening complications?

Options:

Percutaneous pins
Cannulated screws
Cerclage wire
Balser plate
AO locking plate

Correct Answer: Percutaneous pins

Explanation:

DISCUSSION: Numerous reports have documented serious complications including death from migration of intact or broken Kirschner wires or Steinmann pins into hilar structures such as the heart, pulmonary artery, and the aorta.
REFERENCES: Gilot GJ, Wirth MA, Rockwood CA: Injuries to the sternoclavicular joint, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott, Williams and Wilkins, 2006, vol 2, pp 1373-1374.
Lyons FA, Rockwood CA Jr: Migration of pins used in operations of the shoulder. J Bone Joint Surg Am 1990;72:1262-1267.

Question 32:

Options:

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

Correct Answer: Reduced radial artery pulse

Explanation:

Question 33:

Options:

Debridement and IV antibiotics
Wide resection of the lesion
Chemotherapy alone
Observation
Amputation

Correct Answer: Wide resection of the lesion

Explanation:

DISCUSSION: In an adult with an anterior cortical tibial lesion, this is the classic histologic appearance and anatomic location for an adamantinoma. The histology reveals areas of epithelial cells (in a glandular pattern) within a fibrous stroma. The epithelial cells are shown in nests. They would stain positively for keratin. Adamantinoma is a rare malignant bone tumor with a propensity for late metastasis. It has a high incidence of local recurrence unless resected with a wide margin. Chemotherapy and radiation therapy are not helpful in the treatment of this disease. Amputation generally is not necessary because a diaphyseal resection is usually possible.
REFERENCES: McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 263.
Moon NF, Mori H: Adamantinoma of the appendicular skeleton: Updated. Clin Orthop Relat Res 1986;204:215-237.

Question 34:

Options:

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

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

Explanation:

Question 35:

A 17-year-old girl has multidirectional instability of the shoulder. What is the most appropriate initial management?

Options:

Immobilization in a sling and swathe
Open capsular shift
Arthroscopic capsular plication
Thermal capsulorrhaphy
Physical therapy and home exercises

Correct Answer: Physical therapy and home exercises

Explanation:

DISCUSSION: Multidirectional instability of the shoulder is defined as symptomatic instability in two or more directions (anterior, posterior) but must include a component of inferior instability. Initial treatment should always include physical therapy and instruction in a home exercise program that emphasizes periscapular and rotator cuff strengthening to improve the dynamic stability of the glenohumeral joint. Immobilization has not been shown to be effective. Open capsular shift and arthroscopic capsular plication remain the surgical options when appropriate nonsurgical management fails (typically a minimum of 6 months of dedicated therapy and home program). Thermal capsulorrhaphy remains controversial but is not recommended by many clinicians because of reported complications including recurrent instability, axillary nerve injury, chondrolysis, and capsular injury.
REFERENCES: Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908.
D’Alessandro DF, Bradley JP, Fleischli JE, et al: Prospective evaluation of thermal capsulorrhaphy for shoulder instability: Indications and results, two- to five-year follow-up.
Am J Sports Med 2004;32:21-33.
Levine WN, Clark AM Jr, D’Alessandro DF, et al: Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability: A report of two cases. J Bone Joint Surg Am 2005;87:616-621.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 278-279.

Question 36:

Options:

Quadrigia
Intrinsic tightness
Lumbrical plus deformity
Disruption of the tendon repair

Correct Answer: Quadrigia

Explanation:

Question 37:

Which of the following is a contraindication to laminoplasty in a patient with cervical spondylotic myelopathy?

Options:

Space available for the cord of less than 8 mm
Ossification of the posterior longitudinal ligament
Fixed cervical kyphosis
Previous posterior surgery
Concomitant cervical radiculopathy

Correct Answer: Fixed cervical kyphosis

Explanation:

DISCUSSION: Laminoplasty or any posterior decompressive procedure is contraindicated in patients with cervical spondylotic myelopathy and cervical kyphosis. The residual kyphotic posture of the cervical spine results in persistent spinal cord compression. The other choices are not contraindications for laminoplasty. Concomitant cervical radiculopathy can be addressed at the time of laminoplasty with a keyhole foraminotomy.
REFERENCES: Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-247.

Question 38:

When a patient has recurrent anterior shoulder instability, a bony glenoid reconstructive procedure should be considered in which clinical setting?

Options:

Associated humeral avulsion of the glenohumeral ligament (HAGL) lesion
Non-engaging Hill-Sachs lesion
Glenoid bone loss of at least 25%
Anterior labral periosteal sleeve avulsion (ALPSA)

Correct Answer: Glenoid bone loss of at least 25%

Explanation:

Question 39:

Options:

repetitive loading and fatigue failure.
incomplete bone ingrowth with focal osteolysis.
rotational bone axial loading.
a fixed component with a modulus mismatch.
use of titanium instead of cobalt-chromium.

Correct Answer: a fixed component with a modulus mismatch.

Explanation:

Question 40:

Options:

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

Correct Answer: Type II error

Explanation:

Question 41:

Options:

Intravenous fluid administration
Intravenous bisphosphonates
Intranasal calcitonin
Methotrexate
Mithramycin by oral administration

Correct Answer: Intravenous fluid administration

Explanation:

Question 42:

Free flap coverage for severe trauma to the upper extremity has the fewest complications when performed within what time period after injury?

Options:

72 hours
7 to 10 days
2 weeks
4 weeks
4 months

Correct Answer: 72 hours

Explanation:

Question 43:

Options:

Open biopsy
Observation
Cortisone injection
Oncology referral
CT of the chest

Correct Answer: Observation

Explanation:

DISCUSSION: A periosteal desmoid lesion is a tumor simulator. It is characterized by a bone irregularity along the posteromedial aspect of the distal femur at the insertion of the adductor magnus or the origin of the gastrocnemius muscle. It most commonly occurs in patients who are age 10 to 15 years. The lesions are asymptomatic, with no palpable mass, pain, or swelling. They are frequently an incidental finding when radiographs are obtained for nonspecific symptoms or trauma about the knee. Following recognition of the characteristic imaging findings, observation is the management of choice.
REFERENCES: Dunham WK, Marcus NW, Enneking WF, et al: Developmental defects of the distal femoral metaphysis. J Bone Joint Surg Am 1980;62:801-806.
Verdonk PC, Verstraete K, Verdonk R: Distal femoral cortical irregularity in a 13-year old boy: A case report. Acta Orthop Belg 2003;69:377-381.

Question 44:

Options:

Polymorphonuclear leukocytes
Extracellular metal-wear debris
Cement particles within the macrophages
Lymphocytes and plasma cells

Correct Answer: Lymphocytes and plasma cells

Explanation:

Question 45:

Options:

Correction of the flatfoot deformity
Achilles tendon lengthening followed by orthotic support
Excision of the tarsal coalition
Sinus tarsi debridement
Triple arthrodesis

Correct Answer: Correction of the flatfoot deformity

Explanation:

The patient has a calcaneonavicular tarsal coalition. Symptoms of calcaneonavicular coalitions typically are seen between the ages of 10 and 14 years. The cause of pain has not been clearly established. It has been postulated that the coalition stiffens with maturity and microfractures can result, producing pain. Resection of a calcaneonavicular coalition generally has been associated with a satisfactory result. Soft-tissue interposition, most commonly using the extensor digitorum brevis muscle,
appears to be helpful. A hindfoot arthrodesis (usually triple) would be reserved if coalition resection proves to be unsuccessful. Achilles tendon lengthening and orthotic support, as well as debridement of the sinus tarsi, are not expected to result in a satisfactory outcome. The patient does not have a flatfoot deformity.
(SBQ13PE.64) A 5-year-old boy presents to clinic for evaluation of bilateral foot deformities shown in Figure 1. He is fully active and has no pain. The feet appear normal when he is sitting on the examination table, and there is supple passive motion at the subtalar joint. Passive ankle dorsiflexion is to neutral with knee in extension and 15 degrees with knee in flexion. What is the most appropriate next step?
Review
Topic
Spine MRI
Standing radiographs of the bilateral feet
Gastrocnemius stretching and nightime use of ankle foot orthosis
Gastrocnemius stretching and use of UCBL orthotic when ambulating
Gastrocnemius stretching
The patient is presenting with bilateral flexible pes planovalgus (or flexbile flatfoot). The most appropriate treatment in patients with a tight heel cord and no pain is gastrocnemius stretching
A flexible flatfoot in a child typically resolves spontaneously. Radiographs are typically indicated when there is pain to rule out other conditions. Treatment for patients without pain includes observation and gastrocnemius stretching. If there is pain, soft arch support or a more rigid UCBL can be used, but orthotics do not change the natural history. In patients with continued tightness in the heel cord despite aggressive stretching, gastrocnemius lengthening may be necessary.
Mosca reviews the management of flexible flatfeet in children and adolescents. He reports that there is no compelling evidence that an arch can be created with use of
orthotics. He proposes the following algorithm: patients with asymptomatic flatfeet are observed; symptomatic flatfeet with tight heel cords undergoing stretching until they become asymptomatic; symptomatic flatfeet with tight heel cords that do not respond to stretching (rare cases) are considered for surgery.
Figure A shows a young a patient with bilateral flatfeet when standing. Incorrect Answers:
abnormalities can seen in patients with cavovarus deformity Answer 2: Radiographs are indicated when there is pain to rule out other conditions. Answer 3: Ankle foot orthoses are not used for pes planovalgus Answer 4: UCBL would be indicated if the patient was having pain.
(SBQ13PE.42) Submuscular bridge plating is appropriate treatment for which of the following?
Review Topic
A 2-month-old female with displaced, spiral, mid-diaphyseal femur fracture
A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with
<2cm shortening
A 7-year old boy with a transverse, non-comminuted mid-diaphyseal femur fracture
A 7-year-old boy with a highly comminuted mid-diaphyseal femur fracture
A 15-year-old girl with a displaced butterfly fragmented mid-diaphyseal femur fracture
Submuscular bridge plating is appropriate for length-unstable femur fractures in skeletally immature patients ages 6 years and older.
Traditional plating of diaphyseal femur fractures in children has been abandoned due to the large incision and significant periosteal stripping involved. Submuscular plating with limited incisions and percutaneously applied fixation is a more biologically friendly way to achieve rigid internal fixation in length-unstable fracture patterns. External fixation is another acceptable option for these fractures. Locked plating, on the other hand, provides an 'internal external fixator,' avoids pin site issues and allows rapid mobilization while providing a biologically favorable environment for healing.
Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. They concluded that there was insufficient evidence regarding submuscular bridge plating to include it in the guideline.
Flynn et al. review the management of pediatric femoral shaft fractures. The note that
the narrow indications for plating of pediatric femoral fractures are open fractures, multiple trauma, head injury or compartment syndrome in patients less than 12 years old. Plating allows rigid fixation with readily available equipment and allows for rapid mobilization.
Hedequist et al. present a Technical Tricks paper in which they detail their surgical technique for submuscular bridge plating. They recommend this fixation strategy for patients between age 6 and skeletal maturity with comminuted diaphyseal femur fractures that are not easily treated by other methods.
Illustration A shows a preoperative and postoperative radiograph of a comminuted pediatric femur fracture treated with submuscular plating.
Incorrect answers:
(SBQ13PE.88) A 12-month-old boy attends a government regulated childcare center. His parents are called after a fall. Non-accidental trauma has been ruled out. On physical examination the right elbow is swollen and tender. He is unwilling to allow you to move the arm. Radiographs of the elbow are shown in Figure A. What is the orthopaedic management of this injury?
Review Topic
Observation only
Elbow sling for 3 to 4 weeks
Rigid elbow immobilisation for 4 to 5 weeks
Admit for 24-48 hours for continuous intracompartmental pressure measurements
Operative fixation with percutaneous pinning PREFERRED RESPONSE 5
This patient presents with a distal humeral physeal separation. The most appropriate treatment would be closed reduction with internal fixation with percutaneous pins.
Displaced distal humerus physeal separation is typically seen in children under the age of 3 and has a high association with child abuse. The diagnosis can be a difficult as radiographs of a distal humeral physeal separation may be subtle. Often, radiographs show no obvious fracture, but can appear like an elbow dislocation since the secondary ossification centers have not yet developed. MRI or arthrogram can be used to aid in diagnosis.
Shrader et al. reviewed pediatric supracondylar fractures and pediatric physeal elbow fractures. They state the key to diagnosis of distal humerus physeal separation is the assessment is the radial head–capitellum relationship. These injuries should be fixed with closed reduction and smooth wire pinning. An elbow arthrogram may be considered intraoperatively for these patients because of the difficulty visualizing the distal humeral anatomy in children so young.
Skaggs et al. reviewed the diagnosis and management of pediatric elbow fractures. He states that child abuse should be suspected in all cases of elbow fracture when the child is less than 3 years of age and/or the injury pattern occur from a shearing mechanism. The displacement of physeal elbow fractures is almost always posteromedial.
Figure A shows AP and lateral radiographs with posteromedial displacement of the radial and ulnar shafts relative to the distal humerus. This is consistent with distal humeral physeal separation.
Incorrect Answers:

Question 46:

What ligament is the primary restraint to applied valgus loading of the knee?

Options:

Posteromedial capsule
Posterior cruciate ligament (PCL)
Superficial medial collateral ligament (MCL)
Deep MCL
Medial meniscus

Correct Answer: Superficial medial collateral ligament (MCL)

Explanation:

Question 47:

Options:

20% to 30%
35% to 45%
50% to 60%
80% to 95%
100%

Correct Answer: 80% to 95%

Explanation:

Question 48:

Options:

filling the tibial defect with methylmethacrylate.
revision of the tibial component with porous metal augmentation.
reconstruction with iliac crest bone graft.
reconstruction with structural allograft.

Correct Answer: revision of the tibial component with porous metal augmentation.

Explanation:

DISCUSSION
Video 1 for reference
For severe tibial defects (Anderson Orthopaedic Research Institute [AORI] types 2 and 3), metaphyseal fixation is necessary to achieve construct fixation during revision TKA. Metaphyseal fixation may be achieved with cement, structural allograft, or conical metallic implants. The major concerns regarding structural allograft are graft resorption and mechanical failure and technical issues related to fashioning the graft and obtaining a good host-allograft interface. In a systematic review, porous metal cones were associated with a decreased loosening rate in AORI 2 and 3 defects compared to structural allografts. Metallic trabecular metal cones and metaphyseal porous coated sleeves provide a stable construct with which to support the tibial component during revision TKA. Clinical results with these devices include good metaphyseal fixation for severe tibial bone defects.

Question 49:

A neurologic injury at T11-L2 with loss of bowel and bladder control is best described as what syndrome?

Options:

Anterior cord
Central cord
Posterior cord
Conus medullaris
Cauda equina

Correct Answer: Conus medullaris

Explanation:

Question 50:

Options:

Closed reduction and a long arm cast
Closed reduction, a long arm cast, and a skeletal survey
Closed reduction, a long arm cast, a skeletal survey, and a referral to child protective services
Closed reduction and a long arm cast, a bone scan, and referral to child protective services
Closed reduction and a long arm cast, MRI of the brain, and a referral to child protective services

Correct Answer: Closed reduction, a long arm cast, a skeletal survey, and a referral to child protective services

Explanation:

Question 51:

Which of the following methods most reliably detects mechanical loosening of the hip?

Options:

Serial planar radiographs
Joint aspiration
Aspiration and arthrogram
Technetium Tc 99m scan
CT scan

Correct Answer: Serial planar radiographs

Explanation:

Question 52:

Options:

Metastatic lung cancer
Osteomyelitis
Osteosarcoma
Ewing’s sarcoma
Eosinophilic granuloma

Correct Answer: Ewing’s sarcoma

Explanation:

Question 53:

Options:

spinal accessory nerve exploration with repair.
long thoracic nerve exploration with repair.
a sling for comfort, followed by shoulder strengthening exercises.
scapulothoracic arthrodesis.
split pectoralis major transfer.

Correct Answer: a sling for comfort, followed by shoulder strengthening exercises.

Explanation:

Question 54:

Options:

Biotin.
Tramadol.
vitamin A.
vitamin C.
vitamin E.

Correct Answer: vitamin C.

Question 55:

Options:

Chemotherapy and radiation therapy
Intravenous antibiotics, protected weight bearing, and a repeat C-reactive protein after improvement
Open biopsy and debridement of the site, followed by intravenous antibiotics
Technetium Tc 99m bone scan
Empiric oral antibiotics and repeat laboratory studies in 1 week

Correct Answer: Open biopsy and debridement of the site, followed by intravenous antibiotics

Explanation:

DISCUSSION: The history and laboratory findings are consistent with osteomyelitis of the patella. The radiograph reveals bone destruction in the patella; therefore, the next most appropriate step is open biopsy and debridement of the site. Aspiration of the knee joint may be needed to rule out septic arthritis prior to patellar debridement. With this amount of bone destruction, surgical debridement is helpful to obtain cultures and to remove necrotic material. Administering antibiotics without any prior culture increases the risk of negative cultures later and a potentially incorrect choice of antibiotic. A neoplasm should be included in the differential. It would be inappropriate to initiate chemotherapy and radiation therapy without a biopsy-confirmed diagnosis. A bone scan is likely to demonstrate uptake, but radiographs have already localized the abnormality to the patella.
REFERENCES: Morrisy RT: Bone and joint sepsis, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 466-470.
Dormans JP, Drummond DS: Pediatric hematogenous osteomyelitis: New trends in presentation, diagnosis, and treatment. J Am Acad Orthop Surg 1994;2:333-341.

Question 56:

Options:

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

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

Explanation:

Question 57:

Options:

Lateral meniscus repair
Corticosteroid injection and physical therapy
Medial meniscus repair
Unloader brace

Correct Answer: Medial meniscus repair

Explanation:

The MRI scan shows a posterior horn medial meniscus root avulsion with bony edema at the tibial root insertion. The radiograph shows no significant degenerative changes. If left untreated, posterior meniscal
root tears lead to progressive degenerative changes as a result of the altered tibiofemoral contact pressures and areas. Nonsurgical treatment including injections, physical therapy, and unloader braces are more
appropriate in the older patient with pre-existing advanced degenerative changes.

Question 58:

What is the most appropriate treatment for a chordoma involving the sacrum?

Options:

Chemotherapy
External beam radiation therapy
En bloc surgical resection with negative margins
Intralesional resection followed by radiation therapy
Intralesional resection followed by chemotherapy

Correct Answer: En bloc surgical resection with negative margins

Explanation:

Question 59:

Which of the following bones is most frequently involved in stress fractures in athletes? Review Topic

Options:

Femur
Tibia
Fibula
Navicular
Fifth metatarsal

Correct Answer: Tibia

Explanation:

Question 60:

Based on the findings seen at C5-6 in Figure 30, the most likely deficit for this patient will be weakness of the

Options:

deltoid.
wrist flexor.
wrist extensor.
triceps.
grip.

Correct Answer: wrist extensor.

Explanation:

Question 61:

In overhead athletic activities, the kinetic chain generates what percentage of force from the leg and trunk segments of the chain?

Options:

20% to 30%
30% to 40%
50% to 60%
60% to 70%
80% to 90%

Correct Answer: 50% to 60%

Explanation:

Question 62:

Options:

Rett syndrome
Spinal muscular atrophy, type 2
Congenital muscular dystrophy
Duchenne muscular dystrophy
Congenital myotonic dystrophy

Correct Answer: Spinal muscular atrophy, type 2

Explanation:

DISCUSSION: The patient has spinal muscular atrophy, type 2. This type is intermediate in severity between the Werdnig-Hoffmann type (type 1) and the Kugelberg-Welander type
(type 3). It normally manifests itself between the ages of 3 and 15 months. Survival until adolescence is common. All three types of spinal muscular atrophy have been linked to the SMN gene at the 5q12.2-13.3 locus. DNA testing is available and is preferred to muscle biopsy because it is less invasive and more definitive.
REFERENCES: Biros I, Forrest S: Spinal muscular atrophy: Untangling the knot? J Med Genet 1999;36:1-8.
Zerres K, Wirth B, Rudnik-Schoneborn S: Spinal muscular atrophy: Clinical and genetic correlations. Neuromuscul Disord 1997;7:202-207.

Question 63:

Options:

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

Correct Answer: Premature consolidation

Explanation:

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

Question 64:

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

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:

Question 65:

Options:

rasonography-guided aspiration
Excisional biopsy
Observation
MRI of the hand for further characterization of the mass

Correct Answer: Observation

Explanation:

Question 66:

Options:

Synovial herniation pits
Osteoid osteoma
Fibrous dysplasia
Metastatic bone disease
Multiple enchondromas

Correct Answer: Synovial herniation pits

Explanation:

DISCUSSION: Synovial herniation pits or Pitt’s pits are tumor simulators and are incidentally identified on radiographs obtained for either pain or trauma. The main diagnostic pitfall with this lesion is mistakenly identifying it as an osteoid osteoma. Accurate diagnosis is achieved by knowledge of the location and the characteristic imaging appearance. These are common lesions in individuals with femoroacetabular impingement.
REFERENCES: Pitt MJ, Graham AR, Shipman JH, et al: Herniation pit of the femoral neck. Am J Roentgenol 1982;138:1115-1121.
Daenen B, Preidler KW, Padmanabhan S, et al: Symptomatic herniation pits of the femoral neck: Anatomic and clinical study. Am J Roentgenol 1997;168:149-153.

Question 67:

Options:

Constrained to anteroposterior translation, unconstrained to medial-lateral translation, high contact stress on edge (ie, varus-valgus) loading
Constrained to anteroposterior translation, unconstrained to medial-lateral translation, low contact stress on edge (ie, varus-valgus) loading
Unconstrained to anteroposterior translation, constrained to medial-lateral translation, high contact stress on edge (ie, varus-valgus) loading
Unconstrained to anteroposterior translation, constrained to medial-lateral translation, low contact stress on edge (ie, varus-valgus) loading
Constraint is dependent on the status of the posterior cruciate ligament

Correct Answer: Constrained to anteroposterior translation, unconstrained to medial-lateral translation, high contact stress on edge (ie, varus-valgus) loading

Explanation:

Question 68:

Which of the following procedures is not part of the routine evaluation of a patient with suspected metastatic disease to bone?

Options:

Thorough history and physical examination
CBC count, electrolytes, and serum protein electrophoresis
Bone scan
CT of the brain
Radiograph and CT of the chest

Correct Answer: CT of the brain

Explanation:

Question 69:

Options:

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

Correct Answer: Open surgical dislocation with rim trimming

Explanation:

Question 70:

Options:

there are no differences in functional outcome.
open diskectomy is associated with superior functional outcomes.
tubular diskectomy is associated with superior short- and long-term results.
tubular diskectomy is associated with inferior short-term results but superior long-term outcomes.

Correct Answer: there are no differences in functional outcome.

Explanation:

DISCUSSION
Several comparative studies have reported no difference in functional outcomes between tubular diskectomy and microsurgical lumbar diskectomy. A recent systematic review by Kamper and associates in which conventional microdiskectomy and minimally invasive approaches were compared revealed that there was no difference between the procedures in terms of clinical outcomes, complication risk, or rate of revision surgery.
RECOMMENDED READINGS
Kamper SJ, Ostelo RW, Rubinstein SM, Nellensteijn JM, Peul WC, Arts MP, van Tulder MW. Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis. Eur Spine J. 2014 May;23(5):1021-43. doi: 10.1007/s00586-013-3161-2. Epub 2014 Jan 18.
PubMed PMID: 24442183.
View Abstract at PubMed
Dasenbrock HH, Juraschek SP, Schultz LR, Witham TF, Sciubba DM, Wolinsky JP, Gokaslan ZL, Bydon A. The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials. J Neurosurg Spine. 2012 May;16(5):452-62. doi: 10.3171/2012.1.SPINE11404. Epub 2012 Mar 9. PubMed PMID:

Question 71:

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

Options:

Warfarin
Low-molecular-weight heparin
Rivaroxaban
Aspirin

Correct Answer: Rivaroxaban

Explanation:

Question 72:

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 73:

Figure 9 shows a cross-sectional view of the spinal cord at the lower cervical level. Injury to the structure indicated by the black arrow will lead to what neurologic deficit?

Options:

Complete paraplegia
Contralateral weakness below the level of the injury
Ipsilateral weakness below the level of the injury
Unilateral loss of position sense, proprioception, and vibratory sense below the level of the injury
Loss of pain and temperature sensation below the level of the injury

Correct Answer: Unilateral loss of position sense, proprioception, and vibratory sense below the level of the injury

Explanation:

Question 74:

Which of the following is considered an advantage of the tibial inlay fixation compared to transtibial tunnel technique when used in posterior cruciate ligament reconstruction? Review Topic

Options:

Less invasive
Superior published clinical results
Decreased surgical time
Elimination of the critical 90-degree turn at the tibial aperture of the tunnel
Improved cosmesis

Correct Answer: Elimination of the critical 90-degree turn at the tibial aperture of the tunnel

Explanation:

Question 75:

A patient in the recovery room has weakness of the extensor hallucis longus and tibialis anterior muscles following a total knee replacement. Initial management should consist of

Options:

Observation
Removal of the prosthetic components
Operative exploration and decompression of the peroneal nerve
Nerve conduction velocity studies
Loosening of the primary dressings and knee flexion to 30 degrees

Correct Answer: Loosening of the primary dressings and knee flexion to 30 degrees

Explanation:

Question 76:

Options:

BMI >30
Presence of secondary changes of the acetabulum
Osteonecrosis of the femoral head
Age of younger than 55 years old
Male gender

Correct Answer: Osteonecrosis of the femoral head

Explanation:

Question 77:

Options:

Posterior tibial tendon
Impaction fracture of the head of the talus
Posterior tibial neurovascular bundle
Achilles tendon
Calcaneus fracture

Correct Answer: Impaction fracture of the head of the talus

Explanation:

Question 78:

Options:

Unicompartmental arthroplasty
Total knee arthroplasty
Lateral closing wedge proximal tibial osteotomy
Medial opening wedge proximal tibial osteotomy
Medial closing wedge supracondylar femoral osteotomy

Correct Answer: Medial closing wedge supracondylar femoral osteotomy

Explanation:

DISCUSSION: Patients with a valgus alignment about the knee can have lateral compartment arthritis. Similar to a high tibial osteotomy, a supracondylar femoral osteotomy is indicated in younger patients who have a more active lifestyle and isolated unicompartmental disease. In this young patient who works in a factory and has a valgus knee, a medial closing wedge supracondylar femoral osteotomy is the treatment of choice. The role of arthroplasty is limited in younger patients.
REFERENCES: Mathews J, Cobb AG, Richardson S, et al: Distal femoral osteotomy for lateral compartment osteoarthritis of the knee. Orthopedics 1998;21:437-440.
Cameron HU, Botsford DJ, Park YS: Prognostic factors in the outcome of supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee. Can J Surg 1997;40:114-118.

Question 79:

Options:

Silicone replacement arthroplasty through a volar approach
Surface replacement arthroplasty through a volar approach
Silicone replacement arthroplasty through a dorsal approach
Surface replacement arthroplasty through a dorsal approach

Correct Answer: Silicone replacement arthroplasty through a volar approach

Explanation:

EXPLANATION:
A recent systematic review compared silicone replacement, pyrocarbon replacement, and surface replacement arthroplasty for PIP arthritis. Silicone arthroplasty through a volar approach showed the greatest gains in arc of motion and had the lowest rate of revision surgeries. The rates of revision surgeries from low to high for each type of arthroplasty were 6% for silicone volar, 10% for silicone lateral, 11%
Surface replacement arthroplasty through a volar
for silicone dorsal, 18% for surface replacement dorsal, and 37% for surface replacement volar. Revision surgeries include implant replacement (to silicone or maintaining the surface replacement), arthrodesis, explantation, amputation, and other procedures.
approach showed the highest revision rate
,
the worst gain in arc of motion
, and
the greatest extension lag.
However, substantial pain relief and higher satisfaction still were reported after surface replacement
arthroplasty, regardless of the complications.

Question 80:

- Demyelination diseases as multiple sclerosis and Guillain-Barre $ create neurologic symptoms by

Options:

decreasing initiation of action potentials.
increasing action potential amplitude.
blocking the opening of gated sodium channels.
decreasing the number of functional motor units.
slowing or stopping action potential propagation through the axon.

Correct Answer: slowing or stopping action potential propagation through the axon.

Explanation:

Question 81:

Options:

Closed reduction and long arm cast immobilization
Closed reduction and short arm cast immobilization
Closed reduction and percutaneous pinning
Open reduction and internal fixation with Kirschner wires
Open reduction and internal fixation with a headless, cannulated compression screw

Correct Answer: Open reduction and internal fixation with a headless, cannulated compression screw

Explanation:

DISCUSSION: The patient has a scaphoid fracture involving the proximal pole. Surgical treatment is recommended for such fractures because of the prolonged period of cast immobilization necessary and the increased risk of delayed union, nonunion, and/or osteonecrosis with nonsurgical management. A cannulated compression screw, inserted in the central scaphoid via a dorsal approach, is biomechanically advantageous and provides greater stability for fracture healing than Kirschner wires. Recently, good outcomes have been reported with arthroscopic-assisted percutaneous fixation of nondisplaced or minimally displaced scaphoid fractures.
REFERENCES: Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210.
Chan KW, McAdams TR: Central screw placement in percutaneous screw scaphoid fixation: A cadaveric comparison of proximal and distal techniques. J Hand Surg Am 2004;29:74-79.
Bedi A, Jebson PJ, Hayden RJ, et al: Internal fixation of acute non-displaced scaphoid waist fractures via a limited dorsal approach: An assessment or radiographic and functional outcomes. J Hand Surg Am 2007;32:326-333.
McCallister WV, Knight J, Kaliappan R, et al: Central placement of the screw in simulated fractures of the scaphoid waist: A biomechanical study. J Bone Joint Surg Am 2003;85:72-77.

Question 82:

Options:

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

Correct Answer: gradually resorb and widen the spinal canal.

Explanation:

Question 83:

Options:

Ligaments are viscoelastic.
Ligaments are elastic.
Ligaments experience creep.
Ligaments undergo stress relaxation.
Strain in ligaments is recoverable.

Correct Answer: Ligaments are viscoelastic.

Explanation:

Question 84:

Options:

a short leg cast with the ankle in slight plantar flexion.
a corticosteroid injection into the retrocalcaneal bursa.
excision of the os trigonum.
excision of the superior tuberosity of the calcaneus.
ankle arthroscopy with loose body removal.

Correct Answer: excision of the os trigonum.

Explanation:

Question 85:

Options:

In situ subtalar arthrodesis
Cortisone injection in the subtalar joint followed by casting for 4 to 6 weeks
UCBL insert
Lateral wall exostectomy
Bone block arthrodesis of the subtalar joint

Correct Answer: Lateral wall exostectomy

Explanation:

Question 86:

Options:

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

Correct Answer: Placement of a pelvic binder around the patient

Explanation:

Question 87:

A 23-year-old woman has had vague left knee pain for the past 6 months. A radiograph and CT scan are shown in Figures 50a and 50b. What is the most likely diagnosis?

Options:

Myositis ossificans
Osteochondroma
Parosteal osteosarcoma
Dedifferentiated chondrosarcoma
Tumoral calcinosis

Correct Answer: Parosteal osteosarcoma

Explanation:

Question 88:

Options:

Proceed with primary repair with the elbow hyperflexed
Use interposition allograft to reconstruct with elbow in extension
Tenodese distal biceps tendon to underlying brachialis muscle
Forego primary repair, but perform stump debridement

Correct Answer: Proceed with primary repair with the elbow hyperflexed

Explanation:

Question 89:

A 73-year-old man reports increasing back and lower extremity pain. A bone scan is shown in Figure 31. What is the most likely diagnosis?

Options:

Multiple myeloma
Metastatic neuroblastoma
Polyostotic fibrous dysplasia
Hodgkin’s lymphoma
Metastatic prostate cancer

Correct Answer: Metastatic prostate cancer

Explanation:

Question 90:

A 37-year-old laborer falls 12 feet and sustains a comminuted tibial plafond fracture. Three years after treatment using standard techniques, what will be the most likely outcome?

Options:

Need for ankle fusion or arthroplasty
Return to normal function
Ankle stiffness without pain
Severe constant pain and inability to work
Adversely affected general health status and posttraumatic arthritis

Correct Answer: Adversely affected general health status and posttraumatic arthritis

Explanation:

Question 91:

- Which of the following factors is most likely to predispose a patient to dislocation of the patellar component following total knee arthoplasty?

Options:

Internal rotation of the femoral component
External rotation of the tibial component
Lateral placement of the femoral component
Medial placement of the patellar component
Excessive resection of the patella

Correct Answer: Internal rotation of the femoral component

Explanation:

Question 92:

Which of the following structures is most vulnerable during a medial sesamoidectomy of the hallux?

Options:

Abductor hallucis tendon
Intermetatarsal ligament
Plantar-medial cutaneous nerve of the hallux
Dorsomedial cutaneous nerve of the hallux
Crista

Correct Answer: Plantar-medial cutaneous nerve of the hallux

Explanation:

DISCUSSION: The plantar-medial cutaneous nerve is at risk with the surgical approach to the medial sesamoid. It is found directly underlying an incision made at the junction of the glabrous skin of the hallux and must be identified before the approach can proceed. Transection will result in a painful neuroma that impinges on the plantar-medial surface of the toe and cause problems with shoe wear. The only other structure that lies near the surgical field is the abductor hallucis tendon which lies dorsal to the incision.
REFERENCE: Sarrafian SK: Anatomy of the Foot and Ankle, Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993, p 377.

Question 93:

What root is most commonly involved with a segmental root level palsy after laminoplasty?

Options:

Correct Answer: C5

Explanation:

DISCUSSION: The postoperative incidence of C5 root palsy after laminoplasty ranges from 5% to 12%. Other roots also may be affected. The palsies tend to be motor dominant, although sensory dysfunction and radicular pain are also possible. The palsy may arise during the immediate postoperative period or up to 20 days later. C5 may be preferentially involved because it is at the apex of the cervical lordosis. Recovery usually occurs over weeks to months.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-249.
Uematsu Y, Tokuhashi Y, Matsuzaki H: Radiculopathy after laminoplasty of the cervical spine. Spine 1998;23:2057-2062.

Question 94:

Options:

High hip center
Anatomic hip center with trochanteric osteotomy and progressive femoral shortening
Anatomic hip center with subtrochanteric shortening osteotomy
Iliofemoral lengthening followed by an anatomic hip center

Correct Answer: Anatomic hip center with subtrochanteric shortening osteotomy

Explanation:

Question 95:

Options:

glucosamine 1,500 mg/day and chondroitin sulfate 800 mg/day.
weight loss through dietary management and low-impact aerobic exercises.
arthroscopic debridement and lavage.
a valgus-directing brace.

Correct Answer: weight loss through dietary management and low-impact aerobic exercises.

Explanation:

Question 96:

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 97:

Treatment should now include

Options:

Dorsal rhizotomy and facet joint fusion
Multilevel corpectomy and spinal stabilization
Central and lateral recess decompression and bilateral foraminotomy
Central decompression and facet joint fusion
Central decompression, foraminotomy, and spinal fusion from L2 to L5.

Correct Answer: Central and lateral recess decompression and bilateral foraminotomy

Explanation:

Question 98:

Options:

The serum ion levels are not measureable in these patients.
The serum ion levels are measureable, but are of negligible value in these patients.
The serum ion levels measured equal the values measured in the local tissues in total hip arthroplasty metal-on-metal prostheses.
The serum ion levels measured are much lower in terms of their level to the values measured in total hip arthroplasty metal-on-metal prostheses.
The serum ion levels measured are similar in terms of their level to the values measured in total hip arthroplasty metal-on-metal prostheses.

Correct Answer: The serum ion levels measured are similar in terms of their level to the values measured in total hip arthroplasty metal-on-metal prostheses.

Explanation:

Question 99:

Options:

Avascular necrosis of the proximal pole of the scaphoid
Dorsal intercalated segment instability (DISI)
Volar intercalated segment instability
Thumb metacarpophalangeal joint hyperextension

Correct Answer: Dorsal intercalated segment instability (DISI)

Explanation:

Question 100:

Options:

Conversion to a peri-articular hybrid frame
Open reduction and internal fixation with a lateral locking plate
Open reduction and internal fixation with a lateral nonlocking plate
Open reduction and internal fixation with medial and lateral plates
Open reduction and internal fixation with posteromedial and lateral plates

Correct Answer: Open reduction and internal fixation with posteromedial and lateral plates

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

OITE & ABOS Orthopedic Board Prep MCQs: Deformity, Fracture, & Nerve Part 190

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 190

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index