Orthopedic Board Review MCQs: Trauma, Shoulder & Foot

About This Board Review Set

This is Part 200 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 200

This module focuses heavily on: Dislocation, Foot, Fracture, Shoulder, Trauma.

Sample Questions from This Set

Sample Question 1: A 23-year-old man reports a 6-year history of recurrent instability in the right dominant shoulder. He has not undergone surgery and has essentially stopped all of his sporting activities. On examination, he has instability and apprehension...

Sample Question 2: An orthopaedic surgeon in his first year of practice is negotiating with a private for-profit hospital to be their employed trauma specialist. The state of employment is known to have a high rate of malpractice claims because of a favorable...

Sample Question 3: Figures 41a and 41b show the radiographs of a 22-year-old woman who has a bunion on her left foot. She denies pain in the foot, but she reports increasing difficulty with shoe wear. Management should consist of...

Sample Question 4: A 40-year-old man is thrown off his motorcycle and sustains an open Type IIIA fracture shown in Figure A. He is taken to the operating room for debridement and reamed intramedullary nailing with a 10mm diameter nail. He returns at 10 months...

Sample Question 5: Of the following variables, which has the strongest influence on external fixator stiffness?...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

A 23-year-old man reports a 6-year history of recurrent instability in the right dominant shoulder. He has not undergone surgery and has essentially stopped all of his sporting activities. On examination, he has instability and apprehension in the midrange of motion (abduction of 45 to 60 degrees with external rotation) and a palpable clunk representing a transient dislocation over the anterior glenoid rim. A three-dimensional CT scan is shown in Figure 31. What is the most appropriate surgical intervention to provide him with reliable stability postoperatively?

Explanation

DISCUSSION: In the setting of significant anteroinferior glenoid bone deficiency (greater than 20% to 25%), both open and arthroscopic Bankart repairs have demonstrated higher rates of failure. Bony glenoid augmentation procedures such as the Bristow-Lataijet, which describe coracoid transfers to reconstruct the deficient glenoid, have led to decreased rates of recurrent shoulder instability. In this scenario, the patient has a significant loss of glenoid bone. There are also several clues in the history to suspect bone deficiency: multiple recurrences, a long history of recurrence, and instability in the midranges of motion.
A bony augmentation procedure such as the Lataijet has been well-described to provide a well functioning and stable shoulder joint. A hemiarthroplasty is not indicated in the absence of arthritis. Subscapularis
advancement will not address the bone loss.
REFERENCES: Hovelius L, Sandstrom B, Sundgren K, et al: One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: Study I— clinical results. J Shoulder Elbow Surg 2004;13:509-516.
Schroder DT, Provencher MT, Mologne TS, et al: The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen. Am J Sports Med 2006;34:778-786.
Itoi E, Lee SB, Berglund LJ, et al: The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric study. J Bone Joint Surg Am 2000;82:35-46.

Question 2

An orthopaedic surgeon in his first year of practice is negotiating with a private for-profit hospital to be their employed trauma specialist. The state of employment is known to have a high rate of malpractice claims because of a favorable plaintiff legal environment. During the course of negotiations, malpractice insurance is being discussed. The surgeon should ask the hospital to provide which type of malpractice insurance policy? Review Topic

Explanation

An occurrence policy provides coverage for all claims made during employment irrespective of when it is filed (during or postemployment) and therefore is the best option. Claims made policy only covers suits for the time employed. A prepurchased "tail" is needed to provide coverage for cases that occurred during employment but filed postemployment. Nose coverage is applicable if the surgeon was previously employed and did not have tail coverage from previous employment, but this surgeon just emerged from training where it is not applicable. Claims made without tail coverage is unwise because the surgeon would be unprotected or have to purchase his own policy postemployment. Only in certain situations does sovereign immunity exist, and generally not in a for-profit system. Occurrence coverage with nose coverage is incorrect because it does not apply to this surgeon with no previous employment or claims policy lacking tail coverage.

Question 3

Figures 41a and 41b show the radiographs of a 22-year-old woman who has a bunion on her left foot. She denies pain in the foot, but she reports increasing difficulty with shoe wear. Management should consist of

Explanation

DISCUSSION: Surgery is not indicated in a patient who has a mild deformity and no pain. Shoe wear modifications should be recommended.
REFERENCE: Mann RA, Coughlin MJ: Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, p 174.

Question 4

A 40-year-old man is thrown off his motorcycle and sustains an open Type IIIA fracture shown in Figure A. He is taken to the operating room for debridement and reamed intramedullary nailing with a 10mm diameter nail. He returns at 10 months with persistent pain at the fracture site with ambulation. Examination reveals healed wounds with no erythema, warmth or tenderness. Erythrocyte sedimentation rate and C-reactive protein levels are within normal limits. Radiographs taken at that time are shown in Figure B. What is the next best treatment step?

Explanation

This man had a mid-diaphyseal tibial fracture that has gone into nonunion. Reamed exchange nailing is indicated.
Tibial delayed union can be defined as lack of union from 20-26 weeks post-injury, while nonunion is defined as lack of healing at >9mths post-injury, or absence of progressive signs of healing on radiographs for 3 consecutive months. Persistent pain is a symptom of nonunion. ESR and CRP are performed to rule out infection.
Bhandari et al. performed a blinded, multicenter trial on 622 reamed tibial nails and 604 unreamed tibial nails. In closed fractures, patients in the unreamed nail group were at greater risk of primary events than the reamed nail group. There was no difference in groups for open fractures. Primary events were defined as bone-grafting, implant exchange/removal, dynamization, and debridement.
Hak reviewed aseptic tibial nonunion. They discuss exchanged reamed nailing for diaphyseal nonunion, adjunctive plate fixation for metaphyseal nonunion, and nail removal and plating for metadiaphyseal nonunion, external fixation for infected nonunion and distraction osteogenesis of defects.
Figure A shows a mid-diaphyseal tibial fracture Figure B shows nonunion following
IM nailing of the fracture. Illustration A shows union following exchange nailing with a larger 12mm diameter nail.
Incorrect Answers:

Question 5

Of the following variables, which has the strongest influence on external fixator stiffness?

Explanation

Whereas all of the factors will have an impact on frame rigidity and stability, the single biggest factor is the pin diameter because it has an exponential effect.

Question 6

A 10-year-old child was referred for spinal curvature and a 2-year history of back pain. She has pain during the day and pain at night that wakes her from sleep and is temporarily relieved with nonsteroidal anti-inflammatory drugs. Examination shows very tight hamstrings and an irritative spinal curvature. Figures 71a through 7Id show radiographs, a bone scan, and a CT scan. What is the most appropriate treatment?

Explanation

DISCUSSION: The history, examination findings, and studies are consistent with an osteoid osteoma. The CT scan shows a classic “target” lesion, and the bone scan has intense uptake at the site of the osteoid osteoma. The child has had a 2-year history of pain that even wakes her from sleep, so observation and anti-inflammatory drugs is not a preferred treatment. Bracing will not help with the discomfort because the pain is not mechanical in nature. MRI would not be needed in addition to the studies already completed. The osteoid osteoma is close to the spinal cord so radiofrequency ablation is not preferred. Surgical removal and biopsy is the treatment of choice.
REFERENCES: Frassica FJ, Waltrip RL, Sponseller PD, et al: Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents. Orthop Clin North Am 1996;27:559-

Question 7

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

Explanation

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

Question 8

A 20-year-old professional baseball pitcher has had a 3-year history of increased aching in his shoulder that is associated with pitching, and he is now seeking a second opinion. Nonsurgical management consisting of rest, anti-inflammatory drugs, ice, heat, and cortisone injections has failed to provide relief. A previous work-up that included radiographs and gadolinium-enhanced MRI arthrography was negative. Results of an arteriogram suggest quadrilateral space syndrome. Assuming that this is the correct diagnosis, what nerve needs to be decompressed?

Explanation

DISCUSSION: Quadrilateral space syndrome is a rare condition and is the result of compression of the contents of the quadrilateral space. The contents of the quadrilateral space include the posterior circumflex vessels and the axillary nerve.
REFERENCES: Cahill BR, Palmer RE: Quadrilateral space syndrome. J Hand Surg 1983;8:65-69.
Lester B, Jeong GK, Weiland AJ, Wickiewicz TL: Quadrilateral space syndrome: Diagnosis, pathology, and treatment. Am J Orthop 1999;28:718-722.

Question 9

A 10-month-old boy has multiple skeletal lesions and a skin rash that he has had since he was a newborn. Based on the radiographs and biopsy specimens shown in Figures 79a through 79d, what is the most likely diagnosis?

Explanation

DISCUSSION: Langerhans cell histiocytosis or eosinophilic granuloma is a nonneoplastic lesion that is part of a spectrum of clinical diseases featuring histiocytes. Most occur during the first two decades of life within any bone. Radiographs show a radiolucent lesion, frequently diaphyseal in location. A periosteal response is occasionally seen and can resemble more aggressive lesions such as osteomyelitis or Ewing’s sarcoma. Histology demonstrates CD1a positive histiocytes with large oval-shaped nuclei with indentation, and a variable presence of eosinophils.
REFERENCES: Plasschaert F, Craig C, Bell R, et al: Eosinophilic granuloma: A different behaviour in children than in adults. J Bone Joint Surg Br 2002;84:870-872.
Campanacci M: Bone and Soft Tissue Tumors, ed 2. New York, NY, Springer-Verlag, 1999, pp 857-876.

Question 10

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

Explanation

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

Question 11

Which of the following surgical options after resection of a sarcoma about the knee would require a patient to expend the greatest amount of energy while walking?

Explanation

Discussion: The answer to this question is based on a study by Harris which tested the effeciency , rate and percent of max rate in ambulation in amputees, those with arthrodeses and arthroplasties. They found that Above knee amputees expended the most energy, followed by arthrodesis patients, and then arthroplasty patients.

Question 12

A college athlete on a scholarship has a medical condition that you feel presents a life-threatening risk to him with participation in athletics. Because of the gravity of this decision and the potential effect it can have on the student/athlete's future, the college asks for your guidance. As the team physician for the college, what is your ethical obligation?

Explanation

There is legal precedent for banning a scholarship athlete from participation in college athletics if the physician feels that it presents a significant physical risk to the athlete. The courts have decided that the athlete has no constitutional right to participate in NCAA sports, and as a team physician you must advise your athlete and the school as to the best course of action. The athlete must be allowed to keep his or her college scholarship.

Question 13

Figure 31 shows the radiograph of a 64-year-old woman who is seen in the emergency department following a motor vehicle accident. She has no voluntary motor function in her distal upper extremities or lower extremities. She does not have a bulbocavernosus reflex. She has a blood pressure of 80/50 mm Hg with a pulse of 50/min. Her hypotension does not improve with initial fluid resuscitation. Further treatment of her hypotension should consist of

Explanation

DISCUSSION: The hallmark of neurogenic shock is hypotension without tachycardia. It is associated most commonly with high cervical spinal cord injuries and results from loss of function of the sympathetic nervous system. Because the peripheral vasculature is dilated due to loss of its sympathetic tone, continued rapid administration of fluid corrects the hypotension and can quickly lead to fluid overload and congestive heart failure. Therefore, neurogenic shock is best treated by the use of pressors. Cardioversion or administration of antibiotics or systemic steroids is not appropriate treatment for this patient’s hypotension.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 179-187.
Nockels RP: Nonoperative management of acute spinal cord injury. Spine 2001;26:S31-S37.

Question 14

A previously healthy 20-year-old male wrestler is seen for evaluation and treatment of draining sores of the forearm. Empiric treatment for cellulitis was started with oral clindamycin with improvement. Culture of the drainage reveals methicillin-resistant staphylococcus aureus (MRSA). Sensitivities at 48 hours demonstrate additional resistance to erythromycin and a positive D-zone test. Definitive antibiotic treatment until resolution should consist of which of the following? Review Topic

Explanation

Based on the description of the infection and the history of close contact, the clinical scenario is most consistent with community-acquired MRSA (CA-MRSA). It is important to distinguish CA-MRSA and hospital-acquired MRSA (HA-MRSA) as the two display different sensitivities to antibiotics. Antibiotic selection is based on sensitivity and severity of infection. Because this infection is superficial and without
any signs of systemic illness, an oral antibiotic regimen is appropriate. When culture results reveal resistance to erythromycin, then a D-zone test should be performed to check for inducible clindamycin resistance. The D-zone test is performed by plating the sample on an agar and placing antibiotic disks made of clindamycin and erythromycin on the agar. A zone of inhibition in the shape of the letter D is seen with an inducible strain. If the D-zone test is positive, then clindamycin should not be used because the strain of MRSA can become resistant to the treatment. Therefore, because of the positive D-zone test, the antibiotic should be changed to oral doxycycline. IV antibiotics are not indicated for this infection. Oral rifampin should never be used as a single agent as resistance rapidly develops.

Question 15

The implant shown in Figures 47a and 47b is introduced submuscularly employing a minimally invasive technique. A percutaneous method of screw insertion is used distally. What nerve is most at risk?

Explanation

Minimally invasive methods used for stabilizing complex periarticular fractures continue to evolve. Encouraging results suggest a diminished threat to the soft tissues and enhanced preservation of osseous blood supply. Contemporary locking implants combined with indirect reduction lead to desirable biomechanical and biologic environments for osseous and soft-tissue healing. Deangelis and associates, in a cadaveric tibial study, demonstrated the superficial peroneal nerve to be at significant risk during percutaneous screw placement in very distal targeted holes (within laterally applied tibial locking plates). Use of a larger incision and cautious dissection to the plate in this region were encouraged to minimize risk to this structure.

Question 16

Which of the following types of exercise used to increase flexibility is considered most beneficial in increasing joint range of motion?

Explanation

DISCUSSION: Evidence has shown that PNF is the treatment of choice to increase joint range of motion and flexibility. PNF has the advantage of pushing the patient to stretch a little further when the muscle tendon unit is relaxed by a partner. While isokinetic and eccentric exercises can improve flexibility, and therefore increase range of motion, their main purpose is to increase strength and endurance. Ballistic stretching involves a large load applied rapidly; however, evidence has shown that static stretching, where a low load is applied for a long duration, offers a more significant benefit.
REFERENCES: Sady SP, Wortman M, Blanke D: Flexibility training: Ballistic, static or proprioceptive neuromuscular facilitation? Arch Phys Med Rehabil 1982;63:261-263.
Tanigawa MC: Comparison of the hold-relax procedure and passive mobilization on increasing muscle length. Phys Ther 1972;52:725-735.
Wallin D, Ekblom B, Grahn R, Nordenberg T: Improvement of muscle flexibility: A comparison between two techniques. Am J Sports Med 1985;13:263-268.

Question 17

There is a risk of impaired forearm rotation after tension band fixation of an olecranon fracture with which of the following?

Explanation

DISCUSSION: Impaired pronation/supination can be seen if the K-wire is advanced either too radial or too far through the volar (anterior) cortex of the proximal ulna. The anterior interosseous nerve is also at risk with overpenetration. Conversely, migration and loosening of the K-wire is reduced with involvement of the anterior cortex.
The referenced study by Candal-Couto et al is a cadaveric study that found that K-wire insertion in less than 30 degrees in an ulnar direction led to impingement of the K-wire on the radial head/neck, biceps or supinator. They recommend placing these wires away from this danger zone in order to minimize rotation blocks.
The referenced study by Matthews et al is a case series of two patients who had limited forearm rotation after K-wire fixation. The etiology of limited rotation was found to be from direct overpenetration of the K-wire, which led to a mechanical block.

Question 18

A 9-year-old child sustains a proximal tibial physeal fracture with a hyperextension mechanism. What structure is at most risk for serious injury?

Explanation

DISCUSSION: The most serious injury associated with proximal tibial physeal fracture is vascular trauma. The popliteal artery is tethered by its major branches near the posterior surface of the proximal tibial epiphysis. During tibial physeal displacement, the popliteal artery is susceptible to injury. Injuries to the other structures are less common.
REFERENCE: Beaty JH, Kasser JR: Rockwood and Wilkins Fractures in Children. Philadelphia, PA, JB Lippincott, 2006, p 961.

Question 19

In what decade does the peak incidence of conventional osteosarcoma occur?

Explanation

DISCUSSION: Conventional osteosarcoma most frequently occurs in the second decade, followed by the third decade. Approximately 70% to 75% of patients with osteosarcoma are between the ages of 10 and 25 years. Secondary osteosarcoma (arising in Paget’s disease or radiation-induced) is seen in older adults.
REFERENCES: Simon MA, Springfield DS, et al: Osteogenic Sarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 266.
Mirra JM: Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia, PA, Lea and Febiger, 1989.
Wold L, et al: Osteogenic sarcoma: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, p 14.

Question 20

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

Explanation

DISCUSSION: The maximum stress in a bone occurs at the periosteal surface (the greatest distance from the center of the bone). The magnitude of the stress is equal to the magnitude of the applied moment (M) multiplied by the distance to the surface (roughly the radius of the bone, r) divided by the area moment of inertia (I), so that stress = Mr/I. Of the possible answers, only area moment of inertia of the cross section contains any of these three items. The stress can also depend on the length of the bone, but it cannot be determined without knowing the location at which the bending load is applied, information that was not given in the problem. The type of structural support may influence local stresses where the support contacts the bone, but it has little effect on the maximum stress in the bone. The cross-sectional area is not as important as the area moment of inertia because the stress is not evenly distributed over the cross-section. Plastic modulus is a material property, not a geometric or structural property, and it does not affect stress.
REFERENCES: Hayes WC, Bouxsein ML: Biomechanics of cortical and trabecular bone: Implications for assessment of fracture risk, in Mow VC, Hayes WC (eds): Basic Orthopaedic Biomechanics, ed 2. New York, NY, Lippincott-Raven, 1997, pp 76-82.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 161-167.

Question 21

1 mg/L). Aspiration of the right knee reveals hazy yellow fluid with a white blood cell count of 120 and 1% neutrophils. No growth of organisms is seen on routine culture. What is the best next step?

Explanation

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

Question 22

A 45-year-old previously healthy woman has experienced weakness and fatigability for 2 months. She states she feels best in the morning, but tires easily with exertion. If she sits and rests her strength improves, but she easily tires with each activity. When her fatigue is most severe, she has double vision. Physical examination is positive for ptosis with upward gaze after 20 seconds. When she holds her arms out straight she shows good initial strength, but rapidly decreasing strength with time. What is the pathologic cause of her muscle weakness? Review Topic

Explanation

The patient has myasthenia gravis, which has its onset in middle age and causes progressive weakness because of the loss of acetylcholine receptors secondary to autoimmune antibodies at the NM junction. Rest periods allow uptake of acetylcholine and initial strength, but easy fatigability. Treatment is aimed at immunomodulation; acetyl cholinesterase inhibitors often coupled with thymectomy can control symptoms. Decreased release of acetylcholine at the NM junction is the effect of a nondepolarizing drug or toxin botulinum. Patients with muscular dystrophy lack dystrophin that acts at the sarcolemma to regulate calcium channels, and onset of this condition occurs at a younger age. The decrease in myelin indicates Charcot-Marie-Tooth disease and is often seen with long axon degeneration, such as in the feet and lower legs.

Question 23

A 29-year-old obese patient is transferred from an outside facility for the management of a closed-head injury and the fracture shown in Figure A. He presents to the trauma bay as a transient responder to blood products, and undergoes urgent pre-surgical angiography embolization. Surgery is performed within 8 hours from the time of injury. The patient develops a deep wound infection 1 week post-operatively. Which of the following factors would be considered the MOST statistically significant predictor for post-operative infection in this patient.

Explanation

OrthoCash 2020

Question 24

A 23-year-old man reports pain on the superior aspect of his right shoulder with repetitive overhead activities and when lying on his right side. Figure 29 shows an axial MRI scan. What is the most likely diagnosis based on the MRI findings? Review Topic

Explanation

Os acromiale represents a failure of fusion of the anterior acromial apophysis and has been reported in approximately 8% of the population. Patients with a symptomatic os acromiale often report impingement-type symptoms with pain over the superior acromion, especially with overhead activities or sleeping. When nonsurgical management is unsuccessful, surgical options include excision, open reduction and internal fixation, and arthroscopic decompression.

Question 25

A young gymnast fell awkwardly onto an outstretched hand during a competition. At the time of impact, his forearm was positioned in supination. Axial and posterolateral forces were loaded along the forearm into the elbow and the elbow underwent a significant valgus thrust. What injury pattern is most likely to result from the combination of these forces at the elbow?

Explanation

The combination of valgus, axial, and posterolateral rotatory forces (forearm supination) can result in a "terrible triad" injury of the elbow.
The key features of a terrible triad injury include a radial head fracture, coronoid fracture, and dislocation of the elbow. Disruption of the lateral collateral ligament complex often concomitantly occurs. While restoration of the bony anatomy is important for static stability, the key primary stabilizer that needs to be addressed is the lateral collateral ligament complex. In acute injuries LCL repair may be possible. In chronic injury, LCL reconstruction would need to be considered.
O'Driscoll et al. 1991, examined 5 patients with recurrent posterolateral rotatory instability of the elbow. They showed that by applying supination of the forearm with a valgus moment and an axial compression force to the elbow while it is flexed from full extension, this can demonstrate posterolateral rotatory instability of the elbow. The elbow is reduced in full extension and must be subluxated as it is flexed in order to obtain a positive test result (a sudden reduction of the subluxation).
O'Driscoll et al. 1992 looked at a cadaveric study of the elbow. They showed that external rotation and valgus moments with axial forces resulted in posterior dislocations in 12 of the 13 specimens when the anterior medial collateral ligament (AMCL) remained intact. Clinically, it valgus stability in pronation is demonstrated, the AMCL can be assumed to be intact.
Illustration A and B shows radiographs of a terrible triad injury. There is posterolateral dislocation of the elbow with associated radial head fracture, coronoid fracture.
Incorrect Answers:

Question 26

Osteoclastic bone resorption is stimulated primarily by what molecular interaction?

Explanation

OPG is a receptor that competitively binds with RANKL, blocking the interaction with RANK and inhibiting osteoclastogenesis. PTH, secreted by the chief cells of the parathyroid gland, is active in calcium homeostasis independent of inflammatory arthropathies. PTH increases serum calcium indirectly by binding to osteoblasts, increasing expression of RANKL and decreasing expression of OPG. The interaction of RANKL to RANK in turn stimulates osteoclast precursors to fuse, forming
osteoclasts to enhance bone resorption. The pannus of rheumatoid arthritis and monosodium urate crystals of gouty tophi have been shown to trigger release of inflammatory cytokines such as IL-6, IL-8 and tumor necrosis factor alpha. The key to osteoclastic bone resorption of inflammatory arthropathy is regulated by the interaction of RANKL, expressed in osteoblasts and activated T cells, and RANK, expressed in osteoclast progenitors and mature osteoclasts. In inflammatory arthropathy, RANKL expression is increased and OPG is reduced, resulting in increased cortical and subchondral bone.

Question 27

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

Explanation

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

Question 28

..Staging studies show no other lesions and surgical treatment is planned; when should a biopsy be performed?

Explanation

CLINICAL SITUATION FOR QUESTIONS 117 THROUGH 120
Figures 117a through 117c are the radiographs and MRI scan of a 16-year-old boy who has had a persistent fullness in his thigh since being kicked while playing soccer 4 weeks ago. He states that initially the area was painful, but now all symptoms other than the mass have resolved.

Question 29

On the morning of surgery the patient reports in the preop area that she has experienced skin breakdown over the second toe for 10 days. The extensor tendon is disrupted with an exposed proximal interphalangeal joint. She has been applying antibiotic ointment to the wound and denies fever or chills. What is the best plan of care?

Explanation

DISCUSSION
The clinical photograph shows a hallux valgus and a crossover toe deformity. The plantar plate must be damaged for a crossover toe deformity to develop. A moderately severe hallux valgus deformity without arthritic change is best treated with a bunionectomy with a proximal metatarsal osteotomy. The surgeon must assume that the open joint is at least colonized and at significant risk for postsurgical infection; consequently, it is best to cancel elective surgery, and surgical debridement of soft tissue and bone with deep cultures is recommended.
RECOMMENDED READINGS
Kaz AJ, Coughlin MJ. Crossover second toe: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2007 Dec;28(12):1223-37. doi: 10.3113/FAI.2007.1223. PubMed PMID: 18173985. View Abstract at PubMed
Chalayon O, Chertman C, Guss AD, Saltzman CL, Nickisch F, Bachus KN. Role of plantar plate and surgical reconstruction techniques on static stability of lesser metatarsophalangeal joints: a biomechanical study. Foot Ankle Int. 2013 Oct;34(10):1436-42. doi: 10.1177/ 1071100713491728. Epub 2013 Jun 17. PubMed PMID: 23774466. View Abstract at PubMed
Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989 Dec;10(3):156-60. PubMed PMID: 2613128. View Abstract at PubMed

Question 30

A 16-year-old girl who swims on her high school team reports pain in the shoulder after swimming. History reveals a glenohumeral dislocation at age 14 years while doing the backstroke. Examination shows a positive anterior apprehension sign. Treatment at this time should consist of

Explanation

p.579: “The Putti-Platt procedure is contraindicated in multidirectional instability (AMBRI); tightening the front of the shoulder will only increase the likelihood of posterior instability. In traumatic instability (TUBS) the data suggest that such a procedure, which limits external rotation is not necessary if the Bankart lesion is solidly repaired.”
p. 577: “A vigorous effort to stabilize the shoulder with exercises is particularly indicated in patients with multidirectional or posterior instability and in athletes requiring a completely normal or supranormal range of motion.”
p. 989: “If the [swimmer] has symptoms of subluxation, a conservative program that strengthens the external rotators is warranted. Surgery is seldom indicated.”

Question 31

Figures 1 through 6 reveal the radiographs and MR images of a 30-year-old man who has a 1-year history of atraumatic medial-sided left knee pain refractory to nonsurgical measures. What is the most appropriate treatment?

Explanation

The images illustrate a large unstable osteochondral lesion of the medial femoral condyle. Radiographs and MR images clearly show deep subchondral bone involvement. The appropriate choice of surgery is OCA transplantation, which is indicated for primary treatment of large cartilage lesions, osteochondral lesions, and salvage procedure from failed prior cartilage surgery. Correction of mechanical axis malalignment, ligamentous insufficiency, and meniscal deficiency should also be addressed. ACI alone or an arthroscopic microfracture procedure would not address the bone defect, leaving an uneven articular surface. Although an osteotomy may be a viable choice, a distal femoral varus osteotomy would increase the contact pressure in the medial compartment and worsen the situation. The histologic anatomy of articular cartilage is well described. The superficial layer or lamina splendens contains a small amount of proteoglycan with collagen fibrils arranged parallel to the articular surface. In contrast, the deep zone contains the largest-diameter collagen fibrils, oriented perpendicular to the joint surface, and the highest concentration of proteoglycans.

Question 32

A patient who underwent a L4-L5 hemilaminotomy and partial diskectomy for radiculopathy 8 weeks ago now reports increasing low back pain without neurologic symptoms. A sagittal T2-weighted MRI scan is shown in Figure 13a, and a contrast enhanced T1-weighted MRI scan is shown in Figure 13b. What is the most appropriate management for the patient’s symptoms? Review Topic

Explanation

The MRI scans show Modic changes in the L4-L5 vertebral bodies due to spondylosis. There is no increased fluid signal or enhancement in the L4-L5 disk to suggest infection or any other pathologic process. Therefore, the patient’s pain should be treated with a course of physical therapy and rehabilitation. There is no infection; therefore, IV antibiotics and debridement are not indicated. Similarly, a
pseudomeningocele is not present. A revision diskectomy is useful for recurrent radiculopathy but would not be helpful for degenerative low back pain.
(SBQ12SP.29) A 17-year-old female is undergoing posterior instrumented fusion from T5-T12 for adolescent idiopathic scoliosis. At the time of the correction maneuver, the neurophysiologist notifies you of a 60% decrease in somatosensory evoked potential (SSEP) amplitude throughout bilateral lower extremities. Which of the following is an acceptable approach to manage this finding? Review Topic
Immediate wake-up test with examination for clonus
Drop the mean arterial pressure (MAP) to ~60mmHg
Discontinue instrumentation and optimize MAP to 85mmHg or greater
Immediate infusion of intravenous corticosteroids
Modification of the anesthesia plan to include inhalational agents only followed by repeated SSEP testing
The patient has a significant drop in SSEP amplitudes at the completion of the corrective maneuver. The most appropriate response is to raise the MAP to 85 mmHg or greater, discontinue the instrumentation, re-evaluate the SSEPs, and if there is no improvement, to consider reversing the reduction of the deformity.
Intra-operative neurophysiologic monitoring is an effective method to monitor insults to the spinal cord and its exiting roots during spinal instrumentation. The common measurements include SSEPs, which monitor sensory potentials transmitted through the dorsal column system, and motor-evoked potentials (MEPs), which monitor motor response to a trans-cranial stimulus. Decreases in amplitude and latency of the circuits are recorded, however diminished signal amplitudes are more sensitive for neurologic injury, and decreases of of >50-60% being highly concerning. The wake-up test involves reversal of anesthesia so that an intra-operative neurologic examination can be performed.
Devlin et al. reviewed the basic science and practice of neurophysiologic monitoring in spine surgery. They proposed an algorithmic approach to managing intraoperative alerts which include discontinuation of inhalational anesthetics, increasing the MAP to >90 mmHg, discontinuing instrumentation, and performing a wake-up test if neurologic signals fail to normalize.
Herdmann et al. reviewed the practice of neurophysiologic monitoring and the effects of anesthesia upon signal transduction. They report that anesthesia affecting a neuron's intrinsic excitability can alter the results of monitoring. Inhalational anesthetics and decreased MAPs can be responsible for decreased amplitudes.
Vitale et. al. developed a consensus-based intraoperative checklist for management of lost neuromonitoring signals. In this checklist, the first steps across the surgical and anesthetic teams should include: stop the case and announce signal losses to the room, optimize the mean arterial pressure, discuss the status of anesthetic agents, and discuss reversible surgical actions just prior to signal loss.
Incorrect

Question 33

Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure?

Explanation

DISCUSSION: The key to this question is the fact that the patient initially lost flexion postoperatively and this relates to anterior placement of the femoral tunnel, thus capturing the knee. The bone plug seen on the radiograph is actually from the tibial tunnel, but this occurred as the patient forced flexion until failure of the ACL graft and pullout of the plug from the tunnel. Although it could be argued that better tibial fixation would have prevented this failure, poor placement of the femoral tunnel led to the failure of this ACL reconstruction.
REFERENCES: Fu FH, Bennett CH, Latterman C, et al: Current trends in anterior cruciate ligament reconstruction: Part 1. Biology and biomechanics of reconstruction. Am J Sports Med 1999;27:821-830.
Fu FH, Bennett CH, Ma CB, et al: Current trends in anterior cruciate ligament reconstruction: Part II. Operative procedures and clinical correlations. Am J Sports Med 2000;28:124-130.

Question 34

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

Explanation

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

Question 35

-is the photograph of a 2-month-old infant with a left leg deformity. The mother’s pregnancy and delivery were unremarkable, and the infant is otherwise healthy. What is the most appropriate course of action?

Explanation

Question 36

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

Explanation

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

Question 37

Figure 28 shows the radiograph of a 6-year-old girl who has a right thoracic scoliosis that measures 60°. Examination shows multiple cafe-au-lait spots, and family history reveals that the child’s mother has the same disorder. The gene responsible for this disorder codes for

Explanation

DISCUSSION: The patient has the dystrophic type of scoliosis seen in patients with neurofibromatosis type I (NF-1). The NF-1 gene is located on chromosome 17 and codes for neurofibromin, believed to be a tumor-suppresser gene. Abnormalities in the dystrophin gene are seen in Duchenne muscular dystrophy and Becker muscular dystrophy. A mutation in the frataxin gene is responsible for Friedreich ataxia. The most common type of hereditary motor and sensory neuropathy (Charcot-Marie-Tooth), HMSN type IA is caused by a complete duplication of the peripheral myelin protein gene. A defect in the cellular sulfate transport protein results in undersulfation of proteoglycans seen in diastrophic dysplasia.
REFERENCE: Beaty JH: Orthopaedic Knowledge Update 6. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1999, pp 225-234.

Question 38

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

Explanation

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

Question 39

A 24-year-old woman is thrown from her motorcycle and sustains the closed injury shown in Figures A through C. Open reduction and internal fixation is planned. What surgical technique will best allow visualization of the joint surface and allow early range of motion?

Explanation

Chronic suppressive, culture-directed, antibiotic therapy
Above knee amputation
Endocrine consultation, irrigation and debridement, removal of hardware and negative-pressure wound therapy
Irrigation and debridement, removal of hardware, over-reaming medullary canal, external fixation and culture-directed antibiotics
Irrigation and debridement, retention of hardware, acute bone grafting and culture-directed antibiotics
This is a case of fracture nonunion in the setting of chronic osteomyelitis and infected hardware. The best treatment option available would be irrigation and debridement, removal of hardware, ring external fixator and culture directed antibiotics.
The management of infected nonunion in the setting of chronic osteomyelitis is technically demanding. The aims of treatment are to eradicate the infection and obtain bone union. Non-surgical options are largely unsuccessful in patients with draining chronic osteomyeltis in the setting of infected hardware and nonunion. Surgical options involve incision and debridement of necrotic tissue followed by reconstruction of bone and possible soft tissue (to provide healthy viable coverage). The most common techniques are ringed fixator/circular frames, staged intramedullary device with or without external fixator, free tissue transfer, or radical
debridement, bone grafting, and fixation.
Motsitsi et al. reviewed the management of infected nonunion of long bones. They suggest that the Ilizarov technique is regarded as a standard treatment in infected nonunion of the tibia. When there is bone defect after debridement, the bone can be shortened or treated with bone transport.
Egol et al look at a series of patients with chronic osteomyelitis. Limb salvage should be attempted in all patients. The presence of a chronic draining sinus requires surgical debridement and culture directed antibiotics. Infected hardware should be removed. A two-stage strategy is the best and well-proven treatment option.
Figure A shows a intramedullary nail in the left tibia. There is a moderate amount of bone loss at the fracture site with mixed sclerotic bone suggestive of osteomyelitis.
Incorrect Answers:

Question 40

During anatomic medial patellofemoral ligament (MPFL) reconstruction, the surgeon notes that the graft is becoming too tight with greater knee flexion. What is the most likely cause?

Explanation

If the graft becomes tighter with knee flexion, the femoral attachment is too proximal. This error is referred to as “high and tight,” meaning that a high or proximal femoral attachment produces a graft that is too tight with knee flexion. If graft tension increases with increasing knee flexion, the result is loss of knee flexion or graft failure, increased contact forces resulting in patella femoral chondrosis, and possibly medial subluxation.

Question 41

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

Explanation

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

Question 42

A 13-year-old girl has had a firm mass and pain in her right shoulder for the past several weeks. She denies any history of trauma. A radiograph and MRI scan are shown in Figures 31a and 31b. Biopsy specimens are shown in Figures 31c and 31d. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has osteosarcoma. The radiograph suggests an aggressive primary tumor of bone, and the histology shows malignant cells surrounded by osteoid, classic for osteosarcoma. Ewing’s sarcoma histologically consists of small round blue cells. Osteochondroma and periosteal chondroma occur in the shoulder but have a different histologic pattern and a less aggressive radiographic appearance. Chondrosarcomas rarely occur in children.
REFERENCES: Simon MA, Springfield DS, et al: Osteogenic Sarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 266.
Wold LA, et al: Osteogenic Sarcoma: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 14-15.

Question 43

When discussing treatment options with a 35 year-old healthy male with an isolated, closed tibial shaft fracture, the surgeon should inform him that in comparison to closed treatment, the advantages of intramedullary nail fixation include all of the following EXCCEPT?

Explanation

DISCUSSION: All of the answer choices are correct except #3. Intramedullary nailing can increase the risk of compartment syndrome.
In a study of 94 tibial fractures, Finkemeier reported 10 (11%) had compartment syndromes. Three of the 10 patients developed the compartment syndrome postoperatively.
In comparing IM nailing to non-op, Bone et al showed that IM nailing had a shorter time to union (mean, 18 vs 26 weeks; p = 0.02), lower non-union rate (2% vs 10%), decresed incidence of shortening (2% vs 27%), and quicker return to work (mean, 4 vs 6.5 months), but no difference in compartment syndrome (0% in both groups).
The classic article cited by Sarmiento el al. reported that closed treatment with use of a prefabricated functional below-the-knee brace was effective in a study of 1000 closed diaphyseal fractures of the tibia with an incidence of nonunion of only 1.1%. However, those authors had very strict criteria for use of the fracture-brace (exclusion criteria included intact fibular, shortening >2cm).

Question 44

A 50-year-old man with no history of trauma reports new-onset back pain after doing some yard work the previous day. He reports pain radiating down his leg posteriorly and into the first dorsal web space of his foot. MRI scans are shown in Figures 3a through 3c. What nerve root is affected?

Explanation

DISCUSSION: The MRI scans clearly show an extruded L4-5 disk that is affecting the L5 nerve root on the left side. In addition, the L5 nerve root has a cutaneous distribution in the first dorsal web space. S1 affects the lateral foot. L4 affects the medial calf.
REFERENCE: An HS: Principles and Techniques of Spine Surgery. Baltimore, MD,

Williams and Wilkins, 1998, pp 98-100.

Question 45

A 65-year-old woman has nausea, vomiting, and abdominal distention after undergoing total knee arthroplasty 48 hours ago. An abdominal radiograph is shown in Figure 14. Associated risk factors for this disorder include

Explanation

DISCUSSION: The prevalence of postoperative ileus associated with total joint arthroplasty has been reported to be as high as 3%. Metabolic abnormalities such as hypokalemia are believed to contribute to the onset of ileus and Ogilvie’s syndrome (acute pseudo-obstruction of the colon). Prolonged bed rest also has been associated with the development of ileus and Ogilvie’s syndrome. Untreated Ogilvie’s syndrome can result in cecal perforation. Ileus usually is not accompanied by mechanical obstruction. Antibiotic administration and the type of anesthesia used have not been correlated with development of ileus. Administration of warfarin has been associated with elevated prothrombin time/partial thromboplastin time and international normalized ratio levels when ileus is managed with a nasogastric tube and suction. Metabolic imbalances must be corrected to reverse the ileus process.
REFERENCES: Iorio R, Healy WL, Appleby D: The association of excessive warfarin anticoagulation and postoperative ileus after total joint replacement surgery. J Arthroplasty 2000;15:220-223.
Clarke HD, Berry DJ, Larson DR: Acute pseudo-obstruction of the colon as a postoperative complication of hip arthroplasty. J Bone Joint Surg Am 1997;79:1642-1647.

Question 46

An 18-year-old man underwent open reduction and internal fixation of a tibial spine avulsion and a posterolateral corner repair. Two years later, he underwent lateral collateral ligament (LCL) and posterolateral corner reconstruction because of instability. Examination reveals a pronounced lateral varus knee thrust when ambulating. Varus stress in 30 degrees of flexion produces a 10-mm opening that is eliminated in extension. The Lachman’s test is 2 mm with a firm end point, and the posterior drawer test is negative. Standing radiographs show widening of the lateral joint space and a 5-degree mechanical varus alignment. What is the most effective course of treatment?

Explanation

DISCUSSION: The patient has chronic posterolateral instability with a varus knee alignment; therefore, the most effective treatment is a valgus-producing HTO. A repeat soft-tissue reconstruction without correction of the varus alignment will most likely fail. An ACL reconstruction is not indicated with a normal Lachman’s test. Physical therapy and bracing will have little effect.
REFERENCES: Naudie DD, Amendola A, Fowler PJ: Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med 2004;32:60-70.
Covey DC: Injuries of the posterolateral corner of the knee. J Bone Joint Surg Am
2001;83:106-118.

Question 47

A 32-year-old woman has left second toe dactylitis (sausage toe). Radiographs show a “pencil in cup” distal interphalangeal joint deformity. Examination reveals that subtalar motion is markedly reduced. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient’s clinical picture is considered the classic presentation for psoriatic arthritis. The other answers are not applicable for the constellation of findings.
REFERENCES: Jahss MH: Disorders of the Foot and Ankle, ed 2. Philadelphia, PA,

WB Saunders, 1991, pp 1691-1693.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 172-173.

Question 48

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

Explanation

Question 49

A 5-year-old boy sustained an elbow injury. Examination in the emergency department reveals that he is unable to flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger. The radial pulse is palpable at the wrist, and sensation is normal throughout the hand. Radiographs are shown in Figures 6a and 6b. In addition to reduction and pinning of the fracture, initial treatment should include

Explanation

DISCUSSION: The findings are consistent with a neurapraxia of the anterior interosseous branch of the median nerve. This is the most common nerve palsy seen with supracondylar humerus fractures, followed closely by radial nerve palsy. Nearly all cases of neurapraxia following supracondylar humerus fractures resolve spontaneously, and therefore, further diagnostic studies and surgery are not indicated.
REFERENCES: Cramer KE, Green NE, Devito DP: Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. J Pediatr Orthop 1993;13:502-505.
Sood MK, Burke FD: Anterior interosseous nerve palsy: A review of 16 cases. J Hand Surg Br 1997;22:64-68.

Question 50

For a patient with an unstable pelvic fracture, the amount of blood tranfusions required in the first 24 hours has shown to be most predictive for what variable?

Explanation

DISCUSSION: Unstable pelvic fractures can be devastating injuries often resulting in significant morbidity and even death.
According to the referenced study by Smith et al, fracture pattern and angiography/embolization were not predictive of mortality in patients with unstable pelvic injuries. The three factors they found to be predictive were: increased blood transfusions in the first 24 hours, age >60 years, and increased ISS or RTS scores. Deaths were most commonly from exsanguination (<24 hours) or multiorgan failure (>24 hours).
Incorrect Answers: Choices 1-4 are not as predictive of mortality as choice 5.

Question 51

The nucleus pulposus of the intervertebral disk consists of chondrocyte-like cells that have a limited vascular supply and generate energy through which of the following?

Explanation

The intervertebral disk is an avascular structure in the adult. Nucleus pulposus cells have a critical need for glucose because they obtain their energy primarily by glycolysis, even in the absence of oxygen. Disk cells do not require oxygen to remain alive but they die at low glucose levels or acidic pH. Nutrients are supplied from the blood vessels at the margins of the disk and have to traverse the cartilaginous end plate to reach the disk cells. The loss of the nutrient supply through the vertebral body will starve the cells in the disk center and may be a major factor in disk degeneration.

Question 52

An otherwise healthy 25-year-old man underwent a right anterior cruciate ligament reconstruction with a bone-patellar tendon-bone allograft. Routine preimplantation cultures of the allograft taken by the surgeon were positive for coagulase-negative Staphylococcus 5 days postoperatively. The patient has exhibited no evidence of clinical infection and his postoperative course has been uncomplicated during this time. What is the ideal management of this patient?

Explanation

The incidence of preimplantation positive cultures of musculoskeletal allografts used for anterior cruciate ligament reconstruction has varied between 4.8% and 13.3%. Interestingly, in none of the studies evaluating this issue did any of the patients
implanted with a "contaminated" graft develop a clinical infection. The results of the current literature suggest that the treatment of low-virulence organisms is unnecessary if no evidence of clinical infection exists. Preimplantation cultures do not appear to correlate with clinical infection. Therefore, the routine culture of allograft tissue is not recommended.

Question 53

A 17-year-old woman seen in the emergency department reports right knee pain and swelling that has progressively worsened over the past several weeks. Radiographs are shown in Figures 31a and 31b. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs reveal a blastic lesion of the proximal tibial metaphysis with cortical destruction, mineralization extending into the soft tissue laterally, indistinct margins, and destruction of the normal trabecular pattern. In this age group, with this aggressive appearance, osteosarcoma is the most likely diagnosis. Chondroblastoma and giant cell tumor are generally geographic and lytic. Chondrosarcoma is rare in this age group and would likely be a secondary lesion from an underlying chondroid tumor that is not present here. Whereas infection can have a wide variety of appearances, it tends to be more lytic in the acute presentation.
REFERENCES: Sanders TG, Parsons TW: Radiographic imaging of musculoskeletal neoplasia. Cancer Control 2001;8:221-231.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 175-186.

Question 54

Arthrodesis

Explanation

Long term prospective study involving 67 humeral head replacements for OA &RA. "Based on this experience, we would recommend that humeral head replacement alone be used sparingly in patients
with OA or RA. Certainly in patients who have glenoid bone deficiency precluding placement of a glenoid component…" as is apparent in this radiograph.

Question 55

A patient who underwent an L5-S1 hemilaminotomy and partial diskectomy for radiculopathy 3 weeks ago now reports increasing leg and back pain with radicular signs. An axial T2-weighted MRI scan is shown in Figure 97a, an axial T1-weighted MRI scan is shown in Figure 97b, and a contrast enhanced T1-weighted MRI scan is shown in Figure 97c. What is the most appropriate management for the patient's symptoms? Review Topic

Explanation

The MRI scans show a recurrent disk herniation. There is no increase fluid signal or enhancement to suggest infection or any other pathologic process. There is no infection; therefore, IV antibiotics and debridement are not indicated. Similarly, a pseudomeningocele is not present. In addition, with progressive weakness, physical therapy is not appropriate. A revision diskectomy is useful for recurrent radiculopathy.

Question 56

A collegiate rower reports the sudden onset of right chest pain while rowing. The athlete states that the pain is worse with deep inspiration and coughing. Examination reveals localized tenderness over the posterolateral corner of the eighth rib. What is the most likely diagnosis?

Explanation

DISCUSSION: A rib stress fracture, the most common injury to the thorax in rowing athletes, generally occurs during periods of intense training with a low stroke rate and heavy loads. It is characterized by the sudden onset of sharp, localized chest pain while rowing. The fifth through the ninth rib is generally affected, and the diagnosis is best established with a bone scan. An intercostal muscle strain generally has an insidious onset and may be poorly localized. Costochondritis affects the anterior costochondral junction. A pneumothorax and an empyema can cause nonlocalized chest pain but are associated with respiratory distress and systemic physical findings.
REFERENCES: Karlson KA: Rib stress fractures in elite rowers. Am J Sports Med 1998;26:516-520.
Holden DL, Jackson DW: Stress fractures of the ribs in female rowers. Am J Sports Med 1985;13:342-348.

Question 57

Which of the following findings is most prognostic for the ability of a young child with cerebral palsy to walk?

Explanation

DISCUSSION: Several studies have shown that sitting ability by age 2 years is highly prognostic of walking. Molnar and Gordon reported that children not sitting independently by age 2 years had a poor prognosis for walking. Wu and associates reported that children sitting without support by age 2 years had an odds ratio of 26:1 of walking compared with those unable to sit. This was far higher than the odds ratios for cerebral palsy location, motor dysfunction, crawling, creeping, scooting, or rolling.
REFERENCES: Molnar GE, Gordon SU: Cerebral palsy: Predictive value of selected clinical signs for early prognostication of motor function. Arch Phys Med Rehabil 1976;57:153-158.
Wu YW, Day SM, Strauss DJ, et al: Prognosis for ambulation in cerebral palsy: A population-based study. Pediatrics 2004;114:1264-1271.

Question 58

A 78-year-old man with ankylosing spondylitis sustains a minor fall. Shortly afterward he experiences sudden worsening of his chronic back pain and is brought to the emergency department by his caregiver. Radiographs and a CT scan of the spine do not show a clear fracture. What is the most appropriate next step?

Explanation

DISCUSSION
Patients with ankylosing spondylitis are at high risk for occult fractures after low-energy injuries. Although radiographs and a CT scan do not demonstrate a spinal fracture in this patient, high risk for an unstable occult fracture necessitates further imaging with MRI to ensure that no fractures are missed. Although a CT scan is typically the primary imaging modality for workup of spine injuries in similar patients, CT and MRI complement each other and each detects fractures that are missed using the other modality. A CT myelogram might detect cord or root compression but would not aid in the diagnosis of an occult fracture. Nonsteroidal anti-inflammatory drugs are first-line treatment for idiopathic low-back pain. In a patient with ankylosing spondylitis at high risk for fracture, further workup is needed to rule out an occult fracture. Flexion and extension radiographs of the spine are inferior to MRI for evaluating occult fractures and ligamentous injuries. The primary concern for this patient remains an unstable spinal fracture, which necessitates an MRI of the spine before initiating a workup for other possible causes of his back pain.
RECOMMENDED READINGS
Duane TM, Cross J, Scarcella N, Wolfe LG, Mayglothling J, Aboutanos MB, Whelan JF, Malhotra AK, Ivatury RR. Flexion-extension cervical spine plain films compared with MRI in the diagnosis of ligamentous injury. Am Surg. 2010 Jun;76(6):595-8. PubMed PMID: 20583514. View Abstract at PubMed
Hitchon PW, From AM, Brenton MD, Glaser JA, Torner JC. Fractures of the thoracolumbar spine complicating ankylosing spondylitis. J Neurosurg. 2002 Sep;97(2 Suppl):218-22. PubMed PMID: 12296682. View Abstract at PubMed
Koivikko MP, Koskinen SK. MRI of cervical spine injuries complicating ankylosing spondylitis. Skeletal Radiol. 2008 Sep;37(9):813-9. doi: 10.1007/s00256-008-0484-x. Epub 2008 Apr

Question 59

Figure 51 shows the radiograph of a 42-year-old construction worker who has pain and limited motion in his dominant elbow. Management consisting of nonsteroidal anti-inflammatory drugs and cortisone has failed to provide relief. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: The patient has symptomatic primary osteoarthritis of the elbow with multiple loose bodies. Given his age and occupation, an elbow arthroplasty is not an option. Arthroscopic debridement and removal of loose bodies has been shown to be effective for osteoarthritis of the elbow.
REFERENCES: Gramstad GD, Galatz LM: Management of elbow osteoarthritis. J Bone Joint Surg Am 2006;88:421-430.
Steinmann SP, King GJ, Savoie FH III, et al: Arthroscopic treatment of the arthritic elbow.

J Bone Joint Surg Am 2005;87:2114-2121.

Question 60

A toddler is brought in by his parents for evaluation of gait problems. Birth history and neurologic examination are unremarkable. After evaluating femoral torsion, tibial torsion, and foot contour, the diagnosis is excessive internal tibial torsion. The parents should be advised to expect which of the following outcomes? Review Topic

Explanation

Excessive internal tibial torsion is a common cause of intoeing in toddlers. In most children, this resolves spontaneously by 3 to 4 years of age. Intoeing in elementary age children is usually the result of excessive femoral anteversion. Studies have shown that active intervention (casting, splinting, and shoe modifications) has no demonstrable effect on the natural history or resolution of tibial torsion. Surgery is rarely indicated in adolescents with severe internal tibial torsion that has not resolved and is resulting in cosmetic and functional problems.

Question 61

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

Explanation

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

Question 62

Figures 52a and 52b show the plain radiographs of a 12-year-old girl who has right distal leg pain. She reports that symptoms are present with weight-bearing activities and improve with rest. Examination reveals diffuse tenderness over the distal tibial metaphysis and mild swelling. A photomicrograph of the biopsy specimen is shown in Figure 52c. What is the most likely diagnosis?

Explanation

DISCUSSION: This lytic lesion is in the epiphyseal-metaphyseal region of the distal tibia. The most common lesion in this area is a giant cell tumor. Although these lesions are most commonly seen in adults, they can also occur in the skeletally immature patient. The photomicrograph shows a lesion with multiple giant cells, the nuclei of which are similar to those in the background stroma; this finding is characteristic of giant cell tumors. Giant cells can be seen in many benign lesions, including aneurysmal bone cysts, Brown tumors, and eosinophilic granuloma. These lesions usually have fewer giant cells with less nuclei. The location of this lesion in the epiphyseal-metaphyseal area is not seen in aneurysmal bone cysts, unicameral bone cysts, Ewing’s sarcoma, or eosinophilic granuloma.
REFERENCE: Picci P, Manfrini M, Zucchi Z, et al: Giant cell tumor of bone in skeletally immature patients. J Bone Joint Surg Am 1983;65:486-490.

Question 63

-What is the most likely mechanism of injury?

Explanation

DISCUSSION FOR QUESTIONS 56 THROUGH 58
The MRI scan shows a bone bruise of the lateral femoral condyle and lateral tibial plateau. This injury pattern is commonly associated with anterior cruciate ligament (ACL) rupture and an abnormal pivot shift test result. Treatment of an ACL tear in a high-demand athlete should consist of ligament reconstruction.In this patient, surgery should be delayed until she regains full range of motion to minimize risk for arthrofibrosis after surgery. Recent analysis has shown that the noncontact mechanism is more consistent with anterior translation, affecting both the medial and lateral compartments. The bone bruise in the lateral femoral condyle occurs more anterior than that of the medial femoral condyle, suggesting that internal rotation has occurred. The external rotation recurvatum test assesses for posterolateral corner injury, and a positive quadriceps active test is consistent with posterior cruciate ligament rupture. An abnormal patellar apprehension test result is suggestive of patellar instability. Nonsurgical treatment is unlikely to result in sufficient stability if this patient returns to sports at her preinjury level of activity.Primary ACL repair is associated with high failure rates. Although the precise mechanism of injury varies,injuries can be broadly classified into contact and noncontact injuries. Noncontact injuries occur with the knee in slight flexion, valgus, and internal rotation, and contact injuries typically involve a lateralside impact producing a valgus force to the knee. The valgus component of noncontact injuries has been thought to cause mainly lateral compartment bone bruising. Posterior translation is the most common mechanism of posterior cruciate ligament rupture, and hyperextension and varus is associated with posterolateral corner injury.

Question 64

During an open reduction internal fixation of a humerus fracture using the posterior approach, a surgeon can identify the posterior antebrachial cutaneous nerve and trace it proximally to which of the following nerves?

Explanation

DISCUSSION: The posterior antebrachial cutaneous nerve branches from the radial nerve in the axilla. It extends distally to innervate the skin on the back of the arm. Gerwin et al recommended identifying the nerve first when approaching the humerus from the posterior shaft. It can be traced proximally to safely identify the radial nerve before any proximal exposure of the shaft is done. Gerwin et al in their review also found that the radial nerve crossed the posterior aspect of the humerus an average of 20.7 +/- 1.2 centimeters proximal to the medial epicondyle to 14.2 +/-

Question 65

Figure 49 shows a histologic section of the lung in a patient who died during total hip arthroplasty. What unexpected finding is seen in the pulmonary capillaries?

Explanation

DISCUSSION: Sudden death during total hip arthroplasty has been reported. In a report from the Mayo Clinic, intraoperative death occurred during cemented total hip arthroplasty in

23 patients. Fat and marrow embolization during preparation of the femur or cementing of the femoral component was believed to be responsible for the cardiopulmonary collapse that occurred during arthroplasty. Although fat and marrow emboli were found in the pulmonary capillaries of most of the patients on autopsy, this histologic section shows two particles of cement in the pulmonary capillaries.
REFERENCES: Parvizi J, Holiday AD, Ereth MH, et al: The Frank Stinchfield Award. Sudden death during primary hip arthroplasty. Clin Orthop 1999;369:39-48.
Patterson BM, Healy JH, Cornell CN, et al: Cardiac arrest during hip arthroplasty with a cemented long-stem component: A report of seven cases. J Bone Joint Surg Am

1991;73:271-277.

Question 66

A 10-year-old boy has 2 months of right knee pain that started at summer camp. The patient denies constitutional symptoms. There is no lymphadenopathy present. CT of the chest shows no signs of metastatic disease. Imaging studies and biopsy results are shown in Figures A-E. What is the most likely diagnosis?

Explanation

The age, imaging and histology are consistent with an osteosarcoma. The radiograph shows an aggressive (lytic, mottled, sclerotic) appearing lesion around the distal femur metadiaphyseal region. The T2 weighted MRI image shows a significant soft tissue mass which appears to arise from the distal femur with destruction of the adjacent cortex. The biopsy shows an infiltrative pattern with elements of osteoid and bone.
Treatment for osteosarcoma includes neoadjuvant chemotherapy, wide resection, and adjuvant chemotherapy.

Question 67

A 59-year-old woman with a history of osteoporosis is involved in a high-speed motor vehicle accident, resulting in left hip pain and deformity. The initial radiograph from the trauma bay is shown in Figure 1. Postreduction CT is shown in Figures 2 through 4. What is the most appropriate definitive surgical treatment?

Explanation

DISCUSSION:
The radiograph shows a posterior wall acetabular fracture-dislocation. Post reduction CT indicates a large comminuted posterior wall fracture with marginal impaction of the articular surface. A comminuted femoral head fracture also is seen extending to the superior weight-bearing surface. Given the marginal
impaction of the acetabulum and the considerable comminution of the femoral head (which is likely unreconstructible), this injury would have a high risk of causing posttraumatic arthritis if treated with ORIF of the fractures alone. Considering this fact and the patient’s age, ORIF of the posterior wall and acute total hip arthroplasty would likely have the best functional result and the lowest risk of reoperation. Hemiarthroplasty is inappropriate for this injury considering the acetabular fracture. Skeletal traction currently plays a limited role in the definitive treatment of acetabular fractures.

Question 68

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement? Review Topic

Explanation

Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain.
(SBQ13PE.10) Which statement is true regarding discoid menisci? Review Topic
Most commonly involves the medial meniscus
Bilateral in >75% of cases
Asymptomatic discoid meniscus should undergo saucerization
Radiographs will commonly show a hyperplastic lateral intercondylar spine
Radiographs will commonly show squaring of affected condyle with cupping of tibial plateau
Radiographs of knees with discoid menisci will commonly show squaring of affected condyle (lateral>medial) with cupping of tibial plateau.
Discoid meniscus refers to the abnormal development of a hypertrophic and discoid shaped meniscus. It occurs in 3-5% of the population and it is considered the most common cause of a symptomatic clicking or clunking in a childs knee. The lateral meniscus is most commonly affected and it will occur bilaterally in 25% of affected
people. The Watanabe Classification describes the 3 types of discoid menisci. Type 1
= Incomplete, Type 2 = Complete, Type 3 = Wrisberg (lack of posterior meniscotibial attachment to tibia)
Kramer et al. looked at the presentation of pediatric knee pain. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the discoid meniscus.
Lee et al. retrospectively reviewed 36 patients aged less than 15 years who underwent arthroscopic procedures for torn discoid menisci. The mean patient age at the time of surgery was 9.5 years. They showed that partial meniscectomy yielded better radiologic results than subtotal/total meniscectomy for torn discoid menisci in this population.
Illustration A shows the 3 classifications of discoid menisus as originally described by Watanabe. Type 4 is a ring type discoid that was not originally described by Watanabe in his 1978 paper. Illustration B shows an AP and lateral radiograph of a discoid meniscus knee. Note squaring of affected lateral condyle in the presence of a lateral discoid meniscus. Illustration C shows 4 consecutive sagittal MRI images with meniscus continuity. It is important to note that the diagnosis of discoid menisci can be made when 3 or more 5mm sagittal images show meniscal continuity.
Incorrect Answers:

Question 69

A 27-year-old runner training for his first marathon reports lateral knee pain after an unusually long training run. He states that the most significant pain occurs while running downhill. Examination of the patient while he is laying on the unaffected side reveals increased pain when manual pressure is applied to the lateral femoral epicondylar area during knee range of motion of 30° to 45°. What is the most likely diagnosis?

Explanation

DISCUSSION: Iliotibial band friction syndrome is one of the most common causes of lateral knee pain in runners. It is caused by increased friction between the iliotibial band and the lateral femoral condyle because of increased tension on the lateral structures. It may be caused by a prominence of the lateral epicondyle or a malalignment of the lower extremity in the runner, including genu varum, tibia vara, heel varus and forefoot supination, or compensating pronation. These structural characteristics can couple with relative muscle imbalance and lead to an altered running gait, enhancing friction between the lateral femoral condyle and the iliotibial band. Management is usually nonsurgical, including stretching of the iliotibial band and strengthening of the hip abductor muscles, with occasional use of cortisone injections or iontophoresis.
REFERENCES: Noble CA: The treatment of iliotibial band friction syndrome. Br J Sports Med 1979;13:51-54.
James SL: Running injuries to the knee. J Am Acad Orthop Surg 1995;3:309-318.
James SL, Jones DV: Biomechanical aspects of distance running, in Cavanagh PR (ed): Biomechanics of Distance Running. Champaign, IL, Human Kinetic Books, 1990, pp 249-269.

Question 70

When comparing gait parameters between a patient with an anterior cruciate ligament (ACL) deficiency to a patient with a normal knee, the patient with an ACL deficiency has which of the following? Review Topic

Explanation

During normal gait kinematics, the knee is in near full extension at heel strike with relative internal rotation of the femur relative to the tibia. During midstance (swing phase of the contralateral extremity), there is flexion of the knee and external rotation of the femur relative to the tibia. In addition, in the normal knee there is relative anterior translation of the tibia during late swing with contraction of the quadriceps. Between heel strike and midstance there is posterior translation of the tibia relative to the femur. In an ACL-deficient knee, there is abnormal kinematics characterized by absence of the normal femoral internal rotation during the terminal swing phase. Furthermore, there is decreased anterior translation of the tibia in late swing, presumably an adaptive response with decreased quadriceps contraction and/or increased hamstring contraction.

Question 71

-The Coleman block test is used to test for

Explanation

Question 72

What is the best way to determine whether a radial head implant is too thick intraoperatively?

Explanation

Widening of the medial ulnohumeral joint on an AP radiograph is only visible after overlengthening of the radial head by 6 mm or more. At least in this cadaver study, the most sensitive method was to visually assess the lateral aspect of the ulnohumeral joint with the radial head resected and then with the trial radial head in place. This method allows detection of any overlengthening.

Question 73

Which of the following is a long-term complication of ankle arthrodesis for posttraumatic arthritis?

Explanation

DISCUSSION: Ankle arthrodesis for posttraumatic ankle arthrosis provides reliable pain relief. However, the long-term sequela of joint arthrodesis is the development of arthrosis in the surrounding joints. Over time, following ankle arthrodesis, the ipsilateral hindfoot and midfoot joints show signs of joint space wear, and this may be symptomatic. With a stable ankle arthrodesis, progressive limb-length discrepancy or talar osteonecrosis is not expected. Ankle arthrodesis has not been definitively linked to ipsilateral knee arthritis or contralateral ankle arthritis.
REFERENCES: Coester LM, Saltzman CL, Leupold J, Pontarelli W: Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 2001;83:219-228.
Mazur JM, Schwartz E, Simon SR: Ankle arthrodesis: Long-term follow-up with gait analysis. J Bone Joint Surg Am 1979;61:964-975.

Question 74

A 12-year-old boy reports the acute onset of pain and a pop over the right side of his pelvis while swinging a baseball bat during a Little League game. Radiographs reveal an avulsion of the anterior superior iliac spine with 2 cm of displacement. Management should consist of Review Topic

Explanation

Anterior superior iliac spine avulsion fractures are caused by sudden, forceful contractions of the sartorius and tensor fascia lata. These injuries occur in young athletes through the growth plate with the hip extended and the knee flexed, such as while sprinting or swinging a baseball bat. The athlete will often report a pop or snap at the time of injury. Displaced fractures usually can be seen on radiographs. CT or MRI can be obtained to confirm the diagnosis. In most patients, nonsurgical management consisting of rest and protected weight bearing yields satisfactory outcomes. Surgery is usually reserved for fractures with displacement of more than 3 cm and painful nonunions.

Question 75

The husband of a 22-year-old woman has hypophosphatemic rickets. The woman has no orthopaedic abnormalities, but she is concerned about her chances of having a child with the same disease. What should they be told regarding this disorder?

Explanation

DISCUSSION: Hypophosphatemia is a rare genetic disease usually inherited as an X-linked dominant trait. The fact that the woman has no skeletal manifestations would indicate that the husband has the X-linked mutation. The disease is more severe in boys than it is in girls. The husband will not transmit the disease to his sons. However, all of their daughters will be affected either with the disease or as carriers. If the woman has the disease or the trait, there is a 50% chance that her sons will inherit the disease and a 50% chance that her daughters will be carriers or have a milder form of the disease. Parents should be advised to have genetic counseling so they can be informed when deciding whether to have children.
REFERENCES: Herring JA: Metabolic and endocrine bone diseases, in Tachdjian’s Pediatric Orthopaedics, ed 3. New York, NY, WB Saunders, 2002, pp 1685-1743.
Sillence DO: Disorders of bone density, volume, and mineralization, in Rimoin DL, Conner JM, Pyerite RE, et al (eds): Principles and Practice of Medical Genetics, ed 4. New York, NY, Churchill Livingstone, 2002.
Staheli LT: Practice of Pediatric Orthopedics. Philadelphia, PA, Lippincott Williams & Wilkins, 2001.

Question 76

A teenager had pain in the left buttock while running the hurdles. He was treated with 4 weeks of rest and crutch walking, and then started physical therapy for stretching and muscle strengthening. Nine months later he now reports pain with sitting and has not been able to resume running or sports activity. Figure 96 shows a radiograph of the pelvis. Treatment should consist of which of the following?

Explanation

DISCUSSION: The patient has an established nonunion of the ischial tuberosity. Avulsion fractures of the pelvis are generally treated with rest and symptomatic treatment. Avulsion fractures of the ischial tuberosity are the most prone to nonunion. Most patients have few symptoms but some have trouble sitting and returning to sports. Excision of the avulsed fragment or open reduction and internal fixation are indicated for painful nonunions of the ischial tuberosity.
REFERENCES: Fembach SK., Wilkinson RH: Avulsion injuries of the pelvis and proximal femur. AJR Am J Roentgenol 1981;137:581-584.
Watts HG: Fractures of the pelvis in children. Orthop Clin North Am 1976;7:615-624. Question 97
Congenital anomalies of the vertebral column are associated frequently with other organ system problems. In addition to radiographs of the spine, what other screening tests should be ordered?
Spinal MRI, coagulation panel
Liver enzymes, coagulation panel
Renal ultrasound, upper and lower GI
Cardiac evaluation/echocardiogram, upper and lower GI
Renal ultrasound, cardiac evaluation/echocardiogram, spinal MRI
DISCUSSION: Approximately 60% of patients with congenital anomalies of the spine have other associated findings. The spine develops around the same time as the cardiovascular system, the genitourinary system, and the musculoskeletal system. Around 20% of patients with congenital scoliosis have an associated urologic abnormality. Approximately 25% of patients with congenital scoliosis have an associated cardiac defect. Spinal cord abnormalities in one study occurred in approximately 37% of patients with congenital scoliosis.
REFERENCES: Basu PS, Elsebaie H, Noordeen MH: Congenital spinal deformity: A comprehensive assessment at presentation. Spine 2002;27:2255-2259.
Ferguson RL: Medical and congenital comorbidities associated with spinal deformities in the immature spine. J Bone Joint Surg Am 2007;89:34-41.
McMaster MJ, Ohtsuka K: The natural history of congenital scoliosis: A study of two hundred and fifty- one patients. J Bone Joint Surg Am 1982;64:1128-1147.
2010 Pediatric Orthopaedic Examination Answer Book • 81

Figure 98a Figure 98b

Question 77

Which of the following mechanisms of inhibition has been linked to cigarette smoking and lumbar spinal fusion?

Explanation

DISCUSSION: Cigarette smoking has been directly linked to pseudarthrosis in spinal fusions. The direct mechanism of action is diminished revascularization of cancellous bone graft. Additionally, a smaller area of revascularization is seen in these grafts, as well as an increased area of necrosis. Increased activity of osteoblasts would result in more bone production. Increased activity of osteocytes would not affect the fusion because osteocytes are mature bone cells.
REFERENCE: Daftari TK, Whitesides TE Jr, Heller JG, et al: Nicotine on the revascularization of bone graft: An experimental study in rabbits. Spine 1994;19:904-911.

Question 78

Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints?

Explanation

images with tibial stress fractures.
After activity, pain persists longer with tibial stress fractures.
DISCUSSION: Anterior tibial pain can often be difficult to diagnose. A bone scan showing the tibial cortex in a diffuse, longitudinal orientation is consistent with shin splints compared to a more discreet, localized uptake more commonly seen with a stress fracture. Bone stress injuries are due to cyclical overuse of the bone. They are relatively common in athletes and military recruits but are also seem in otherwise healthy people who have recently started new or intensive physical activity. Diagnosis of bone stress injuries is based on the patient’s history of increased physical activity and on imaging findings.
The general symptom of a bone stress injury is stress-related pain. Bone stress injuries are difficult to diagnose based only on a clinical examination because the clinical symptoms may vary depending on the phase of the pathophysiological spectrum in the bone stress injury. Imaging studies are needed to ensure an early and exact diagnosis. If the diagnosis is made early, most bone stress injuries heal well without complications.
REFERENCES: Mubarak SJ, Gould RN, Lee YF, et al: The medial tibial stress syndrome: A cause of shin splints. Am J Sports Med 1982;10:201-205.
Knobloch K, Yoon U, Vogt PM: Acute and overuse injuries correlated to hours of training in master running athletes. Foot Ankle Int 2008:29:671-676.
Kiuru MJ, Pihlajamaki HK, Ahovuo JA: Bone stress injuries. Acta Radiol 2004;45:317-326.

Question 79

The arrow in the axial T 1 -weighted MRI scan shown in Figure 18 is pointing to which of the following structures?

Explanation

DISCUSSION: The arrow is pointing to the ulnar nerve within Guyon’s canal. Guyon’s canal is approximately 4 cm long, beginning at the proximal extent of the transverse carpal ligament and ending at the aponeurotic arch of the hypothenar muscles. Many structures comprise the boundaries of Guyon’s canal. The floor, for example, consists of the transverse carpal ligament, the pisohamate and pisometacarpal ligaments, and the opponens digiti minimi. Within Guyon’s canal, the ulnar nerve bifurcates into the superficial and deep branches, with the deep branch of the ulnar nerve persisting distal to the canal. The ulnar artery is immediately adjacent and radial to the ulnar nerve. The median nerve is visualized within the carpal tunnel. The radial artery is on the radial side of the wrist. The hook of the hamate is clearly seen in the figure, orienting the observer to the ulnar side of the wrist.
REFERENCES: Goss MS, Gelberman RH: The anatomy of the distal ulnar tunnel. Clin Orthop 1985;196:238-247.
Denman EE: The anatomy of the space of Guyon. Hand 1978;10:69-76.

Question 80

Six months later, the patient’s fracture has healed and a CT scan to further evaluate the physis is performed (Video 85). Based on these findings, how should you advise the family?

Explanation

DISCUSSION
The hypertrophic zone is the weakest biomechanical zone of the physis and is most likely to fracture. The deep peroneal nerve supplies motor innervation to the ankle and toe
dorsiflexors (anterior compartment) and the first web space, which, in this history, have deficits. The superficial peroneal nerve supplies sensation to the dorsum of the foot and motor to the lateral compartment peroneal musculature (ankle evertors), which also has deficits. The injury must involve both peroneal branches (the common peroneal nerve). Because sensation to the sole of the foot and toe/ankle plantar flexion is intact, the tibial nerve is intact.
Because the nerve was visualized intact, a neuropraxia is the most likely type of nerve injury. This should recover in time and does not necessitate urgent exploration. In pediatric patients, an advancing Tinel sign and partial nerve recovery by 3 months is expected and can be followed clinically. If there is no sign of nerve recovery, an electromyogram should be ordered with consideration for nerve exploration if there is no sign of reinnervation. There is no sign of compartment syndrome because the patient has an unchanged neurologic deficit, is comfortable, and has no pain with passive range of motion.
These injuries are associated with a very high rate of growth arrest (up to 80% in some studies). The CT scan shows an asymmetric growth arrest, which suggests angulation through the distal femur.

Question 81

A 14-year-old boy reports progressive right wrist pain. Radiographs are shown in Figure 3a, and a photomicrograph is shown in Figure 3b. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs show a benign-appearing, well-defined lytic lesion with a thin rim of surrounding reactive bone. The photomicrograph shows spindle cells with a myxoid cartilaginous matrix. These findings are diagnostic of chondromyxoid fibroma. This is a rare, benign tumor that usually causes pain and can be locally aggressive.
REFERENCES: Lersundi A, Mankin HJ, Mourikis A, et al: Chondromyxoid fibroma: A rarely encountered and puzzling tumor. Clin Orthop Relat Res 2005;439:171-175.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.

Question 82

A 28-year-old man sustains the closed injury shown in Figures 3a through 3c after falling 8 feet while rock climbing. Management should consist of

Explanation

DISCUSSION: The radiographs show a comminuted talar body fracture. The goal of treatment is to minimize the risks of posttraumatic arthrosis of the ankle and subtalar joint and to maintain vascularity. Open reduction and internal fixation with an attempt at anatomic reduction will lead to improved outcomes. Attempting to repair this fracture via an arthrotomy only is extremely difficult, and the addition of a medial malleolar osteotomy is warranted. A limited anterior lateral arthrotomy with minimal soft-tissue stripping may assist with fixation of anterior-lateral and lateral fragments and allow better assessment of reduction of the major fracture line. Nonsurgical care would lead to inadequate reduction and increased risk of both ankle and hindfoot arthrosis. Talectomy and primary ankle and hindfoot arthrodesis should not be performed as primary surgical reconstructive options in this closed injury pattern.
REFERENCES: Sanders R: Fractures and fracture-dislocations of the talus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp

1465-1518.
Grob D, Simpson LA, Weber BG, Bray T: Operative treatment of displaced talus fractures. Clin Orthop 1985;199:88-96.

Question 83

A 30-year-old patient has wrist pain. A radiograph and biopsy specimen are shown in Figures 34a and 34b. What is the most likely diagnosis?

Explanation

DISCUSSION: Aneurysmal bone cysts typically present as radiolucent lesions with an expansile remodeled cortex. The histologic appearance consists of blood-filled lakes surrounded by a benign lining that contains fibroblasts, giant cells, and hemosiderin. Although the other lesions are in the radiographic differential diagnosis, these histologic findings indicate an aneurysmal bone cyst.
REFERENCES: Bieselker JL, Marcove RC, Huvos AG, Mike V: Aneurysmal bone cyst: A Clinico-pathologic study of 66 cases. Cancer 1973;26:615.
Martinez V, Sissons HA: A review of 123 cases including primary lesions and those secondary to other bone pathology. Cancer 1988;61:2291.

Question 84

A 20-year-old man sustained an injury to his arm during a tug-of-war contest. An MRI scan is shown in Figure 18. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scan reveals a transection of the biceps muscle. The underlying brachialis is intact. This injury can occur as a result of a cord wrapped around the upper arm. Care should be taken to ensure that there is no concurrent vascular injury. A posterior subcutaneous lipoma appears as a well-encapsulated mass on T₂-weighted images.
REFERENCES: Heckman JD, Levine MI: Traumatic closed transection of the biceps brachii in the military parachutist. J Bone Joint Surg Am 1978;60:369-372.
Mellen PF: Parachute static line injury with vascular compromise. Mil Med 1989;154:364-365.

Question 85

Figure 38 shows the radiograph of a 75-year-old woman who has had right shoulder pain, difficulty sleeping on the affected arm, and difficulties performing activities of daily living for the past 6 weeks. Initial nonsurgical management includes analgesics, a subacromial cortisone injection, and gentle range-of-motion exercises. However, these modalities have failed to provide relief, and the patient reports that she is unable to elevate her arm. Her pain is worse and she would like the most reliable treatment method for pain relief and functional improvement. What is the best surgical treatment? Review Topic

Explanation

The authors of several studies conducted in Europe have reported promising results in the short- and medium-term with use of a reversed or inverted shoulder implant. The most recent investigation, a multicenter study in Europe in which 77 patients (80 shoulders) with glenohumeral osteoarthritis and a massive rupture of the rotator cuff were treated with the Delta III prosthesis, described an improvement in the mean constant score of 42 points, an increase of 65 degrees in forward elevation, and minimal or no pain in 96% of the patients. Hemiarthroplasty, the “nonconstrained”
option, has long been the standard of care for rotator cuff tear arthropathy. However, careful examination of the literature reveals that the results have not been uniform.

Question 86

Figures 18a and 18b show the radiographs of a patient who has pain with walking. On careful questioning, it is determined that the discomfort occurs at push-off, or when the patient attempts to climb stairs. What nonsurgical option is most likely to ameliorate the symptoms?

Explanation

DISCUSSION: The patient has a malunion of an attempted open reduction of a Lisfranc dislocation. The pain occurs during the terminal stance phase of gait as load is being transferred from the hindfoot to the forefoot. The bending moment can be best neutralized with shoe modification with a cushioned heel and rocker sole, which best unloads the tarsal-metatarsal junction.
REFERENCES: Bono CM, Berberian WS: Orthotic devices: Degenerative disorders of the foot and ankle. Foot Ankle Clin 2001;6:329-340.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 58-63.

Question 87

A 56-year-old mechanic has had pain in the hypothenar region of his dominant right hand for the past 6 months. He reports weakness in his grip and pain is worse with activity. Which of the following examination findings is most suggestive of a cervical etiology? Review Topic

Explanation

Hypothenar atrophy is a nonspecific sign that can be seen in ulnar neuropathy, C8 radiculopathy, or even cervical myelopathy; however, the atrophy usually is not unilateral and includes other muscle groups. The Spurling test is an excellent method of eliciting cervical radicular pain but involves hyperextension and ipsilateral rotation of the cervical spine, resulting in nerve root compression by reducing the cross-sectional area of the ipsilateral neuroforamen. Tinel’s sign at the levator scapulae, if present, is indicative of an upper cervical (C3 or C4) radiculopathy. A subluxable ulnar nerve at the cubital tunnel, while often asymptomatic, points toward cubital tunnel syndrome as an etiology for this patient’s pain. The shoulder abduction relief (SAR) sign (relief of upper extremity pain with shoulder abduction) is virtually pathognomic of cervical radiculopathy because this maneuver results in relaxation of a compressed and/or inflamed cervical nerve root. The SAR sign is the converse analog of the straight leg raising sign in the lumbar examination for lumbar radiculopathy, as it relieves tension in the nerve root, thereby relieving symptoms.

Question 88

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

Explanation

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

Question 89

What is the treatment of choice for an adult who has an isolated fracture of the ulna at the junction of the distal and middle thirds, with 5 degrees apex dorsal angulation and 25% displacement?

Explanation

This is the correct answer for various reasons, based on the question. Key points isolated fracture, distal and middle thirds, and only 25% displace. The author is implying minimal displacement. According to Gebuhr, Holmich a fracture such as describe in the question which does not require close reduction and only initial mobilization are better satisfied with a functional brace. Their study revealed that elbow extension/flexion and forearm pronation/supination had no difference with long arm cast, but wrist extension/flexion greatly improved with the functional bracing. Selections (1) more indicated for midshaft (3) is not inappropriate, but the authors felt it was not necessary because there was greater patient satisfaction with functional bracing and same results except wrist motion was better. (4), (5) are indicated for greater severity of fracture and failed union.

Question 90

-A 12-year-old boy who plays multiple sports has had insidious-onset heel pain while running for 4 months. On examination, he had ankle dorsiflexion of 5 degrees. The squeeze test result was positive and the Thompson test result was negative. He has no pain with forced ankle plantar flexion. What is the most likely diagnosis?

Explanation

CLINICAL SITUATION FOR QUESTIONS 60 AND 61
A 15-year-old boy has had shoulder pain for 4 weeks during the middle of baseball season. The patient says his pain is “all over my shoulder.” Examination reveals tenderness to palpation over the anterolateral aspect of the shoulder. Internal and external rotation range of motion is restricted.
Radiographs show metaphyseal sclerosis.

Question 91

According to clinical and biomechanical studies, the most appropriate position for a headless scaphoid compression screw for repair of a scaphoid waist fracture is

Explanation

demonstrated significantly improved biomechanical stability with centrally placed long screws vs centrally placed short screws. The screw may be placed retrograde or antegrade. Although the screw position may be relatively parallel to the radial inclination as the shape of the scaphoid body follows the contour of the radial styloid, screw position should be assessed relative to the scaphoid’s own architecture. Placing the screw in a retrograde fashion can force the treating surgeon to start the screw eccentrically in an attempt to avoid the interference of the trapezium lying over the distal pole of the scaphoid. This may result in noncentral screw placement.

Question 92

What allograft has the highest antigenicity when used for ligament reconstruction about the knee?

Explanation

Although theoretically the intra-articular environment is slightly more immune privileged, the role of immunogenicity is related more to bone than soft tissue. Therefore, the bone-patellar tendon-bone used for ACL reconstruction would have the highest risk of immunogenicity if storage techniques and harvest techniques were similar. This also is true for bone plugs associated with meniscal allografts.

Question 93

In total knee arthroplasty, in vitro testing has shown that cross-linking can diminish the rate of polyethylene wear by 30% to 80%. What other change in material properties is possible when polyethylene is highly cross-linked?

Explanation

DISCUSSION:
The most important concern regarding highly cross-linked polyethylene relates to decreased mechanical properties. Cross-linking results in reduced ductility, tensile strength, and fatigue crack propagation resistance. These problems have not been shown to cause implant failure in the most recent clinical trials, but they remain the most important mechanical issues associated with current material processing methods.

Question 94

Figures 24a through 24c show the coronal T 1 -weighted, T 2 -weighted fat-saturated, and T 1 -weighted fat-saturated gadolinium MRI scans of the proximal thigh of a 52-year-old woman who reports a mass in the medial thigh and groin area. She notes that the fullness has grown in size over the course of many months. Based on these findings, what is the most likely diagnosis?

Explanation

DISCUSSION: The images show a complex, lobular lesion of the thigh that has signal characteristics that follow fat. The size of the lesion, the areas of stranding within the mass, along with mild uptake on the gadolinium sequences and the mild edema within the lesion on the T₂-weighted image make liposarcoma the most likely diagnosis and simple intramuscular lipoma far less likely. All other diagnoses listed would not follow fat characteristics shown on the MRI sequences.
REFERENCE: Sanders TG, Parsons TW: Radiographic imaging of musculoskeletal neoplasia. Cancer Control 2001;8:221-231.

Question 95

A 42-year-old woman with a long-standing history of rheumatoid arthritis undergoes total shoulder arthroplasty for persistent pain that has failed to respond to nonsurgical management. Intraoperative radiographs reveal an oblique, minimally displaced fracture of the greater tuberosity. Based on these findings, what is the best course of action?

Explanation

DISCUSSION: The risk of intraoperative fracture in osteoporotic bone in patients with rheumatoid arthritis is significant. Fractures most often occur during humeral head dislocation and positioning for canal reaming. If the fracture occurs at the greater tuberosity, cerclage suture fixation of the tuberosity fracture with autogenous cancellous bone graft from the resected humeral head is the treatment of choice.
REFERENCES: Wright TW, Cofield RH: Humeral fractures after shoulder arthroplasty. J Bone Joint Surg Am 1995;77:1340-1346.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 215-225.
Frankle MA, Ondrovic LE, Markee BA, et al: Stability of tuberosity reattachment in proximal humeral hemiarthroplasty. J Shoulder Elbow Surg 2002;11:413-420.

Question 96

A patient who sustained injuries in a motorcycle accident 30 minutes ago has significant motor and sensory deficits corresponding to a C6 level of injury. A lateral radiograph obtained during the initial on-scene evaluation reveals bilateral jumped facets at C5-C6; this appears to be an isolated injury. The patient is awake and alert. The next step in management of the dislocation should consist of

Explanation

DISCUSSION: Surgical open reduction may increase the neurologic deficit if a disk herniation exists. Evidence from animal studies suggests that rapid decompression of the spinal cord may improve recovery. Serially increasing traction weight to reduce the dislocation has been shown to be safe when used in patients who are awake. Indications for MRI include patients who are unable to cooperate with serial examinations, the need for open reduction, and progression of deficit during awake reduction.
REFERENCES: Delamarter RB, Sherman J, Carr JB: Pathophysiology of spinal cord injury: Recovery after immediate and delayed decompression. J Bone Joint Surg Am

1995;77:1042-1049.
Star AM, Jones AA, Cotler JM, Balderston RA, Sinha R: Immediate closed reduction of cervical spine dislocations using traction. Spine 1990;15:1068-1072.
Eismont FJ, Arena MJ, Green BA: Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets: Case report. J Bone Joint Surg Am

1991;73:1555-1560.

Question 97

A 75-year-old man presents with worsening low back and bilateral leg pain. The pain worsens with ambulation and improves with sitting. On exam, he has strong DP and PT pulses. Straight leg raise is negative. A MRI of the lumbar spine is performed and is pictured in Figure A. On further questioning, which of the following is the patient also likely to report? Review Topic

Explanation

The patient has lumbar spinal stenosis with neurogenic claudication and therefore is likely to experience worsening pain with activities that result in lumbar extension, such as walking down stairs.
Lumbar spinal stenosis often results from degenerative changes of the intervertebral disc and facet joints which ultimately narrows the space available for the thecal sac and exiting nerve roots. Patients can present with neurogenic claudication, reported as worsening leg and/or back pain with ambulation and diminished walking capacity. MRI may demonstrate disc degeneration/bulging, hypertrophy of the ligamentum flavum and facet capsule, and narrowing of the central canal. Nonoperative management includes NSAIDs, PT and epidural steroid injections (ESI). Surgery is reserved for patients who have failed nonoperative measures and includes decompressive laminectomy with or without fusion depending on presence of instability.
Issack et al reviewed degenerative lumbar spinal stenosis. Unlike patients with vascular claudication, patients with neurogenic claudication are able to improve walking tolerance with postural changes, specifically with flexed-forward posture (such as leaning forward on a shopping cart). They are unable to improve their symptoms simply by cessation of walking. Patients with neurogenic claudication tend to lack the trophic changes of the skin on the legs/feet as well as diminished pulses characteristic of vascular disease.
Young et al reviewed the utilization of lumbar ESI for low back and leg pain. The authors concluded that lumbar ESI are a reasonable nonsurgical option to provide temporary symptomatic relief. Fluoroscopic guidance facilitates accurate placement of the injection into the epidural space, while its nonuse may lead to higher percentage of technical failures. Lastly, the transforaminal approach is more selective
than the interlaminar approach and can provide diagnostic information as well as symptom relief.
Figures A and B are T1 sagittal and T2 axial MR images, respectively, of the lumbar spine demonstrating significant central canal stenosis most notable at L4-L5 with broad disc protrusion, facet degeneration and infolding of the ligamentum flavum.
Incorrect
Responses:

Question 98

Figure 10 is an anteroposterior pelvis radiograph of an 82-year-old man who had right hip pain that began 2 weeks ago but has since resolved with use of over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs). Currently he has no pain. Examination of his hip shows decreased internal rotation and minimal pain at the extremes of motion. What is the most appropriate treatment at this point?

Explanation

DISCUSSION
The radiograph shown is consistent with Paget disease of the bone. It demonstrates classic findings of widened lamellae and disorganized sclerotic and lytic areas. The cause is not clearly defined, but may be linked to a viral infection and subsequent alterations of osteoblastic and osteoclastic activity. Most patients are asymptomatic, and Paget disease is often found incidentally on radiographs. In this case, the patient’s symptoms likely were caused by hip arthritis, but Paget disease can cause diffuse bone pain in some cases. Considering the patient’s mild and short-term symptoms, observation and NSAID use is most appropriate. An MRI scan or biopsy is indicated if sarcomatous transformation is suspected, but this condition is rare and is associated with a substantial, unrelenting increase in pain. SPEP and UPEP are tests for multiple myeloma, of which the radiographs show no signs.
RECOMMENDED READINGS
Ralston SH. Pathogenesis of Paget's disease of bone. Bone. 2008 Nov;43(5):819-25. doi: 10.1016/j.bone.2008.06.015. Epub 2008 Jul 11. Review. PubMed PMID: 18672105.View Abstract at PubMed
Bonenberger E, Einhorn T. Metabolic bone diseases. In: Callaghan JJ, Rosenberg
AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams 14
& Wilkins; 2007:514-533.

Question 99

Which of the following methods best aids in diagnosis of an interdigital neuroma?

Explanation

DISCUSSION: History and physical examination are still the gold standard for diagnosis of an interdigital neuroma. Ultrasound and MRI may be helpful adjuncts but are dependent on equipment and operator expertise. Web space injection may be helpful for diagnostic and therapeutic purposes. Electromyography and nerve conduction velocity studies are of little benefit for distal lesions.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 145-147.
Bennett GL, Graham CE, Mauldin DM: Morton’s interdigital neuroma: A comprehensive treatment protocol. Foot Ankle Int 1995;16:760-763.

Question 100

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

Explanation

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

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Arthroscopic Bankart surgery
Bony glenoid augmentation procedure
Subscapularis advancement
Open capsular shift
Hemiarthroplasty

Correct Answer: Bony glenoid augmentation procedure

Explanation:

Question 2:

Options:

Claims made with "nose" coverage
Claims made without tail coverage
No policy because of employed status and sovereign immunity
Occurrence coverage
Occurrence coverage with "nose" coverage

Correct Answer: Occurrence coverage

Explanation:

Question 3:

Options:

distal Chevron osteotomy.
proximal metatarsal osteotomy with soft-tissue release.
shoe wear modifications.
dorsal cheilectomy with Moberg osteotomy.
hallux metatarsophalangeal joint arthroplasty.

Correct Answer: shoe wear modifications.

Explanation:

Question 4:

Options:

Adjunctive plate fixation without nail removal
Nail removal and plating
Partial fibulectomy at the same level as the tibia fracture and weightbearing cast application
Exchange nailing
Local administration of rhBMP-2

Correct Answer: Adjunctive plate fixation without nail removal

Explanation:

Question 5:

Of the following variables, which has the strongest influence on external fixator stiffness?

Options:

Pin diameter
Pin spread
Bone quality
Stacking a second fixator bar
Distance from bone to fixator bar

Correct Answer: Pin diameter

Explanation:

Whereas all of the factors will have an impact on frame rigidity and stability, the single biggest factor is the pin diameter because it has an exponential effect.

Question 6:

Options:

Bracing with a thoracolumbosacral orthosis (TLSO)
Observation with repeat radiographs of the scoliosis in 3 months and nonsteroidal antiinflammatory drugs for the pain
MRI of the neuro-axis
Surgical removal
Radiofrequency ablation

Correct Answer: Surgical removal

Explanation:

Question 7:

Options:

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

Correct Answer: Remove the Kirschner wires and reposition the ankle

Explanation:

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

Question 8:

Options:

Suprascapular
Infraspinatus branch of the suprascapular
Long thoracic
Axillary
Lateral cord of the brachial plexus

Correct Answer: Axillary

Explanation:

Question 9:

Options:

Osteomyelitis
Langerhan’s cell histiocytosis
Ewing’s sarcoma
Lymphoma
Neuroblastoma

Correct Answer: Langerhan’s cell histiocytosis

Explanation:

DISCUSSION: Langerhans cell histiocytosis or eosinophilic granuloma is a nonneoplastic lesion that is part of a spectrum of clinical diseases featuring histiocytes. Most occur during the first two decades of life within any bone. Radiographs show a radiolucent lesion, frequently diaphyseal in location. A periosteal response is occasionally seen and can resemble more aggressive lesions such as osteomyelitis or Ewing’s sarcoma. Histology demonstrates CD1a positive histiocytes with large oval-shaped nuclei with indentation, and a variable presence of eosinophils.
REFERENCES: Plasschaert F, Craig C, Bell R, et al: Eosinophilic granuloma: A different behaviour in children than in adults. J Bone Joint Surg Br 2002;84:870-872.
Campanacci M: Bone and Soft Tissue Tumors, ed 2.
New York, NY, Springer-Verlag, 1999, pp 857-876.

Question 10:

Options:

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

Correct Answer: aspiration.

Explanation:

Question 11:

Which of the following surgical options after resection of a sarcoma about the knee would require a patient to expend the greatest amount of energy while walking?

Options:

Arthrodesis
Rotationplasty
Above-knee amputation
Osteoarticular allograft
Endoprosthesis (custom arthroplasty)

Correct Answer: Above-knee amputation

Explanation:

Question 12:

Options:

Ban the athlete from sports participation.
Allow the athlete to participate as it is his constitutional right to do so.
Advise the college to revoke the athlete's college scholarship.
Offer no opinion as it is a matter strictly between the college and the athlete.
Recuse yourself from all decision making and advise the athlete to get an opinion from a third-party physician who is not employed by the college or university.

Correct Answer: Ban the athlete from sports participation.

Explanation:

Question 13:

Options:

continued rapid fluid infusion.
administration of broad-spectrum antibiotics.
administration of 30/mg/kg methylprednisolone over 1 hour.
administration of pressors.
cardioversion and implantation of a pacemaker.

Correct Answer: administration of pressors.

Explanation:

DISCUSSION: The hallmark of neurogenic shock is hypotension without tachycardia. It is associated most commonly with high cervical spinal cord injuries and results from loss of function of the sympathetic nervous system. Because the peripheral vasculature is dilated due to loss of its sympathetic tone, continued rapid administration of fluid corrects the hypotension and can quickly lead to fluid overload and congestive heart failure. Therefore, neurogenic shock is best treated by the use of pressors. Cardioversion or administration of antibiotics or systemic steroids is not appropriate treatment for this patient’s hypotension.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 179-187.
Nockels RP: Nonoperative management of acute spinal cord injury. Spine 2001;26:S31-S37.

Question 14:

Options:

Change to oral doxycycline
Change to IV cefazolin
Change to IV vancomycin
Change to oral rifampin
Continuation of oral clindamycin

Correct Answer: Change to oral doxycycline

Explanation:

Question 15:

The implant shown in Figures 47a and 47b is introduced submuscularly employing a minimally invasive technique. A percutaneous method of screw insertion is used distally. What nerve is most at risk?

Options:

Sural
Saphenous
Superficial peroneal
Deep peroneal
Posterior tibial

Correct Answer: Superficial peroneal

Explanation:

Question 16:

Which of the following types of exercise used to increase flexibility is considered most beneficial in increasing joint range of motion?

Options:

Ballistic stretching
Static stretching
Proprioceptive neuromuscular facilitation (PNF)
Isokinetic
Eccentric

Correct Answer: Proprioceptive neuromuscular facilitation (PNF)

Explanation:

Question 17:

There is a risk of impaired forearm rotation after tension band fixation of an olecranon fracture with which of the following?

Options:

Ipsilateral proximal humerus fracture
Protrusion of Kirschner wire fixation through the volar cortex of the proximal ulna
Use of ulnar intramedullary Kirschner wire fixation
Olecranon fracture comminution
Lack of triceps tendon repair

Correct Answer: Ipsilateral proximal humerus fracture

Explanation:

Question 18:

A 9-year-old child sustains a proximal tibial physeal fracture with a hyperextension mechanism. What structure is at most risk for serious injury?

Options:

Tibial nerve
Popliteal artery
Common peroneal nerve
Posterior cruciate ligament
Popliteus muscle

Correct Answer: Popliteal artery

Explanation:

DISCUSSION: The most serious injury associated with proximal tibial physeal fracture is vascular trauma. The popliteal artery is tethered by its major branches near the posterior surface of the proximal tibial epiphysis. During tibial physeal displacement, the popliteal artery is susceptible to injury. Injuries to the other structures are less common.
REFERENCE: Beaty JH, Kasser JR: Rockwood and Wilkins Fractures in Children. Philadelphia, PA, JB Lippincott, 2006, p 961.

Question 19:

In what decade does the peak incidence of conventional osteosarcoma occur?

Options:

First
Second
Fourth
Fifth
Sixth

Correct Answer: Second

Explanation:

Question 20:

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

Options:

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

Correct Answer: Area moment of inertia of the cross section

Explanation:

Question 21:

1 mg/L). Aspiration of the right knee reveals hazy yellow fluid with a white blood cell count of 120 and 1% neutrophils. No growth of organisms is seen on routine culture. What is the best next step?

Options:

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

Correct Answer: Revision total knee arthroplasty with extensor mechanism allograft

Explanation:

Question 22:

Options:

Ig antibodies at the neuromuscular (NM) junction
Decreased release of acetylcholine at the NM junction
Decrease in myelin sheath of axonal nerves with loss of NM junction
Absence of dystrophin with excess calcium at sarcolemma

Correct Answer: Ig antibodies at the neuromuscular (NM) junction

Explanation:

Question 23:

Options:

Head injury
Obesity
Male
Early surgery
Transfer from an outside facility Corrent answer: 2 From the following options, only obesity has been shown to be associated with a statistically higher incidence of wound complications following pelvic and acetabular fracture fixation for trauma. Wound complications following pelvic and acetabular fracture fixation is relatively uncommon. Literature suggests and prevalence of 2-8% with closed fracture injuries. Factors shown to increase infection rates include both patient and surgical factors. They include obesity, diabetes, immunocompromised, elderly, pre-operative embolization and open fractures. Sagi et al. looked at the factors contributing to wound infection after pelvic and acetabular surgery. Open pelvic or acetabular fractures were excluded. Of all the factors, only obesity (OR 8, PPV 33%), obesity plus leukocytosis (OR 12, PPV 39%), and preoperative angioembolization (OR 11, PPV 67%) were strong predictors of postoperative infection. Manson et al. aimed to determine if embolization of pelvic arterial injuries before open reduction and internal fixation (ORIF) of acetabular fractures is associated with an increased rate of deep surgical site infection. They retrospective reviewed 1440 patients who underwent ORIF of acetabular fractures. They found a 58% infection rate of the patients who underwent embolization before ORIF vs, historical controls (2%-5%) and angiography without embolization (14%). Figure A shows an AP radiograph and 3D CT reconstruction of a APC3 pelvic ring fracture. Incorrect Answers:

Correct Answer: Early surgery

Explanation:

OrthoCash 2020

Question 24:

Options:

Osteoarthritis of the acromioclavicular joint
Acromioclavicular joint separation
Os acromiale
Partial-thickness rotator cuff tear
Superior labral tear

Correct Answer: Os acromiale

Explanation:

Question 25:

Options:

Extension-type supracondylar fracture
Flexion-type supracondylar fracture
Anterior olecranon fracture dislocation
Coronoid fracture, olecranon fracture and elbow dislocation
Coronoid fracture, radial head fracture and elbow dislocation

Correct Answer: Coronoid fracture, olecranon fracture and elbow dislocation

Explanation:

Question 26:

Osteoclastic bone resorption is stimulated primarily by what molecular interaction?

Options:

Parathyroid hormone (PTH)-osteoclasts
Interleukin-6 (IL-6) and IL-8
Receptor activator of nuclear factor kappa beta (RANK)-RANK ligand (RANKL)
Osteoprotegrin (OPG)-RANKL

Correct Answer: Receptor activator of nuclear factor kappa beta (RANK)-RANK ligand (RANKL)

Explanation:

Question 27:

Options:

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

Correct Answer: loss of external rotation.

Explanation:

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

Question 28:

..Staging studies show no other lesions and surgical treatment is planned; when should a biopsy be performed?

Options:

Before surgery
Intraoperatively after instrumentation
After surgery (reamings/curettings sent)
No biopsy is needed DISCUSSION… Patients with a metastatic lung carcinoma are best staged and imaged with a PET scan. Although many tumors are clinically evaluated with PET scans, metastatic lung cancer is one of the few “approved” indications for PET imaging. This imaging modality is sensitive for delineating the extent of disease and helpful for identifying areas that may also be at risk for pathologic fracture. Stabilization of painful, lytic lesions in weight-bearing bones is recommended to prevent pathologic fracture. Stabilization of an impending pathologic fracture is generally easier than stabilization of a pathologic fracture; once the patient in this vignette sustains a fracture, resection and reconstruction is indicated because stabilization alone is unlikely to heal and poses high risk for failure. In cases of extreme bone loss, especially in the epiphyseal region, reconstruction with tumor megaprostheses is desirable to avoid mechanical failure of additional internal fixation. Patients with widely metastatic disease may not be able to use ambulatory assistance aids effectively, placing traditional internal fixation at risk for failure. Use of megaprostheses obviates the need for adjuvant therapies to correct the loss of bone stock. Radiation therapy alone to lesions that are radiosensitive is effective but does not alleviate the risk for pathologic fracture. Chemotherapy alone is insufficient treatment for bone metastases. Hormonal therapy is acceptable for treatment of hormone-sensitive tumors; however, is not sufficient treatment for an impending pathologic fracture. For patients with remote diagnoses of carcinoma, biopsy of new-onset presumed metastases is mandatory to avoid an incorrect treatment regimen being employed. Patients can develop a secondary malignancy or infection, both of which will require a different treatment regimen. Biopsy should be done and diagnosis established either preoperatively or intraoperatively prior to instrumentation (with frozen section analysis) to avoid contamination of the femoral canal and soft-tissue envelope. Sending a specimen after instrumenting the femur or after surgery contaminates the femur if a sarcoma is diagnosed and lessens the likelihood of limb salvage.

Correct Answer: Before surgery

Explanation:

Question 29:

Options:

Continue with plans for bunion and crossover toe correction.
Cancel the surgery and send the patient home with empiric oral medications.
Inform the patient that surgical joint debridement is necessary and the elective reconstructive surgery will be put on hold.
Swab the ulcer and admit the patient for peripherally inserted central catheter line placement and intravenous antibiotics.

Correct Answer: Inform the patient that surgical joint debridement is necessary and the elective reconstructive surgery will be put on hold.

Explanation:

DISCUSSION
The clinical photograph shows a hallux valgus and a crossover toe deformity. The plantar plate must be damaged for a crossover toe deformity to develop. A moderately severe hallux valgus deformity without arthritic change is best treated with a bunionectomy with a proximal metatarsal osteotomy. The surgeon must assume that the open joint is at least colonized and at significant risk for postsurgical infection; consequently, it is best to cancel elective surgery, and surgical debridement of soft tissue and bone with deep cultures is recommended.
RECOMMENDED READINGS
Kaz AJ, Coughlin MJ. Crossover second toe: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2007 Dec;28(12):1223-37. doi: 10.3113/FAI.2007.1223. PubMed PMID: 18173985.
View Abstract at PubMed
Chalayon O, Chertman C, Guss AD, Saltzman CL, Nickisch F, Bachus KN. Role of plantar plate and surgical reconstruction techniques on static stability of lesser metatarsophalangeal joints: a biomechanical study. Foot Ankle Int. 2013 Oct;34(10):1436-42. doi: 10.1177/ 1071100713491728. Epub 2013 Jun 17. PubMed PMID: 23774466.
View
Abstract at PubMed
Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989 Dec;10(3):156-60. PubMed PMID: 2613128.
View Abstract at PubMed

Question 30:

- A 16-year-old girl who swims on her high school team reports pain in the shoulder after swimming. History reveals a glenohumeral dislocation at age 14 years while doing the backstroke. Examination shows a positive anterior apprehension sign. Treatment at this time should consist of

Options:

Putti-platt repair
Open Bankart repair
Injection of a subacromial corticosteroid
Arthroscopic transglenoid capsular shift
Rehabilitation of the scapular and rotator cuff muscles

Correct Answer: Rehabilitation of the scapular and rotator cuff muscles

Explanation:

Question 31:

Options:

Distal femoral varus osteotomy
Autologous chondrocyte implantation (ACI)
Fresh osteochondral allograft (OCA) transplantation
Arthroscopic microfracture

Correct Answer: Fresh osteochondral allograft (OCA) transplantation

Explanation:

Question 32:

Options:

Physical therapy
CT-guided needle biopsy and IV antibiotics
Revision laminotomy and diskectomy
L4-L5 anterior debridement and fusion
Open repair of the L4-L5 pseudomeningocele

Correct Answer: Physical therapy

Explanation:

The MRI scans show Modic changes in the L4-L5 vertebral bodies due to spondylosis. There is no increased fluid signal or enhancement in the L4-L5 disk to suggest infection or any other pathologic process. Therefore, the patient’s pain should be treated with a course of physical therapy and rehabilitation. There is no infection; therefore, IV antibiotics and debridement are not indicated. Similarly, a
pseudomeningocele is not present. A revision diskectomy is useful for recurrent radiculopathy but would not be helpful for degenerative low back pain.
(SBQ12SP.29) A 17-year-old female is undergoing posterior instrumented fusion from T5-T12 for adolescent idiopathic scoliosis. At the time of the correction maneuver, the neurophysiologist notifies you of a 60% decrease in somatosensory evoked potential (SSEP) amplitude throughout bilateral lower extremities. Which of the following is an acceptable approach to manage this finding?
Review Topic
Immediate wake-up test with examination for clonus
Drop the mean arterial pressure (MAP) to ~60mmHg
Discontinue instrumentation and optimize MAP to 85mmHg or greater
Immediate infusion of intravenous corticosteroids
Modification of the anesthesia plan to include inhalational agents only followed by repeated SSEP testing
The patient has a significant drop in SSEP amplitudes at the completion of the corrective maneuver. The most appropriate response is to raise the MAP to 85 mmHg or greater, discontinue the instrumentation, re-evaluate the SSEPs, and if there is no improvement, to consider reversing the reduction of the deformity.
Intra-operative neurophysiologic monitoring is an effective method to monitor insults to the spinal cord and its exiting roots during spinal instrumentation. The common measurements include SSEPs, which monitor sensory potentials transmitted through the dorsal column system, and motor-evoked potentials (MEPs), which monitor motor response to a trans-cranial stimulus. Decreases in amplitude and latency of the circuits are recorded, however diminished signal amplitudes are more sensitive for neurologic injury, and decreases of of >50-60% being highly concerning. The wake-up test involves reversal of anesthesia so that an intra-operative neurologic examination can be performed.
Devlin et al. reviewed the basic science and practice of neurophysiologic monitoring in spine surgery. They proposed an algorithmic approach to managing intraoperative alerts which include discontinuation of inhalational anesthetics, increasing the MAP to >90 mmHg, discontinuing instrumentation, and performing a wake-up test if neurologic signals fail to normalize.
Herdmann et al. reviewed the practice of neurophysiologic monitoring and the effects of anesthesia upon signal transduction. They report that anesthesia affecting a neuron's intrinsic excitability can alter the results of monitoring. Inhalational anesthetics and decreased MAPs can be responsible for decreased amplitudes.
Vitale et. al. developed a consensus-based intraoperative checklist for management of lost neuromonitoring signals. In this checklist, the first steps across the surgical and anesthetic teams should include: stop the case and announce signal losses to the room, optimize the mean arterial pressure, discuss the status of anesthetic agents, and discuss reversible surgical actions just prior to signal loss.
Incorrect

Question 33:

Options:

Fixation in the tibial tunnel
Fixation in the femoral tunnel
Posterior placement of the tibial tunnel
Anterior placement of the femoral tunnel
Size of the patellar autograft

Correct Answer: Anterior placement of the femoral tunnel

Explanation:

Question 34:

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

Options:

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

Correct Answer: Posterior cruciate ligament

Explanation:

Question 35:

Options:

Osteotomy of the tibia and fibula
Clamshell knee-ankle-foot orthotic
Serial casts
Observation and a repeat visit in 4 months DISCUSSION-The photograph shows posteromedial bowing of the tibia. The child should be followed for later limblength discrepancy, which may need treatment. Treatment with bracing or serial casts has not been shown to alter this condition. Surgery is not indicated in infancy because much of the deformity corrects with time. At a later age, treatment of a limb-length discrepancy or residual deformity can be addressed.

Correct Answer: Observation and a repeat visit in 4 months DISCUSSION-The photograph shows posteromedial bowing of the tibia. The child should be followed for later limblength discrepancy, which may need treatment. Treatment with bracing or serial casts has not been shown to alter this condition. Surgery is not indicated in infancy because much of the deformity corrects with time. At a later age, treatment of a limb-length discrepancy or residual deformity can be addressed.

Question 36:

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

Options:

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

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

Explanation:

Question 37:

Options:

dystrophin.
frataxin.
neurofibromin.
peripheral myelin protein.
sulfate transport protein.

Correct Answer: neurofibromin.

Explanation:

Question 38:

Options:

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

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

Explanation:

Question 39:

Options:

Bryan-Morrey approach and parallel plating
Triceps reflecting anconeus pedicle approach and parallel plating
Triceps reflecting anconeus pedicle approach and orthogonal plating on the posteromedial and lateral surfaces
Olecranon osteotomy and parallel plating
Olecranon osteotomy and orthogonal plating on the posteromedial and lateral surfaces

Correct Answer: Olecranon osteotomy and orthogonal plating on the posteromedial and lateral surfaces

Explanation:

Access to complex intra-articular fractures is best achieved by an olecranon osteotomy (OO). Fixation can be with parallel plating or orthogonal plating.
Bicolumnar fixation of distal humerus fractures should follow the principles outlined by O'Driscoll: Distal fragments should be held by as many screws as possible; every screw in the distal fragments should pass through a plate; each screw should engage as many articular fragments as possible.
Galano et al. review treatment for bicolumnar distal humerus fractures. They note that the olecranon osteotomy, Alonso-Llames triceps sparing and Campbell triceps splitting approaches expose 57%, 46% and 35% of the articular surface, respectively. The OO and paratricipital (triceps sparing) approaches allow for early ROM. Protected motion is required for the O'Driscoll TRAP and Bryan-Morrey approaches for tendon-to-bone healing.
Coles et al. retrospectively reviewed the OO in fixation of 70 fractures. Osteotomy fixation was with an intramedullary screw and dorsal ulnar wiring, or with a plate.
The rate of OO increased with fracture difficulty (from AO type C1-C3). There was 1 delayed union but no nonunions.
Figures A and B show a AO/OTA type C2 intraarticular distal humerus fracture. Figure C is a coronal CT scan showing intraarticular comminution. Illustration A shows fixation of the fracture with bicolumnar plating through an olecranon osteotomy approach. Illustration B shows the various approaches to the distal humerus (left, Campbell triceps splitting; center left, O'Driscoll triceps reflecting anconeus pedicle; center right, Bryan-Morrey approach, leaving the triceps attached laterally to the fasciocutaneous flap, but elevating it off the ulna; right, olecranon osteotomy). Illustration C shows 3 methods of olecranon osteotomy (A and B, Intraarticular transverse; C-F, Extra-articular oblique; G, Intra-articular chevron).
Incorrect Answers:
(SBQ12TR.84) Figure A shows a radiograph of a 30-year-old male who underwent fixation of a left leg injury just over two years ago. He presents with persistent pain and drainage from the distal wound despite 4 months of oral antibiotics. He has no systemic symptoms. He has a past medical history of Grave's disease and Irritable Bowel Syndrome. What would be the best management at this stage?
Review
Topic
Chronic suppressive, culture-directed, antibiotic therapy
Above knee amputation
Endocrine consultation, irrigation and debridement, removal of hardware and negative-pressure wound therapy
Irrigation and debridement, removal of hardware, over-reaming medullary canal, external fixation and culture-directed antibiotics
Irrigation and debridement, retention of hardware, acute bone grafting and culture-directed antibiotics
This is a case of fracture nonunion in the setting of chronic osteomyelitis and infected hardware. The best treatment option available would be irrigation and debridement, removal of hardware, ring external fixator and culture directed antibiotics.
The management of infected nonunion in the setting of chronic osteomyelitis is technically demanding. The aims of treatment are to eradicate the infection and obtain bone union. Non-surgical options are largely unsuccessful in patients with draining chronic osteomyeltis in the setting of infected hardware and nonunion. Surgical options involve incision and debridement of necrotic tissue followed by reconstruction of bone and possible soft tissue (to provide healthy viable coverage). The most common techniques are ringed fixator/circular frames, staged intramedullary device with or without external fixator, free tissue transfer, or radical
debridement, bone grafting, and fixation.
Motsitsi et al. reviewed the management of infected nonunion of long bones. They suggest that the Ilizarov technique is regarded as a standard treatment in infected nonunion of the tibia. When there is bone defect after debridement, the bone can be shortened or treated with bone transport.
Egol et al look at a series of patients with chronic osteomyelitis. Limb salvage should be attempted in all patients. The presence of a chronic draining sinus requires surgical debridement and culture directed antibiotics. Infected hardware should be removed. A two-stage strategy is the best and well-proven treatment option.
Figure A shows a intramedullary nail in the left tibia. There is a moderate amount of bone loss at the fracture site with mixed sclerotic bone suggestive of osteomyelitis.
Incorrect Answers:

Question 40:

During anatomic medial patellofemoral ligament (MPFL) reconstruction, the surgeon notes that the graft is becoming too tight with greater knee flexion. What is the most likely cause?

Options:

Femoral attachment placed too distal
Femoral attachment placed too proximal
Patellar attachment placed too distal
Patellar attachment placed too proximal

Correct Answer: Femoral attachment placed too proximal

Explanation:

Question 41:

Options:

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

Correct Answer: Reduces the strain on posterior instrumentation

Explanation:

Question 42:

Options:

Osteosarcoma
Ewing’s sarcoma
Osteochondroma
Chondrosarcoma
Periosteal chondroma

Correct Answer: Osteosarcoma

Explanation:

Question 43:

Options:

Quicker time to union
Decreased risk of malunion
Decreased risk of compartment syndrome
Decreased risk of shortening
Quicker return to work

Correct Answer: Quicker time to union

Explanation:

Question 44:

Options:

Left L4
Right L4
Left L5
Right L5
Left S1

Correct Answer: Left L5

Explanation:

Question 45:

Options:

hypokalemia.
administration of warfarin.
administration of antibiotics.
general anesthesia.
early mobilization and physical therapy.

Correct Answer: hypokalemia.

Explanation:

Question 46:

Options:

Physical therapy for quadriceps strengthening
Functional bracing
Anterior cruciate ligament (ACL) reconstruction
Revision reconstruction of the LCL and posterolateral corner
Valgus-producing high tibial osteotomy (HTO)

Correct Answer: Valgus-producing high tibial osteotomy (HTO)

Explanation:

Question 47:

Options:

Rheumatoid arthritis
Lyme disease
Psoriatic arthritis
Crohn’s disease arthropathy
Gout

Correct Answer: Psoriatic arthritis

Explanation:

DISCUSSION: The patient’s clinical picture is considered the classic presentation for psoriatic arthritis. The other answers are not applicable for the constellation of findings.
REFERENCES: Jahss MH: Disorders of the Foot and Ankle, ed 2. Philadelphia, PA,
WB Saunders, 1991, pp 1691-1693.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 172-173.

Question 48:

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

Options:

Ligamentous reconstruction
Meniscal repair
Meniscectomy
Immobilization

Correct Answer: Immobilization

Question 49:

Options:

repair of the posterior interosseous nerve.
repair of the median nerve at the elbow.
neurolysis of the anterior interosseous nerve.
observation of the nerve palsy.
immediate electromyography and nerve conduction velocity studies.

Correct Answer: observation of the nerve palsy.

Explanation:

DISCUSSION: The findings are consistent with a neurapraxia of the anterior interosseous branch of the median nerve. This is the most common nerve palsy seen with supracondylar humerus fractures, followed closely by radial nerve palsy. Nearly all cases of neurapraxia following supracondylar humerus fractures resolve spontaneously, and therefore, further diagnostic studies and surgery are not indicated.
REFERENCES: Cramer KE, Green NE, Devito DP: Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. J Pediatr Orthop 1993;13:502-505.
Sood MK, Burke FD: Anterior interosseous nerve palsy: A review of 16 cases. J Hand Surg Br 1997;22:64-68.

Question 50:

For a patient with an unstable pelvic fracture, the amount of blood tranfusions required in the first 24 hours has shown to be most predictive for what variable?

Options:

Length of hospital stay
Association with neurological deficit(s)
Length of intensive care stay
Cardiac collapse
Mortality

Correct Answer: Length of hospital stay

Explanation:

Question 51:

The nucleus pulposus of the intervertebral disk consists of chondrocyte-like cells that have a limited vascular supply and generate energy through which of the following?

Options:

Anaerobic glycolysis
Kreb's cycle
Ketosis
Gluconeogenesis
Lipogenesis

Correct Answer: Anaerobic glycolysis

Explanation:

Question 52:

Options:

Observation
Oral antibiotics for 6 weeks
IV antibiotics for 6 weeks
Arthroscopic irrigation and debridement with graft retention
Arthroscopic irrigation and debridement with graft removal

Correct Answer: Observation

Explanation:

Question 53:

Options:

Giant cell tumor
Infection
Chondrosarcoma
Osteosarcoma
Chondroblastoma

Correct Answer: Osteosarcoma

Explanation:

DISCUSSION: The radiographs reveal a blastic lesion of the proximal tibial metaphysis with cortical destruction, mineralization extending into the soft tissue laterally, indistinct margins, and destruction of the normal trabecular pattern. In this age group, with this aggressive appearance, osteosarcoma is the most likely diagnosis. Chondroblastoma and giant cell tumor are generally geographic and lytic. Chondrosarcoma is rare in this age group and would likely be a secondary lesion from an underlying chondroid tumor that is not present here. Whereas infection can have a wide variety of appearances, it tends to be more lytic in the acute presentation.
REFERENCES: Sanders TG, Parsons TW: Radiographic imaging of musculoskeletal neoplasia. Cancer Control 2001;8:221-231.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 175-186.

Question 54:

Arthrodesis

Options:

Repair of the rotator cuff
Replacement of the humeral head
Resection arthroplasty
Total shoulder arthroplasty

Correct Answer: Resection arthroplasty

Explanation:

Question 55:

Options:

Irrigation and debridement of deep wound infection
CT-guided needle biopsy and IV antibiotics
Revision laminotomy and diskectomy
L4-L5 anterior debridement and fusion
Open repair of the L4-L5 pseudomeningocele

Correct Answer: Revision laminotomy and diskectomy

Explanation:

Question 56:

Options:

Intercostal muscle strain
Rib stress fracture
Pneumothorax
Costochondritis
Empyema

Correct Answer: Rib stress fracture

Explanation:

Question 57:

Which of the following findings is most prognostic for the ability of a young child with cerebral palsy to walk?

Options:

Ability to sit independently by age 2 years
Ability to creep by age 2 years
Ability to roll by age 2 years
Pattern of cerebral palsy (quadriplegia, diplegia, hemiplegia)
Type of motor dysfunction (spastic, ataxic, dyskinetic, hypotonic)

Correct Answer: Ability to sit independently by age 2 years

Explanation:

DISCUSSION: Several studies have shown that sitting ability by age 2 years is highly prognostic of walking. Molnar and Gordon reported that children not sitting independently by age 2 years had a poor prognosis for walking. Wu and associates reported that children sitting without support by age 2 years had an odds ratio of 26:1 of walking compared with those unable to sit. This was far higher than the odds ratios for cerebral palsy location, motor dysfunction, crawling, creeping, scooting, or rolling.
REFERENCES: Molnar GE, Gordon SU: Cerebral palsy: Predictive value of selected clinical signs for early prognostication of motor function. Arch Phys Med Rehabil 1976;57:153-158.
Wu YW, Day SM, Strauss DJ, et al: Prognosis for ambulation in cerebral palsy: A population-based study. Pediatrics 2004;114:1264-1271.

Question 58:

Options:

Nonsteroidal anti-inflammatory drugs
MRI of the spine
CT myelography
Flexion-extension plain films

Correct Answer: MRI of the spine

Explanation:

DISCUSSION
Patients with ankylosing spondylitis are at high risk for occult fractures after low-energy injuries. Although radiographs and a CT scan do not demonstrate a spinal fracture in this patient, high risk for an unstable occult fracture necessitates further imaging with MRI to ensure that no fractures are missed. Although a CT scan is typically the primary imaging modality for workup of spine injuries in similar patients, CT and MRI complement each other and each detects fractures that are missed using the other modality. A CT myelogram might detect cord or root compression but would not aid in the diagnosis of an occult fracture. Nonsteroidal anti-inflammatory drugs are first-line treatment for idiopathic low-back pain. In a patient with ankylosing spondylitis at high risk for fracture, further workup is needed to rule out an occult fracture. Flexion and extension radiographs of the spine are inferior to MRI for evaluating occult fractures and ligamentous injuries. The primary concern for this patient remains an unstable spinal fracture, which necessitates an MRI of the spine before initiating a workup for other possible causes of his back pain.
RECOMMENDED READINGS
Duane TM, Cross J, Scarcella N, Wolfe LG, Mayglothling J, Aboutanos MB, Whelan JF, Malhotra AK, Ivatury RR. Flexion-extension cervical spine plain films compared with MRI in the diagnosis of ligamentous injury. Am Surg. 2010 Jun;76(6):595-8. PubMed PMID: 20583514.
View Abstract at PubMed
Hitchon PW, From AM, Brenton MD, Glaser JA, Torner JC. Fractures of the thoracolumbar spine complicating ankylosing spondylitis. J Neurosurg. 2002 Sep;97(2 Suppl):218-22. PubMed PMID: 12296682.
View Abstract at PubMed
Koivikko MP, Koskinen SK. MRI of cervical spine injuries complicating ankylosing spondylitis. Skeletal Radiol. 2008 Sep;37(9):813-9. doi: 10.1007/s00256-008-0484-x. Epub 2008 Apr

Question 59:

Options:

Unlinked elbow arthroplasty
Linked elbow arthroplasty
Interposition arthroplasty
Arthroscopic or open debridement
Radial head excision

Correct Answer: Arthroscopic or open debridement

Explanation:

DISCUSSION: The patient has symptomatic primary osteoarthritis of the elbow with multiple loose bodies. Given his age and occupation, an elbow arthroplasty is not an option. Arthroscopic debridement and removal of loose bodies has been shown to be effective for osteoarthritis of the elbow.
REFERENCES: Gramstad GD, Galatz LM: Management of elbow osteoarthritis. J Bone Joint Surg Am 2006;88:421-430.
Steinmann SP, King GJ, Savoie FH III, et al: Arthroscopic treatment of the arthritic elbow.
J Bone Joint Surg Am 2005;87:2114-2121.

Question 60:

Options:

Resolution by age 3 or 4 years without active treatment in most patients
Resolution by age 8 or 9 years without active treatment in most patients
Resolution with casting as the most effective treatment
Resolution with bracing and shoe modification as the most effective treatment
Resolution with surgery as the most effective treatment

Correct Answer: Resolution by age 3 or 4 years without active treatment in most patients

Explanation:

Question 61:

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

Options:

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

Correct Answer: Intrinsics of the hand

Explanation:

Question 62:

Options:

Giant cell tumor
Aneurysmal bone cyst
Unicameral bone cyst
Eosinophilic granuloma
Ewing’s sarcoma

Correct Answer: Giant cell tumor

Explanation:

Question 63:

-What is the most likely mechanism of injury?

Options:

External rotation
Posterior translation
Hyperextension and varus
Anterior translation and internal rotation

Correct Answer: Anterior translation and internal rotation

Explanation:

DISCUSSION FOR QUESTIONS 56 THROUGH 58
The MRI scan shows a bone bruise of the lateral femoral condyle and lateral tibial plateau. This injury pattern is commonly associated with anterior cruciate ligament (ACL) rupture and an abnormal pivot shift test result. Treatment of an ACL tear in a high-demand athlete should consist of ligament reconstruction.In this patient, surgery should be delayed until she regains full range of motion to minimize risk for arthrofibrosis after surgery. Recent analysis has shown that the noncontact mechanism is more consistent with anterior translation, affecting both the medial and lateral compartments. The bone bruise in the lateral femoral condyle occurs more anterior than that of the medial femoral condyle, suggesting that internal rotation has occurred. The external rotation recurvatum test assesses for posterolateral corner injury, and a positive quadriceps active test is consistent with posterior cruciate ligament rupture. An abnormal patellar apprehension test result is suggestive of patellar instability. Nonsurgical treatment is unlikely to result in sufficient stability if this patient returns to sports at her preinjury level of activity.Primary ACL repair is associated with high failure rates. Although the precise mechanism of injury varies,injuries can be broadly classified into contact and noncontact injuries. Noncontact injuries occur with the knee in slight flexion, valgus, and internal rotation, and contact injuries typically involve a lateralside impact producing a valgus force to the knee. The valgus component of noncontact injuries has been thought to cause mainly lateral compartment bone bruising. Posterior translation is the most common mechanism of posterior cruciate ligament rupture, and hyperextension and varus is associated with posterolateral corner injury.

Question 64:

Options:

Ulnar
Musculocutaneous
Radial
Median
Axillary

Correct Answer: Ulnar

Explanation:

Question 65:

Figure 49 shows a histologic section of the lung in a patient who died during total hip arthroplasty. What unexpected finding is seen in the pulmonary capillaries?

Options:

Pulmonary embolism
Methylmethacrylate cement
Hemorrhagic infarct
Granuloma formation
Amyloid

Correct Answer: Methylmethacrylate cement

Explanation:

DISCUSSION: Sudden death during total hip arthroplasty has been reported. In a report from the Mayo Clinic, intraoperative death occurred during cemented total hip arthroplasty in
23 patients. Fat and marrow embolization during preparation of the femur or cementing of the femoral component was believed to be responsible for the cardiopulmonary collapse that occurred during arthroplasty. Although fat and marrow emboli were found in the pulmonary capillaries of most of the patients on autopsy, this histologic section shows two particles of cement in the pulmonary capillaries.
REFERENCES: Parvizi J, Holiday AD, Ereth MH, et al: The Frank Stinchfield Award. Sudden death during primary hip arthroplasty. Clin Orthop 1999;369:39-48.
Patterson BM, Healy JH, Cornell CN, et al: Cardiac arrest during hip arthroplasty with a cemented long-stem component: A report of seven cases. J Bone Joint Surg Am
1991;73:271-277.

Question 66:

Options:

Synovial sarcoma
Malignant fibrous histiocytoma
Chondrosarcoma
Ewing's sarcoma
Osteosarcoma

Correct Answer: Osteosarcoma

Explanation:

Question 67:

Options:

Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty
ORIF of the acetabular fracture and ORIF of the femoral head fracture fragments
ORIF of the acetabular fracture and hemiarthroplasty
Skeletal traction with delayed total hip arthroplasty after the acetabular fracture has healed

Correct Answer: Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty

Explanation:

Question 68:

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement? Review Topic

Options:

Hip is internally rotated, passively flexed to 90 degrees, and adducted
Hip is internally rotated, passively flexed to 90 degrees, and abducted
Hip is externally rotated, maximally flexed to 90 degrees, and adducted
Hip is externally rotated, passively flexed to 90 degrees, and abducted
Hip is externally rotated, maximally flexed, and abducted

Correct Answer: Hip is internally rotated, passively flexed to 90 degrees, and adducted

Explanation:

Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain.
(SBQ13PE.10) Which statement is true regarding discoid menisci?
Review Topic
Most commonly involves the medial meniscus
Bilateral in >75% of cases
Asymptomatic discoid meniscus should undergo saucerization
Radiographs will commonly show a hyperplastic lateral intercondylar spine
Radiographs will commonly show squaring of affected condyle with cupping of tibial plateau
Radiographs of knees with discoid menisci will commonly show squaring of affected condyle (lateral>medial) with cupping of tibial plateau.
Discoid meniscus refers to the abnormal development of a hypertrophic and discoid shaped meniscus. It occurs in 3-5% of the population and it is considered the most common cause of a symptomatic clicking or clunking in a childs knee. The lateral meniscus is most commonly affected and it will occur bilaterally in 25% of affected
people. The Watanabe Classification describes the 3 types of discoid menisci. Type 1
= Incomplete, Type 2 = Complete, Type 3 = Wrisberg (lack of posterior meniscotibial attachment to tibia)
Kramer et al. looked at the presentation of pediatric knee pain. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the discoid meniscus.
Lee et al. retrospectively reviewed 36 patients aged less than 15 years who underwent arthroscopic procedures for torn discoid menisci. The mean patient age at the time of surgery was 9.5 years. They showed that partial meniscectomy yielded better radiologic results than subtotal/total meniscectomy for torn discoid menisci in this population.
Illustration A shows the 3 classifications of discoid menisus as originally described by Watanabe. Type 4 is a ring type discoid that was not originally described by Watanabe in his 1978 paper. Illustration B shows an AP and lateral radiograph of a discoid meniscus knee. Note squaring of affected lateral condyle in the presence of a lateral discoid meniscus. Illustration C shows 4 consecutive sagittal MRI images with meniscus continuity. It is important to note that the diagnosis of discoid menisci can be made when 3 or more 5mm sagittal images show meniscal continuity.
Incorrect Answers:

Question 69:

Options:

Popliteal tendinitis
Iliotibial band friction syndrome
Excessive lateral pressure syndrome
Lateral meniscal tear
Stress fracture

Correct Answer: Iliotibial band friction syndrome

Explanation:

Question 70:

Options:

An absence of the normal internal rotation of the femur during the terminal swing phase
An absence of the normal external rotation of the femur during the terminal swing phase
Greater posterior translation of the femur during late swing
Greater knee flexion during midstance
Greater adduction of the hip

Correct Answer: An absence of the normal internal rotation of the femur during the terminal swing phase

Explanation:

Question 71:

-The Coleman block test is used to test for

Options:

flexibility of the forefoot.
flexibility of the hindfoot.
valgus deformity of the hindfoot.
tightness of tendo Achilles. DISCUSSION -The Coleman block test is used to determine the flexibility of the hindfoot. When a block is placed under the lateral border of the foot, the medial column is unsupported. As a result, the first metatarsal drops off the side of the block. If the subtalar joint is flexible, there is no fixed varus deformity of the hindfoot. The hindfoot will no longer be in varus from behind. The varus deformity of the hindfoot will be corrected. If there is no subtalar motion, the varus deformity remains fixed.

Correct Answer: flexibility of the hindfoot.

Question 72:

What is the best way to determine whether a radial head implant is too thick intraoperatively?

Options:

Visually assess the radiocapitellar joint.
Visually assess widening of the lateral ulnohumeral joint.
Assess widening of the radiocapitellar joint on an AP radiograph.
Assess the elbow for concentric reduction on a lateral radiograph.
Assess widening of the medial ulnohumeral joint on an AP radiograph.

Correct Answer: Visually assess widening of the lateral ulnohumeral joint.

Explanation:

Question 73:

Which of the following is a long-term complication of ankle arthrodesis for posttraumatic arthritis?

Options:

Progressive limb-length discrepancy
Contralateral ankle arthritis
Ipsilateral hindfoot and midfoot arthritis
Ipsilateral knee arthritis
Talar osteonecrosis

Correct Answer: Ipsilateral hindfoot and midfoot arthritis

Explanation:

Question 74:

Options:

open reduction and internal fixation of the fragment along with the rectus femoris.
open reduction and internal fixation of the fragment along with the sartorius.
open reduction and internal fixation of the fragment along with the iliopsoas.
rest and protected weight bearing with crutches.
excision of the fragment.

Correct Answer: rest and protected weight bearing with crutches.

Explanation:

Question 75:

Options:

Their sons will have a 50% chance of having this X-linked dominant disorder.
All of their daughters will be carriers or will have this disorder.
They should be advised to not have any children as the risk of having boys with the disorder and girls who will be carriers is too hard for any parent.
As long as the woman does not carry the trait, the children will not be affected because the husband has the disease and this is an X-linked dominant disorder.
Their sons or daughters may be born with this disorder, but males are more severely affected.

Correct Answer: All of their daughters will be carriers or will have this disorder.

Explanation:

DISCUSSION: Hypophosphatemia is a rare genetic disease usually inherited as an X-linked dominant trait. The fact that the woman has no skeletal manifestations would indicate that the husband has the X-linked mutation. The disease is more severe in boys than it is in girls. The husband will not transmit the disease to his sons. However, all of their daughters will be affected either with the disease or as carriers. If the woman has the disease or the trait, there is a 50% chance that her sons will inherit the disease and a 50% chance that her daughters will be carriers or have a milder form of the disease. Parents should be advised to have genetic counseling so they can be informed when deciding whether to have children.
REFERENCES: Herring JA: Metabolic and endocrine bone diseases, in Tachdjian’s Pediatric Orthopaedics, ed 3. New York, NY, WB Saunders, 2002, pp 1685-1743.
Sillence DO: Disorders of bone density, volume, and mineralization, in Rimoin DL, Conner JM, Pyerite RE, et al (eds): Principles and Practice of Medical Genetics, ed 4. New York, NY, Churchill Livingstone, 2002.
Staheli LT: Practice of Pediatric Orthopedics. Philadelphia, PA, Lippincott Williams & Wilkins, 2001.

Question 76:

Options:

Continued physical therapy
Spica casting for 6 weeks
Biopsy of the lesion
Steroid injection into the area of discomfort
Excision of the fragment

Correct Answer: Excision of the fragment

Explanation:

Question 77:

Which of the following mechanisms of inhibition has been linked to cigarette smoking and lumbar spinal fusion?

Options:

Diminished revascularization of cancellous bone graft
Increased activity of osteoblasts
Increased activity of osteocytes
Antibody-induced necrosis
Inhibition of prostaglandins

Correct Answer: Diminished revascularization of cancellous bone graft

Explanation:

DISCUSSION: Cigarette smoking has been directly linked to pseudarthrosis in spinal fusions. The direct mechanism of action is diminished revascularization of cancellous bone graft. Additionally, a smaller area of revascularization is seen in these grafts, as well as an increased area of necrosis. Increased activity of osteoblasts would result in more bone production. Increased activity of osteocytes would not affect the fusion because osteocytes are mature bone cells.
REFERENCE: Daftari TK, Whitesides TE Jr, Heller JG, et al: Nicotine on the revascularization of bone graft: An experimental study in rabbits. Spine 1994;19:904-911.

Question 78:

Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints?

Options:

With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.
With tibial shin splints, the bone scan is more intense.
A more diffuse area of tenderness is seen in tibial stress fractures.
A three-phase bone scan is positive in all phases with shin splints, but only positive in delayed

Correct Answer: With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.

Explanation:

Question 79:

The arrow in the axial T 1 -weighted MRI scan shown in Figure 18 is pointing to which of the following structures?

Options:

Ulnar artery
Ulnar nerve in Guyon’s canal
Deep branch of the ulnar nerve only
Median nerve
Radial artery

Correct Answer: Ulnar nerve in Guyon’s canal

Explanation:

Question 80:

Six months later, the patient’s fracture has healed and a CT scan to further evaluate the physis is performed (Video 85). Based on these findings, how should you advise the family?

Options:

The fracture is healed and the physis is growing well with no problems expected.
Complete physeal closure has occurred. There will be no significant leg length difference because the patient is almost done growing.
Complete physeal closure has occurred. There will be a significant (> 2-cm) leg length difference if no other surgical treatment is offered.
Asymmetric physeal closure has occurred. There will be an increasing angular deformity at the knee as well as a significant (> 2-cm) leg length difference if no other surgical treatment is offered.

Correct Answer: Asymmetric physeal closure has occurred. There will be an increasing angular deformity at the knee as well as a significant (> 2-cm) leg length difference if no other surgical treatment is offered.

Explanation:

Question 81:

A 14-year-old boy reports progressive right wrist pain. Radiographs are shown in Figure 3a, and a photomicrograph is shown in Figure 3b. What is the most likely diagnosis?

Options:

Enchondroma
Nonossifying fibroma
Chondromyxoid fibroma
Osteosarcoma
Chondrosarcoma

Correct Answer: Chondromyxoid fibroma

Explanation:

DISCUSSION: The radiographs show a benign-appearing, well-defined lytic lesion with a thin rim of surrounding reactive bone. The photomicrograph shows spindle cells with a myxoid cartilaginous matrix. These findings are diagnostic of chondromyxoid fibroma. This is a rare, benign tumor that usually causes pain and can be locally aggressive.
REFERENCES: Lersundi A, Mankin HJ, Mourikis A, et al: Chondromyxoid fibroma: A rarely encountered and puzzling tumor. Clin Orthop Relat Res 2005;439:171-175.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.

Question 82:

A 28-year-old man sustains the closed injury shown in Figures 3a through 3c after falling 8 feet while rock climbing. Management should consist of

Options:

open reduction and internal fixation via an anteromedial arthrotomy.
talectomy.
primary tibiotalocalcaneal arthrodesis.
open reduction and internal fixation via a medial malleolar osteotomy and limited anterior lateral arthrotomy.
closed reduction and a non-weight-bearing cast.

Correct Answer: open reduction and internal fixation via a medial malleolar osteotomy and limited anterior lateral arthrotomy.

Explanation:

DISCUSSION: The radiographs show a comminuted talar body fracture. The goal of treatment is to minimize the risks of posttraumatic arthrosis of the ankle and subtalar joint and to maintain vascularity. Open reduction and internal fixation with an attempt at anatomic reduction will lead to improved outcomes. Attempting to repair this fracture via an arthrotomy only is extremely difficult, and the addition of a medial malleolar osteotomy is warranted. A limited anterior lateral arthrotomy with minimal soft-tissue stripping may assist with fixation of anterior-lateral and lateral fragments and allow better assessment of reduction of the major fracture line. Nonsurgical care would lead to inadequate reduction and increased risk of both ankle and hindfoot arthrosis. Talectomy and primary ankle and hindfoot arthrodesis should not be performed as primary surgical reconstructive options in this closed injury pattern.
REFERENCES: Sanders R: Fractures and fracture-dislocations of the talus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp
1465-1518.
Grob D, Simpson LA, Weber BG, Bray T: Operative treatment of displaced talus fractures. Clin Orthop 1985;199:88-96.

Question 83:

A 30-year-old patient has wrist pain. A radiograph and biopsy specimen are shown in Figures 34a and 34b. What is the most likely diagnosis?

Options:

Aneurysmal bone cyst
Giant cell tumor
Brown tumor
Pigmented villonodular synovitis
Telangiectatic osteosarcoma

Correct Answer: Aneurysmal bone cyst

Explanation:

Question 84:

A 20-year-old man sustained an injury to his arm during a tug-of-war contest. An MRI scan is shown in Figure 18. What is the most likely diagnosis?

Options:

Lipoma
Proximal biceps rupture
Distal biceps rupture
Biceps and brachialis rupture
Biceps brachii transection

Correct Answer: Biceps brachii transection

Explanation:

DISCUSSION: The MRI scan reveals a transection of the biceps muscle. The underlying brachialis is intact. This injury can occur as a result of a cord wrapped around the upper arm. Care should be taken to ensure that there is no concurrent vascular injury. A posterior subcutaneous lipoma appears as a well-encapsulated mass on T
2
-weighted images.
REFERENCES: Heckman JD, Levine MI: Traumatic closed transection of the biceps brachii in the military parachutist. J Bone Joint Surg Am 1978;60:369-372.
Mellen PF: Parachute static line injury with vascular compromise. Mil Med 1989;154:364-365.

Question 85:

Options:

Reverse shoulder arthroplasty
Hemiarthroplasty
Resurfacing of the humeral head
Arthroscopic debridement
Shoulder fusion

Correct Answer: Reverse shoulder arthroplasty

Explanation:

Question 86:

Options:

Neutral posted rigid custom foot orthosis
Custom rigid UCBL foot orthosis
Ankle-foot orthosis with the ankle locked at 90 degrees
Shoe modification with a cushioned heel and rocker sole
Metal hinged/leather short ankle “Arizona” orthosis

Correct Answer: Shoe modification with a cushioned heel and rocker sole

Explanation:

DISCUSSION: The patient has a malunion of an attempted open reduction of a Lisfranc dislocation. The pain occurs during the terminal stance phase of gait as load is being transferred from the hindfoot to the forefoot. The bending moment can be best neutralized with shoe modification with a cushioned heel and rocker sole, which best unloads the tarsal-metatarsal junction.
REFERENCES: Bono CM, Berberian WS: Orthotic devices: Degenerative disorders of the foot and ankle. Foot Ankle Clin 2001;6:329-340.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 58-63.

Question 87:

Options:

Relief of symptoms with shoulder abduction (placing hand over the head)
Hypothenar atrophy
Reproduction of pain with hyperflexion and contralateral rotation of the head
Positive Tinel’s sign at the levator scapulae
Subluxable ulnar nerve at the cubital tunnel

Correct Answer: Relief of symptoms with shoulder abduction (placing hand over the head)

Explanation:

Question 88:

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

Options:

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

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

Explanation:

Question 89:

- What is the treatment of choice for an adult who has an isolated fracture of the ulna at the junction of the distal and middle thirds, with 5 degrees apex dorsal angulation and 25% displacement?

Options:

Intramedullary rodding
Functional bracing
Closed reduction and a long arm cast
Closed reduction and application of an external fixator
Open reduction and internal fixation with a dorsal plate

Correct Answer: Functional bracing

Explanation:

Question 90:

Options:

Achilles rupture
Gastrocnemius strain
Calcaneal apophysitis
Os trigonum syndrome DISCUSSION-Calcaneal apophysitis (Sever disease) is a common cause of heel pain in adolescent athletes who participate in running or jumping sports. The condition occurs primarily before or during peak growth and is characterized by a tight Achilles tendon, a positive squeeze test, and tenderness over the calcaneal apophysis. Pain is localized to the heel and exacerbated by running. Os trigonum syndrome involves posterior ankle impingement and is commonly associated with ballet dancers. Gastrocnemius strain typically causes pain more proximally at the myotendinous junction. The Thompson test is performed with the patient lying prone on the examination table. Absence of ankle plantar flexion when the examiner squeezes the calf constitutes a positive test and is indicative of Achilles rupture.

Correct Answer: Calcaneal apophysitis

Explanation:

CLINICAL SITUATION FOR QUESTIONS 60 AND 61
A 15-year-old boy has had shoulder pain for 4 weeks during the middle of baseball season. The patient says his pain is “all over my shoulder.” Examination reveals tenderness to palpation over the anterolateral aspect of the shoulder. Internal and external rotation range of motion is restricted.
Radiographs show metaphyseal sclerosis.

Question 91:

According to clinical and biomechanical studies, the most appropriate position for a headless scaphoid compression screw for repair of a scaphoid waist fracture is

Options:

retrograde to protect the dorsal blood supply to the scaphoid.
retrograde eccentrically in the dorsal scaphoid to avoidtrapezium impingement.
deep and centrally placed, respecting the articular surface.
anterograde to protect the volar blood supply to the scaphoid.

Correct Answer: deep and centrally placed, respecting the articular surface.

Explanation:

EXPLANATION:
The position of a scaphoid screw for scaphoid fracture repair (Figure 1) is as critical as the position of a sliding hip screw for intertrochanteric fracture repair. Positioning the screw deep in the center of the densest portion of cancellous bone is beneficial for both of these fracture types.Trumble and associates have shown time to union for scaphoid nonunions to be decreased for centrally placed scaphoid screws. McCallister and associates documented improved biomechanical stability for scaphoid waist fractures repaired with a centrally placed screw vs an eccentrically placed screw. Dodds and associates
demonstrated significantly improved biomechanical stability with centrally placed long screws vs centrally placed short screws. The screw may be placed retrograde or antegrade. Although the screw position may be relatively parallel to the radial inclination as the shape of the scaphoid body follows the contour of the radial styloid, screw position should be assessed relative to the scaphoid’s own architecture. Placing the screw in a retrograde fashion can force the treating surgeon to start the screw eccentrically in an attempt to avoid the interference of the trapezium lying over the distal pole of the scaphoid. This may result in noncentral screw placement.

Question 92:

What allograft has the highest antigenicity when used for ligament reconstruction about the knee?

Options:

Tibialis anterior used for anterior cruciate ligament (ACL) reconstruction
Tibialis anterior used for posterolateral reconstruction
Bone-patellar tendon-bone used for ACL reconstruction
Semitendinosus used for posterior cruciate ligament reconstruction
Semitendinosus used for medial collateral ligament reconstruction

Correct Answer: Bone-patellar tendon-bone used for ACL reconstruction

Explanation:

Question 93:

Options:

Increased ductility
Increased wettability
Diminished fatigue strength
Decreased resistance to abrasive wear

Correct Answer: Diminished fatigue strength

Explanation:

Question 94:

Options:

Malignant fibrous histiocytoma
Liposarcoma
Synovial cell sarcoma
Leiomyosarcoma
Clear cell sarcoma

Correct Answer: Liposarcoma

Explanation:

DISCUSSION: The images show a complex, lobular lesion of the thigh that has signal characteristics that follow fat. The size of the lesion, the areas of stranding within the mass, along with mild uptake on the gadolinium sequences and the mild edema within the lesion on the T
2
-weighted image make liposarcoma the most likely diagnosis and simple intramuscular lipoma far less likely. All other diagnoses listed would not follow fat characteristics shown on the MRI sequences.
REFERENCE: Sanders TG, Parsons TW: Radiographic imaging of musculoskeletal neoplasia. Cancer Control 2001;8:221-231.

Question 95:

Options:

Discontinue the procedure and delay completion of the total arthroplasty until the fracture has healed.
Cement a long-stemmed humeral component to bypass the fracture site and supplement with cerclage wires.
Remove all instrumentation, perform an open reduction and internal fixation of the fracture, and delay completion of the total arthroplasty until the fracture has healed.
Insert a standard humeral component and apply a humeral orthosis postoperatively.
Insert a standard humeral prosthesis with suture fixation and autogenous cancellous bone grafting of the greater tuberosity fracture.

Correct Answer: Insert a standard humeral prosthesis with suture fixation and autogenous cancellous bone grafting of the greater tuberosity fracture.

Explanation:

Question 96:

Options:

immediate posterior surgical reduction and stabilization.
immediate anterior diskectomy and fusion.
MRI.
reduction in Gardner-Wells tongs with serial traction.
rigid collar immobilization until spinal shock resolves.

Correct Answer: reduction in Gardner-Wells tongs with serial traction.

Explanation:

DISCUSSION: Surgical open reduction may increase the neurologic deficit if a disk herniation exists. Evidence from animal studies suggests that rapid decompression of the spinal cord may improve recovery. Serially increasing traction weight to reduce the dislocation has been shown to be safe when used in patients who are awake. Indications for MRI include patients who are unable to cooperate with serial examinations, the need for open reduction, and progression of deficit during awake reduction.
REFERENCES: Delamarter RB, Sherman J, Carr JB: Pathophysiology of spinal cord injury: Recovery after immediate and delayed decompression. J Bone Joint Surg Am
1995;77:1042-1049.
Star AM, Jones AA, Cotler JM, Balderston RA, Sinha R: Immediate closed reduction of cervical spine dislocations using traction. Spine 1990;15:1068-1072.
Eismont FJ, Arena MJ, Green BA: Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets: Case report. J Bone Joint Surg Am
1991;73:1555-1560.

Question 97:

Options:

Increased pain walking down stairs
Increased pain while using a stationary bike
Increased pain with coughing or sneezing
Increased pain after driving a car for a long distance
Pain that is worst first thing in the morning and gradually improves as the day goes on

Correct Answer: Increased pain while using a stationary bike

Explanation:

Question 98:

Options:

Observation and NSAID use as needed
MRI scan
Bone biopsy
Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP).

Correct Answer: Observation and NSAID use as needed

Explanation:

DISCUSSION
The radiograph shown is consistent with Paget disease of the bone. It demonstrates classic findings of widened lamellae and disorganized sclerotic and lytic areas. The cause is not clearly defined, but may be linked to a viral infection and subsequent alterations of osteoblastic and osteoclastic activity. Most patients are asymptomatic, and Paget disease is often found incidentally on radiographs. In this case, the patient’s symptoms likely were caused by hip arthritis, but Paget disease can cause diffuse bone pain in some cases. Considering the patient’s mild and short-term symptoms, observation and NSAID use is most appropriate. An MRI scan or biopsy is indicated if sarcomatous transformation is suspected, but this condition is rare and is associated with a substantial, unrelenting increase in pain. SPEP and UPEP are tests for multiple myeloma, of which the radiographs show no signs.
RECOMMENDED READINGS
Ralston SH. Pathogenesis of Paget's disease of bone. Bone. 2008 Nov;43(5):819-25. doi: 10.1016/j.bone.2008.06.015. Epub 2008 Jul 11. Review. PubMed PMID: 18672105.
View Abstract at PubMed
Bonenberger E, Einhorn T. Metabolic bone diseases. In: Callaghan JJ, Rosenberg
AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams
14
& Wilkins; 2007:514-533.

Question 99:

Which of the following methods best aids in diagnosis of an interdigital neuroma?

Options:

Ultrasound
MRI
Web space injection
Electromyography and nerve conduction velocity studies
History and physical examination

Correct Answer: History and physical examination

Explanation:

Question 100:

Options:

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

Correct Answer: more wound complications.

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

Orthopedic Board Review MCQs: Trauma, Shoulder & Foot | Part 200

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 200

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index