OITE & ABOS Orthopedic MCQ Prep: Arthroplasty & Knee

About This Board Review Set

This is Part 208 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.

How to Use the Interactive Quiz

Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
Exam Mode — All feedback is hidden until you click Submit & See Results. A live timer tracks elapsed time. A percentage score and detailed breakdown are displayed upon submission.

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 208

This module focuses heavily on: Arthroplasty, Fracture, Knee, Ligament, Tendon.

Sample Questions from This Set

Sample Question 1: A 25-year-old man sustained a head injury after being ejected from his car. Examination reveals a Glasgow Coma Scale score of 7 and a swollen right knee. Clinical examination shows that the knee is very unstable, suggesting tears of the med...

Sample Question 2: Figure 13 is the photograph of 18-month-old triplets with a lower-limb condition. What is the best initial treatment? Review Topic...

Sample Question 3: Injurytothepoplitealarteryduringtotalkneearthroplasty(TKA)ismostlikelytooccurwhenplacingasharpretractor...

Sample Question 4: A 42-year-old woman sustained a closed, displaced talar neck fracture in a motor vehicle accident. Which of the following is an avoidable complication of surgical treatment?...

Sample Question 5: A 52-year-old woman has a 60-degree extensor lag following a right total knee arthroplasty performed 16 months ago. Since the time of her primary total knee arthroplasty she has undergone primary repair of a patellar tendon rupture that occ...

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

00:00

Start Quiz

Question 1

A 25-year-old man sustained a head injury after being ejected from his car. Examination reveals a Glasgow Coma Scale score of 7 and a swollen right knee. Clinical examination shows that the knee is very unstable, suggesting tears of the medial collateral and anterior and posterior cruciate ligaments, as well as the posterior lateral corner. What is the most appropriate first step to rule out a vascular injury?

Explanation

DISCUSSION: A knee dislocation carries the potential for an arterial injury and has always brought up the question of need for arteriography to rule out this limb-threatening injury. However, arteriography has an inherent complication rate that may compromise the general care of the patient. In over 240 published cases with documented knee dislocations that were evaluated for vascular injury by physical examination (without imaging studies), not a single missed injury was reported, for a 100% negative predictive value (0% false-negative rate). This degree of accuracy at excluding major vascular injury is unsurpassed by the results obtained with arteriography but with no risk involved and a marked savings in time, equipment, and costs. Therefore, the most appropriate first step to rule out vascular injury is examination of the pedal pulses. If there is any doubt about an arterial injury, another option is the ankle-brachial index (ABI). If the ABI is greater than 0.9, the chance of arterial injury is again nonexistent. However, a positive physical examination or an ABI of less than 0.9 is not 100% predictive of an arterial injury; therefore, arteriography is recommended.
REFERENCES: Miranda FE, Dennis JW, Veldenz HC, et al: Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: A prospective study. J Trauma 2002;52:247-252.
Mills WJ, Barei DP, McNair P: The value of the ankle-brachial index for diagnosing arterial injury afterknee dislocation: A prospective study. J Trauma 2004;56:1261-1265.

Question 2

Figure 13 is the photograph of 18-month-old triplets with a lower-limb condition. What is the best initial treatment? Review Topic

Explanation

Brodie's Abscess
Osteomyelitis of the humeral metaphysis
Subperiosteal abscess of the humerus
Presence of subcutaneous air
High risk of proximal humeral growth arrest
This patient has osteomyelitis of the humerus with a large subperiosteal abscess. The presence of subperiosteal abscess necessitates surgical intervention for irrigation and debridement (I&D).
The diagnosis of acute osteomyelitis in children is made based upon a constellation of findings including pain, systemic signs of infection, elevated serum inflammatory markers, and imaging studies demonstrative of osseous infection. It is most commonly hematogenously spread to the metaphysis of immature bone, which is highly vascular prior to skeletal maturity. Treatment involves obtaining specimen for culture, empiric antibiotic treatment, and surgical irrigation and debridement of known abscesses. The end-point of treatment is return of pain-free functionality and the resolution of local/systemic signs of infection.
Conrad reviewed the management of acute hematogenous osteomyelitis and emphasized that surgical intervention in the presence of abscess can be both therapeutic and diagnostic: I&D can obtain culture and narrow the antibiotic plan.
Jones et. al. reviewed chronic pediatric osteomyelitis and report that surgery is the mainstay of treatment because removal of dead bone is essential for resolution of infection. This may be performed with sequestrectomy and curettage, with an emphasis on prevention of pathologic fracture, growth disturbances, bone loss, joint involvement, and permanent loss of function.
Figure A is a coronal STIR MRI image of the humerus demonstrating osteomyelitis
with extensive subperiosteal abscess.
Incorrect Answers:
Brodie's abscess is a type of subacute osteomyelitis which remains indolent and creates a focal intra-osseous abscess. This is not demonstrated in the clinical image.
The patient does have osteomyelitis of the humeral metaphysis, but this alone is not the indication for surgery. Uncomplicated osteomyelitis may be treated effectively with antibiotics alone.
Presence of subcutaneous air is suggestive of necrotizing fasciitis, which is a surgical emergency. The MRI however does not demonstrate this finding.
The infection and its surgical management both increase risk of injury to the proximal humeral physis and has the potential for growth arrest or angular deformity.
(SBQ13PE.3) Figure A demonstrates a physical examination maneuver in a 1 month old infant. What is this maneuver? Review Topic

Ortolani Test
Barlow Test
Galeazzi Sign
Patrick test
Teratologic Sign
Figure A shows a schematic image of the Ortalani test.
The Ortolani test, or Ortolani maneuver, is part of the physical examination for developmental dysplasia of the hip. It is used alongside the Barlow test to detect subluxated hips that are either reducible or irreducible. A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral head relocates anteriorly into the acetabulum.
Guille et al. showed that the use of Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step before they are able to stand.
Video V is a lecture discussing the hip examination of the infant. Incorrect Answers:
pressure on the knee, directing the force the femoral head posteriorly. A positive Barlow test would result in posterior subluxation/dislocation of the hip. Answer 3: Galeazzi test is performed by flexing an infant's knees in the supine position so that the ankles touch the buttocks. If the knees are not level then the test is positive, which indicates a potential congenital hip issue (e.g. DDH). Answer 4: Patrick or Faber test (flexion, abduction, external rotation) has been described both for stressing the SI joint and for isolating symptoms to the hip Answer 5: Teratologic dislocation of the hip is a term used to imply that the hip joint did not develop normally in utero, thus the hip is in a fixed dislocated position at birth.

Question 3

Injury to the popliteal artery during total knee arthroplasty (TKA) is most likely to occur when placing a sharp retractor

Explanation

DISCUSSION:
Vascular complications during TKA are rare but do occur. Traditionally, it was taught that the popliteal artery was situated posterior to the PCL; however, more recent anatomic dissections have demonstrated that this artery is usually located posterolateral to the PCL.

Question 4

A 42-year-old woman sustained a closed, displaced talar neck fracture in a motor vehicle accident. Which of the following is an avoidable complication of surgical treatment?

Explanation

DISCUSSION: Malunion of the talus is a devastating complication that leads to malpositioning of the foot and subsequent arthrosis of the subtalar joint complex. This is considered an avoidable complication in that accurate surgical reduction will minimize its development. Posttraumatic arthritis of the subtalar joint, osteonecrosis of the talus, posttraumatic arthritis of the ankle joint, and complex regional pain syndrome all may develop as a result of the initial traumatic event and may not be avoidable despite anatomic reduction.
REFERENCES: Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott, Williams and Wilkins, 2001, pp 2091-2132.
Daniels TR, Smith JW, Ross TI: Varus malalignment of the talar neck: Its affects on the position of the foot and on subtalar motion. J Bone Joint Surg Am 1996;78:1559-1567.

Question 5

A 52-year-old woman has a 60-degree extensor lag following a right total knee arthroplasty performed 16 months ago. Since the time of her primary total knee arthroplasty she has undergone primary repair of a patellar tendon rupture that occurred after a fall 8 months ago. A lateral radiograph of the knee is shown in Figure 52. A CT scan obtained to determine component rotation showed that the femoral component is internally rotated 9 degrees and the tibial component is internally rotated 12 degrees. Appropriate management at this time should include

Explanation

DISCUSSION: A chronic patellar tendon rupture is a difficult complication to manage. Patients typically present with both inability to extend their leg and instability of the extremity, oftentimes associated with multiple falls.
Attempts at secondary repair have been associated with high failure rates whereas the use of an extensor mechanism allograft has been shown to more effectively restore active extension in a substantial percentage of patients. Important aspects of the technique include fully tensioning the graft in full extension and immobilization of the extremity for 6 to 8 weeks postoperatively to allow for graft healing. Nonsurgical management will not result in an acceptable outcome for a young patient, and attempted secondary repair is associated with a high rate of failure, even when augmented with local tissues. This patient has gross rotational
malalignment of the components and the surgeon faced with this problem should consider obtaining a CT scan to determine component rotation preoperatively.
REFERENCES: Burnett RS, Berger RA, Paprosky WG, et al: Extensor mechanism allograft reconstruction after total knee arthroplasty: A comparison of two techniques. J Bone Joint Surg Am 2004;86:2694-2699.
Nazarian DG, Booth RE: Extensor mechanism allografts in total knee arthroplasty. Clin Orthop Relat Res
1999;367-123-129. , „. H
AL-Madena Copy ^Lj-^M) <UjJlU

Question 6

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

Explanation

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

Question 7

Figures 56a through 56c are the lateral radiograph and MRI scans of a 32-year-old woman who reports a 3-week history of heel pain, tenderness, swelling, and onset following an increase in running activity. What is the most likely diagnosis?

Explanation

The sagittal T1-weighted MRI scan reveals a linear streak of low signal intensity consistent with a stress fracture of the posterior calcaneal tuberosity. The surrounding area of hypointensity on the T1 MRI scan and the hyperintensity on the T2 MRI scan represent bone contusion, hemorrhage, and edema within the calcaneus, with an unremarkable radiograph. The plantar fascia, Achilles tendon, retrocalcaneal bursa, and heel pad all display normal signal in the accompanying MRI scans.

Question 8

03 5.

Explanation

In long bones, radiographs initially show a radiolucency in the metaphysis that progresses into the diaphysis. The entire progression of the disease takes years.
The radiograph here shows the typical Paget’s lesion in the right iliac wing with mixed lytic and sclerotic areas.

Question 9

Figure 33 shows the MRI scan of a 55-year-old woman who has had a 6-week history of back and leg pain. Which of the following clinical scenarios is most consistent with the MRI scan findings at L4-L5?

Explanation

DISCUSSION: The MRI scan reveals a L4-L5 foraminal disk herniation originating from the L4-5 disk space that has migrated up into the foramen, compressing the left L4 nerve root. There is normal distribution of the roots in the cerebrospinal fluid, excluding arachnoiditis as a diagnosis, and disk herniation in this location would not result in cauda equina syndrome or myelopathy.
REFERENCE: McCullouch JA, Transfeldt EE: Macnab’s Backache, ed 3. Philadelphia, PA, Williams and Wilkins, 1997, pp 569-608.

Question 10

A patient has a painful metal-on-metal (MOM) left total hip arthroplasty (THA). Which test(s) best correlate with prognosis if this patient is having a reaction to metal debris?

Explanation

DISCUSSION
Painful MOM THA and taper corrosion can cause substantial damage to a patient's hip if left untreated. In this case, the workup for a painful MOM THA starts the same as a workup for a painful metal-on-polyethylene bearing couple. Infection must be ruled out in every case with a set of inflammatory markers. If these markers are remotely elevated, this is an indication for joint aspiration. In patients with metal debris, the pathology report often indicates too many cells to count or cellular debris. Metal ion levels do not seem to correlate with prognosis. There are well-functioning patients with high ion levels and poor-functioning patients with low ion levels. Advanced imaging with MARS MRI to evaluate for peritrochanteric fluid collection, a soft-tissue mass, or synovial/capsular hypertrophy will reveal signs of a metal reaction that indicate the need for a revision discussion. A CT scan can show more advanced bony destruction as an indicator of poor prognosis. These films can be used to determine the need for a structural graft or augments for reconstruction of bone loss attributable to metal debris.

Question 11

A 23-year-old man has had heel pain and fullness for the past several months. He reports that initially the pain was present only with activity, but more recently the pain has become constant. Figures 53a through 53d show a radiograph, a bone scan, and T2-weighted and gadolinium MRI scans. What is the most likely diagnosis?

Explanation

DISCUSSION: The imaging studies reveal an expansile lesion with the classic soap bubble appearance that involves most of the calcaneus. The bone scan reveals a very active lesion with intense uptake, and the MRI scans show the classic, loculated appearance of the lesion with multiple fluid-fluid levels. While it is important to rule out telangiectatic osteosarcoma, the most likely diagnosis is an aneurysmal bone cyst. While giant cell tumor might have a similar appearance, the multiple fluid levels in a expansile lesion strongly favor an aneurysmal

bone cyst.

REFERENCES: Parsons TW: Benign bone tumors, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1027-1035.
Dorfman HD, Czerniak B: Bone Tumors. St Louis, MO, Mosby, 1998, pp 855-879.

Question 12

A patient who is an observant Jehovah’s Witness requires major surgery for scoliosis that will likely result in significant blood loss. Which of the following might the patient consider allowing the surgical team to use?

Explanation

DISCUSSION: Jehovah’s Witnesses will not accept the transfusion of blood or blood products such as packed red or white cells, platelets, or plasma. However, many Jehovah’s Witnesses will accept the use of a cell saver in a “closed circuit.”
REFERENCES: Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.
www.watchtower.org. Official Web Site of Jehovah’s Witnesses. Link verified as active as of August 8, 2008.

Question 13

A 24-year-old man is ejected from his motorcycle and sustains a significant hip injury. The fracture shown in Figures 64a through 64e is best described as what type of fracture?

Explanation

DISCUSSION: The radiographs and CT scans reveal an anterior column acetabular fracture. The fracture has quadrilateral plate extension but does not exit out the posterior column. The CT scans confirm an intact posterior column and no wall fracture. A transverse fracture is best seen on the CT scan and runs in the sagittal plane, not the coronal plane.
REFERENCES: Letournel E, Judet R: Fractures of the Acetabulum, ed 2. New York, NY, Springer-Verlag, 1993, pp 115-140.
Beaule PE, Dorey FJ, Matta JM: Letournel classification of acetabular fractures: Assessment of interobserver and intraobserver reliability. J Bone Joint Surg Am 2003;85:1704-1709.

Question 14

A healed fracture of the tibia that demonstrates 25 degrees apex posterior angulation and 28 degrees varus angulation on AP and lateral radiographs is most accurately described as a

Explanation

Deformities that are seen simultaneously on the AP and lateral roentgenograms of the same bone are actually shadows of the true deformity. If, for example, angulation is seen at the site of a fracture on both of the standard roentgenograms, then the true plane of angulation is somewhere between the coronal and sagittal planes, and the actual amount of angulation is greater than that visualized on either roentgenogram. Because the standard roentgenograms are orthogonal (at right angles) to each other, it is possible to calculate the actual plane and angle of deformity on the basis of dimensions measured from the roentgenograms.

Question 15

In the nonsurgical management of posterior tibial tendon dysfunction with flexible deformity, a common strategy is to prescribe an ankle-foot orthosis or a University of California Biomechanics Laboratory (UCBL) orthosis with medial posting. A high patient satisfaction rating and favorable outcome with this nonsurgical management is most likely in which of the following situations?

Explanation

DISCUSSION: Most authors recommend an initial trial of nonsurgical management in the treatment of adult-acquired flatfoot deformity such as posterior tibial tendon dysfunction. Chao and associates found that there is high patient satisfaction with ankle-foot orthoses and UCBL-type inserts in elderly patients with a relatively sedentary lifestyle. Alternatively, there was a higher dissatisfaction rate in young active patients, those with balance and ambulation difficulties (Parkinson’s, severe arthritis of the hip or knee), and patients with inflammatory systemic disorders.
REFERENCES: Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int 1996;17:736-741.
Noll KH: The use of orthotic devices in adult acquired flatfoot deformity. Foot Ankle Clin 2001;6:25-36.

Question 16

A 40-year-old laborer sustains the injury shown in the radiograph and CT scan in Figures 56a and 56b. What is the most common complication associated with surgical intervention?

Explanation

DISCUSSION: The patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence.
REFERENCES: Sanders R: Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-250.
Sanders R, Fortin P, DiPasquale T, et al: Operative treatment in 120 displaced intra-articular calcaneal fractures: Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;290:87-95.

Question 17

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

Explanation

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

Question 18

Which of the following factors is most likely to contribute to pseudarthrosis in a patient who has undergone a single-level anterior decompression and fusion procedure for the treatment of cervical radiculopathy? Review Topic

Explanation

Various factors affect the pseudarthrosis rate in patients who undergo anterior cervical decompression and fusion. Patient factors, including history of smoking and history of
diabetes mellitus, have been shown to significantly increase pseudarthrosis rates. The literature has been mixed with regard to fusion rates for allograft versus autograft, especially for one-level fusions; in that category, there is minimal, if any, difference. Similarly, several authors have shown higher rates of fusion with uninstrumented single-level rather than instrumented anterior cervical decompressions and fusions. The level (ie, cranial or caudal) of fusion and sagittal alignment have not been correlated with fusion rates.

Question 19

A 37-year-old man has left shoulder pain and weakness. Coronal T1- and axial T2-weighted MRI scans are shown in Figures 17a and 17b. The biopsy specimen is shown in Figure 17c. What is the most likely diagnosis?

Explanation

DISCUSSION: A ganglion cyst arising from the posterior labrum of the shoulder is a known cause of suprascapular nerve impingement. The MRI characteristics of low-signal intensity on T1 and high-signal intensity on T2 are seen in lesions with a high fluid content. The histology shows a cavity with a thin fibrous lining.
REFERENCES: Ferrick MR, Marzo JM: Suprascapular entrapment neuropathy and ganglion cysts about the shoulder. Orthopedics 1999;22:430-434.
Post M: Diagnosis and treatment of suprascapular nerve entrapment. Clin Orthop 1999;368:92-100.

Question 20

A 17-year-old quarterback reports shoulder pain localized over the anterior aspect of the shoulder that occurs during the follow through phase of throwing. The pain worsens toward the end of the game, but becomes asymptomatic the next day. He denies any pain during the cocking phase of throwing or during normal daily activities. Examination reveals a negative relocation test and a negative posterior load and shift test. Motion of the shoulder is normal. An MRI arthrogram is shown in Figure 75. Based on the history, examination, and MRI findings, what initial treatment should be recommended? Review Topic

Explanation

The MRI scan shows a small amount of contrast between the posterior labrum and the glenoid, suggesting a posterior labral tear. The patient's symptoms are more consistent, however, with rotator cuff deconditioning because of the timing of his pain during the throwing motion and increased severity at the end of the game. Treatment should focus on reconditioning of the rotator cuff and scapular stabilizers, combined with a return to throw program. Posterior labral tears are often found on MRI scans of asymptomatic throwers, and therefore, should not be considered the primary cause of a patient's symptoms unless it is supported by the history and physical examination. Internal rotation contractures can cause a similar pain pattern, but this patient has full and equal range of motion.

Question 21

A man who weighs 75 kg (165 pounds) is scheduled for elective total hip arthroplasty. He reports a history consistent with anaphylaxis from penicillin. Within 1 hour of the incision the patient should receive 1000 mg of

Explanation

The recommended antimicrobial prophylaxis for total hip arthroplasty is cefazolin or cefuroxime unless the patient has an allergy to beta-lactam antibiotics. Patients with an allergy should be given vancomycin 10 to 15 mg/kg or clindamycin 600 to 900 mg. Because this patient has an allergy to penicillin, he should be given 1000 mg of vancomycin within 1 hour of the skin incision.

Question 22

03 A patient with carpometacarpal joint arthritis of the thumb undergoes trapezium excision and interposition arthroplasty. One year after treatment, radiographs reveal that there has been 25% subsidence of the thumb metacarpal compared with its preoperative height. This degree of subsidence will have what effect on the surgical outcome?

Explanation

Yang and Weiland, from New York studied subsidence after trapezium excision and interposition arthroplasty. They compared preoperative and postoperative x-rays at rest as well as with maximal lateral key pinch stress. Lateral key
pinch stress causes a large amount of axial compressive force through the CMC joint. They also compared preoperative and postoperative functional measurements, including key pinch strength, tipto-tip pinch strength, grip strength, and thumb ROM. Their findings were that postoperatively the first metacarpal subsided 21% at rest (p=0.001). and it subsided another 10.5% during maximal lateral key pinch. Even with this degree of subsidence, the patients experienced increases in pinch strength and grip strength. Also, all patients except for one who had bony impingement reported that they were subjectively much better and more functional.
Lin et. al. also studied trapezium excision and interposition arthroplasty and found no significant differences between results in patients with varying degrees of subsidence. Thus, subsidence does not affect the results of interposition arthroplasty for basal thumb arthritis.
back to this question next question

Question 23

A 19-year-old rugby player has severe knee pain after being injured in a game 2 weeks ago. Examination reveals a knee effusion, limited motion, and increased 3+ Lachman’s test and anterior drawer. There is also increased external rotation at 30 degrees of knee flexion when the patient is placed in the prone position. Based on these findings, which of the following actions would most likely increase the risk of anterior cruciate ligament (ACL) reconstruction failure?

Explanation

DISCUSSION: The patient has a combined ACL and posterolateral corner injury. Failure to diagnose and treat an injury of the posterolateral corner in a patient who has a tear of the anterior or posterior cruciate ligament can result in failure of the reconstructed cruciate ligament. The tibial external rotation test is best performed with the patient in the prone position. A 10-degree side-to-side difference of external rotation at 30 degrees of knee flexion indicates injury to the posterolateral corner. Acute grade III isolated or combined injuries of the posterolateral corner are best treated early by direct repair or by augmentation or reconstruction of all injured ligaments. Postoperative arthrofibrosis after an ACL reconstruction has been observed with preoperative deficiencies of knee motion.
REFERENCES: Veltri DM, Warren RF: Posterolateral instability of the knee. J Bone Joint Surg Am 1994;76:460-472.
Covey DC: Injuries of the posterolateral corner of the knee. J Bone Joint Surg Am

2001;83:106-118.

Question 24

Figure 46 shows the radiograph of a 65-year-old man who reports restricted range of motion and pain with sitting 18 months after undergoing right side revision total hip arthroplasty. What is the most appropriate management? L Intensive physiotherapy

Explanation

DISCUSSION: The presence of Brooker grade 1 or 2 heterotopic ossification (HO) does not influence the outcome of total hip arthroplasty, whereas restricted range of motion and pain may occur in patients with more severe grade 3 or 4 HO. Treatment may be nonsurgical or surgical. Nonsurgical management includes intensive physiotherapy during the maturation phase of the disease in an attempt to limit the final stiffness. There appears to be no data regarding the effectiveness of this treatment. There is no role for NSAIDs or radiotherapy as a treatment for preexisting HO. Surgical treatment involves excision of the heterotopic bone and can be expected to improve the functional outcome. Bisphosphonates have been used in the past, but their use has been discontinued as they only postpone ossification until treatment is stopped.
REFERENCES: Board TN, Karva A, Board RE, et al: The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty. J Bone Joint Surg Br 2007;89:434-440.
Harkess JW, Crockarell JR: Arthroplasty of the hip, in Canale ST, Beaty JH (eds): Campbell’s Operative
Orthopaedics, ed 11. Philadelphia, PA, Mosby Elsevier, 2008, vol 1, pp 314-483.

Question 25

A 22-year-old man has mild hip pain bilaterally and multiple skeletal lesions. Based on the pelvic radiograph shown in Figure 30, what is the inheritance pattern for his disorder?

Explanation

DISCUSSION: Multiple hereditary exostoses (MHE) is an autosomal dominant disorder manifested by multiple osteochondromas and characteristic skeletal involvement. EXT1 on 8q24.1 and EXT2 on 11p13 are the two genes most strongly associated with MHE. Mutations in these genes affect proper development of endochondral bone, such that in all affected individuals exostoses develop adjacent to the growth plates of long bones, and some exhibit additional bone deformities. Defects in the EXT genes result in increased chondrocyte proliferation and delayed hypertrophic differentiation.
REFERENCES: Stieber JR, Dormans JP: Manifestations of hereditary multiple exostoses. J Am Acad Orthop Surg 2005;13:110-120.
Hilton MJ, Gutierrez L, Martinez DA, et al: EXT1 regulates chondrocyte proliferation and differentiation during endochondral bone development. Bone 2005;36:379-386.

Question 26

A 25-year old right-hand dominant professional baseball pitcher complains of posteromedial right elbow pain that is worsened by throwing. He also reports occasional paresthesias in his small and ring finger after lengthy bullpen sessions. On examination, he is tender along the medial olecranon and complains of pain when extending the elbow >- 20° of extension. He has negative valgus stress, moving valgus stress, and milking maneuver tests. He is stable to varus stress, chair rise, and lateral pivot shift tests. Radiographs reveal a small osteophyte along the posteromedial border of the olecranon. What is the most likely diagnosis?

Explanation

A patient sustains a displaced diaphyseal humerus fracture following a motor vehicle accident. Open reduction internal fixation is indicated due to concomitant lower extremity trauma and is planned through an anterior approach. Which intramuscular interval is exploited during the deep dissection of the mid-humerus in this approach?

A. Lateral head of triceps (radial nerve) and brachialis

(musculocutaneous nerve)

B. Lateral head of the triceps (radial nerve) and biceps brachii

(musculocutaneous nerve)

C. Lateral brachialis (radial nerve) and medial brachialis

(musculocutaneous nerve)

D. Brachialis (musculocutaneous nerve) and coracobrachialis

(musculocutaneous nerve)

Question 27

Which intervention most effectively prevents surgical-site infections following spine surgery?

Explanation

DISCUSSION
The use of IV antibiotics for prophylaxis of surgical-site infection is supported by Level 1 evidence in spine surgery. It has been given a "B" recommendation by the North American Spine Society. The use of specific bathing solutions the day of surgery may be beneficial, but the evidence in spine surgery is lacking. Similarly, evidence for use of vancomycin (either topically or IV) is not supported by high-level studies, although retrospective and basic science studies support topical vancomycin use.
RECOMMENDED READINGS
Brown MD, Brookfield KF. A randomized study of closed wound suction drainage for extensive lumbar spine surgery. Spine (Phila Pa 1976). 2004 May 15;29(10):1066-8. PubMed PMID: 15131430. View Abstract at PubMed
Diab M, Smucny M, Dormans JP, Erickson MA, Ibrahim K, Lenke LG, Sucato DJ, Sanders JO. Use and outcomes of wound drain in spinal fusion for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2012 May 15;37(11):966-73. doi: 10.1097/BRS.0b013e31823bbf0b.
PubMed PMID: 22037527. View Abstract at PubMed
Evaniew N, Khan M, Drew B, Peterson D, Bhandari M, Ghert M. Intrawound vancomycin to prevent infections after spine surgery: a systematic review and meta-analysis. Eur Spine J. 2014 May 18. [Epub ahead of print] PubMed PMID: 24838506. View Abstract at PubMed Rubinstein E, Findler G, Amit P, Shaked I. Perioperative prophylactic cephazolin in spinal surgery. A double-blind placebo-controlled trial. J Bone Joint Surg Br. 1994 Jan;76(1):99-

Question 28

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

Explanation

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

Question 29

-If a physician elects to shorten a femur by 4 cm for traumatic bone loss treatment and places an intramedullary nail for fixation, which deformity will be created in the lower extremity?

Explanation

Question 30

Figures 6a and 6b are the radiographs of a thin 23-year-old man who sustained a closed injury to his left arm in a fall. He has no other injuries and his

Explanation

The patient is a thin man with an isolated left humerus fracture. The fracture has bony apposition and should be amenable to closed treatment; therefore the most appropriate treatment is coaptation splinting with conversion to a fracture brace. A hanging arm cast is not recommended for a transverse fracture because of the propensity to distract the fragments, especially if left in place for a long period of time. A shoulder immobilizer is not an appropriate treatment for a humeral shaft fracture. A transverse fracture line is sometimes considered a relative indication for surgical treatment if the fragments are distracted, but in this patient, immediate surgical fixation is not warranted in the absence of other indications for surgical treatment.

Question 31

A 15-year-old boy with a type I hereditary sensory motor neuropathy (Charcot-Marie-Tooth disease) reports recurrent ankle sprains and significant pain in the hindfoot and midfoot despite orthotic management. Examination reveals that he walks with a drop foot and has dynamic clawing of the toes. Clinical photographs of the left foot are shown in Figure 7. Management should consist of

Explanation

DISCUSSION: The clinical photographs show a patient with a type I hereditary sensory motor neuropathy who has cavus feet with a flexible hindfoot. The Coleman block test shows that the hindfoot corrects into valgus. To prevent progressive cavus, patients with this condition may benefit from soft-tissue releases at a younger age while the foot is flexible. Once there is fixed deformity, combined soft-tissue and bone procedures usually are necessary. Metatarsal osteotomies will correct the cavus, but will do nothing for the drop foot. Transfer of the extensor hallucis longus to the neck of the first metatarsal and modified transfer of the extensor digitorum longus to the dorsum of the foot will prevent further claw toes and improve foot dorsiflexion. Anterior transfer of the posterior tibialis tendon will also aid in dorsiflexion. Calcaneal osteotomy should be reserved for fixed hindfoot varus that does not correct with block testing, and triple arthrodesis should be avoided as long as possible because the long-term outcome is poor.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1999, pp 235-245.
Coleman SS: Complex Foot Deformities in Children. Philadelphia, Pa, Lea & Febiger, 1983, pp 147-165.
Thometz JG, Gould JS: Cavus deformity, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992, pp 343-353.

Question 32

An 80-year-old man with a history of chronic obstructive pulmonary disease (COPD) and dementia is involved in a fall from standing height, striking his forehead. He is seen in the emergency department with predominantly mechanical neck pain but no obvious neurologic deficits. Radiographs reveal a nondisplaced type II odontoid fracture. What is the most appropriate treatment? Review Topic

Explanation

The treatment options for a type II odontoid fracture include halo immobilization, odontoid screw fixation, and posterior atlantoaxial arthrodesis. However, surgical care at this time without attempting nonsurgical management is not warranted; therefore, the most appropriate management at this time is immobilization in a rigid cervical orthosis for 6 to 8 weeks. Halo vest fixation can lead to high healing rates but is generally contraindicated in elderly patients, especially one with COPD and dementia. Posterior surgical fusion techniques provide high fusion rates, but do so at the expense of loss of cervical rotation and surgical complications. Resection of a nondisplaced odontoid fracture without cord compression via a transoral approach is not necessary.

Question 33

A 70-year old woman undergoes revision total knee arthroplasty for tibial component aseptic loosening. She is concerned about recurrent loosening, and tibial stem fixation options during revision are reviewed. Figure below displays a radiograph of the revision technique used for this patient. What is the incidence of intraoperative tibial shaft fracture that is associated with this type of revision surgery?

Explanation

DISCUSSION:
Using press-fit tibial stems during a hybrid revision total knee arthroplasty is associated with a 3% to 5% incidence of intraoperative tibial shaft fracture. Diaphyseal fixation of press-fit stems has the advantage of setting component alignment, dispersing forces on the proximal tibia, and offers excellent clinical results. The disadvantages include proximal and distal tibia anatomic mismatch and tibial shaft fracture. Cipriano and associates reported a tibial shaft fracture incidence of 4.9% in a series of 420 consecutive
knee revisions. All fractures healed with nonsurgical management, and none led to implant loosening. In this patient, it is important to recognize on the radiograph that this technique is a hybrid method of revision total knee arthroplasty, with cementation along the tibial tray and metaphysis and with press-fit fixation of the diaphyseal engaging stem. Then, it is important to know the risk and management of intraoperative diaphyseal tibial fractures. Cemented tibial stems are associated with a low rate of intraoperative fracture, because the implant is typically undersized to allow for an appropriate cement mantle. Option C is incorrect, because this revision is not cemented. Option A underestimates the incidence of fracture, whereas D overestimates the rate of fracture.

Question 34

Figures 1 through 3 show the MRI images and a radiograph obtained from a 31-year-old woman who has a 1-year history of diffuse right wrist pain that is gradually worsening. She denies fever or chills and also denies a history of injury. Her examination reveals no swelling, no erythema, an 80 degree arc of active wrist flexion and extension, and dorsal wrist tenderness. The most likely diagnosis is

Explanation

EXPLANATION:

Question 35

New painful paresthesias near the site of the incision after an ulnar nerve transposition is the result of injury to what nerve?

Explanation

DISCUSSION: Branches of the medial antebrachial cutaneous nerve can often be identified during routine ulnar nerve surgery crossing the medial aspect of the elbow. It should be preserved to avoid development of painful paresthesias.
REFERENCE: Dellon AL, Mackinnon SE: Injury to the medial antebrachial cutaneous nerve during cubital tunnel surgery. J Hand Surg Br 1985;10:33-36.

Question 36

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

Explanation

Question 37

A 3-year old child from an isolated mountain area is evaluated for multiple medical problems, including vomiting, loss of appetite, polyuria, and failure to thrive. History reveals the child was normal at birth. The parents, who appear healthy, are second cousins and have two other children who are normal. The parents state that they know of another family member who died at age 6 years after a similar medical history. Radiographs of the lower extremities show bowing of the long bones with cupping and widening of the physes. What is the most likely diagnosis?

Explanation

Hypophosphatemia-The patients who were symptomatic had obtundation,
hemolytic anemia, rhabdomyolysis, and hepatocellular injury that began during refeeding and resolved with treatment. The signs and symptoms, pathophysiology, and treatment of refeeding hypophosphatemia are reviewed.
Renal Osteodystrophy-Musculoskeletal complications in patients with chronic renal failure are common and may be related to the disease itself or to treatment. The altered metabolism in patients with chronic renal failure leads to renal osteodystrophy, which consists of osteomalacia and secondary hyperparathyroidism [1]. Erosive changes attributable to secondary hyperparathyroidism may be easily confused with rheumatoid arthritis, seronegative spondyloarthropathies, infection, or even malignancy.
Primary Hyperparathyroidism-Preferential involvement of cortical bone with apparent preservation of cancellous bone in primary hyperparathyroidism was confirmed by percutaneous bone biopsy. Over 80% of patients had a mean cortical width below the expected mean, whereas cancellous bone volume in over 80% of patients was above the expected mean.
Skeletal disease in primary hyperparathyroidism J Bone Miner Res 1989 Jun; 4(3):283-91
Nutritional vitamin D deficiency-Rickets, osteomalacia, and renal osteodystrophy are disorders of the mineralization of bone that result from a lack of available calcium, phosphorus, or both. The diseases that result from numerous mechanisms present with a symptom-sign-radiographic complex with such a high degree of stereotypy that laboratory investigation is often required to distinguish one form from another. The disorders in children, known as rickets, produce bowing and other deformities of the long bones and dwarfism. These disorders are principally related to the profound effect of the deficiency states on the epiphyseal plate; whereas the same disorders in adults produce an often severe osteopenia and pathologic fractures. Because of newer developments in our understanding of the factors affecting calcium-phosphorus
hemostasis and vitamin D metabolism, many of the children and Rickets, osteomalacia, and renal osteodystrophy.

Question 38

An axial T 1 -weighted MRI scan of the pelvis is shown in Figure 35. Which of the following structures is enclosed by the circle?

Explanation

DISCUSSION: The obturator vessels and nerve pass along the lateral pelvic wall along the true pelvic brim (nerve lies anterior to the vessels and lies on the obturator internus muscle) and descend into the obturator groove at the upper portion of the obturator foramen.
REFERENCES: Higuchi T: Normal anatomy and magnetic resonance appearance of the pelvis, in Takahashi HE, Morita T, Hotta T, et al (eds): Operative Treatment of Pelvic Tumors. Tokyo, Japan, Springer-Verlag, 2003, pp 4-21.
Berquist TH: Pelvis, hips and thigh, in Berquist TH (ed): MRI of the Musculoskeletal System,

ed 4. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 210-238.

Question 39

Which of the following illustrations shown in Figures 21a through 21e correctly shows the projection of the sacroiliac joint on the outer table of the ilium?

Explanation

DISCUSSION: The projection of the sacroiliac joint on the outer surface of the ilium should be well understood to avoid violation of the joint during bone graft harvesting and to help in insertion of the screw across the joint. The sacroiliac joint has superior and inferior limbs. The average lengths of the superior and inferior limbs are 4.4 cm and 5.6 cm, respectively. The average width of each limb is 2.0 cm. The average distance from the longitudinal axis of the superior limb to the posterior superior iliac spine is 5.5 cm. The average longitudinal axis of the inferior limb is 1.2 cm superior to the inferior margin of the posterior inferior iliac spine. The average angle between the two axes is 93 degrees. Figure 21c most closely shows the projection of the sacroiliac joint on the outer table of the ilium.
REFERENCES: Waldrop JT, Ebraheim NA, Yeasting RA, Jackson WT: The location of the sacroiliac joint on the outer table of the posterior ilium. J Orthop Trauma 1993;7:510-513.
Xu R, Ebraheim NA, Yeasting RA, Jackson WT: Anatomic considerations for posterior iliac bone harvesting. Spine 1996;21:1017-1020.

Question 40

A 60-year-old woman with a history of osteoporosis fell from a standing height and sustained a supracondylar distal humerus fracture with an intercondylar extension. Which of the following plate constructs yields the highest stiffness for fixation of the fracture?

Explanation

Optimal treatment of distal humeral fractures relies on reestablishment of a congruent articular surface with a fixation construct that is stable enough to allow for early range of motion. Several biomechanical studies have been performed to evaluate the biomechanical strength of various plating configurations. These studies have shown that dual plate configurations are more stable than single plates, regardless of the type of plate used. One third tubular plates have been shown to be significantly weaker than LC-DCP or reconstruction plates, resulting in weaker constructs, and clinically higher rates of hardware failure and nonunion. Whereas traditional teaching has suggested plating in perpendicular planes, recent biomechanical studies have demonstrated that parallel medial and lateral plates confer a greater rigidity to the construct than perpendicular plating schemes.

Question 41

Which of the following is a true statement regarding thoracic disk herniations? Review Topic

Explanation

Symptomatic herniations of the thoracic spine are much less common than those of the cervical or lumbar region. They tend to occur most commonly during the third to fifth decades of life and although they can be found at all levels, they are most
common in the lower third near the thoracolumbar region. Posterior laminectomy and disk excision has the highest rate of neurologic deterioration and is not recommended. Multiple studies have shown that herniated thoracic disks can be found at one or more levels in 40% of asymptomatic individuals.

Question 42

A 24-year-old woman who has hypotension, a head injury, and who experienced a poor response to resuscitation has been taken to the operating room for a splenectomy. Following abdominal surgery she remains unstable with increasing pulmonary respiratory pressures and decreasing oxygen saturation. She has a transverse mid-diaphyseal fracture of the tibia with a 4-cm laceration and soil-contaminated muscle in the wound. Based on these findings, management should consist of

Explanation

DISCUSSION: Because the patient is critically ill and requires expeditious care, stabilization of the long bone fracture is required, but definitive care of the fracture should be postponed. The treatment of choice at this time is irrigation with 12 L of saline solution, followed by debridement and nondefinitive stabilization with a simple four-pin external frame to regain axial and rotational alignment. When the patient’s condition is more stable, more definitive care can be performed.
REFERENCES: Bosse MJ, Kellam JF: Orthopaedic management decisions in the multiple trauma patient, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 151-164.
Weresh MJ, Stover MD, Bosse MJ, Jeray K, Kellam JF: Pulmonary gas exchange during intramedullary fixation of femoral shaft fractures. J Trauma 1999;46:863-868.
Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN: External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: Damage control orthopedics. J Trauma 2000;48:613-623.

Question 43

The clinical factors shown to most significantly predict the long-term outcome of Perthes disease of the hip include which of the following? Review Topic

Explanation

Age at presentation and range of motion of the hip are the two most significant predictors of long-term outcome. Younger patients and patients who maintain range of motion of the hip are more likely to have a good outcome. In Herring's study, children with a chronologic age of younger than 8 years or a bone age of less than 6 years had significantly more favorable outcomes compared with older children. Limited hip range of motion may be due to muscle spasm early on, or synovitis; but in late disease, it may reflect incongruity of the joint. Classifications based on femoral head shape have also been correlated to prognosis. Significant shortening of the affected hip is not common.
(SBQ13PE.87) A 4-week-old child is suspected to have classic arthrogryposis, also known as amyoplasia. Clinical examination and hip ultrasound reveal a unilateral, non-reducible, hip dislocation. What do you recommend to reduce the hip? Review Topic
Pavlik harness application
Semi-rigid abduction brace application
Skeletal traction
Early closed reduction and spica casting
Delayed open reduction with or without pelvic and femoral osteotomy
Delayed open reduction with or without pelvic and femoral osteotomy is recommended in the management of unilateral hip deformities associated with amyoplassia. This procedure should be performed at 6-9 months of age. In order to proceed with reduction, there must be a reasonable arc of flexion/extension and active movement of the lower limbs.
Amyoplasia is the most common recognizable form of arthrogryposis. It most commonly occurs as a sporadic symmetric contracture syndrome that is characterized by symmetrical limb involvement, normal to above-average intelligence, and often a midline facial hemangioma. Approximately 80% of children with amyoplasia will have involvement of the hip ranging from soft tissue contractures to unilateral or bilateral hip dislocations.
Bevan et al. reviewed arthrogryposis. They state that open hip reduction is recommended for the management of unilateral dislocation. There is more controversy with regard to the treatment of bilateral hip dislocations. Open reduction can be performed by a medial or anterolateral approach, with or without pelvic and
femoral osteotomy. This procedure is generally delayed for 6-9 months to facilitate the procedure.
Bernstein et al. also reviewed arthrogryposis. They state that the term 'arthrogryposis' encompasses a broad spectrum of diseases, all with the common phenotype of multiple congenital contractures.
Illustration A shows the characteristic features of an infant with severe arthrogryposis. Note the internal rotation of the shoulders, elbow and knee hyperextension, flexed and ulnarly deviated wrists, flexed finger, external rotation of hips and bilateral clubfeet.
Incorrect answers:

Question 44

Figures below show the radiographs obtained from a 79-year-old woman who has been experiencing increasing tibial pain 10 years after undergoing revision total knee arthroplasty. No evidence of infection is seen. What is the most appropriate treatment?

Explanation

DISCUSSION:
Stems are available for cemented and press-fit implantation. To be effective, press-fit stems should engage the diaphysis, as shown in Figures 3 and 4. They also assist in obtaining correct limb alignment. Short metaphyseal-engaging stems are associated with failure rates that range between 16% and 29%. Cemented stems may be shorter than press-fit stems, because they do not have to engage the diaphysis. Short, fully cemented stems offer the advantage of metaphyseal fixation. Hybrid stem fixation makes use of the metaphysis for cement fixation with metaphyseal cones or sleeves and diaphyseal-engaging press-fit stems.

Question 45

In the anterior cruciate ligament-deficient knee, what structure provides an important secondary restraint to anterior tibial translation? Review Topic

Explanation

Cadaveric studies have demonstrated the important role of the posterior horn of the medial meniscus in stabilizing the anterior cruciate ligament-deficient knee with significantly greater resultant force in the medial meniscus when subjected to anterior tibial loads. The posterior horn of the medial meniscus is thought to limit anterior tibial translation by acting as a buttress by wedging against the posterior aspect of the medial femoral condyle. The other soft tissues mentioned do not play any significant role in prevention of anterior tibial translation in the anterior cruciate ligament-deficient knee.

Question 46

Which of the following therapies has a direct anabolic effect on bone?

Explanation

Bisphosphonates are antiresorptive agents that act by targeting osteoclatic bone resorption. Calcitonin also inhibits osteoclastic bone resorption. Excessive cortisol decreases intestinal calcium absorption, increases calcium loss from the kidney, inhibits bone matrix formation, and causes secondary hyperparathyroidism. TNF-a inhibits osteoblastic activity and enhances osteoclastic bone resorption. Intermittent administration of PTH isoforms is anabolic, whereas persistent elevated levels of PTH promotes bone resorption.

Question 47

Which of the following radiographic images is best for detecting anterior acetabular deficiency in the dysplastic hip?

Explanation

DISCUSSION: The false profile view of Lequesne and de Seze is obtained with the patient standing with the affected hip on the cassette, the ipsilateral foot parallel to the cassette, and the pelvis rotated 65 degrees from the plane of the cassette. This view best assesses anterior coverage of the femoral head.
REFERENCES: Garbuz DS, Masri BA, Haddad F, et al: Clinical and radiographic assessment the young adult with symptomatic dysplasia. Clin Orthop Relat Res 2004;418:18-22.
Delauney S, Dussault RG, Kaplan PA, et al: Radiographic measurements of dysplastic adult hips. Skelelal Radiol 1997;26:75-81.

Question 48

A 56-year-old man has a chief complaint of leg weakness and inability to walk. Examination reveals 5 out of 5 motor strength in all lower extremity muscle groups tested and normal sensation to light touch in both lower extremities. The patient is slow in getting up from a seated position and has an unsteady wide-based

Explanation

The patient is having gait problems suspicious for spinal cord compression. MRI of the thoracic and cervical spine should be performed to evaluate for spinal cord compression. Reports of leg weakness in the absence of discrete motor weakness on manual testing, and the appearance of an unsteady wide-based gait are more consistent with myelopathy as a cause of the gait difficulty rather than lumbar stenosis. Although the MRI scan of the lumbar spine shows multilevel spinal stenosis that is mild to moderate, it does not clearly explain the patient's signs and symptoms. Electromyography and nerve conduction velocity studies of the lower extremities are unlikely to add significantly to the diagnosis. Epidural steroid injections are not indicated. Lumbar decompression is unlikely to help the patient because the source of the patient's problem does not originate in the lumbar spine. MRI of the brain could be considered as a secondary imaging study if the cervical and thoracic MRI scans fail to identify an obvious cause for gait instability.

Question 49

A 54-year-old woman with idiopathic carpal tunnel syndrome undergoes open carpal tunnel release with a flexor tenosynovectomy. The pathology from the tenosynovium is likely to show

Explanation

DISCUSSION: The tenosynovium excised at the time of a carpal tunnel release for idiopathic carpal tunnel syndrome rarely shows signs of acute or chronic inflammation. Fibrosis, edema, and vascular sclerosis are the most common histologic findings. A tenosynovectomy with a carpal tunnel release usually is not necessary in the treatment of idiopathic carpal tunnel syndrome.
REFERENCES: Shum C, Parisien M, Strauch RJ, et al: The role of flexor tenosynovectomy in the operative treatment of carpal tunnel syndrome. J Bone Joint Surg Am 2002;84:221-225.
Fuchs PC, Nathan PA, Myers LD: Synovial histology in carpal tunnel syndrome. J Hand Surg Am 1991;16:753-758.
Kerr CD, Sybert DR, Albarracin NS: An analysis of the flexor synovium in idiopathic carpal tunnel syndrome: Report of 625 cases. J Hand Surg Am 1992;17:1028-1030.

Question 50

A woman injures the metacarpophalangeal (MCP) joint of her thumb while skiing. Examination reveals tenderness along the ulnar aspect of the MCP joint. Radially directed stress of the joint in full extension produces 5° of angulation. When the MCP joint is flexed 30°, a radially directed stress produces 45° of angulation. Radiographs are otherwise normal. Management should consist of

Explanation

DISCUSSION: Injuries to the ulnar collateral ligament of the MCP joint of the thumb commonly occur in recreational skiers. Historically, this injury has been referred to as “gamekeeper’s thumb.” The ligament consists of the proper collateral ligament and the more volar accessory collateral ligament. In extension, the accessory ligament is taut, and in flexion, the proper ligament is taut. For a complete tear of the ligament complex to occur, there must be laxity in full extension. Incomplete tears respond well to thumb spica splinting or casting for 2 to 3 weeks and gradual resumption of range of motion. Prolonged immobilization of incomplete injuries leads to higher rates of MCP joint stiffness.
REFERENCES: Stener B: Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb: A clinical and anatomical study. J Bone Joint Surg Br 1971;44:869.
Heyman P: Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint.

J Am Acad Orthop Surg 1997;5:224-229.

Question 51

Figure 1 points to the "tear drop" of the wrist. This radiographic landmark represents which anatomic portion of the wrist?

Explanation

Medoff described the radiographic teardrop of the distal radius. This radiographic landmark matches the critical volar ulnar corner of the distal radius. A malreduction of the volar ulnar corner of the distal radius in an intra-articular distal radius fracture leads to volar subluxation of the lunate and the rapid development of posttraumatic arthritis at the distal radioulnar and radiolunate joints. Knowledge of the specific shape and appearance of this radiographic landmark helps the surgeon when he or she is critically analyzing postreduction imaging. The volar portion of the ulnar head may be mistaken for this teardrop sign and should be separately identified as distinct from the distal radius. The radial styloid and Lister tubercle are not part of the volar aspect of the lunate facet.

Question 52

Sciatic nerve

Explanation

(999) Q1-1306:
The principal thrombogenic stimulus leading to the production of venous thromboembolic disease during total hip arthroplasty occurs at which time:

Question 53

A 56-year-old man underwent right total shoulder arthroplasty 2 months ago. Recently while reaching with his shoulder in a flexed and adducted position, he noted shoulder pain and afterwards he could not externally rotate his arm. An axillary radiograph is shown in Figure 30. What is the most likely cause of this problem?

Explanation

DISCUSSION: Anteversion of the humeral component may result in anterior instability of the component. Posterior instability after total shoulder arthroplasty is usually the result of some combination of the following factors: untreated anterior soft-tissue contractures, excessive posterior capsular laxity, and excessive retroversion of the humeral and/or glenoid components.
REFERENCES: Cofield RH, Edgerton BC: Total shoulder arthroplasty: Complications and revision surgery. Instr Course Lect 1990;39:449-462.
Wirth MA, Rockwood CA Jr: Complications of total shoulder replacement arthroplasty. J Bone Joint Surg Am 1996;78:603-616.

Question 54

Figure 34 shows the standing AP radiograph of a 2-year-old girl who has a left bowleg deformity. Her mother states that she first noticed the problem when the child began walking at age 10 months, and the deformity has worsened over the past 6 months. Examination reveals a definite lateral thrust of the knee during the stance phase of gait. Management should consist of

Explanation

DISCUSSION: Infantile tibia vara is a developmental condition characterized by a varus angulation of the proximal end of the tibia that is caused by a growth disturbance of the proximal medial physis. In a study of 42 affected extremities in 24 children younger than age 3 years, it was found that daytime ambulatory brace treatment favorably altered the natural history of tibia vara. Another study of 27 patients with stage II Langenskiöld disease found a success rate of 70% (improved alignment without the need for osteotomy) using brace treatment. These authors also noted that children with unilateral disease were more likely to obtain correction of the deformity compared with those with bilateral disease. In this patient, observation is not warranted because untreated tibia vara has a significant risk for progressive worsening. Osteotomy is best reserved for those patients who, despite bracing, do not show satisfactory clinical and radiographic improvement by age 4 years. Elevation of the medial tibial plateau is a treatment option for older patients who have more advanced disease. An MRI scan would not provide any useful clinical information at this time.
REFERENCES: Zionts LE, Shean CJ: Brace treatment of early infantile tibia vara. J Pediatr Orthop 1998;18:102-109.
Richards BS, Katz DE, Sims JB: Effectiveness of brace treatment in early infantile Blount’s disease. J Pediatr Orthop 1998;18:374-380.
Raney EM, Topoleski TA, Yaghoubian R, Guidera KJ, Marshall JG: Orthotic treatment of infantile tibia vara. J Pediatr Orthop 1998;18:670-674.

Question 55

An 11-year-old boy sustained an ankle injury while playing football. Figure 20 shows an AP radiograph obtained the day of injury. Treatment should consist of

Explanation

DISCUSSION: The child has an injury involving both the growth plate and the articular surface of the ankle. Because of the significant displacement, open reduction and internal fixation is indicated to realign the physis and joint surface. The best method of fixation to avoid growth arrest is one that does not cross the physis. This is usually achieved by a transverse epiphyseal screw parallel to the physis. If the metaphyseal fragment was large enough, a transverse metaphyseal screw could be used instead. The incidence of growth arrest following physeal ankle injuries is as high as 50%, and long-term follow-up is indicated.
REFERENCES: Cass JR, Peterson HA: Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. J Bone Joint Surg Am 1983;65:1059-1070.
Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibia physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23:733-739.

Question 56

A 46-year-old woman reports pain and a shortened appearance of her toe after undergoing a Keller resection arthroplasty 2 years ago for hallux rigidus. Examination reveals mild swelling and motion limited to 25 degrees at the metatarsophalangeal joint. Radiographs show large dorsal osteophytes on the first metatarsal head, 50% resection of the proximal phalanx, and complete loss of the metatarsophalangeal joint space. Which of the following is considered the most reliable procedure to improve her pain and the appearance of her toe?

Explanation

DISCUSSION: Because the patient has significant arthritis, arthrodesis is the treatment of choice. Adding a bone graft will prevent further shortening and add length to her toe, resulting in improved cosmesis. A cheilectomy will not alleviate her arthritis pain. The toe is too short for an effective Moberg phalangeal dorsiflexion osteotomy. A Waterman first metatarsal dorsal osteotomy will not address the degenerative joint disease or shortening. Silastic arthroplasty may help, but there is the risk of additional problems with foreign body reaction and a significant risk of failure known to occur with Silastic materials.
REFERENCES: Myerson MS, Schon LC, McGuigan FX, Oznur A:Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int 2000;21:297-306.
Mann RA, Coughlin MJ: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 252-253.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 293-303.

Question 57

What is the prognosis for ambulation, from best to worst, for patients with an incomplete spinal cord injury?

Explanation

DISCUSSION: Of the incomplete spinal cord injuries, Brown-Sequard syndrome has the best prognosis for ambulation. Central cord syndrome has a variable recovery. Anterior cord syndrome has the worst prognosis, with motor recovery rare below the level of the injury.
REFERENCES: Apple DF: Spinal cord injury rehabilitation, in Herkowitz HN, Garfin SR, Balderston RA, Eismont FJ, Bell GR, Wiesel SW (eds): Rothman-Simeone The Spine, ed 4. Philadelphia, PA, WB Saunders, 1999, pp 1130-1131.
Northrup BE: Evaluation and early treatment of acute injuries to the spine and spinal cord, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 544-545.

Question 58

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

Explanation

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

Question 59

All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:

Explanation

DISCUSSION: Based on the references provided, the advantages of the lateral position include: facilitates the retraction of the vastus lateralis, allows hip flexion to aid reduction, improves access to the proximal segment (easier to get starting point). Disadvantages of the lateral position include: intraoperative imaging may be more difficult, rotation is more difficult to judge, and lateral positioning may not be practical in the polytraumatized patient.
Advantages of the supine position include: may help protect a potentially unstable spine, facilitates access to sites other than the injured femur, shorter setup time, rotational and angulatory deformities may be more easily appreciated. Disadvantages of the supine position include: starting point localization may be more difficult.

Question 60

A 9-year-old girl has had bilateral knee and leg pain for the past 2 years. The family has noted increasing deformity in both lower extremities. She is less than the fifth percentile for height. Examination reveals bilateral femoral bowing, mild medial-lateral laxity of the knees, and the deformities shown in the radiograph seen in Figure 3. What is the most likely diagnosis? Review Topic

Explanation

The widening, bowing, and cupping of the physes indicate some form of metabolic bone disease; therefore, the most likely diagnosis is renal osteodystrophy. The age of onset makes X-linked hypophosphatemic rickets less likely. The ground glass lesions and widening of the medullary canal characteristic of fibrous dysplasia are not present. There are no fractures creating the deformities indicating osteogenesis imperfecta. There is an asymmetry of the deformities that makes diastrophic dysplasia less likely.

Question 61

Figures 150a through 150d are the radiographs and MR images of a 37-year-old woman who has a 3-month history of severe right hip pain. She does not recall any trauma prior to the pain onset and denies any past steroid exposure. She has 3 children and is not currently pregnant. The pain is located in her groin and the onset was sudden. The pain is refractory to anti-inflammatory medications. What is the most appropriate treatment?

Explanation

DISCUSSION
The patient’s MR images are consistent with transient hip osteoporosis. No signs suggest avascular necrosis. She has no joint narrowing. Transient osteoporosis of the hip is characterized by bone marrow edema in the femoral head and neck. This condition affects more men than women and is sometimes seen in the third trimester of pregnancy but can be seen in women who are not pregnant as well. This is a self-limiting condition, and the treatment is limited weight-bearing activity until the symptoms resolve. Core decompression is rarely used in these cases. There is no indication for arthroplasty or osteotomy in this scenario.

Question 62

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

Explanation

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

Question 63

In infantile idiopathic scoliosis, which of the following factors suggests progression?

Explanation

DISCUSSION: Infantile idiopathic scoliosis occurs more commonly in boys, with a 3 to 1 male to female ratio. Neural axis abnormalities, hip dysplasia, and congenital heart disease are all associated with the condition; spontaneous correction frequently occurs. Curve progression can be predicted by the rib vertebral angle difference or the phase of the rib head. Rib overlap of the apical vertebral body or a rib vertebral angle difference of greater than 20 degrees indicates that the curve is likely to progress. Gender, family history, and age at presentation have not been found to be risk factors for progression.
REFERENCES: Mehta MH: The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. J Bone Joint Surg Br 1972;54:230-243.
Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, p 697.

Question 64

An otherwise healthy 45-year-old man has a 3-cm subcutaneous mass on his anterior thigh that is presumed to be a lipoma. Removal of the mass is performed in the office of his primary care physician. Pathologic evaluation shows a high-grade malignant fibrous histiocytoma. Staging reveals no evidence of metastatic disease. Management at this time should consist of

Explanation

DISCUSSION: Resection of a previously excised soft-tissue sarcoma is recommended. Reoperation is recommended after removal of malignant tumors previously believed to be benign, as approximately one half of the patients will have residual tumor in the re-excised specimen. Observation is not indicated in most patients because local recurrence is likely. Radiation therapy alone may result in long-term local control but is felt to be less effective than reoperation. Chemotherapy and radiation therapy alone are not recommended. Wide excision is the most important factor for local disease control. Radiation therapy after surgical re-excision may also decrease the risk of local recurrence.
REFERENCES: Peabody TD, Monson D, Montag A, Schell MJ, Finn H, Simon MA: A comparison of the prognoses for deep and subcutaneous sarcomas of the extremities. J Bone Joint Surg Am 1994;76:1167-1173.
Giuliano AE, Eilber FR: The rationale for planned reoperation after unplanned total excision of soft-tissue sarcomas. J Clin Oncol 1985;3:1344-1348.
Lewis JJ, Leung D, Espat J, Woodruff JM, Brennan MF: Effect of resection in extremity soft tissue sarcoma. Ann Surg 2000;231:655-663.
Noria S, Davis A, Kardel R, et al: Residual disease following unplanned excision of soft-tissue sarcoma of an extremity. J Bone Joint Surg Am 1996;78:650-655.

Question 65

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

Explanation

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

Question 66

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

Explanation

Question 67

A 1-year-old infant has the hand deformities shown in Figure 40. What pathologic process is the most likely cause of these deformities?

Explanation

DISCUSSION: Streeter’s dysplasia is clearly related to rupture of the amnion in utero and is now most commonly referred to as premature amnion rupture sequence. The deformities arise from amniotic bands that wrap about protruding parts and from uterine packing because of the accompanying oligohydramnios. Clubfoot can develop as a result of the latter mechanism. Three limb involvement is most commonly seen, along with syndactyly. Treatment involves resection of bands and Z-plasty of skin. The disease is not genetic and has not been related to teratogen exposure or to iatrogenic influences such as amniocentesis. Developmental field disruption is not seen in this disease, and the growth potential of the involved parts is normal unless neurovascular disruption has arisen from band formation.
REFERENCE: Foulkes GD, Reinker K: Congenital constriction band syndrome: A seventy-year experience. J Pediatr Orthop 1994;14:242-248.

Question 68

A 32-year-old amateur bowler has progressive pain in the lateral aspect of the proximal forearm and elbow. Nonsurgical management consisting of a tennis elbow brace, nonsteroidal anti-inflammatory drugs, and activity modification has failed to provide relief. Examination reveals tenderness in the lateral aspect of the proximal forearm and exacerbation of symptoms with resisted finger extension. Radiographs of the elbow reveal no abnormalities. Which of the following studies will aid in diagnosis?

Explanation

DISCUSSION: It is often difficult to accurately discern between lateral epicondylitis and radial tunnel syndrome. Neither MRI nor a bone scan is likely to reveal abnormalities. Electrodiagnostic studies are often inconclusive, and radial tunnel syndrome often presents without motor weakness. The symptoms of radial tunnel syndrome are expected to improve with an injection of lidocaine into the radial tunnel; therefore, this is the test of choice in this clinical scenario. Radiographs of the wrist will not assist in making the diagnosis.
REFERENCES: Eversmann WW Jr: Entrapment and compression neuropathies, in Green DP (ed): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingston, 1993, pp 1341-1385.
Sarhadi NS, Korday SN, Bainbridge LC: Radial tunnel syndrome: Diagnosis and management. J Hand Surg Br 1998;23:617-619.

Question 69

Based on the MR arthrogram of the elbow shown in Figure 8, which of the following structures is torn?

Explanation

DISCUSSION: Based on the MR arthrogram in which gadolinium (bright on T1-weighted images) was injected into the joint space prior to imaging, the study shows a tear of the anterior band of the ulnar collateral ligament (UCL). The disruption in the distal end of the UCL is outlined by contrast. A small collection of contrast extravasation into the flexor musculature further confirms the presence of a tear. The UCL has a broad-based attachment on the medial epicondyle and has a pointed or tapered attachment distally on the ulna. Most UCL tears occur distally at the ulnar (coronoid) attachment.
MR arthrography provides improved sensitivity compared to conventional MRI, without contrast, for the detection of UCL pathology, particularly in the subacute or chronic setting. After the soft-tissue edema and joint fluid associated with the injury have resolved, the torn end of the ligament may lie in contact with its adjacent attachment and create a false-negative appearance. In this patient, a noncontrasted MR arthrogram showed no tear, yet the tear is apparent with intra-articular contrast and distention. MR arthrography of the elbow also may be useful in detecting intra-articular bodies or in evaluation for loose osteochondral fragments or flaps.
REFERENCES: Morrey BF: Acute and chronic instability of the elbow. J Am Acad Orthop Surg 1996;4:117-128.
Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 200-210.

Question 70

A 16-year-old high school pitcher notes acute pain on the medial side of his elbow during a pitch. Examination that day reveals medial elbow tenderness, pain with valgus stress, mild swelling, and loss of extension. Plain radiographs show closed physes and no fracture. Which of the following diagnostic studies will best reveal his injury?

Explanation

DISCUSSION: The history and findings are consistent with a diagnosis of a sprain of the medial collateral ligament (MCL) of the elbow; therefore, contrast-enhanced MRI is considered the most sensitive and specific study for accurately showing this injury. Arthroscopic visualization of the MCL is limited to the most anterior portion of the anterior bundle only; complete inspection of the MCL using the arthroscope is not possible. CT without the addition of contrast is of no value in this situation. Use of a technetium Tc 99m bone scan is limited to aiding in the diagnosis of occult fracture, a highly unlikely injury in this patient. There are no clinical indications for electromyography.
REFERENCES: Timmerman LA, Andrews JR: Undersurface tear of the ulnar collateral ligament in baseball players: A newly recognized lesion. Am J Sports Med 1994;22:33-36.
Timmerman LA, Schwartz ML, Andrews JR: Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography arthrography: Evaluation of 25 baseball players with surgical confirmation. Am J Sports Med 1994;22:26-32.
Fritz RC, Stoller DW: The elbow, in Stoller DW (ed): Magnetic Resonance Imaging in Orthopedics and Sports Medicine, ed 2. Philadelphia, PA, Lippincott Raven, 1995, pp 743-849.

Question 71

Which of the following patients requires preoperative noninvasive cardiac testing?

Explanation

DISCUSSION: Noninvasive cardiac testing is recommended in the presence of the three or more of the following risk factors in a sedentary patient: history of coronary artery disease or myocardial infarction, history of heart failure, prior cerebrovascular accident, and diabetes mellitus or chronic renal disease. Preoperative stress testing is not recommended if patients can perform moderate activities such as climbing a flight of stairs.
REFERENCES: Bushnell BD, Horton JK, McDonald MF, et al: Perioperative medical comorbidities in the orthopaedic patient. J Am Acad Orthop Surg 2008;16:216-227.
Auerback A, Goldman L: Assessing and reducing the cardiac risk of noncardiac surgery. Circulation 2006;113:1361-1376.
Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 105-113.

Question 72

A 26-year-old man is brought to the emergency department unresponsive and intubated after being found lying on the side of the road. He has a Glasgow Coma Scale score of 6. A chest tube has been inserted on the right side of the chest for a pneumothorax. An abdominal CT scan reveals a small liver laceration and minimal intraperitoneal hematoma. A pneumatic antishock garment (PASG) is on but not inflated. He has bilateral tibia fractures. A pelvic CT scan shows an anterior minimally displaced left sacral ala fracture and left superior and inferior rami fractures. He has received 2 L of saline solution and 4 units of blood but remains hemodynamically unstable. What is the next most appropriate step in management?

Explanation

DISCUSSION: There is no identifiable thoracic, abdominal, or long bone source of ongoing bleeding. The patient has a lateral compression Burgess-Young type I pelvic ring injury. This injury does not increase the pelvic volume because it is not unstable in external rotation. Application of a PASG, a pelvic clamp, or an external fixator may be helpful if the patient has a pelvic injury that is unstable in external rotation or translation but would be of little use in this injury pattern. Persistent hemodynamic instability after administration of 4 units of blood is the decision point where most authors would recommend angiography and embolization. If the pelvis is unstable in external rotation or translation, inflation of the PASG trousers or application of an external fixator is recommended before angiography. Attributing the hemodynamic instability to the head injury before ruling out the pelvis as a source is not indicated.
REFERENCES: Burgess AR, Eastridge BJ, Young JW, et al: Pelvic ring disruptions: Effective classification system and treatment protocols. J Trauma 1990;30:848-856.
Evers BM, Cryer HM, Miller FB: Pelvic fracture hemorrhage: Priorities in management. Arch Surg 1989;124:422-424.
Flint L, Babikian G, Anders M, Rodriguez J, Steinberg S: Definitive control of mortality from severe pelvic fracture. Ann Surg 1990;211:703-707.

Question 73

A 55-year-old man who underwent total shoulder arthroplasty 10 years ago recently reports an increase in shoulder pain. Laboratory studies consisting of a white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are all negative, as is joint aspiration. Radiographs are shown in Figures 95a and 95b. If all intraoperative frozen sections are negative, what is the appropriate treatment during revision surgery to provide pain relief and improved function? Review Topic

Explanation

The radiographs reveal a loose glenoid in the setting of no infection. Glenoid removal may give this patient the best chance of improved function and pain relief if sufficient bone stock remains. Bone grafting of defects may allow future glenoid implantation. Conversion to reverse shoulder arthroplasty would be a salvage procedure in this younger patient. Shoulder arthrodesis would be difficult and unpredictable after shoulder arthroplasty.

Question 74

Which of the following is the most relevant clinical factor in the maturation assessment of an adolescent female athlete contemplating anterior cruciate ligament (ACL) reconstruction?

Explanation

DISCUSSION: Age of menarche is the most accurate clinical factor to assess the degree of skeletal maturity in the female athlete. Such an assessment is necessary prior to ACL reconstruction in a skeletally immature female because of the risk of damage to the distal femoral and proximal tibial physes. Height of an older male sibling is not relevant to the female athlete. Parental height and recent change in shoe size are only moderately useful in predicting final growth, and hence, skeletal maturity. The presence of breast buds occurs early in adolescent development; therefore, its presence suggests a high likelihood of future growth.
REFERENCES: Micheli LJ, Foster TE: Acute knee injuries in the immature athlete. Instr Course Lect 1993;42:473-481.
Stanitski CL: Anterior cruciate ligament injury in the skeletally immature patient: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:146-158.
Fowler PJ: Anterior cruciate ligament injuries in the child, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2067-2074.

Question 75

Figures 74a through 74c are the postsurgical radiographs of a 74-year-old man who has stiffness in his right knee 8 weeks after undergoing elective right total knee arthroplasty (TKA). The surgery was performed for primary varus osteoarthritis and was uncomplicated. His range of motion is 5 to 80 degrees. What is the most appropriate next treatment step?

Explanation

DISCUSSION
Stiffness following TKA is a disabling complication. One option involves MUA, a valuable technique with which to increase range of motion after TKA for patients with stiff knees. A systematic review of the literature was performed to identify studies that reported the clinical outcomes and measured range of motion for patients undergoing MUA. Fourteen studies (913 patients) reported range of motion results following MUA at up to 10-year followup. The review demonstrated that MUA for a stiff primary TKA is an efficacious procedure to restore range of motion, and it carries a low complication rate. Early gains in motion were
reported to be maintained in the long term. A second review systematically evaluated the outcomes of 4 treatments for arthrofibrosis that develops subsequent to TKA (MUA, arthroscopic debridement, open surgical release, and revision TKA). This study showed that there were no significant differences in the Knee Society Score of the 4 treatment modalities. Although open surgical release resulted in the greatest increase in range of motion, there were methodological study limitations because the majority of the papers were case series, which decreased the quality of the evidence. Response 1 is correct because the TKA appears appropriately sized and is well aligned. Responses 2 and 3 are incorrect, considering the early time frame (8 weeks) from initial surgery. Although the patella is unresurfaced in the radiographs, there is no indication for revision TKA (even secondary patellar resurfacing) at this early juncture.

Question 76

Figures 46a through 46d are the injury radiographs and postsurgical open treatment radiographs of a 13-year-old girl who fell while on a trampoline and sustained an injury to her right-dominant elbow. The skin is closed and she has normal vascular and neurologic examination findings. Which complication most likely could occur as a result of this injury and treatment?

Explanation

CLINICAL SITUATION FOR QUESTIONS 47 THROUGH 50
A 6-year-old boy arrives at the emergency department with forearm pain. Today he was picking up his backpack when he felt a pop in his forearm that resulted in the current injury. His history is significant for 6 other fractures treated nonsurgically. His mother states that she had 15 fractures during childhood but is healthy now. Both the boy and his mother have blue sclera. Figures 47a and 47b are the radiographs of his injured forearm.

Question 77

An infant is born with a mass that involves both the volar and dorsal compartments of the left arm. A clinical photograph and biopsy specimen are shown in Figures 41a and 41b. What is the best initial course of action?

Explanation

DISCUSSION: The patient has infantile fibrosarcoma. For unresectable lesions, the treatment of choice is chemotherapy with vincristine, actinomycin-D, and cyclophosphamide, followed by excision if there is an adequate decrease in the size of the lesion.
REFERENCE: Kurkchubasche AG, Halvorson EG, Forman EN, Terek RM, Ferguson WS: The role of preoperative chemotherapy in the treatment of infantile fibrosarcoma. J Pediatr Surgery 2000;35:880-883.

Question 78

A 45-year-old man who smokes reports the rapid onset of color changes and coolness in the fingers. Examination shows an abnormal Allen test. Plain radiographs of the hand and wrist are normal. Which of the following studies will best aid in diagnosis?

Explanation

DISCUSSION: The patient has symptoms typical of Raynaud’s phenomenon secondary to underlying vascular disease. The next most appropriate step in the management of this patient should be to perform contrast angiography on the involved upper extremity to look for proximal or distal arterial lesions or insufficiencies. MRI and contrast CT are not as specific as angiography for the identification of vascular lesions of the upper extremity. Although patients with primary Raynaud’s vasospastic disease can have normal angiographic findings, they typically are younger than age 40 years, are female, and have normal results on an Allen test.
REFERENCES: Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 2288-2290.
Manske PR (ed): Hand Surgery Update. Rosemont, IL, American Society for Surgery of the Hand, 1994, pp 197-205.

Question 79

A professional baseball team has several pitchers with complaints of velocity loss with their pitches and shoulder pain of their dominant shoulders during spring training. Pitch counts are properly monitored. The average glenohumeral internal rotation deficit on the pitching staff is 45 degrees. The best intervention would be: Review Topic

Explanation

Glenohumeral Internal Rotation Deficit (GIRD) is a phenomenon that occurs in baseball pitchers and is due to posterior capsular tightness. Treatment should begin with a therapy program addressing the pathologic posterior capsule.
GIRD is a phenomenon that is frequently found in high-level overhead throwing athletes, predominantly baseball pitchers. It is defined as the measured difference in internal rotation between the non-dominant arm and dominant arm. Worsening range of motion deficits are seen with increased repetitions, both over a single season and a career. GIRD > 25º is associated with development of shoulder pathologies or pain requiring periods of inactivity. Cessation of overhead throwing activities and initiation of a stretching program to address posterior capsular contractures is largely effective (90% in some series).
Burkhart et al. reviewed the conditions associated with high-level overhead throwing athletes shoulders, culminating in a theory of pathologic progression to "dead arm syndrome" (loss of velocity and effective pitching). Their theory attributes adaptive hyperexternal rotation (occurs during late-cocking / early acceleration phases of pitching) to lead to posterior-inferior capsular contracture and GIRD. Subsequent injuries to anterior structures - including SLAP lesions - would then occur.
Illustration A is a cartoon depiction of how to perform the sleeper stretch. This is a common component of a pitcher's maintenance stretching program.
Incorrect Answers:

Question 80

An 8-year-old girl was treated for a Salter-Harris type I fracture of the right distal femur 2 years ago. Examination reveals symmetric knee flexion, extension, and frontal alignment compared to the contralateral knee. She has 1-cm of shortening of the right femur. History reveals that she has always been in the 50th percentile for height, and her skeletal age matches her chronologic age. Radiographs are shown in Figure 9. What is the expected consequence at maturity?

Explanation

DISCUSSION: The child has a near complete central physeal arrest of the distal femur and worsening limb-length discrepancy will develop. She is growing at the average rate for the population. The distal femoral physis grows at a rate of roughly 9 mm per year. Girls finish their growth at approximately age 14 years. Thus, at maturity the left leg will be 6.4 cm longer than the right. An angular deformity has not developed at this point and her arrest is central; therefore, angular deformity is unlikely to develop in any plane.
REFERENCES: Little DG, Nigo L, Aiona MD: Deficiencies of current methods for the timing of epiphysiodesis. J Pediatr Orthop 1996;16:173-179.
Moseley CF: Assessment and prediction in leg-length discrepancy. Instr Course Lect 1989;38:325-330.

Question 81

A 34-year- woman has pain at the base of the thumb that worsens é pinching activities. Nonsurgical treatment has failed to provide relief. Examination reveals that the basilar joint is hypermobile, tender and painful when stressed. A radiograph of the trapeziometacarpal joint shows normal contour with widening when compared with the opposite side. Management should consist of

Explanation

Painful instability of the thumb carpometacarpal (CMC) joint as manifested by “idiopathic hypermobility of the basal joint is not uncommon, particularly in women, and would seem to be a significant factor in producing the arthrosis that so frequently afflicts this joint.” “Extra-articular ligament reconstruction to stabilize the thumb carpometacarpal (CMC) (basal) joint by routing a portion of the flexor carpi radialis (FCR) through the base of the thumb metacarpal … is recommended only for patients in stage I and stage II disease (i.e., patient’s having zero to only slight cartilage attrition). With 95 % of stage I and stage II patients having achieved and maintained good or excellent results, (restoration of stability, pain reduction and possibly retarding joint degeneration) … we feel the procedure has proved predictable and durable. Despite limited success in patients with significant articular deterioration (stage III and stage IV), we do not recommend ligament reconstruction alone in such cases. Instead we would recommend articular resurfacing or implant arthroplasty that would depend on the number of trapezium surfaces involved.”

Question 82

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

Explanation

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

Question 83

Figures 3a and 3b show the current radiographs of a 58-year-old man who underwent total knee arthroplasty with a cruciate ligament sparing prosthesis 7 years ago. Examination reveals boggy synovitis and moderate pain, particularly anteriorly. Management should consist of

Explanation

DISCUSSION: The patient has symptoms of synovitis that are most likely the result of the release of particles from the tibial polyethylene. While observation may be warranted in a completely asymtomatic knee, some intervention is indicated for this patient as there is clear radiographic evidence of lysis in both the tibia and femur. The decision about the extent of the revision should be made at the time of surgery. A limited incision technique is not indicated. Grafting (or using graft substitute) the defect is the most appropriate approach for treating the osteolytic lesions. While a posterior stabilized prosthesis might be the solution, surgical findings might dictate otherwise.
REFERENCE: Brassard MF, Insall JN, Scuderi GR: Complications of total knee arthroplasty, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 3. Philadelphia, PA, Churchill Livingstone, 2001, vol 2, pp 1801-1844.

Question 84

A 45-year-old woman has had right wrist pain for the past 2 months. A radiograph, bone scan, and MRI scan are shown in Figures 66a through 66c, and a photomicrograph is shown in Figure 66d. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph shows a purely radiolucent lesion without matrix mineralization in the epiphysis of the distal radius. The lesion is “hot” on bone scan, and the MRI scan reveals cortical destruction with a soft-tissue mass. These findings are most consistent with giant cell tumor. The distal radius is a common location for giant cell tumors. The other options would be very uncommon in this location in a 45-year-old patient. The photomicrograph demonstrates multinucleated giant cells in a sea of mononuclear cells. The nuclei of the giant cells and the nuclei of the mononuclear stromal cells are identical. This feature helps distinguish giant cell tumor from other lesions that might contain giant cells.
REFERENCES: Cheng CY, Shih HN, Hsu KY, et al: Treatment of giant cell tumor of the distal radius. Clin Orthop Relat Res 2001;383:221-228.
Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 263-284.

Question 85

Which of the following tendons is the primary antagonist of the posterior tibialis tendon?

Explanation

DISCUSSION: The primary action of the posterior tibialis tendon is inversion of the foot; secondarily, it plantar flexes the ankle. The anterior tibialis tendon also inverts the foot and only partially antagonizes the posterior tibialis tendon. The primary action of the peroneus longus is plantar flexion of the first ray. It secondarily everts the posterior tibialis tendon. The action of the flexor digitorum longus tendon is synergistic with the posterior tibialis tendon. The primary action of the peroneus brevis tendon is eversion; therefore, it is the primary antagonist of the posterior tibialis tendon.
REFERENCES: Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993, pp 550-551.
Mann RA: Biomechanics of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 2-36.

Question 86

Anterior approach

Explanation

DISCUSSION
The nerve most commonly injured in the posterior approach to the hip is the sciatic nerve. Overall injury prevalence is 1% to 2%. This nerve is more commonly injured in cases of hip dysplasia with excessive leg lengthening. The superior gluteal nerve is at highest risk with the direct lateral approach to the hip. This nerve courses in the gluteus medius muscle and is
at risk when splitting the muscle 5 cm proximal to the greater trochanter. The lateral femoral 73
cutaneous nerve is commonly damaged with anterior total hip replacement surgery. Neuropraxia has been reported in 81% of patients. The inferior gluteal nerve travels from the greater sciatic notch and enters the gluteus maximus muscle. It is at risk when the posterior approach to the hip is used.
RECOMMENDED READINGS
Hoppenfeld S, deBoer P. Surgical Exposures in Orthopedics. 3rd ed. Philadelphia.
PA: Lippincott Williams & Wilkins; 2003:365-453.
DeHart MM, Riley LH Jr. Nerve injuries in total hip arthroplasty. J Am Acad Orthop Surg. 1999 Mar-Apr;7(2):101-11. Review. PubMed PMID: 10217818. View Abstract at PubMed
Goulding K, Beaulé PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Clin Orthop Relat Res. 2010 Sep;468(9):2397-404. doi: 10.1007/s11999-010-1406-5. PubMed PMID:

Question 87

An active 68-year-old woman undergoes an uncomplicated rotator cuff repair with a double-row construct using biocomposite knotless anchors. At her two month follow up, she is noted to have increased shoulder pain, weakness and limited motion. Imaging reveals failure of the rotator cuff repair. What is the most likely mechanism of failure? Review Topic

Explanation

Rotator cuff repair (RCR) failure most commonly occurs from a failure of the repaired tissue to heal with suture anchor pull out from the repaired tissue.
The overall complication rate of arthroscopic RCR is roughly 10%. Failed RCR most commonly results from failure to heal (19-94%) secondary to poor rotator cuff tissue, insufficient vascularity or poor bone quality. Other causes of RCR failure include surgical complications (deltoid disruption, infection, foreign body reaction, stiffness, neurologic injury), diagnostic errors (missed lesions of the rotator interval, long head of biceps or subscapularis tear), and technical errors (excessive tension due to lack of proper tissue mobilization, anchor pull out secondary to improper anchor placement).
George et al evaluated the causes of failed RCR and results of revision RCR. While results of revision RCR are inferior to primary RCR, arthroscopic repair yields > 60% good or excellent results. Risk factors for poor results following revision RCR include poor tissue quality, detachment of the deltoid origin and multiple previous surgeries.
Diduch et al reviewed the design and composition of various anchors used in arthroscopic shoulder surgery. Current advancements in the field include high-strength polyethylene sutures, new biocompatible anchor materials (PEEK, biocomposite) and modified designs including knotless systems. With improved strength of the current anchors and repair constructs, the most common mode of arthroscopic RCR failure is now related to tissue failure occurring at the tissue-anchor interface.
Cole et al discussed the different primary rotator cuff repair constructs, including single row, double row, transosseous and transosseous equivalent. The authors concluded that construct selection depends on tear acuity, size and tissue quality. For acute tears < 12mm in anteroposterior length, single-row configuration likely has sufficient strength to maintain the repair and promote healing. For more chronic tears, poor tissue quality, or tears > 12-15mm in the anteroposterior dimension, the authors recommend double-row or transosseous-equivalent repair to better restore the anatomic footprint and provide optimal mechanical stability to achieve healing.
Illustration A is an algorithm from George et al detailing the decision-making process when considering revision RCR for a symptomatic failed RCR.
Incorrect Responses

Question 88

When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?

Explanation

DISCUSSION: As the chance of success of lumbosacral fusion increases with the stiffness and rigidity of the construct, fixation and stiffness improve with fixation into both the upper sacrum and the ilium. In a review of individuals treated with long constructs to the pelvis for adult scoliosis, Islam and associates reported that the rate of pseudarthrosis was significantly lower with sacral and iliac fixation compared with sacral fixation alone or iliac fixation alone. Iliac screws provide significant fixation anterior to the instantaneous axis of rotation for flexion and extension, as well as provides resistance to lateral bending and rotational forces. Numerous biomechanical studies support the concept of increasing biomechanical stabilization with increased fixation from the sacrum to the ilium.
REFERENCES: Islam NC, Wood KB, Transfeldt EE, et al: Extension of fusions to the pelvis in idiopathic scoliosis. Spine 2001;26:166-173.
O’Brien N, et al: Sacral pelvic fixation and spinal deformity, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 601-614.
McCord DH, Cunningham BW, Shono Y, et al: Biomechanical analysis of lumbosacral fixation. Spine 1992;17:S235-S243.

Question 89

A 62-year-old woman with a bone mass density (BMD) T-score of -2.0 sustained a subcapital fracture of her hip. She is an avid tennis player, and history reveals no previous fractures. What is the most appropriate follow-up care?

Explanation

DISCUSSION: A DEXA scan is most appropriately used to establish a baseline score. Even if the bone mineral density is not within the osteoporotic range (T-score less than -2.5), a prior fragility fracture is a strong risk factor for a second fracture as a result of factors other than bone density, such as worsening vision or balance, confusion, or other predispositions to falls. The guidelines of the National Osteoporosis Foundation indicate that, following a fragility hip fracture, active anti-osteoporotic medication should be initiated, whether or not a DEXA scan is performed. A recent study showed that antiresorptive therapy following a hip fracture reduces not only the risk of a second fracture but also overall mortality.
REFERENCE: Gardner MJ, Brophy RH, Demetrakopoulos D, et al: Interventions to improve osteoporosis treatment following hip fracture: A prospective, randomized trial. J Bone Joint Surg Am 2005;87:3-7.

Question 90

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

Explanation

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

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

Acta Chir Scand 1941;84:1.

Question 91

A 47-year-old woman has had a 1-month history of left hip and medial thigh pain that is exacerbated by sitting. Laboratory studies show a total protein level of 8.2 g/dL (normal 6.0 to 8.0) and an immunoglobulin G (IGG) level of 2,130 mg/dL (normal 562 to 1,835). A radiograph, CT scan, and biopsy specimen are shown in Figures 38a through 38c. What is the most likely diagnosis?

Explanation

DISCUSSION: The laboratory studies and histology are both consistent with myeloma. Infection should show white blood cells other than plasma cells on histology. Lymphoma would show lymphocytes, not plasma cells. The lack of bone formation on the imaging studies and the lack of osteoid on histology rule out osteosarcoma. The cells have too much cytoplasm and nuclear chromatin to be Ewing’s sarcoma cells.
REFERENCE: Mirra J: Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia, PA, Lea & Febiger, 1989, vol 2, ch 16.

Question 92

Histologic studies of surgically resected tissue in lateral epicondylitis demonstrate which of the following findings? Review Topic

Explanation

The extensor carpi radialis brevis is most often cited as the anatomic location of pathology in lateral epicondylitis. Histologic examination demonstrates noninflammatory tissue, primarily angiofibroblastic tendinosis though normal tendon histology is also present. There is usually no evidence of acute inflammation or chondroblastic tissue, or significant calcium deposition.

Question 93

A 75-year-old woman reports persistent severe low back pain after lifting a bag of groceries 8 weeks ago. She denies the presence of any lower extremity pain, weakness, or other symptoms. AP and lateral lumbar spine radiographs are shown in Figures 47a and 47b. For further evaluation, what imaging study should be obtained next? Review Topic

Explanation

The radiographs show a L1 vertebral compression fracture. MRI scans of the lumbar spine are indicated to help determine the age of the fracture via evaluation of the fat-suppressed T2-weighted images. If those images show edema (bright signal) within the fracture, it can be assumed to be an acute or subacute fracture. Also, MRI scans may help further characterize the fracture as a benign osteoporosis-related fracture versus a pathologic fracture. Lastly, MRI scans allow for evaluation of the absence, presence, and degree of spinal stenosis. Although a lumbar spine CT scan is also a good option as a next step, given that the patient has a known fracture as seen on the radiographs, MRI scans will likely provide more relevant information in this case. A CT scan may assist in the evaluation of the posterior vertebral body wall and posterior elements in patients with burst fractures. A three-phase bone scan is a good alternative for the evaluation of the acuity of vertebral compression fractures in patients who have a contraindication to MRI scans. Flexion-extension radiographs are most commonly used to evaluate for instability and will not help determine the age of this fracture. Tagged white blood cell scans are performed to evaluate for infection, which is highly unlikely in this patient.

Question 94

A 38-year-old left hand-dominant bodybuilder reports ecchymosis in the left axilla and anterior brachium after sustaining an injury while bench pressing 3 weeks ago. Coronal and axial MRI scans are shown in Figures 16a and 16b. What treatment method yields the best long-term results? Review Topic

Explanation

The MRI scans show a rupture of the sternocostal portion of the pectoralis major tendon. This is the most common site of rupture and bench pressing is the most common etiology. Surgical repair yields better functional outcomes and patient satisfaction for tears not only at the tendon/bone interface but also at the myotendinous junction.

Question 95

Surgical treatment for symptomatic disk herniations is associated with which of the following?

Explanation

DISCUSSION: The recently published SPORT trial verifies that surgical treatment of symptomatic disk herniations is associated with early and sustained pain relief. The trial also verifies that nonsurgical management is associated with improved symptoms as well. Nerve root injury, recurrent herniation, and diskitis are known complications of surgery, but all are less common than described above.
REFERENCE: Weinstein JN, Lurie JD, Tosteson TD, et al: Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006;296:2451-2459.

Question 96

Osteonecrosis of the humeral head is a rare complication seen after dislocation of the glenohumeral joint in skeletally immature patients. When this complication is encountered, treatment should consist of Review Topic

Explanation

This rare complication occurs after fracture-dislocation and has been seen after surgical stabilization in the adolescent. In most reported cases, prolonged observation has been shown to result in revascularization.

Question 97

A 20-year-old collegiate pitcher has had a 5-month history of shoulder pain while throwing, decreased velocity, and difficulty with location of his pitches despite multiple attempts at rest. He reports no traumatic event. Examination with his throwing arm abducted at 90 degrees reveals external rotation to 110 degrees and internal rotation to 70 degrees when compared with his nonthrowing shoulder which has external rotation to 95 degrees and internal rotation to 85 degrees. He has a positive O'Brien's sign, positive modified Jobe's relocation test, full rotator cuff strength, no obvious muscular atrophy, and no scapular winging. Radiographs of the affected shoulder show no abnormalities. What is the next most appropriate step in management? Review Topic

Explanation

The study of choice to evaluate the superior labrum is an MR arthrogram. The patient has symptoms suspicious for superior labral pathology (ie, positive O'Brien's test, Jobe's relocation test, pain with throwing, loss of velocity and location). Whereas he does have increased external rotation and decreased internal rotation of his throwing arm compared with his non-throwing arm, the total arc of motion is 180 degrees and this is considered a normal adaptive change in the overhead throwing athlete; therefore, ultrasound is not considered appropriate management. There are no signs of weakness or rotator cuff pathology to suggest suprascapular nerve compression or a full-thickness rotator cuff tear; therefore, electrodiagnostic testing or physical therapy are inappropriate. There are also no signs or symptoms suggesting infection or rheumatologic issues; therefore, laboratory studies are unnecessary. If the MR arthrogram shows a labral tear, the initial management would include posterior capsular stretching and rotator cuff strengthening.

Question 98

A 52-year-old man who dislocated his dominant shoulder has it reduced in the emergency department and he is placed in a sling. At his 5-day followup evaluation, he reports that this is his first shoulder dislocation and that the pain is mostly gone but he notes difficulty using his arm overhead and away from his body. Examination reveals minimal pain with passive range of motion, a positive apprehension and relocation test, and 3/5 strength with the empty can test and external rotation at the side compared with 5/5 with those tests on the contralateral side. Cutaneous sensation over the lateral aspect of the shoulder is intact. Radiographs show the glenohumeral joint is reduced with no fractures or degenerative changes. What is the next step in management? Review Topic

Explanation

Obtaining an MRI scan to evaluate for a rotator cuff tear is a reasonable next step. The patient sustained a first-time shoulder dislocation, and given his age and clinical presentation, it is likely that he injured the rotator cuff. Large, full-thickness rotator
cuff tears following dislocation in young individuals warrants early surgical intervention. Delay of surgical repair for large, full-thickness tears may lead to irreversible changes, including atrophy and retraction of the tendon. As a result, clinical outcomes may be compromised. CT will demonstrate bony changes, but it is not as effective as MRI for soft-tissue pathology. While in the short term a sling for comfort might be helpful, 6 weeks of immobilization is unnecessary because recurrent instability is rarely an issue. Physical therapy can be beneficial but could potentially delay identification of an acute rotator cuff tear. In the event the MRI does not reveal a large, full-thickness rotator cuff tear, physical therapy would be an appropriate next step. There is no indication for urgent shoulder arthroscopy.

Question 99

A 35-year-old man has a brachial plexus injury affecting the lateral cord. He partially improves with observation and now has complete return of median nerve function and pectoral muscle function. What nerve transfer is most likely to restore the motor function he is lacking?

Explanation

EXPLANATION:
The lateral cord of the brachial plexus gives off the lateral pectoral nerve, the musculocutaneous nerve, and then contributes to the median nerve. The patient has had recovery of function of these components except for the musculocutaneous nerve. The musculocutaneous nerve innervates the biceps and the brachialis, which provide elbow flexion. To restore motor function, a nerve transfer would have to provide reinnervation of the biceps and brachialis.

Question 100

A 24-year-old professional football player underwent surgery for a symptomatic cervical disk herniation with radiculopathy 9 months ago. A current radiograph is shown in Figure 17. He has normal neurologic findings, no pain, and full range of motion. A CT scan shows a solid fusion. When can he expect to return to play?

Explanation

DISCUSSION: The radiograph shows that the two-level anterior cervical diskectomy and fusion has healed. In addition, the patient has good range of motion and the neurologic examination is normal. Based on these findings, the patient can return to play immediately. Patients with one- or two-level anterior cervical diskectomies and fusions that have healed fully can return to play. Any loss of motion, persistent neurologic deficit, or significant adjacent segment degeneration may preclude a player from returning.
REFERENCES: Thomas B, McCullen GM, Yuan HA: Cervical spine injuries in football players. J Am Acad Orthop Surg 1999;7:338-347.
Torg JS, Ramsey-Emrhein JA: Management guidelines for participation in collision activities with congenital, developmental, or post-injury lesions involving the cervical spine. Clin Sports Med 1997;16:501-530.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Examination of the pedal pulses
Ankle-brachial pressure index
Duplex ultrasound
Arteriography
Exploration of the popliteal artery

Correct Answer: Examination of the pedal pulses

Explanation:

Question 2:

Figure 13 is the photograph of 18-month-old triplets with a lower-limb condition. What is the best initial treatment? Review Topic

Options:

Vitamin D supplementation and serum level monitoring
Mechanical axis alignment measurements on serial standing knee radiographs
Genetic testing and counseling for short-stature syndrome
Observation and clinical follow-up.

Correct Answer: Mechanical axis alignment measurements on serial standing knee radiographs

Explanation:

These triplets exhibit genu varum and internal tibial torsion that can be part of normal development. Fetal packing is the likely major contributing cause for these triplets, however. Observation and follow-up will be sufficient. Bowing and torsion can be clinical features of vitamin D deficiency, Blount disease, and short-stature syndromes, but these are not the most likely diagnoses. Radiographic diagnosis of Blount disease may not be accurate at this age.
(SBQ13PE.56) A 22-month-old female is hospitalized with a fever and malaise. She is found to be bacteremic, and blood cultures grow methicillin-sensitive Staphylococcus aureus (MSSA). During her hospitalization, the pediatrician notices her arm is slightly swollen and appears painful to use. MRI is obtained and demonstrated in figure A. Which feature of the MRI suggests the need for surgical management?
Review Topic
Brodie's Abscess
Osteomyelitis of the humeral metaphysis
Subperiosteal abscess of the humerus
Presence of subcutaneous air
High risk of proximal humeral growth arrest
This patient has osteomyelitis of the humerus with a large subperiosteal abscess. The presence of subperiosteal abscess necessitates surgical intervention for irrigation and debridement (I&D).
The diagnosis of acute osteomyelitis in children is made based upon a constellation of findings including pain, systemic signs of infection, elevated serum inflammatory markers, and imaging studies demonstrative of osseous infection. It is most commonly hematogenously spread to the metaphysis of immature bone, which is highly vascular prior to skeletal maturity. Treatment involves obtaining specimen for culture, empiric antibiotic treatment, and surgical irrigation and debridement of known abscesses. The end-point of treatment is return of pain-free functionality and the resolution of local/systemic signs of infection.
Conrad reviewed the management of acute hematogenous osteomyelitis and emphasized that surgical intervention in the presence of abscess can be both therapeutic and diagnostic: I&D can obtain culture and narrow the antibiotic plan.
Jones et. al. reviewed chronic pediatric osteomyelitis and report that surgery is the mainstay of treatment because removal of dead bone is essential for resolution of infection. This may be performed with sequestrectomy and curettage, with an emphasis on prevention of pathologic fracture, growth disturbances, bone loss, joint involvement, and permanent loss of function.
Figure A is a coronal STIR MRI image of the humerus demonstrating osteomyelitis
with extensive subperiosteal abscess.
Incorrect Answers:
Brodie's abscess is a type of subacute osteomyelitis which remains indolent and creates a focal intra-osseous abscess. This is not demonstrated in the clinical image.
The patient does have osteomyelitis of the humeral metaphysis, but this alone is not the indication for surgery. Uncomplicated osteomyelitis may be treated effectively with antibiotics alone.
Presence of subcutaneous air is suggestive of necrotizing fasciitis, which is a surgical emergency. The MRI however does not demonstrate this finding.
The infection and its surgical management both increase risk of injury to the proximal humeral physis and has the potential for growth arrest or angular deformity.
(SBQ13PE.3) Figure A demonstrates a physical examination maneuver in a 1 month old infant. What is this maneuver?
Review Topic
Ortolani Test
Barlow Test
Galeazzi Sign
Patrick test
Teratologic Sign
Figure A shows a schematic image of the Ortalani test.
The Ortolani test, or Ortolani maneuver, is part of the physical examination for developmental dysplasia of the hip. It is used alongside the Barlow test to detect subluxated hips that are either reducible or irreducible. A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral head relocates anteriorly into the acetabulum.
Guille et al. showed that the use of Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step before they are able to stand.
Video V is a lecture discussing the hip examination of the infant. Incorrect Answers:
pressure on the knee, directing the force the femoral head posteriorly. A positive Barlow test would result in posterior subluxation/dislocation of the hip. Answer 3: Galeazzi test is performed by flexing an infant's knees in the supine position so that the ankles touch the buttocks. If the knees are not level then the test is positive, which indicates a potential congenital hip issue (e.g. DDH). Answer 4: Patrick or Faber test (flexion, abduction, external rotation) has been described both for stressing the SI joint and for isolating symptoms to the hip Answer 5: Teratologic dislocation of the hip is a term used to imply that the hip joint did not develop normally in utero, thus the hip is in a fixed dislocated position at birth.

Question 3:

Injury to the popliteal artery during total knee arthroplasty (TKA) is most likely to occur when placing a sharp retractor

Options:

directly posterior to the posterior cruciate ligament (PCL).
posteromedial to the PCL.
posterolateral to the PCL.
in the posteromedial corner of the knee.

Correct Answer: posterolateral to the PCL.

Explanation:

Question 4:

A 42-year-old woman sustained a closed, displaced talar neck fracture in a motor vehicle accident. Which of the following is an avoidable complication of surgical treatment?

Options:

Posttraumatic arthritis of the subtalar joint
Posttraumatic arthritis of the ankle joint
Malunion of the talus
Osteonecrosis of the talus
Complex regional pain syndrome

Correct Answer: Malunion of the talus

Explanation:

Question 5:

Options:

a structured physical therapy program to increase quadriceps muscle strength.
a hinged knee brace locked in extension while ambulating.
exchange of the modular polyethylene spacer to a thicker insert and reconstruction of the patellar tendon using hamstring augmentation.
exchange of the modular polyethylene spacer to a thicker insert and reconstruction of the patellar tendon using an extensor mechanism allograft tensioned tightly in full extension.
revision of the tibial and femoral components and reconstruction of the patellar tendon using an extensor mechanism allograft tensioned tightly in full extension.

Correct Answer: revision of the tibial and femoral components and reconstruction of the patellar tendon using an extensor mechanism allograft tensioned tightly in full extension.

Explanation:

Question 6:

Options:

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

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

Explanation:

Question 7:

Options:

Plantar fasciitis
Atrophic heel pad
Achilles tendinitis
Retrocalcaneal bursitis
Stress fracture of the calcaneus

Correct Answer: Stress fracture of the calcaneus

Explanation:

Question 8:

03 5.

Options:

Second only to osteoperosis as the most common metabolic bone disease, Paget’s disease is most often asymptomatic and diagnosed incidentally on routine x-rays. There three distinct histologic phases:
increase in bone resorption with increase in the number and size of osteoclasts, AKA the “hot” phase.
Rapid increase in osteoblast activity and new bone formation, AKA the “intermediate” phase
Decrease in both osteoclastic and osteoblastic activity, AKA “cold” phase

Correct Answer: Second only to osteoperosis as the most common metabolic bone disease, Paget’s disease is most often asymptomatic and diagnosed incidentally on routine x-rays. There three distinct histologic phases:

Explanation:

Question 9:

Options:

L4 nerve root radiculopathy
L5 nerve root radiculopathy
Associated bowel and bladder dysfunction
Symptoms associated with arachnoiditis
Wide-based gait, left-sided Hoffman’s sign

Correct Answer: L4 nerve root radiculopathy

Explanation:

DISCUSSION: The MRI scan reveals a L4-L5 foraminal disk herniation originating from the L4-5 disk space that has migrated up into the foramen, compressing the left L4 nerve root. There is normal distribution of the roots in the cerebrospinal fluid, excluding arachnoiditis as a diagnosis, and disk herniation in this location would not result in cauda equina syndrome or myelopathy.
REFERENCE: McCullouch JA, Transfeldt EE: Macnab’s Backache, ed 3. Philadelphia, PA, Williams and Wilkins, 1997, pp 569-608.

Question 10:

A patient has a painful metal-on-metal (MOM) left total hip arthroplasty (THA). Which test(s) best correlate with prognosis if this patient is having a reaction to metal debris?

Options:

Erythrocyte sedimentation rate, C-reactive protein, and white blood cell count
Serum cobalt and chromium ion levels
Metal artifact reduction sequence (MARS) MRI
CT scan of pelvis

Correct Answer: Metal artifact reduction sequence (MARS) MRI

Explanation:

Question 11:

Options:

Chondroblastoma
Fibrous dysplasia
Simple bone cyst
Aneurysmal bone cyst
Giant cell tumor

Correct Answer: Aneurysmal bone cyst

Explanation:

DISCUSSION: The imaging studies reveal an expansile lesion with the classic soap bubble appearance that involves most of the calcaneus. The bone scan reveals a very active lesion with intense uptake, and the MRI scans show the classic, loculated appearance of the lesion with multiple fluid-fluid levels. While it is important to rule out telangiectatic osteosarcoma, the most likely diagnosis is an aneurysmal bone cyst. While giant cell tumor might have a similar appearance, the multiple fluid levels in a expansile lesion strongly favor an aneurysmal
bone cyst.
REFERENCES: Parsons TW: Benign bone tumors, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1027-1035.
Dorfman HD, Czerniak B: Bone Tumors. St Louis, MO, Mosby, 1998, pp 855-879.

Question 12:

Options:

Transfusion of whole blood
Transfusion of packed red blood cells
A cell saver with continuity maintained in a “closed circuit”
Transfusion of plasma
Transfusion of platelets

Correct Answer: A cell saver with continuity maintained in a “closed circuit”

Explanation:

DISCUSSION: Jehovah’s Witnesses will not accept the transfusion of blood or blood products such as packed red or white cells, platelets, or plasma. However, many Jehovah’s Witnesses will accept the use of a cell saver in a “closed circuit.”
REFERENCES: Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.
www.watchtower.org. Official Web Site of Jehovah’s Witnesses. Link verified as active as of August 8, 2008.

Question 13:

A 24-year-old man is ejected from his motorcycle and sustains a significant hip injury. The fracture shown in Figures 64a through 64e is best described as what type of fracture?

Options:

Posterior column/posterior wall acetabular
Associated both column acetabular
Transverse plus posterior wall acetabular
Anterior column posterior hemitransverse acetabular
Anterior column acetabular

Correct Answer: Anterior column acetabular

Explanation:

DISCUSSION: The radiographs and CT scans reveal an anterior column acetabular fracture. The fracture has quadrilateral plate extension but does not exit out the posterior column. The CT scans confirm an intact posterior column and no wall fracture. A transverse fracture is best seen on the CT scan and runs in the sagittal plane, not the coronal plane.
REFERENCES: Letournel E, Judet R: Fractures of the Acetabulum, ed 2. New York, NY, Springer-Verlag, 1993, pp 115-140.
Beaule PE, Dorey FJ, Matta JM: Letournel classification of acetabular fractures: Assessment of interobserver and intraobserver reliability. J Bone Joint Surg Am 2003;85:1704-1709.

Question 14:

- A healed fracture of the tibia that demonstrates 25 degrees apex posterior angulation and 28 degrees varus angulation on AP and lateral radiographs is most accurately described as a

Options:

Complex deformity with an angulation in two planes
Single deformity less than 20 degrees, apex posterolateral
Single deformity greater than 30 degrees, apex posterolateral
Single deformity less than 20 degrees, apex posteromedial
Single deformity greater than 30 degrees, apex posteromedial

Correct Answer: Single deformity greater than 30 degrees, apex posterolateral

Explanation:

Question 15:

Options:

Relatively young, active patient
Patient with an inflammatory systemic disorder
Elderly patient with a sedentary lifestyle
Patient with severe arthritis of the ipsilateral hip or knee
Patient with Parkinson’s disease

Correct Answer: Elderly patient with a sedentary lifestyle

Explanation:

DISCUSSION: Most authors recommend an initial trial of nonsurgical management in the treatment of adult-acquired flatfoot deformity such as posterior tibial tendon dysfunction. Chao and associates found that there is high patient satisfaction with ankle-foot orthoses and UCBL-type inserts in elderly patients with a relatively sedentary lifestyle. Alternatively, there was a higher dissatisfaction rate in young active patients, those with balance and ambulation difficulties (Parkinson’s, severe arthritis of the hip or knee), and patients with inflammatory systemic disorders.
REFERENCES: Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int 1996;17:736-741.
Noll KH: The use of orthotic devices in adult acquired flatfoot deformity. Foot Ankle Clin 2001;6:25-36.

Question 16:

A 40-year-old laborer sustains the injury shown in the radiograph and CT scan in Figures 56a and 56b. What is the most common complication associated with surgical intervention?

Options:

Chronic osteomyelitis
Planovalgus hindfoot
Plantar nerve entrapment
Wound dehiscence
Painful hardware

Correct Answer: Wound dehiscence

Explanation:

DISCUSSION: The patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence.
REFERENCES: Sanders R: Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-250.
Sanders R, Fortin P, DiPasquale T, et al: Operative treatment in 120 displaced intra-articular calcaneal fractures: Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;290:87-95.

Question 17:

Options:

Hip arthroscopy
Corticosteroid injection
Percutaneous adductor tenotomy
Bone scan
Rheumatology consultation

Correct Answer: Corticosteroid injection

Explanation:

Question 18:

Options:

Sagittal alignment
History of diabetes mellitus and tobacco use
Performance of an uninstrumented fusion (ie, no plate and screws)
Use of allograft (instead of autograft)
Fusion at the C3-C4 level

Correct Answer: History of diabetes mellitus and tobacco use

Explanation:

Question 19:

Options:

Abscess
Ganglion cyst
Nerve sheath tumor
Lymphoma
Metastatic cancer

Correct Answer: Ganglion cyst

Explanation:

Question 20:

Options:

Labrum repair
Capsular release
Labrum debridement
Physical therapy emphasizing a throwing program
Physical therapy emphasizing an internal rotation stretching program

Correct Answer: Physical therapy emphasizing a throwing program

Explanation:

Question 21:

Options:

cefazolin.
cefuroxime.
vancomycin.
clindamycin.

Correct Answer: vancomycin.

Explanation:

Question 22:

Options:

Will not affect functional outcome
Will result in diminished thumb motion
Will result in diminished pinch strength
Will result in diminished grip strength
Will result in moderate activity-related pain back answer Question 61.03

Correct Answer: Will not affect functional outcome

Explanation:

Question 23:

Options:

Inadvertent rotation of the graft 90 degrees internally prior to its final fixation
Lack of full knee extension at the time of surgery
Persistent posterolateral corner injury
Leaving 1 to 2 mm of bone posterior to the femoral tunnel at the time of the ACL reconstruction
Placing the tibial tunnel within the ACL footprint

Correct Answer: Persistent posterolateral corner injury

Explanation:

Question 24:

Options:

Alendronate
Indomethacin
Radiotherapy
Excision

Correct Answer: Alendronate

Explanation:

Question 25:

A 22-year-old man has mild hip pain bilaterally and multiple skeletal lesions. Based on the pelvic radiograph shown in Figure 30, what is the inheritance pattern for his disorder?

Options:

X-linked
Autosomal recessive
Autosomal dominant
Mitochondral inheritance
Germline mutation

Correct Answer: Autosomal dominant

Explanation:

DISCUSSION: Multiple hereditary exostoses (MHE) is an autosomal dominant disorder manifested by multiple osteochondromas and characteristic skeletal involvement. EXT1 on 8q24.1 and EXT2 on 11p13 are the two genes most strongly associated with MHE. Mutations in these genes affect proper development of endochondral bone, such that in all affected individuals exostoses develop adjacent to the growth plates of long bones, and some exhibit additional bone deformities. Defects in the EXT genes result in increased chondrocyte proliferation and delayed hypertrophic differentiation.
REFERENCES: Stieber JR, Dormans JP: Manifestations of hereditary multiple exostoses. J Am Acad Orthop Surg 2005;13:110-120.
Hilton MJ, Gutierrez L, Martinez DA, et al: EXT1 regulates chondrocyte proliferation and differentiation during endochondral bone development. Bone 2005;36:379-386.

Question 26:

Options:

Valgus extension overload
Varus posteromedial rotatory instability (VPMRI) C. Valgus posterolateral rotatory instability (VPLRI) D. Olecranon bursitis The patient has valgus extension overload. This is a spectrum of pathologies, often seen in pitchers, that begins with posteromedial impingement between the medial olecranon and posterior trochlea during forceful elbow extension. As a result, a medial olecranon osteophyte is typically the first notable imaging finding. As pathology increases, there can be progressive damage to the medial collateral ligament (MCL), degeneration of the radiocapitellar articulation, and neuritis of the ulnar nerve. VPMRI is often associated with a large anteromedial coronoid fracture and posterior band MCL rupture. VPLRI occurs when the lateral collateral ligament complex is ruptured. Olecranon bursitis presents with focal swelling or a fluid collection over the posterior aspect of the olecranon.

Correct Answer: Valgus extension overload

Explanation:

A patient sustains a displaced diaphyseal humerus fracture following a motor vehicle accident. Open reduction internal fixation is indicated due to concomitant lower extremity trauma and is planned through an anterior approach. Which intramuscular interval is exploited during the deep dissection of the mid-humerus in this approach?
A. Lateral head of triceps (radial nerve) and brachialis
(musculocutaneous nerve)
B. Lateral head of the triceps (radial nerve) and biceps brachii
(musculocutaneous nerve)
C. Lateral brachialis (radial nerve) and medial brachialis
(musculocutaneous nerve)
D. Brachialis (musculocutaneous nerve) and coracobrachialis
(musculocutaneous nerve)

Question 27:

Which intervention most effectively prevents surgical-site infections following spine surgery?

Options:

Bathing the day of surgery
Intravenous (IV) vancomycin
Preincision IV antibiotics
Vancomycin powder in wound

Correct Answer: Preincision IV antibiotics

Explanation:

DISCUSSION
The use of IV antibiotics for prophylaxis of surgical-site infection is supported by Level 1 evidence in spine surgery. It has been given a "B" recommendation by the North American Spine Society. The use of specific bathing solutions the day of surgery may be beneficial, but the evidence in spine surgery is lacking. Similarly, evidence for use of vancomycin (either topically or IV) is not supported by high-level studies, although retrospective and basic science studies support topical vancomycin use.
RECOMMENDED READINGS
Brown MD, Brookfield KF. A randomized study of closed wound suction drainage for extensive lumbar spine surgery. Spine (Phila Pa 1976). 2004 May 15;29(10):1066-8. PubMed PMID: 15131430.
View Abstract at PubMed
Diab M, Smucny M, Dormans JP, Erickson MA, Ibrahim K, Lenke LG, Sucato DJ, Sanders JO. Use and outcomes of wound drain in spinal fusion for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2012 May 15;37(11):966-73. doi: 10.1097/BRS.0b013e31823bbf0b.
PubMed PMID: 22037527.
View Abstract at PubMed
Evaniew N, Khan M, Drew B, Peterson D, Bhandari M, Ghert M. Intrawound vancomycin to prevent infections after spine surgery: a systematic review and meta-analysis. Eur Spine J. 2014 May 18. [Epub ahead of print] PubMed PMID: 24838506.
View Abstract at PubMed
Rubinstein E, Findler G, Amit P, Shaked I. Perioperative prophylactic cephazolin in spinal surgery. A double-blind placebo-controlled trial. J Bone Joint Surg Br. 1994 Jan;76(1):99-

Question 28:

Options:

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

Correct Answer: Anatomic hip center with subtrochanteric shortening osteotomy

Explanation:

Question 29:

-If a physician elects to shorten a femur by 4 cm for traumatic bone loss treatment and places an intramedullary nail for fixation, which deformity will be created in the lower extremity?

Options:

Patella alta
Medial mechanical axis deviation
Lateral mechanical axis deviation
Increased anatomic tibiofemoral angle
Translation of the anatomical axis of the femur

Correct Answer: Medial mechanical axis deviation

Question 30:

Figures 6a and 6b are the radiographs of a thin 23-year-old man who sustained a closed injury to his left arm in a fall. He has no other injuries and his

Options:

Intramedullary nailing
Hanging arm cast for 6 weeks
Shoulder immobilizer for 4 to 6 weeks
Open reduction and internal fixation
Coaptation splinting with conversion to a fracture brace

Correct Answer: Coaptation splinting with conversion to a fracture brace

Explanation:

Question 31:

Options:

revision of the current orthotics.
metatarsal osteotomies to correct cavus.
a sliding calcaneal osteotomy to correct hindfoot varus.
triple arthrodesis, with anterior transfer of the posterior tibialis.
extensor transfer to the metatarsal necks, soft-tissue releases, and anterior transfer of the posterior tibialis tendon.

Correct Answer: extensor transfer to the metatarsal necks, soft-tissue releases, and anterior transfer of the posterior tibialis tendon.

Explanation:

Question 32:

Options:

Immobilization in a rigid cervical orthosis for 6 to 8 weeks
Posterior occipital-cervical fusion with iliac crest bone graft
Open reduction and internal fixation of the odontoid process with an anterior odontoid screw
Resection of the odontoid process through a transoral approach
Halo skeletal fixation

Correct Answer: Immobilization in a rigid cervical orthosis for 6 to 8 weeks

Explanation:

Question 33:

Options:

0% to 1% with press-fit tibial stems
3% to 5% with press-fit tibial stems
3% to 5% with cemented tibial stems
More than 5% with press-fit tibial stems

Correct Answer: 3% to 5% with press-fit tibial stems

Explanation:

Question 34:

Options:

scapholunate advanced collapse (SLAC) wrist with cystic capitate changes.
idiopathic avascular necrosis (AVN) of the capitate.
capitate osteomyelitis.
aneurysmal bone cyst in the capitate.

Correct Answer: idiopathic avascular necrosis (AVN) of the capitate.

Explanation:

EXPLANATION:

Question 35:

New painful paresthesias near the site of the incision after an ulnar nerve transposition is the result of injury to what nerve?

Options:

Medial antebrachial cutaneous
Lateral antebrachial cutaneous
Posterior antebrachial cutaneous
Medial brachial cutaneous
Dorsal antebrachial cutaneous

Correct Answer: Medial antebrachial cutaneous

Explanation:

DISCUSSION: Branches of the medial antebrachial cutaneous nerve can often be identified during routine ulnar nerve surgery crossing the medial aspect of the elbow. It should be preserved to avoid development of painful paresthesias.
REFERENCE: Dellon AL, Mackinnon SE: Injury to the medial antebrachial cutaneous nerve during cubital tunnel surgery. J Hand Surg Br 1985;10:33-36.

Question 36:

Options:

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

Correct Answer: Medial and anterolateral nonlocked plates

Question 37:

Options:

Cystinosis
Hypophosphatemia
Renal osteodystrophy
Primary hyperparathyroidism
Nutritional vitamin D deficiency

Correct Answer: Cystinosis

Explanation:

Question 38:

An axial T 1 -weighted MRI scan of the pelvis is shown in Figure 35. Which of the following structures is enclosed by the circle?

Options:

Obturator vessels and nerve
Tendinous origin of the obturator internus muscle
Tendinous origin of the obturator externus muscle
Seminal vesicle
Suprapubic pelvic lymph nodes

Correct Answer: Obturator vessels and nerve

Explanation:

DISCUSSION: The obturator vessels and nerve pass along the lateral pelvic wall along the true pelvic brim (nerve lies anterior to the vessels and lies on the obturator internus muscle) and descend into the obturator groove at the upper portion of the obturator foramen.
REFERENCES: Higuchi T: Normal anatomy and magnetic resonance appearance of the pelvis, in Takahashi HE, Morita T, Hotta T, et al (eds): Operative Treatment of Pelvic Tumors. Tokyo, Japan, Springer-Verlag, 2003, pp 4-21.
Berquist TH: Pelvis, hips and thigh, in Berquist TH (ed): MRI of the Musculoskeletal System,
ed 4. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 210-238.

Question 39:

Which of the following illustrations shown in Figures 21a through 21e correctly shows the projection of the sacroiliac joint on the outer table of the ilium?

Options:

Correct Answer: 21c

Explanation:

Question 40:

Options:

Single posterior Y plate
Single medial plate with bicortical locking screws
Dual plating with medial and posterolateral LC-DCP
Dual plating with medial and posterolateral one third tubular plates
Dual plating with medial and lateral LC-DCP

Correct Answer: Dual plating with medial and lateral LC-DCP

Explanation:

Question 41:

Which of the following is a true statement regarding thoracic disk herniations? Review Topic

Options:

Are most commonly discovered during the fifth to seventh decades of life
Occur with similar frequency as cervical disk herniations
Occur most commonly in the midthoracic or apical region of the spine
Can be found in 40% of asymptomatic individuals
Are best treated surgically with posterior laminectomy and excision

Correct Answer: Can be found in 40% of asymptomatic individuals

Explanation:

Question 42:

Options:

debridement and locked intermedullary nailing.
debridement and plate fixation.
debridement and external fixation.
debridement and traction.
skeletal traction.

Correct Answer: debridement and external fixation.

Explanation:

Question 43:

The clinical factors shown to most significantly predict the long-term outcome of Perthes disease of the hip include which of the following? Review Topic

Options:

Limb-length discrepancy, range of motion of the hip
Age at presentation, range of motion of the hip
Age at presentation, limb-length discrepancy
Range of motion, pain/limp for more than 6 months
Limb-length discrepancy, pain/limp for more than 6 months

Correct Answer: Limb-length discrepancy, range of motion of the hip

Explanation:

Age at presentation and range of motion of the hip are the two most significant predictors of long-term outcome. Younger patients and patients who maintain range of motion of the hip are more likely to have a good outcome. In Herring's study, children with a chronologic age of younger than 8 years or a bone age of less than 6 years had significantly more favorable outcomes compared with older children. Limited hip range of motion may be due to muscle spasm early on, or synovitis; but in late disease, it may reflect incongruity of the joint. Classifications based on femoral head shape have also been correlated to prognosis. Significant shortening of the affected hip is not common.
(SBQ13PE.87) A 4-week-old child is suspected to have classic arthrogryposis, also known as amyoplasia. Clinical examination and hip ultrasound reveal a unilateral, non-reducible, hip dislocation. What do you recommend to reduce the hip?
Review
Topic
Pavlik harness application
Semi-rigid abduction brace application
Skeletal traction
Early closed reduction and spica casting
Delayed open reduction with or without pelvic and femoral osteotomy
Delayed open reduction with or without pelvic and femoral osteotomy is recommended in the management of unilateral hip deformities associated with amyoplassia. This procedure should be performed at 6-9 months of age. In order to proceed with reduction, there must be a reasonable arc of flexion/extension and active movement of the lower limbs.
Amyoplasia is the most common recognizable form of arthrogryposis. It most commonly occurs as a sporadic symmetric contracture syndrome that is characterized by symmetrical limb involvement, normal to above-average intelligence, and often a midline facial hemangioma. Approximately 80% of children with amyoplasia will have involvement of the hip ranging from soft tissue contractures to unilateral or bilateral hip dislocations.
Bevan et al. reviewed arthrogryposis. They state that open hip reduction is recommended for the management of unilateral dislocation. There is more controversy with regard to the treatment of bilateral hip dislocations. Open reduction can be performed by a medial or anterolateral approach, with or without pelvic and
femoral osteotomy. This procedure is generally delayed for 6-9 months to facilitate the procedure.
Bernstein et al. also reviewed arthrogryposis. They state that the term 'arthrogryposis' encompasses a broad spectrum of diseases, all with the common phenotype of multiple congenital contractures.
Illustration A shows the characteristic features of an infant with severe arthrogryposis. Note the internal rotation of the shoulders, elbow and knee hyperextension, flexed and ulnarly deviated wrists, flexed finger, external rotation of hips and bilateral clubfeet.
Incorrect answers:

Question 44:

Options:

Retain the components, and implant a tibial strut allograft.
Revise the tibial component with a metaphyseal cone and metaphyseal uncemented stem.
Revise the tibial component with a metaphyseal cone and a press-fit diaphyseal-engaging stem.
Revise the tibial component with a long cemented diaphyseal-engaging stem.

Correct Answer: Revise the tibial component with a metaphyseal cone and a press-fit diaphyseal-engaging stem.

Explanation:

Question 45:

In the anterior cruciate ligament-deficient knee, what structure provides an important secondary restraint to anterior tibial translation? Review Topic

Options:

Anterior horn of the lateral meniscus
Posterior cruciate ligament
Posterior horn of the medial meniscus
Popliteus tendon
Quadriceps muscle

Correct Answer: Posterior horn of the medial meniscus

Explanation:

Question 46:

Which of the following therapies has a direct anabolic effect on bone?

Options:

Bisphosphonates
Tumor necrosis factor-a (TNF-a) inhibitors
Calcitonin
Intermittent PTH
Corticosteroids

Correct Answer: Intermittent PTH

Explanation:

Question 47:

Which of the following radiographic images is best for detecting anterior acetabular deficiency in the dysplastic hip?

Options:

Pelvic inlet
Judet
AP pelvis
False profile
Frog lateral

Correct Answer: False profile

Explanation:

DISCUSSION: The false profile view of Lequesne and de Seze is obtained with the patient standing with the affected hip on the cassette, the ipsilateral foot parallel to the cassette, and the pelvis rotated 65 degrees from the plane of the cassette. This view best assesses anterior coverage of the femoral head.
REFERENCES: Garbuz DS, Masri BA, Haddad F, et al: Clinical and radiographic assessment the young adult with symptomatic dysplasia. Clin Orthop Relat Res 2004;418:18-22.
Delauney S, Dussault RG, Kaplan PA, et al: Radiographic measurements of dysplastic adult hips. Skelelal Radiol 1997;26:75-81.

Question 48:

Options:

Electromyography and nerve conduction velocity studies of bilateral lower extremities
Multilevel lumbar laminectomy
MRI of the thoracic and cervical spine
MRI of the brain
Epidural steroid injections

Correct Answer: MRI of the thoracic and cervical spine

Explanation:

Question 49:

A 54-year-old woman with idiopathic carpal tunnel syndrome undergoes open carpal tunnel release with a flexor tenosynovectomy. The pathology from the tenosynovium is likely to show

Options:

fibrosis and edema.
polymorphonuclear cells.
negatively birefringent crystals.
macrophages and lymphocytes.
fibrinous degeneration of collagen fibers.

Correct Answer: fibrosis and edema.

Explanation:

Question 50:

Options:

a thumb spica cast and reassessment in 3 weeks.
a thumb spica cast and reassessment in 6 weeks.
repair of the ulnar collateral ligament of the MCP joint.
adductor pollicis advancement on the proximal phalanx.
repair of the MCP joint dorsal capsule.

Correct Answer: a thumb spica cast and reassessment in 3 weeks.

Explanation:

Question 51:

Figure 1 points to the "tear drop" of the wrist. This radiographic landmark represents which anatomic portion of the wrist?

Options:

Ulnar head
Volar ulnar corner
Radial styloid
Lister tubercle

Correct Answer: Volar ulnar corner

Explanation:

Question 52:

Sciatic nerve

Options:

The sciatic nerve is in the posterior compartment of the thigh and can be palpated at the midpoint between the ischial tuberosity and the greater trochanter when the hip is flexed.
The obturator nerve is in the medial compartment of the thigh. The femoral nerve is in the anterior compartment of the thigh.
The peroneal (common peroneal) nerve bifurcates into the deep peroneal and the superficial peroneal nerves which lie in the anterior and lateral compartments of the leg, respectively.

Correct Answer: The sciatic nerve is in the posterior compartment of the thigh and can be palpated at the midpoint between the ischial tuberosity and the greater trochanter when the hip is flexed.

Explanation:

(999) Q1-1306:
The principal thrombogenic stimulus leading to the production of venous thromboembolic disease during total hip arthroplasty occurs at which time:

Question 53:

Options:

Excessive anteversion of the humeral component
Excessive anteversion of the glenoid component
Excessive posterior capsular laxity
Anterior capsular laxity
Use of an oversized humeral head

Correct Answer: Excessive posterior capsular laxity

Explanation:

Question 54:

Options:

observation.
a proximal tibial and fibular osteotomy.
daytime ambulatory bracing.
elevation of the medial tibial plateau.
an MRI scan of the knee.

Correct Answer: daytime ambulatory bracing.

Explanation:

Question 55:

An 11-year-old boy sustained an ankle injury while playing football. Figure 20 shows an AP radiograph obtained the day of injury. Treatment should consist of

Options:

closed manipulation and a long leg cast.
closed manipulation and a short leg walking cast.
a long leg cast and long-term follow-up to rule out growth arrest.
open reduction and internal fixation with a transphyseal lag screw and a non-weight-bearing cast.
open reduction and internal fixation with fixation parallel to the physis and a non-weight-bearing cast.

Correct Answer: open reduction and internal fixation with fixation parallel to the physis and a non-weight-bearing cast.

Explanation:

DISCUSSION: The child has an injury involving both the growth plate and the articular surface of the ankle. Because of the significant displacement, open reduction and internal fixation is indicated to realign the physis and joint surface. The best method of fixation to avoid growth arrest is one that does not cross the physis. This is usually achieved by a transverse epiphyseal screw parallel to the physis. If the metaphyseal fragment was large enough, a transverse metaphyseal screw could be used instead. The incidence of growth arrest following physeal ankle injuries is as high as 50%, and long-term follow-up is indicated.
REFERENCES: Cass JR, Peterson HA: Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. J Bone Joint Surg Am 1983;65:1059-1070.
Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibia physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23:733-739.

Question 56:

Options:

Silastic arthroplasty
Cheilectomy and soft-tissue interposition arthroplasty
Moberg phalangeal dorsiflexion osteotomy
Bone graft interposition arthrodesis
Waterman first metatarsal dorsal osteotomy

Correct Answer: Bone graft interposition arthrodesis

Explanation:

Question 57:

What is the prognosis for ambulation, from best to worst, for patients with an incomplete spinal cord injury?

Options:

Central cord syndrome, anterior cord syndrome, Brown-Sequard syndrome
Central cord syndrome, Brown-Sequard syndrome, anterior cord syndrome
Brown-Sequard syndrome, anterior cord syndrome, central cord syndrome
Brown-Sequard syndrome, central cord syndrome, anterior cord syndrome
Anterior cord syndrome, central cord syndrome, Brown-Sequard syndrome

Correct Answer: Brown-Sequard syndrome, central cord syndrome, anterior cord syndrome

Explanation:

Question 58:

Options:

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

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

Explanation:

Question 59:

All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:

Options:

Can be protective to an injured spine
Facilitates access to other injured sites in the polytrauma patient
Provides easier fluoroscopic imaging
Allows for easy reduction of the distal fragment to the flexed proximal fragment
Easier to assess rotation

Correct Answer: Can be protective to an injured spine

Explanation:

Question 60:

Options:

Renal osteodystrophy
Diastrophic dysplasia
Metaphyseal dysplasia
Osteogenesis imperfecta
Fibrous dysplasia

Correct Answer: Renal osteodystrophy

Explanation:

Question 61:

Options:

Toe-touch weight-bearing activity and supportive care
Core decompression and femoral head grafting
Periacetabular osteotomy
Hemiarthroplasty

Correct Answer: Toe-touch weight-bearing activity and supportive care

Explanation:

Question 62:

Options:

closed reduction and percutaneous screw placement.
open reduction internal fixation through an anterior midline approach.
spanning external fixation and closed manipulative realignment.
ring fixation.

Correct Answer: spanning external fixation and closed manipulative realignment.

Explanation:

Question 63:

In infantile idiopathic scoliosis, which of the following factors suggests progression?

Options:

Age at presentation
Rib overlap of the apical vertebra
Rib vertebral angle difference of greater then 10 degrees
Male gender
Family history

Correct Answer: Rib overlap of the apical vertebra

Explanation:

Question 64:

Options:

resection of the biopsy site and tumor bed, including the deep fascia and a portion of underlying muscle, and skin grafting.
resection of the anterior compartment of the thigh and rotational flap, followed by radiation therapy.
radiation therapy.
chemotherapy and radiation therapy.
observation.

Correct Answer: resection of the biopsy site and tumor bed, including the deep fascia and a portion of underlying muscle, and skin grafting.

Explanation:

Question 65:

Options:

Correct Answer: C7

Explanation:

Question 66:

Options:

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

Correct Answer: Anatomic hip center with subtrochanteric shortening osteotomy

Explanation:

Question 67:

A 1-year-old infant has the hand deformities shown in Figure 40. What pathologic process is the most likely cause of these deformities?

Options:

Genetic mutation
Teratogen exposure
Amniotic rupture
Iatrogenic influences
Developmental field disruption

Correct Answer: Amniotic rupture

Explanation:

Question 68:

Options:

MRI of the elbow and forearm
Bone scan
Electrodiagnostic studies
Radial tunnel injection
Radiographs of the wrist

Correct Answer: Radial tunnel injection

Explanation:

Question 69:

Based on the MR arthrogram of the elbow shown in Figure 8, which of the following structures is torn?

Options:

Common flexor tendon
Anconeus
Radial collateral ligament
Ulnar collateral ligament
Lateral ulnar collateral ligament

Correct Answer: Ulnar collateral ligament

Explanation:

Question 70:

Options:

Technetium Tc 99m bone scan
Contrast-enhanced MRI
CT
Electromyography
Arthroscopy

Correct Answer: Contrast-enhanced MRI

Explanation:

Question 71:

Which of the following patients requires preoperative noninvasive cardiac testing?

Options:

year-old man scheduled to undergo elective lumbar decompression and fusion, with a history of hypercholesteremia, hypertension, and deep venous thrombosis following treatment of an ankle fracture
year-old woman scheduled to undergo total knee arthroplasty, with a history of myocardial infarction, cerebrovascular accident, and diabetes mellitus
year-old woman scheduled to undergo total hip arthroplasty for osteonecrosis, no known medical comorbidities, but has not seen a physician in more than 20 years and drinks 7 to 10 alcoholic beverages per week
year-old man with an intertrochanteric hip fracture, with a history of chronic renal failure, colon
cancer, and obesity
year-old man with a fracture of the proximal femur, history of myocardial infarction, prostate adenocarcinoma, and hypothyroidism, and prior to the fracture he was able to climb a flight of stairs

Correct Answer: year-old woman scheduled to undergo total knee arthroplasty, with a history of myocardial infarction, cerebrovascular accident, and diabetes mellitus

Explanation:

Question 72:

Options:

Inflation of the abdominal portion of the PASG
Application of a pelvic clamp
Application of a pelvic external fixator
Rapid infusion of 4 more units of blood
Angiography and embolization

Correct Answer: Angiography and embolization

Explanation:

Question 73:

Options:

Placement of antibiotic spacer
Removal of the glenoid, and possible bone grafting
Conversion to reverse shoulder arthroplasty
Referral to pain management
Shoulder arthrodesis

Correct Answer: Removal of the glenoid, and possible bone grafting

Explanation:

Question 74:

Which of the following is the most relevant clinical factor in the maturation assessment of an adolescent female athlete contemplating anterior cruciate ligament (ACL) reconstruction?

Options:

Parental height
Height of older male sibling
Age of menarche
Recent change in shoe size
Presence of breast buds

Correct Answer: Age of menarche

Explanation:

Question 75:

Options:

Manipulation under anesthesia (MUA)
Arthroscopic lysis of adhesions
Open arthrolysis of adhesions
Revision TKA

Correct Answer: Manipulation under anesthesia (MUA)

Explanation:

Question 76:

Options:

Compartment syndrome
Loss of elbow motion
Avascular necrosis (AVN) of the radial head
Nonunion of the fracture site

Correct Answer: Loss of elbow motion

Explanation:

DISCUSSION
This girl sustained a fracture dislocation of the elbow with a severely displaced and rotated radial neck fracture. Required treatment was open reduction and internal fixation (ORIF). Less severely displaced radial neck fractures can be treated with closed reduction, percutaneous pinning, or flexible nail manipulation. In this scenario, interposed capsular tissue and rotation of the radial head were indications for ORIF. ORIF is associated with a higher risk for poor
outcomes. Complications following ORIF of radial neck fractures in children include posterior interosseous neuropraxia, valgus angulation, premature closure of the radial head physis, AVN of the radial head, nonunion, and elbow stiffness. Stiffness is most common. Compartment syndrome, infection, and anterior interosseous nerve palsy are less common complications.
CLINICAL SITUATION FOR QUESTIONS 47 THROUGH 50
A 6-year-old boy arrives at the emergency department with forearm pain. Today he was picking up his backpack when he felt a pop in his forearm that resulted in the current injury. His history is significant for 6 other fractures treated nonsurgically. His mother states that she had 15 fractures during childhood but is healthy now. Both the boy and his mother have blue sclera. Figures 47a and 47b are the radiographs of his injured forearm.

Question 77:

Options:

Debulking
Wide resection with vascular and nerve grafting
Above-elbow amputation
Chemotherapy
Radiation therapy

Correct Answer: Chemotherapy

Explanation:

Question 78:

Options:

Contrast CT of the hand and wrist
MRI of the hand and wrist
Contrast angiography of the involved upper extremity
Digital subtraction angiography
Single-shot fluoroscopic angiography

Correct Answer: Contrast angiography of the involved upper extremity

Explanation:

Question 79:

Options:

Pitchers throwing less fastballs and more changeups
Evaluate the pitchers elbows for ulnar collateral ligament acute ruptures.
Increasing the weight training for the deltoid and latissimus dorsi muscles
Focused stretches and therapies that address posterior capsular tightness
Firing the general manager for finding pitchers that "lose their stuff"

Correct Answer: Pitchers throwing less fastballs and more changeups

Explanation:

Question 80:

Options:

cm limb-length discrepancy with the right femur longer
cm limb-length discrepancy with the left femur longer
degree varus deformity
degree valgus deformity
degree recurvatum deformity

Correct Answer: cm limb-length discrepancy with the left femur longer

Explanation:

DISCUSSION: The child has a near complete central physeal arrest of the distal femur and worsening limb-length discrepancy will develop. She is growing at the average rate for the population. The distal femoral physis grows at a rate of roughly 9 mm per year. Girls finish their growth at approximately age 14 years. Thus, at maturity the left leg will be 6.4 cm longer than the right. An angular deformity has not developed at this point and her arrest is central; therefore, angular deformity is unlikely to develop in any plane.
REFERENCES: Little DG, Nigo L, Aiona MD: Deficiencies of current methods for the timing of epiphysiodesis. J Pediatr Orthop 1996;16:173-179.
Moseley CF: Assessment and prediction in leg-length discrepancy. Instr Course Lect 1989;38:325-330.

Question 81:

Options:

Trapeziometacarpal arthrodesis
Osteotomy of the thumb metacarpal
Arthrotomy and joint debridement
Ligament reconstruction using one half of the flexor carpi radialis
Trapezium resection, tendon interposition, and reconstruction of the ligament

Correct Answer: Ligament reconstruction using one half of the flexor carpi radialis

Explanation:

Question 82:

Options:

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

Correct Answer: Repeat EMG studies

Explanation:

Question 83:

Options:

follow-up radiographs.
alendronate, with follow-up examinations every 6 months.
revision to a posterior stabilized prosthesis.
exchange of the tibial insert through a limited incision.
surgical exploration with revision or exchange based on the findings.

Correct Answer: surgical exploration with revision or exchange based on the findings.

Explanation:

Question 84:

Options:

Osteomyelitis
Giant cell tumor
Osteosarcoma
Chondroblastoma
Histiocytosis

Correct Answer: Giant cell tumor

Explanation:

DISCUSSION: The radiograph shows a purely radiolucent lesion without matrix mineralization in the epiphysis of the distal radius. The lesion is “hot” on bone scan, and the MRI scan reveals cortical destruction with a soft-tissue mass. These findings are most consistent with giant cell tumor. The distal radius is a common location for giant cell tumors. The other options would be very uncommon in this location in a 45-year-old patient. The photomicrograph demonstrates multinucleated giant cells in a sea of mononuclear cells. The nuclei of the giant cells and the nuclei of the mononuclear stromal cells are identical. This feature helps distinguish giant cell tumor from other lesions that might contain giant cells.
REFERENCES: Cheng CY, Shih HN, Hsu KY, et al: Treatment of giant cell tumor of the distal radius. Clin Orthop Relat Res 2001;383:221-228.
Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 263-284.

Question 85:

Which of the following tendons is the primary antagonist of the posterior tibialis tendon?

Options:

Anterior tibialis
Achilles
Peroneus brevis
Peroneus longus
Flexor digitorum longus

Correct Answer: Peroneus brevis

Explanation:

Question 86:

Anterior approach

Options:

Lateral femoral cutaneous nerve
Inferior gluteal nerve
Superior gluteal nerve
Sciatic nerve

Correct Answer: Lateral femoral cutaneous nerve

Explanation:

DISCUSSION
The nerve most commonly injured in the posterior approach to the hip is the sciatic nerve. Overall injury prevalence is 1% to 2%. This nerve is more commonly injured in cases of hip dysplasia with excessive leg lengthening. The superior gluteal nerve is at highest risk with the direct lateral approach to the hip. This nerve courses in the gluteus medius muscle and is
at risk when splitting the muscle 5 cm proximal to the greater trochanter. The lateral femoral
73
cutaneous nerve is commonly damaged with anterior total hip replacement surgery. Neuropraxia has been reported in 81% of patients. The inferior gluteal nerve travels from the greater sciatic notch and enters the gluteus maximus muscle. It is at risk when the posterior approach to the hip is used.
RECOMMENDED READINGS
Hoppenfeld S, deBoer P. Surgical Exposures in Orthopedics. 3rd ed. Philadelphia.
PA: Lippincott Williams & Wilkins; 2003:365-453.
DeHart MM, Riley LH Jr. Nerve injuries in total hip arthroplasty. J Am Acad Orthop Surg. 1999 Mar-Apr;7(2):101-11. Review. PubMed PMID: 10217818.
View Abstract
at PubMed
Goulding K, Beaulé PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Clin Orthop Relat Res. 2010 Sep;468(9):2397-404. doi: 10.1007/s11999-010-1406-5. PubMed PMID:

Question 87:

Options:

Anchor fatigue and breakage
Anchor pull out from bone
Suture rupture secondary to anchor eyelet abrasion
Suture pull out from the repaired tissue
Infection

Correct Answer: Anchor pull out from bone

Explanation:

Question 88:

When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?

Options:

Addition of sublaminar wires to the midlumbar spine
Cross-linking of the longitudinal rods
Use of multiple claw hook fixation in the upper thoracic spine
Use of large-diameter rods and pedicle screws
Fixation into both the ilium and the sacrum

Correct Answer: Fixation into both the ilium and the sacrum

Explanation:

Question 89:

Options:

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

Correct Answer: Antiresorptive bisphosphonate medication

Explanation:

DISCUSSION: A DEXA scan is most appropriately used to establish a baseline score. Even if the bone mineral density is not within the osteoporotic range (T-score less than -2.5), a prior fragility fracture is a strong risk factor for a second fracture as a result of factors other than bone density, such as worsening vision or balance, confusion, or other predispositions to falls. The guidelines of the National Osteoporosis Foundation indicate that, following a fragility hip fracture, active anti-osteoporotic medication should be initiated, whether or not a DEXA scan is performed. A recent study showed that antiresorptive therapy following a hip fracture reduces not only the risk of a second fracture but also overall mortality.
REFERENCE: Gardner MJ, Brophy RH, Demetrakopoulos D, et al: Interventions to improve osteoporosis treatment following hip fracture: A prospective, randomized trial. J Bone Joint Surg Am 2005;87:3-7.

Question 90:

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

Options:

Limbus
Pulvinar
Ligamentum teres
Transverse acetabular ligament
Acetabular labrum

Correct Answer: Acetabular labrum

Explanation:

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

Question 91:

Options:

Osteomyelitis
Lymphoma
Myeloma
Ewing’s sarcoma
Osteosarcoma

Correct Answer: Myeloma

Explanation:

Question 92:

Histologic studies of surgically resected tissue in lateral epicondylitis demonstrate which of the following findings? Review Topic

Options:

Chondroblastic proliferation
Angiofibroblastic tendinosis
Significant active inflammation
Primarily calcium deposition
No normal tendon histology

Correct Answer: Angiofibroblastic tendinosis

Explanation:

Question 93:

Options:

Lumbar spine flexion and extension radiographs
Lumbar spine CT
Lumbar spine MRI
Whole body bone scan
Tagged white blood cell scan

Correct Answer: Lumbar spine MRI

Explanation:

Question 94:

Options:

Physical therapy and nonsteroidal anti-inflammatory drugs
Local corticosteroid injection and physical therapy
Open repair of the long head of the biceps
Open repair of the sternocostal portion of the pectoralis major tendon
Open repair of the clavicular portion of the pectoralis major tendon

Correct Answer: Open repair of the sternocostal portion of the pectoralis major tendon

Explanation:

Question 95:

Surgical treatment for symptomatic disk herniations is associated with which of the following?

Options:

Substantial rate of nerve root injury
Early relief of pain sustained out to 2 years
Recurrent herniation rate of 35%
Outcomes that are substantially worse than nonsurgical management
10% rate of infectious diskitis

Correct Answer: Early relief of pain sustained out to 2 years

Explanation:

Question 96:

Options:

humeral head arthroplasty.
observation.
arthroscopic capsular release.
grafting of the humeral head defect.
electrical stimulation.

Correct Answer: observation.

Explanation:

Question 97:

Options:

Dynamic ultrasound examination of the rotator cuff
Electrodiagnostic testing of the throwing shoulder
MR arthrogram of the throwing shoulder
Referral to a physical therapist to concentrate on range of motion
Laboratory studies to evaluate C-reactive protein and erythrocyte sedimentation rate

Correct Answer: MR arthrogram of the throwing shoulder

Explanation:

Question 98:

Options:

CT of the shoulder
MRI of the shoulder
Application of a sling for 6 weeks
Surgery for diagnostic shoulder arthroscopy
Physical therapy to work on range of motion and strengthening

Correct Answer: MRI of the shoulder

Explanation:

Question 99:

Options:

Median and ulnar fascicles to musculocutaneous nerve transfer
Medial triceps branch to axillary nerve transfer
ntercostal nerve to triceps branch of radial nerve transfer
Anterior interosseous nerve (AIN) to ulnar motor transfer

Correct Answer: Median and ulnar fascicles to musculocutaneous nerve transfer

Explanation:

Question 100:

Options:

Immediately
In three games
After anterior plate removal
Next season
Cannot return

Correct Answer: Immediately

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

OITE & ABOS Orthopedic MCQ Prep: Arthroplasty, Trauma & Knee - Part 208

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 208

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index