Orthopedic Board Exam MCQs: OITE & AAOS Part 220

About This Board Review Set

This is Part 220 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.
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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 220

This module focuses heavily on: Ankle, Elbow, Fracture, Shoulder, Tumor.

Sample Questions from This Set

Sample Question 1: The radiographic feature seen in Figure 37 that best indicates a slow-growing process is the...

Sample Question 2: What is the neoplastic cell of origin for this tumor?...

Sample Question 3: A 12-year-old boy with an ankle fracture undergoes closed reduction under sedation in the emergency department. Figure 27 shows a lateral radiograph of the ankle after two attempts at closed reduction. Based on these findings, treatment sho...

Sample Question 4: During shoulder motion with the elbow controlled in a brace, electromyographic studies of the supraspinatus show significant activity with all range-of-motion testing. Concurrent electromyographic studies of the long head of the biceps will...

Sample Question 5: An 8-year-old boy weighing 70 lb sustains a displaced diaphyseal femur fracture and is treated with two flexible retrograde intramedullary rods. What is the most common complication following treatment with this technique? Review Topic...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

The radiographic feature seen in Figure 37 that best indicates a slow-growing process is the

Explanation

DISCUSSION: For the fibula (or any bone) to bow, a long-standing process needs to be present. Pressure from a rapid process would cause erosion, not allowing the bone to remodel. The other features are helpful confirmatory findings but also may be associated with aggressive processes. In this patient, the fibular deformity is caused by a sessile osteochondroma of the tibia.
REFERENCES: Lodwick GS, Wilson AJ, Farrell C, Virtama P, Dittrich F: Determining growth rates of focal lesions of bone from radiographs. Radiology 1980;134:577-583.
Moser RP Jr, Madewell JE: An approach to primary bone tumors. Radiol Clin North Am 1987;25:1049-1093.

Question 2

What is the neoplastic cell of origin for this tumor?

Explanation

DISCUSSION
Tenosynovial giant-cell tumors are widely known as pigmented villonodular synovitis (PVNS), although this term is misleading because this tumor type is a clonal neoplasm and does not involve an inflammatory process. It often is shown to have a t(1:2)(p13q37) karyotype resulting in CSF1-COL6A3 gene fusion. There are various amounts of mononuclear cells, osteoclastlike giant cells, foamy histiocytes, hemosiderophages, and chronic inflammatory cells. Local recurrences are common, but CSF1R inhibitors are being investigated in studies involving local control improvement and disease regression.
Targeted therapy trials to assist in control of the diffuse-type tenosynovial giant-cell tumor (formerly called PVNS) involve the use of monoclonal antibodies that inhibit CSF1R activation. CSF1R-expressing mononuclear phagocytes are affected by these monoclonal antibodies.
Infantile fibrosarcoma is associated with the t(12;15)(p13;q25) karyotype and ETV6-NTRK3 gene fusion product. Nodular fasciitis is associated with the t(17;22)(p13;q13.1) karyotype and MYH9-USP6 gene fusion product. Inflammatory myofibroblastic tumor is associated with translocations involving 2p23 resulting in multiple fusion products of ALK with TPM4 (19p13.1), TPM3 (1q21), CLTC (17q23), RANBP2 (2q13), ATIC (2q35), SEC31A (4q21), and CARS (11p15). No
nonpreferred response has a histologic appearance that includes hemosiderin, foamy histiocytes, and osteoclastlike giant cells.
A conformation-specific inhibitor of the juxtamembrane region of CSF1R is a synthetic molecule that is designed to access the autoinhibited state of the receptor through direct interactions with the juxtamembrane residues embedded in the adenosine 5’-triphosphate-binding pocket. It is designed to bind in the regulatory a-helix of the N-terminal lobe of the kinase domain in neoplastic cells of tenosynovial giant-cell tumor that have expression of the CSF1 gene. There is a structural plasticity of the domain of the CSF1R that allows the molecule to directly bind the autoinhibited state of CSF1R.
Another approach involves the development of the anti-CSF1R antibody, emactuzumab, which targets tumor-associated macrophages. A lower percentage of volume reduction has been reported with imatinib, a tyrosine kinase inhibitor. Alkylating agents have not been used in this benign neoplasm.
Tenosynovial giant-cell tumor is characterized by an overexpression of CSF1. CSF1R activation leads to recruitment of CSF1R-expressing cells of the mononuclear phagocyte lineage.
RECOMMENDED READINGS
Cassier PA, Gelderblom H, Stacchiotti S, Thomas D, Maki RG, Kroep JR, van der Graaf WT, Italiano A, Seddon B, Dômont J, Bompas E, Wagner AJ, Blay JY. Efficacy of imatinib mesylate for the treatment of locally advanced and/or metastatic tenosynovial giant cell tumor/pigmented villonodular synovitis. Cancer. 2012 Mar 15;118(6):1649-55. doi: 10.1002/cncr.26409. Epub 2011 Aug 5. PubMed PMID: 21823110. View Abstract at PubMed
Ladanyi M, Fletcher JA, Dal Cin P. Cytogenetic and molecular genetic pathology of soft tissue tumors. In: Goldblum JR, Folpe AL, Weis SW, eds. Enzinger & Weiss’s Soft Tissue Tumors. 6th ed. Philadelphia, PA: Elsevier Saunders; 2014:76-109.
Staals EL, Ferrari S, Donati DM, Palmerini E. Diffuse-type tenosynovial giant cell tumour: Current treatment concepts and future perspectives. Eur J Cancer. 2016 Aug;63:34-40. doi: 10.1016/j.ejca.2016.04.022. Epub 2016 Jun 5. Review. View Abstract at PubMed
Tap WD, Wainberg ZA, Anthony SP, Ibrahim PN, Zhang C, Healey JH, Chmielowski B, Staddon AP, Cohn AL, Shapiro GI, Keedy VL, Singh AS, Puzanov I, Kwak EL, Wagner AJ, Von Hoff DD, Weiss GJ, Ramanathan RK, Zhang J, Habets G, Zhang Y, Burton EA, Visor G, Sanftner L, Severson P, Nguyen H, Kim MJ, Marimuthu A, Tsang G, Shellooe R, Gee C, West BL, Hirth P, Nolop K, van de Rijn M, Hsu HH, Peterfy C, Lin PS, Tong-Starksen S, Bollag G. Structure-Guided Blockade of CSF1R Kinase in Tenosynovial Giant-Cell Tumor. N Engl J Med. 2015 Jul 30;373(5):428-37. doi:10.1056/NEJMoa1411366. PubMed PMID: 26222558. View Abstract at PubMed
Ries CH, Cannarile MA, Hoves S, Benz J, Wartha K, Runza V, Rey-Giraud F, Pradel LP, Feuerhake F, Klaman I, Jones T, Jucknischke U, Scheiblich S, Kaluza K, Gorr IH, Walz A, Abiraj K, Cassier PA, Sica A, Gomez-Roca C, de Visser KE, Italiano A, Le Tourneau C, Delord JP, Levitsky H, Blay JY, Rüttinger D. Targeting tumor-associated macrophages with anti-CSF-1R antibody reveals a strategy for cancer therapy. Cancer Cell. 2014 Jun 16;25(6):846-59. doi: 10.1016/j.ccr.2014.05.016. Epub 2014 Jun 2. PubMed PMID: 24898549.View Abstract at PubMed

Question 3

A 12-year-old boy with an ankle fracture undergoes closed reduction under sedation in the emergency department. Figure 27 shows a lateral radiograph of the ankle after two attempts at closed reduction. Based on these findings, treatment should now consist of

Explanation

DISCUSSION: The widening of the physis associated with incomplete reduction of this fracture suggests that periosteum is interposed at the fracture site. Clinical and animal study findings suggest that the interposed periosteum may lead to premature physeal closure. Repeated forceful attempts at reduction may subject the physis to further injury and should be avoided. Growth problems are common in children with Salter-Harris type I fractures of the lower extremities. Nonunions are rare in children with Salter-Harris type I fractures.
REFERENCES: Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibial physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23:733-739.
Gruber HE, Phieffer LS, Wattenbarger JM: Physeal fractures: Part II. Fate of interposed periosteum in a physeal fracture. J Pediatr Orthop 2002;22:710-716.

Question 4

During shoulder motion with the elbow controlled in a brace, electromyographic studies of the supraspinatus show significant activity with all range-of-motion testing. Concurrent electromyographic studies of the long head of the biceps will most likely show

Explanation

DISCUSSION: During electromyographic studies, the long head of the biceps has been shown to have little activity throughout a wide range of shoulder motion as long as the elbow is immobilized. The supraspinatus is active throughout the range of shoulder motion. Rotator cuff tears do not influence biceps activity as long as the elbow is controlled.
REFERENCES: Yamaguchi K, Riew KD, Galutz LM, et al: Biceps activity during shoulder motion: An electromyographic analysis. Clin Orthop 1997;336:122-129.
Levy AS, Kelly BT, Lintner SA, et al: Function of the long head of the biceps at the shoulder: Electromyographic analysis. J Shoulder Elbow Surg 2001;10:250-255.

Question 5

An 8-year-old boy weighing 70 lb sustains a displaced diaphyseal femur fracture and is treated with two flexible retrograde intramedullary rods. What is the most common complication following treatment with this technique? Review Topic

Explanation

Flexible retrograde intramedullary nailing is now the preferred treatment for most length-stable diaphyseal femur fractures in school-aged children. The most commonly described complication is irritation about the knee at the rod insertion sites that resolves with rod removal. Limb-length discrepancy and weakness have also been described at lower rates. Malunion or rod bending is usually related to placement of the rods in an unstable fracture pattern or in a larger patient.

Question 6

What is the most frequent late complication of cementless fixation in total knee arthroplasty?

Explanation

DISCUSSION: The incidence of osteolysis, particularly around fixation screws in the tibia, can be as high as 30%. Stable femoral component fixation is generally maintained. Infection, subluxation of the patella, and stiffness can occur with either cemented or cementless fixation.
REFERENCES: Peters PC, Engh GA, Dwyer KA, Vinh TN: Osteolysis after total knee arthroplasty without cement. J Bone Joint Surg Am 1992;74:864-876.
Parks NL, Engh GA, Topoleski LDT, Emperado J: Modular tibial insert micromotion: A concern with contemporary knee implants. Clin Orthop 1998;356:10-15.

Question 7

A 31-year-old man who is a recent immigrant from Guatemala has had pain in his back and thighs for the past 12 months. History notes a recent diagnosis of gout, and the patient reports falling a distance of 3 feet on his buttocks immediately before the pain began. Examination reveals that he is neurologically intact. Plain radiographs are shown in Figures 44a and 44b, and T2-weighted MRI scans are shown in Figures 44c and 44d. The most likely cause of the pathologic fracture is

Explanation

The plain films demonstrate lumbar AP and Lateral radiographs with 32 degree anteriorly wedged compression fracture of L1. On closer evaluation one notices the adjacent disc spaces are narrowed. The center of the vertebra is sclerotic with the anterior inferior endplate irregular.
The MR demonstrates involvement of L1 and adjacent disc spaces. With peri-vertebral edema and mass involving the posterior aspect of the vertebral body, placing pressure on the spinal cord. There is also involvement of the L2-3 disc with early signal changes.
The slow clinical course of the patients symptoms, being from a third world country and the findings on imaging studies, with an anterior wedge compression fracture. The level most commonly involved with TB is lower thoracic and upper lumbar. The anterior wedging results in the classic “Gibbus”.
Some of the MR findings are also consistent with metastatic disease, but with the localized mass, peri-vertebral abscess make this choice more unlikely.
The usual findings on MR found with TB are: Confluently decreased signal intensity of the vertebral bodies associated interspace with poor distinction between these on short TR/short TE images: Abnormal increased signal of the disk on long TR/long TE images with an abnormal configuration (i.e., absent intranuclear cleft): Increased signal of the vertebral endplates at the abnormal disk level on long TR/long TE images.

Question 8

When comparing the overall outcomes of surgical versus nonsurgical treatment of stable thoracolumbar burst fractures in patients without neurologic injury, 5 years following injury, the principle differences lie in Review Topic

Explanation

When patients are compared at 5 years follow-up, there are no statistically significant differences between the two groups with respect to kyphosis, the degree of retropulsed bone resorption, pain and function levels, or the ability to return to work. Nonsurgical management of stable neurologically intact burst fractures has a very low incidence of complications.

Question 9

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

Explanation

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

Question 10

-The patient asks if something about her anatomy has resulted in this injury. ACL anatomy differs between men and women in what manner?

Explanation

DISCUSSION FOR QUESTIONS 18 THROUGH 20
This patient has the clinical findings of an ACL rupture that is confirmed on MRI scan. She is a professional athlete and would like to return to her sport. Immediate ACL reconstruction in the setting of a knee with limited motion carries an increased risk for postsurgical stiffness. Delayed surgery after the patient regains range of motion is the preferred response. It has been shown that a woman’s ACL is smaller in the cross-sectional area.

Question 11

A 13-year-old girl injures her ankle playing soccer. Radiographs reveal a displaced Tillaux fracture. CT scans are shown in Figure 25. What is the most important consideration for appropriate management?

Explanation

DISCUSSION: Tillaux and triplane fractures occur in adolescents as the result of an external rotation injury of the ankle. As seen on the CT scan, the growth plate starts to close during adolescence; therefore, growth arrest resulting in limb-length discrepancy or angulation is less of a concern in this age group than achieving joint congruity. The joint should be surgically reduced if displacement is greater than 2 mm to minimize the chances of late arthrosis.
REFERENCES: Kay RM, Matthys GA: Pediatric ankle fractures: Evaluation and treatment.

J Am Acad Orthop Surg 2001;9:268-278.
Kling TF Jr: Operative treatment of ankle fractures in children. Orthop Clin North Am 1990;21:381-392.
Duchesneau S, Fallat LM: The Tillaux fracture. J Foot Ankle Surg 1996;35:127-133.

Question 12

Figures below show the radiographs obtained from a 90-year-old woman who is seen in the emergency department after a fall from a height. She has right hip and thigh pain and is unable to bear weight. Based on this patient's history and imaging, what is the best next step?

Explanation

DISCUSSION:
Periprosthetic fracture is the third most common reason (after loosening and infection) for revision surgery after total hip arthroplasty (THA). Late periprosthetic fracture risk is 0.4% to 1.1% after primary
THA and 2.1% to 4% after revision THA. Risk factors for periprosthetic fracture include age over 70 years, decreasing bone mass, and loosening of implants and osteolysis. The risk of concomitant infection in the presence of a periprosthetic fracture is 11%, according to Chevillotte and associates. Obtaining presurgical aspiration or intrasurgical tissue for culture is recommended if concomitant infection is suspected.

Question 13

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 14

Which of the following is considered an important factor in improved cemented femoral stem survivorship?

Explanation

DISCUSSION: Cement technique, relative stem to canal size and position, stem design, surgical technique, and femoral anatomy are important factors in cemented stem survivorship. Varus stem position, a wide diaphyseal to metaphyseal ratio (stovepipe femur), thin cement mantles (1 mm or less), and nonrounded femoral stem designs are negative prognostic factors for stem survivorship. Precoating with methylmethacrylate has not been shown to provide any increased survivorship over nonprecoated stems.
REFERENCES: Noble PC, Collier MB, Maltry JA, Kamaric E, Tullos HS: Pressurization and centalization enhance the quality and reproducibility of cement mantles. Clin Orthop 1998;355:77-89.
Crowninshield RD, Brand RA, Johnston RC, Milroy JC: The effect of femoral stem cross-sectional geometry on cement stresses in total hip reconstruction. Clin Orthop 1980;146:71-77.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.

Question 15

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

Explanation

DISCUSSION: Anterior superior iliac spine avulsion fractures are caused by sudden, forceful contractions of the sartorius and tensor fascia lata. These injuries occur in young athletes through the growth plate with the hip extended and the knee flexed, such as while sprinting or swinging a baseball bat. The athlete will often report a pop or snap at the time of injury. Displaced fractures usually can be seen on radiographs. CT or MRI can be obtained to confirm the diagnosis. In most patients, nonsurgical management consisting of rest and protected weight bearing yields satisfactory outcomes. Surgery is usually reserved for fractures with displacement of more than 3 cm and painful nonunions.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 139-153.
White KK, Williams SK, Mubarack SJ: Definition of two types of anterior superior iliac spine avulsion fractures. J Pediatr Orthop 2002;22:578-582.

Question 16

A 42-year-old female with chronic discogenic back pain undergoes lumbar spine surgery via retroperitoneal approach. Figure A is the postoperative radiograph of her lumbar spine. Six weeks after the surgery the patient develops worsening low back pain. You obtain a radiograph of her lumbar spine, pictured in Figure B. What is the next best step in management? Review Topic

Explanation

This patient has a failed lumbar total disc replacement (TDR) with anterior dislocation of the polyethylene inlay and requires revision surgery, either revision arthroplasty or anterior interbody fusion, via retroperitoneal approach.
Management of failed TDR is dictated by (1) patient symptoms and (2) radiographic implant position. Asymptomatic patients with implant subsidence without extrusion can be managed with close observation. Patients with persistent symptomatic back pain relating to facet joint or implant microinstability in the setting of an otherwise well-positioned TDR can be treated with posterior stabilization alone. Symptomatic patients with unacceptable implant position (i.e. complete dislodgement, fracture) require either revision arthroplasty or conversion to arthrodesis (anterior +/-
posterior).
Harrison et al. authored a report detailing a case of failed L5-S1 TDR with anterior dislocation of the polyethylene inlay and bilateral L5 pars fractures noted 2 weeks postoperatively. It is unclear whether the pars defect was missed following previous microdiscectomy, acquired during instrumentation, or acquired postoperatively due to abnormal endplate forces during rehabilitation. The patient underwent removal of TDR components and revision to anterior arthrodesis followed by percutaneous fixation of the bilateral L5 pars fractures.
Patel et al. published a review of the literature regarding revision lumbar TDR. Retroperitoneal revision procedures are complicated by higher risk of injury to vascular structures (16.7% versus 3.6% at primary surgery) and urogenital structures due to adhesions. Revision surgery should only be performed by surgeons familiar with the retroperitoneal approach to the spine. Alternative surgical approaches, such as the far lateral approach, should be considered to access the anterior spine at L4-L5 and above.
Madigan et al. reviewed the management of lumbar degenerative disc disease (DDD). They state that TDR is a motion-sparing surgical option designed to temper the problem of adjacent-segment disease. They report that long-term studies are limited, but point out that several short-term comparisons between TDR and ALIF show equivalent improvement in pain and function, equal complication rate, shorter hospitalization and lower rate of reoperation in the TDR group.
Figure A is a lateral radiograph of the lumbar spine showing L5-S1 total disc replacement. Figure B is a lateral radiograph of the lumbar spine showing L5-S1 total disc replacement with anterior dislocation of the polyethylene inlay.
Incorrect Responses:

Question 17

A farmer is seen in the emergency department after falling out of a hay loft onto the barn floor below. He is unable to bear weight. Exploration of a 0.5 cm laceration over the anterior tibia reveals bone. Radiographs reveal oblique displaced midshaft tibial and fibular fractures. Based on these findings, what is the most appropriate antibiotic prophylaxis?

Explanation

DISCUSSION: A farm injury is automatically considered a grade III (Gustillo classification) injury regardless of size, energy, or additional soft-tissue injury due to the likelihood of substantial contamination. Antibiotic recommendations for grade III injuries include a first- or second-generation cephalosporin with an aminoglycoside or fluoroquinolone within 3 hours of injury, with penicillin added for farm injuries.
REFERENCES: Okike K, Bhattacharyya T: Trends in the management of open fractures: A critical analysis. J Bone Joint Surg Am 2006;88:2739-2748.
Holtom PD: Antibiotic prophylaxis: Current recommendations. J Am Acad Orthop Surg 2006:14:S98-S100.

Question 18

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

Explanation

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

Question 19

In articular cartilage, Interleukin 1 (IL-1) increases

Explanation

IL-1 stimulates matrix metalloproteinase that directly degrade cartilage. It also stimulates enzymes such as cyclooxygenase 2 and nitric oxide synthetase, which further cause tissue catabolism and damage. Glucosamine has anabolic effects on proteoglycan synthesis and can also prevent tissue catabolism by preventing an IL-1 beta-induced decrease in proteoglycan synthesis. Transforming growth factor beta has chondroprotective functions and has been shown to increase both collagen and proteoglycan synthesis while inhibiting matrix degradation and cell proliferation. Insulin-like growth factor 1 (IGF1) is produced by articular chondrocytes and increased collagen and proteoglycan synthesis. It has a role in the development of osteoarthritis. Decreased expression of IGF1 and increased binding proteins decrease the availability of the growth factors, accelerating tissue catabolism in arthritic cartilage.

Question 20

The mother of a healthy 8-month-old boy reports that her son refuses to use his left arm. Examination reveals that the arm hangs limp at his side in an adducted and internally rotated position, and the affected shoulder subluxates posteriorly. Passive external rotation measures 15 degrees. Management should consist of

Explanation

DISCUSSION: Injury to the upper trunk of the brachial plexus during birth (Erb’s palsy) occurs in approximately 1 in 3,000 births. In a complete lesion, paralysis of the deltoid, supraspinatus, infraspinatus, teres minor, biceps, and brachioradialis results in the findings described above. Spontaneous recovery may occur for up to 2 years. Passive exercises administered daily by the parents are the initial recommended treatment at this age. If significant contracture results in posterior dislocation, surgical correction may be considered.
REFERENCES: Neer CS: Shoulder Reconstruction. Philadelphia, PA, WB Saunders, 1990,

pp 452-454.
Pearl ML: Arthroscopy release of shoulder contracture secondary to birth palsy: An early report on findings and surgical technique. Arthroscopy 2003;19:577-582.
Pearl ML, Edgerton BW, Kon DS, et al: Comparison of arthroscopic findings with MRI and arthrography in children with GH deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 2003;85:890-898.

Question 21

When comparing arthroscopic and open rotator cuff repairs, which of the following tears shows a decreased recurrent tear rate in the open versus the arthroscopic group? Review Topic

Explanation

As a tool for rotator cuff repair, arthroscopy has afforded surgeons the ability to repair tears without causing potential morbidity to the overlying deltoid. Follow-up studies looking at functional recovery have now shown equivalent or slightly better outcomes with arthroscopic procedures versus standard open procedures. However, small tear size may serve as a better predictor of success with arthroscopic approaches. Imaging studies have shown a higher rate of tear recurrence and/or failure of healing when tears greater than 3 cm in size are repaired arthroscopically versus a standard open approach.

Question 22

When performing an inside-out lateral meniscal repair, capsule exposure is provided by developing the

Explanation

DISCUSSION: Capsular exposure for an inside-out lateral meniscal repair is performed by developing the interval between the iliotibial band and biceps tendon. Posterior retraction of the biceps tendon exposes the lateral head of the gastrocnemius. Posterior retraction of the gastrocnemius provides access to the posterolateral capsule.
REFERENCES: Miller DB Jr: Arthroscopic meniscus repair. Am J Sports Med 1988;16:315-320.
Nawab A, Hester PW, Caborn DN: Arthroscopic meniscus repair, in Miller MD, Cole BJ (eds): Textbook of Arthroscopy. Philadelphia, PA, WB Saunders, 2004, pp 517-537.

Question 23

A 44-year-old woman has had lower extremity dysesthesias, urinary incontinence, and has been unable to walk for the past 2 days. She reports no pain or history of trauma. She notes that 3 weeks ago she missed work for 2 days because of back pain, but it resolved with rest. Examination shows decreased or absent sensation below the knees, no motor function below the knees, and decreased rectal tone. Catheterization results in a postvoid residual of 2,000 mL. Plain radiographs and MRI scans without contrast are shown in Figures 1a through 1d. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has had a clear and sudden onset of a profound neurologic deficit. The radiographic studies suggest a lesion in the conus medullaris that appears to be intradural and intramedullary. MRI, with and without contrast, will best evaluate this mass further. The addition of gadolinium allows further evaluation of vascularity and the extent of the lesion.
REFERENCES: Eichler ME, Dacey RG: Intramedullary spinal cord tumors, in Bridwell KH, Dewald RL (eds): The Textbook of Spine Surgery, ed 2. Philadelphia, PA, Lippincott-Raven, 1997, vol 2, pp 2089-2116.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 81-87.

Question 24

Which of the following substances is least likely to affect the success of bone union after lumbar arthrodesis?

Explanation

DISCUSSION: Much attention has been given to the use of supplemental postoperative analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs), and a significant reduction in narcotic use has been recorded. However, a high failure rate of arthrodesis has been associated with the use of postoperative NSAIDs. Glassman and associates reported 29 cases of pseudarthrosis in 167 patients when ketorolac was used as a postoperative analgesic, whereas only five fusion failures were noted in 121 patients not using ketorolac. Indomethacin and ibuprofen have been shown to adversely affect bone formation in clinical and animal trials. Nicotine has also been shown in a number of studies to decrease the fusion rate. Oxycodone hydrochloride is a synthetic morphine and does not affect the fusion process.
REFERENCES: Glassman SD, Rose SM, Dimar JR, Puno RM, Campbell MJ, Johnson JR: The effect of postoperative nonsteroidal anti-inflammatory drug administration on spinal fusion. Spine 1998;23:834-838.
Deguchi M, Rapoff AJ, Zdeblick TA: Posterolateral fusion for isthmic spondylolisthesis in adults: Analysis of fusion rate and clinical results. J Spinal Disord 1998;11:459-464.
Dimar JR II, Ante WA, Zhang YP, Glassman SD: The effect of nonsteroidal anti-inflammatory drugs on posterior spinal fusions in the rat. Spine 1996;21:1870-1876.

Question 25

Figures 1 through 4 are the CT scans and intraoperative image of a 17-year-old boy who sustained a gunshot wound to his knee. What is the most appropriate definitive surgical management for his articular cartilage defect?

Explanation

The images show a full-thickness cartilage defect with significant bony involvement >4 cm2. Microfracture should be considered for lesions <2 cm2 without an underlying osseous defect. Autologous chondrocyte implantation, although used for lesions between 1 and 10 cm2, should be restricted for defects with minimal (<8 mm depth) bone loss. Osteochondral allograft transfer with the mosaicplasty technique (transfer of multiple plugs) would be well-suited for this large defect with significant osseous involvement. Dejour trochleoplasty is performed for patellar instability to correct trochlear dysplasia and would not be indicated in this case.

Question 26

A 10-year-old child with cerebral palsy undergoes bilateral hamstring lengthening for severe knee flexion contractures, and knee immobilizers are applied postoperatively. Examination at the initial postoperative check 2 hours after surgery reveals that she can dorsiflex her toes on the right foot, but not on the left foot. The physician should now

Explanation

DISCUSSION: Children with cerebral palsy are often difficult to examine. However, this patient clearly has a peroneal nerve deficit, most likely from the acute stretch after the hamstring lengthening. The nerve has the best chance of recovery if it is relaxed by flexing the knee. Once the nerve has recovered, gradual knee extension can be accomplished.
REFERENCES: Aspden RM, Porter RW: Nerve traction during correction of knee flexion deformity: A case report and calculation. J Bone Joint Surg Br 1994;76:471-473.
Heydarian K, Akbarnia BA, Jabalameli M, Tabador K: Posterior capsulotomy for the treatment of severe flexion contractures of the knee. J Pediatr Orthop 1984;4:700-704.

Question 27

A 20-year-old man involved in a motor vehicle accident is brought to the emergency department with a C6-7 unilateral facet dislocation. His neurologic examination reveals a focal left-sided C7 nerve root palsy. He is awake and cooperative with questioning and has no other obvious traumatic injuries. What is the most appropriate treatment at this time? Review Topic

Explanation

In the patient who is neurologically intact or has an incomplete injury from a cervical facet dislocation, a closed reduction with weighted tong traction is appropriate when the patient is awake, alert, and cooperative. Although there is a risk that a cervical facet dislocation could occur with an underlying cervical disk herniation, Vaccaro and associates have shown that closed reduction can be safely carried out in the awake, responsive patient. Closed reduction can be performed in the emergency department with traction with skull tongs or a halo ring. A slow stepwise application of weight is added until a reduction is achieved. Any worsening of the neurologic status of the patient requires immediate termination of the closed reduction and further diagnostic imaging before proceeding with further treatment.

Question 28

Type II collagen in nondiseased adult human articular cartilage has a half-life that is generally

Explanation

DISCUSSION: Type II collagen in articular cartilage is amazingly stable. This is important to know because matrix homeostasis generally is associated with minimal synthesis and degradation of type II collagen. Passive glycation has a consistent rate and occurs over decades. The relative amount of glycation in cartilage with age has been used as a measure of stability. Also, the rate of racemization of aspartic acid from the L to D form occurs spontaneously at a very slow rate. The relative stability of collagen can be estimated by calculating the percentage of D aspartic acid per dry weight of type II collagen.
REFERENCES: Maroudas A, Palla G, Gilav E: Racemization of aspartic acid in human articular cartilage. Connect Tissue Res 1992;28:161-169.
Verzijl N, DeGroot J, Thorpe SR, et al: Effect of collagen turnover on the accumulation of advanced glycation end products. J Biol Chem 2000;275:39027-39031.

Question 29

An 18-year-old football player lands on a flexed knee and ankle after being tackled. Examination reveals increased external rotation and posterior translation and varus at 30° of flexion, which decreases as the knee is flexed to 90°. What is the most likely diagnosis?

Explanation

DISCUSSION: The flexed knee and ankle mechanism of injury can result in a PCL and/or posterolateral corner injury. The examination reveals an isolated injury to the posterolateral corner (arcuate, popliteus, posterolateral capsule). This results in increased posterior translation and external rotation, as well as varus that is most notable at 30° of flexion and decreases as the knee is further flexed to 90°. Combined PCL and posterolateral corner injuries are characterized by increasing instability as the knee is flexed to 90° from 30°, while isolated PCL tears show the greatest degree of instability at 90° of flexion. A rupture of the quadriceps tendon would not affect anterior or posterior stability, whereas an isolated rupture of the lateral collateral ligament, which is a rare injury, is characterized by varus instability at 30° of knee flexion without posterior translation.
REFERENCES: Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.
Veltri DM, Warren RF: Isolated and combined posterior cruciate ligament injuries. J Am Acad Orthop Surg 1993;1:67-75.

Question 30

Figures 23a and 23b show the radiographs of a 75-year-old woman who sustained an injury to her nondominant hand. Initial treatment should consist of

Explanation

DISCUSSION: Definitive treatment decisions for displaced distal radius fractures in the elderly are based on a number of factors related to the fracture pattern and patient demographics. The first step in any treatment algorithm is a closed reduction and splinting with reassessment of alignment parameters. This is an extra-articular fracture with dorsal angulation. Low-demand elderly patients can be treated well with accepted minor malreduction.
REFERENCES: Handoll HH, Madhok R: Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;2:CD000314.
Young CF, Nanu AM, Checketts RG: Seven-year outcome following Colles’ type distal radial fracture: A comparison of two treatment methods. J Hand Surg Br 2003;28:422-426.

Question 31

Figures 45a and 45b show the CT scans of a 41-year-old man who was ejected from a vehicle after a high-speed collision. Examination reveals weak (2/5) toe flexion on the right side, but otherwise he has no voluntary motor function in his lower extremities and no sensation. He has some perianal sensation. He has no other associated injuries and his upper extremities are neurologically intact. Which of the following represents the best treatment option? Review Topic

Explanation

Increasing Age
Intraoperative blood loss
Number of levels fused
All of the above
Age, intraoperative blood loss, and number of spinal levels fused are associated with increased rates of inpatient complication following lumbar decompression and fusion for degenerative spondylolisthesis. Older age correlates with the highest risk for complications.
Lumbar decompression and fusion is well supported in the literature to be effective in the treatment of degenerative spondylolithesis when nonoperative modalities fail. Common complications associated with lumbar decompression and fusion include asymptomatic or symptomatic pseudarthroses (estimated 5-30%), surgical site infection (0.10-2%),and adjacent level degeneration (2-3%). Age, intraoperative blood loss, longer operative times, number of levels fused are associated with increased risk of complication. Smoking is associated with worse outcome after surgery.
Kalanithi et al. reviewed the Nationwide Inpatient Sample adminstrative data on sixty six thousand patients undergoing lumbar laminectomy and fusion. They found the increased age and having 3 or more medical comorbidities was associated with increased risk of complication.
Carreon et al. reviewed cases of ninety eight patients who underwent laminectomy and fusion for lumbar degenerative disease. They found that rates of major and minor complication increased with older age, increased blood loss, longer operative time, number of levels fused.
Figure A is a AP lumbar spine radiograph. Figure B is a lateral lumbar spine radiograph showing degenerative spondylolisthesis at L4-L5. Illustration A shows the postoperative images of the patient treated with an L4-5 fusion with an interbody device.
Incorrect

Question 32

An active 72-year-old woman sustained a mid-diaphyseal right humerus fracture 16 months ago. History reveals that she was first treated with a brace for 7 months. Additional treatment consisted of intramedullary nailing 9 months ago. Recently the rod was removed, and the patient now reports pain and gross motion at the fracture site. Current radiographs are shown in Figures 37a and 37b. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has a well-established nonunion in a very porotic bone. Electrical stimulation has been found effective in treating tibial nonunions, but there is very little data on humeral nonunions, especially chronic well-established ones. Ultrasound stimulation is effective in accelerating fracture healing, but there is little data concerning the treatment of nonunions. Intramedullary nailing with bone graft is an option, but it maybe difficult to obtain a rigid construct in a very porotic bone. An Ilizarov-type external fixator would be an alternative, but there is little clinical data for the humerus and it may be poorly tolerated. A plate and screw construct with bone graft combines rigidity with the biologic advantage of the bone graft. A recent series reported on the use of a plate combined with onlay allograft for recalitrant nonunions. Cement augmentation for screw fixation either in the canal or added to the screw holes may be helpful in select cases.
REFERENCES: Hornicek FJ, Zych GA, Hutson JJ, Malinin TI: Salvage of humeral nonunions with onlay bone plate allograft augmentation. Clin Orthop 2001;386:203-209.
Jupiter JB: The treatment of complex non-unions of the humeral shaft with a combination of surgical techniques. J Bone Joint Surg Am 1990;72:701-707.

Question 33

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

Explanation

DISCUSSION: Excessive internal tibial torsion is a common cause of intoeing in toddlers. In most children, this resolves spontaneously by 3 to 4 years of age. Intoeing in elementary age children is usually the result of excessive femoral anteversion. Studies have shown that active intervention (casting, splinting, and shoe modifications) has no demonstrable effect on the natural history or resolution of tibial torsion. Surgery is rarely indicated in adolescents with severe internal tibial torsion that has not resolved and is resulting in cosmetic and functional problems.
REFERENCES: Canale ST, Beaty JH: Operative Pediatric Orthopaedics. St Louis, MO, Mosby Year Book, 1991, pp 357-385.
Lincoln TL, Suen PW: Common rotational variations in children. J Am Acad Orthop Surg 2003;11:312-320.

Question 34

A surgeon decides to report outcomes for a new surgical procedure that he has performed on 10 patients who have a rare type of arthritis. He provides data on the functional and subjective patient outcomes. This type of study design is best described as a

Explanation

The type of study design in which a series of cases is presented with outcomes (without a control population or comparison group) is known as a case series. This type of study design, although frequently seen in orthopaedic literature, provides the lowest level of evidence. There is no control group and the population is usually poorly defined. This type of study can be helpful as a starting point for further analysis. A randomized trial provides the highest level of evidence in medical research, featuring a comparison group and randomized (and usually blinded) placement of subjects into study groups. In case-control studies, cases are compared to a control group. The control group has not been randomized, but may be a naturally occurring group of subjects who have not had the same exposure or intervention as the case group. A cohort study can be retrospective or prospective and usually looks at a large group of people over time to assess exposures and incidence of disease.

Question 35

The palmar cutaneous branch of the median nerve (PCBMN) originates from the

Explanation

DISCUSSION: The PCBMN originates from the median nerve proper between 3 and 21 cm proximal to the wrist with moderate variation. It virtually always originates from the radial side of the nerve and travels distally with the median nerve, radial to the palmaris longus, and ulnar to the flexor carpi radialis.
REFERENCES: Hobbs RA, Magnussen PA, Tonkin MA: Palmar cutaneous branch of the median nerve. J Hand Surg Am 1990;15:38-43.
Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System: Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy, 1991, vol 8,

p 52.

Question 36

Figure 7 is the MR image of a 43-year-old man who has left shoulder pain with a traumatic rotator cuff tear after a fall. An examination reveals active forward elevation at 120 degrees and positive Yergason and lift-off test results. Arthroscopy reveals that the articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment at this time?

Explanation

DISCUSSION

Video 7 for reference
The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove.
The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer.

Question 37

Autosomal dominant

Explanation

slide 1 slide 2 slide 3
A patient presents with a hard leg mass and pain with activity. The anteroposterior and lateral radiographs are shown in Slide 1 and Slide 2. An axial computed tomography scan is shown in Slide 3. Which of the following tumor suppressor genes is most likely involved:

Question 38

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain. The patient experiences little improvement with activity modification and more physical therapy. An intra-articular corticosteroid injection provides excellent relief, but relief only lasts for 1 month. The player requests further treatment for his hip and is counseled regarding surgical intervention. Hip arthroscopy is performed. Intraoperatively, a capsulolabral separation is observed with an underlying pincer lesion. No articular cartilage injury is seen. Which treatment is most appropriate considering these findings?

Explanation

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has important functions for hip stability and maintenance of the suction seal of the joint.

Question 39

A 45-year-old IV drug abuser has sternoclavicular (SC) joint pain for the past 2 weeks. He is afebrile and physical exam findings include point tenderness and swelling. He most likely has septic arthritis of the sternoclavicular joint. If so, what is the most likely infecting organism?

Explanation

DISCUSSION: Risk factors for sternoclavicular septic arthritis include IV drug abuse, diabetes, and HIV.
According to the reference by Ross et al, Staphylococcus aureus accounts for 49% of infections. SC joint arthritis accounts for 1% of septic arthritis in the general population but 17% in the IV drug abuse population. Symptoms include spontaneous swelling with the appearance of joint subluxation and localized pain. These patients are not uncommonly afebrile.

Question 40

A 26-year-old man has recurrent right knee pain. Figures 9a and 9b show consecutive sagittal T2-weighted MRI scans, and Figure 9c shows a coronal T1-weighted MRI scan. What is the most likely diagnosis?

Explanation

DISCUSSION: A discoid meniscus is a large disk-like meniscus. It is seen in the lateral meniscus in 3% of the population; a discoid medial meniscus is much less common. It can be identified on the coronal view by noting meniscal tissue extending into the tibial spine at the intercondylar notch.
The average width of a normal meniscus is less than 11 mm. A bow-tie appearance should not be seen on more than two consecutive sagittal images because the conventional thickness of the sagittal slices is 3 mm and the interval between two consecutive slices is 1.5 mm. Two sagittal slices will cover a 9-mm thickness. A discoid meniscus can be diagnosed on the sagittal views by noting a bow-tie appearance on more than two consecutive images.
REFERENCES: Helms CA: MR image of the knee, in Fundamentals of Skeletal Radiology, ed 2. Philadelphia, PA, WB Saunders, 1995, pp 172-191.
Mink JH, Deutsch AL: The knee, in MRI of the Musculoskeletal System, ed 1. New York, NY, Raven Press, 1990, pp 251-387.

Question 41

Which of the following cohorts of patients is at highest risk of a future anterior cruciate ligament (ACL) tear? Review Topic

Explanation

Hewett and associates reported in a study of 205 female athletes that female athletes, with increased dynamic valgus and high abduction loads, were at increased risk of ACL injury. The same investigators in an earlier study of 81 high school basketball players reported that female athletes landed with greater total valgus knee motion and a greater maximum valgus knee angle than male athletes. Female athletes were also found to have significant differences between their dominant and nondominant side in maximum valgus knee angle. Lephart and associates reported that in single-leg landing and forward hop tasks that female athletes had significantly less knee flexion and lower leg internal rotation maximum angular displacement, and less knee flexion time to maximum angular displacement than males. Females with an adduction moment during landing should have a lower incidence of ACL tears. Males in general have a lower incidence of ACL tears.

Question 42

After surgery, this patient continues to experience pain and swelling of the knee with recurrent effusions. He returns to the office with continued pain 2 years after surgery. He describes instability, particularly when descending stairs. Upon examination, there is range of motion from 0 to 120 degrees with no extensor lag. The knee is stable to varus and valgus stress in extension, but there is flexion instability in both the anterior-posterior direction and in the varus-valgus direction. Bracing leads to a slight decrease in symptoms but is not well tolerated. Isokinetic testing demonstrates decreased knee extension velocity at mid push. Radiographs demonstrate well-aligned and fixed knee implants. An infection workup is negative. What is the most appropriate surgical intervention at this time?

Explanation

DISCUSSION

Video 99 for reference
This patient has valgus knee alignment, and, after undergoing appropriate bone resections and soft-tissue balancing, has demonstrated a tight PCL on trial reduction as evidenced by lift-off of the trial insert as described by Scott and Chmell. The appropriate maneuver is PCL recession with partial release of tight (usually anterolateral) PCL fibers. However, for this patient, instability resulted in increased anterior translation. At this stage, the options are to convert to either a deeper-dish insert with increased sagittal conformity or a posterior stabilized insert. The only appropriate choice among the responses is use of an insert with increased sagittal conformity to prevent excessive anterior translation. Increasing the polyethylene could improve stability in flexion, but, considering there is good stability in extension, this likely would lead to an inability to achieve full extension. The patient’s valgus deformity, flexion contracture, correction with release of the iliotibial band, and posterolateral capsule predispose him to increased risk for peroneal nerve palsy. His symptoms at follow-up suggest knee flexion
instability with pain, swelling, and difficulty descending stairs. Considering his history, an incompetent PCL must be considered. Revision of the knee to a posterior stabilized or nonlinked constrained condylar implant depending on the condition of the ligaments likely is needed to address his symptoms. The difference in extension vs flexion stability makes polyethylene exchange a poor option. There is no reason to believe a constrained rotating hinge design is necessary. Repeat use of a PCL-retaining insert is not recommended.

Question 43

What structure is most at risk for injury from a retractor against the tracheoesophageal junction during an anterior approach to the cervical spine?

Explanation

DISCUSSION: Although any of these structures can be injured by pressure from the medial blade of a self-retaining retractor, the recurrent laryngeal nerve runs cephalad in the interval between the esophagus and trachea and is vulnerable to pressure if caught between the retractor and an inflated endotracheal tube balloon.
REFERENCES: Ebraheim NA, Lu J, Skie M, et al: Vulnerability of the recurrent laryngeal nerve in the anterior approach to the lower cervical spine. Spine 1997;22:2664-2667.
Kilburg C, Sullivan HG, Mathiason MA: Effect of approach side during anterior cervical discectomy and fusion on the incidence of recurrent laryngeal nerve injury. J Neurosurg Spine 2006;4:273-277.

Question 44

A 23-year-old college basketball player reports persistent lateral ankle pain after sustaining an inversion injury 6 months ago. Examination reveals pain over the anterolateral ankle, absence of swelling, and no clinical instability. Management consisting of vigorous physical therapy fails to provide relief, and a intra-articular corticosteroid injection provides only temporary relief. Radiographs obtained at the time of injury and subsequent AP and varus stress views are normal. A recent MRI scan fails to show any abnormalities. Management should now include

Explanation

DISCUSSION: Because the patient has failed to respond to appropriate nonsurgical management and imaging studies are normal, the use of arthroscopy not only aids in the diagnosis of chronic ankle pain, but is also helpful in its treatment. In patients with this condition, typical findings include synovitis in the lateral gutter and fibrosis along the talofibular articulation; syndesmosis chondromalacia of the talus and ankle also may be found. In patients with anterior soft-tissue impingement, approximately 84% who have a poor response to nonsurgical management will have a good to excellent response after arthroscopic synovectomy and debridement.
REFERENCES: Ferkel RD, Fasulo GJ: Arthroscopic treatment of ankle injuries. Orthop Clin North Am 1994;25:17-32.
Ferkel RD, Karzel RP, Del Pizzo W, Friedman MJ, Fischer SP: Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med 1991;19:440-446.

Question 45

Figures 37a and 37b show radiographs of a 24-year-old man who has a humeral bone lesion that was found during a screening chest radiograph. He denies any symptoms despite leading a very active lifestyle. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs reveal a geographic, diaphyseal lesion with very subtle cortical expansion, cortical thinning, relatively sharp demarcation, and angular rather than rounded borders, suggesting a fibrous bone lesion. This lesion demonstrates the classic ground glass appearance of fibrous dysplasia. Ewing’s sarcoma, metastases, and aneurysmal bone cyst all typically have a more aggressive appearance.
REFERENCES: Parsons TW: Benign bone tumors, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1027-1035.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 69-75.

Question 46

A 32-year-old powerlifter who was performing a dead lift 3 days ago noted a sharp pain in the front of his dominant right arm just after beginning to lower the weight. He now reports pain in the anterior aspect of the arm that worsens when he opens a door. Examination reveals moderate ecchymosis and swelling of the forearm and tenderness in the antecubital fossa. The MRI scans are shown in Figures 15a and 15b. If the injury is left unrepaired, the greatest functional deficit will most likely be the loss of

Explanation

DISCUSSION: A complete tear of the distal biceps brachii most often occurs from a large, rapid eccentric elbow extension load. A pop or tearing sensation usually occurs, and a palpable defect in the antecubital fossa is often present on examination. The treatment of choice is a direct primary repair by a two-incision technique. If left unrepaired, the most disabling consequence is the loss of forearm supination strength. It is unlikely that significant elbow or forearm motion will be lost if the rupture is left unrepaired and early motion exercises are initiated. Elbow flexion strength tends to return with time, but the loss of forearm supination strength remains problematic.
REFERENCES: D’Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. Am J Sports Med 1993;21:114-119.
Agins HJ, Chess JL, Hoekstra DV, Teitge RA: Rupture of the distal insertion of the biceps brachii tendon. Clin Orthop 1988;234:34-38.

Question 47

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

Explanation

DISCUSSION: The patient has sustained an iatrogenic injury to the lateral ulnar collateral ligament. This injury has been reported after lateral approaches to the elbow. The orbicular, annular, and lateral radial collateral ligaments have a much less important role in lateral elbow stability. The anterior band of the ulnar collateral ligament is on the medial side of the elbow and is important for valgus stability.
REFERENCES: O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.
O’Driscoll SW, Morrey BF: Surgical reconstruction of the lateral collateral ligament, in Morrey BF (ed): The Elbow. Philadelphia, PA, Lippincott, Williams and Wilkins, 1994, pp 169-182.

Question 48

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 49

Figures 2a and 2b show the radiographs of a 72-year-old man with aseptic loosening of the tibial component of his total knee arthroplasty. Optimal management should include

Explanation

DISCUSSION: The radiographs show massive subsidence of the lateral side of the tibia with severe tibial bone loss and a fractured proximal fibula. Reconstruction should consist of a large metal or bony lateral tibial augmentation, and a stem long enough to bypass the defect is required. The femoral and tibial components are articulating without any remaining polyethylene medially; therefore, the femoral component is damaged and needs revision.

The insertions of the lateral ligaments are absent, thereby rendering the lateral side of the knee predictably unstable. Also, the large valgus deformity compromises the medial collateral ligament. The posterior cruciate ligament is also likely to be deficient with this much tibial bone destruction. The patient requires a posterior stabilized femoral component at the minimum, and possibly a constrained femoral component. Retention of the femoral component, even though it may be well-fixed, jeopardizes the outcome.
REFERENCES: Lotke PA, Garino JP: Revision Total Knee Arthroplasty. New York, NY, Lippincott-Raven, 1999, pp 137-250.
Insall JN, Windsor RE, Scott WN, et al: (eds): Surgery of the Knee, ed 2. New York, NY, Churchill Livingstone, 1993, pp 935-957.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,

pp 339-365.

Question 50

A 6-year-old boy is being treated for acute hematogeneous osteomyelitis of the distal femur with intravenous antibiotics. The best method to determine the success or failure of initial treatment is by serial evaluations of which of the following studies?

Explanation

DISCUSSION: Successful antibiotic treatment of acute osteomyelitis should lead to a rapid decline in the CRP. The CRP is the most sensitive study to follow the treatment of osteomyelitis. The CRP should decline after 48 to 72 hours of appropriate treatment. CBC and ESR are helpful in initial evaluation and diagnosis, but remain abnormal in the early phase of treatment regardless of response. Imaging studies are useful for surgical planning or secondarily if the CRP remains elevated.
REFERENCES: Unkila-Kallio L. Kallio MJ, Eskola J, et al: Serum C-reactive protein, erythrocyte sedimentation rate, and white blood cell count in acute hematogenous osteomyelitis of children. Pediatrics 1994;93:59-62.
Herring JA(ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia. PA. WB Saunders, 2008, pp 2090-2100.
AL-Madena Copy

Question 51

Which of the following physical examination findings is most likely present in the condition producing the MRI findings shown in Figure 92?

Explanation

DISCUSSION: The T2-weighted sagittal MRI scan shows the classic “bone bruise” pattern seen with an anterior cruciate ligament (ACL) tear. These lesions are thought to represent subcortical trabecular hemorrhages and are manifested as an increase in signal intensity on T2-weighted images and diminished signal intensity on Trweighted images. They are classically located in the mid-portion of the lateral femoral condyle and posterior aspect of the lateral tibial plateau. This is due to the fact that an ACL tear typically is the result of a valgus-extemal rotation of the femur on the fixed tibia. This places most of the weight-bearing stress on the lateral femoral condyle, which rotates laterally and impacts the posterior lip of the lateral tibial plateau. This may result in an impaction fracture if the force is great enough, but more frequently causes merely a microfracture of the involved subcortical trabeculae.
REFERENCES: Vellet AP, Marks PH, Fowler PJ, et al: Occult posttraumatic osteochondral lesions of the knee: Prevalence, classification, and short-term sequelae evaluated with MR imaging. Radiology 1991;178:271-276.
Cone R: Imaging sports-related injuries of the knee, in DeLee J, Drez D, Miller M (eds): DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 2, pp 1595-1652.

Question 52

When the data are normally distributed, what statistical test is best used to compare means of three or more independent groups?

Explanation

Analysis of variance (ANOVA) is used to compare means of three or more independent groups with continuous variables that are normally distributed (eg, age, weight, height, etc). Kaplan-Meier analysis is used to analyze survivorship of subjects or products in an outcome study. Chi-square test is used to compare proportions for categorical variables. Meta-analysis is a systematic review method to analyze combined results of several independent studies, usually randomized clinical trials. Log rank is a statistical test to compare survivorship.

Question 53

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

Explanation

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

Question 54

Figure 1 is the MR image of a 55-year-old man who sustained an acute traumatic injury to his right shoulder with loss of active range of motion. He was initially evaluated by his primary care physician and treated with physical therapy without success. He was referred to an orthopaedist for surgical consultation 8 weeks after sustaining the injury. The orthopaedic surgeon performs a successful arthroscopic repair but notes poor tendon quality at the repair site. The treating surgeon keeps the patient in a sling full time for 6 weeks without formal therapy. One year after surgery, in comparison to early therapy, this rehabilitation program will likely result in

Explanation

Stemless shoulder arthroplasty prostheses have recently been suggested as an alternative to traditional stemmed replacement. Advantages of the stemless surgical technique would include

A. better glenoid exposure than with stemmed prostheses.

B. reliable use in four-part proximal humerus fracture reconstruction.

C. use in proximal humeral malunion without the need for an osteotomy. D. improved long-term survivorship profile.

Question 55

What is the primary reason for including the ilium in the distal fixation of long instrumentation constructs in adult scoliosis?

Explanation

DISCUSSION: Studies have shown that when compared with fixation to the sacrum alone, the success rate of fusion across the lumbosacral junction increases when both the sacrum and ilium are included in the posterolateral construct. Curve correction, coronal balance, and pelvic balance are all attended to within the thoracolumbar spine and are not directly related to the pelvic fixation. Fretting and corrosion are a byproduct of metal-to-metal connections.
REFERENCES: Islam NC, Wood KB, Transfeldt EE, et al: Extension of fusions to the pelvis in idiopathic scoliosis. Spine 2001;26:166-173.
Emami A, Deviren V, Berven S, et al: Outcome and complications of long fusions to the sacrum in adult spine deformity: Luque-Galveston, combined iliac and sacral screws, and sacral fixation. Spine 2002;27:776-786.

Question 56

A 58-year-old woman with rheumatoid arthritis and a severe hindfoot valgus deformity now reports recurrent lateral ankle pain. Examination reveals pain over the fibula and sinus tarsi, with a valgus hindfoot that is passively correctable. Despite the use of an ankle-foot orthosis, this is the second time this problem has occurred. Radiographs and a clinical photograph are shown in Figures 28a through 28c. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: Excessive hindfoot valgus can lead to abutment between the calcaneus and fibula. This valgus force can lead to a stress fracture of the distal fibula. Surgery may be required if an insufficiency fracture recurs despite orthotic management. Of the choices listed, a subtalar arthrodesis is most likely to achieve rebalancing of the foot at the level of the deformity.
REFERENCES: Stephens HM, Walling AK, Solmen JD, Tankson CJ: Subtalar repositional arthrodesis for adult acquired flatfoot. Clin Orthop 1999;365:69-73
Easley ME, Trnka HJ, Schon LC, Myerson MS: Isolated subtalar arthrodesis. J Bone Joint Surg Am 2000;82:613-624.

Question 57

A 24-year-old man sustains the injury shown in Figures 19a through 19e in a paragliding accident. He is neurologically intact. He also sustained fractures of his left femur and right distal radius. Which of the following represents the best option for management of the spinal injury?

Explanation

DISCUSSION: The injury pattern is that of a burst fracture at L1 contiguous with a compression fracture at T12. There is associated kyphosis and slight spondylolisthesis of T12 on L1. Treatment of this type of burst fracture in neurologically intact patients is somewhat controversial, with at least one study demonstrating equal long-term results comparing nonsurgical treatment to surgical treatment. In this study, however, body casts were used initially in the nonsurgical group. Moreover, because this patient has multiple fractures, spinal fracture stabilization should be considered to facilitate early mobilization. Surgical stabilization and fusion via a posterior approach is the best treatment option in this patient. Anterior decompression is not necessary since the patient is neurologically intact.
REFERENCES: McLain RF, Benson DR: Urgent surgical stabilization of spinal fractures in polytrauma patients. Spine 1999;24:1646-1654.
Wood K, Butterman G, Mehbod A, et al: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: A prospective, randomized study.

J Bone Joint Surg Am 2003;85:773-781.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 58

Which of the following antibiotics is contraindicated in children?

Explanation

DISCUSSION: The tetracycline family of medications can stain teeth and bone in skeletally immature patients and as a result should be avoided in those patients. The remaining antibiotics have no known specific contraindication to use in children.
REFERENCE: Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 433-457.

Question 59

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

Explanation

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

Question 60

The use of nonsteroidal anti-inflammatory drugs following femoral nailing has been associated with which of the following?

Explanation

DISCUSSION: The risk of femoral nonunion after intramedullary nailing is significantly increased when NSAIDs are administered post-operatively.
Giannoudis et al assessed factors which could affect union in 32 patients with nonunion of a fracture of the diaphysis of the femur and 67 matched patients whose fracture had united. They found that there was no relationship between the rate of union and the type of implant, mode of locking, reaming, distraction or smoking. They also concluded that there was a marked association between nonunion and the use of NSAIDs after injury and delayed healing was noted in patients who took NSAIDs and whose fractures had united.
Burd et al performed a study to determine if patients with an acetabular fracture, who received indomethacin for prophylaxis against HO, were at risk of delayed healing or nonunion of any associated fractures of long bones. The study group consisted of 112 patients who had sustained at least one concomitant fracture of a long bone; of which 36 needed no prophylaxis, 38 received focal radiation and 38 received indomethacin. When comparing patients who received indomethacin with those who did not, a significant difference was noted in the rate of long bone nonunion (26% vs 7%).

Question 61

An 18-year-old boy has had pain in the right knee for the past 6 months. Examination reveals some fullness behind the knee but no significant palpable soft-tissue mass. There is no effusion, and he has full knee range of motion. The remainder of the examination is unremarkable. A radiograph and MRI scans are shown in Figures 33a through 33c, and biopsy specimens are shown in Figures 33d and 33e. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has parosteal osteosarcoma. The posterior aspect of the distal femur is the typical location for this variant of osteogenic sarcoma. The imaging studies indicate a surface lesion with no involvement of the adjacent intramedullary canal. The histologic appearance is that of a low-grade fibroblastic osteosarcoma, consisting of relatively mature bone and a bland fibroblastic stroma lacking cytologic atypia and mitotic activity. A cartilaginous component is also frequently seen. Classic osteosarcoma typically has a more aggressive radiologic and histologic appearance. Sessile osteochondromas, while common behind the knee, have a presence of hematopoietic marrow and fat. The cartilage found in the associated cartilaginous cap is oriented. Chondrosarcomas are more typical in an older age group and have a histologic pattern consisting of malignant chondroid.
REFERENCES: Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 20-21.
Unni KK, Dahlin DC, Beabout JW, Ivins JC: Parosteal osteogenic sarcoma. Cancer 1976;37:2466-2475.

Question 62

Which of the following substances makes up the majority by weight of the extracellular matrix for articular cartilage?

Explanation

The extracellular matrix consists of water, proteoglycans, and collagen. Water makes up the majority (approximately 65% to 80%) of wet weight; 95% of the collage is type II with much smaller amounts of other collagens, including types IV, VI, IX, X, and XI. The exact functions of these other collagens are unknown, but they are believed to be important in matrix attachment and stabilization of the diameter of collagen fibrils.

Question 63

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

Explanation

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

Question 64

A 16-year-old boy who is a competitive basketball player (Figure 43)

Explanation

Question 65

Explanation

Rheumatoid synovitis in the cervical spine causes pathologic changes in the ligaments with distention and rupture, articular cartilage destruction, and, in bone osteoporosis, cyst formation, and erosion. The specific deformity caused is dependent on the structure destroyed. The inflammatory cells involved in rheumatoid inflammation have been identified in biopsy specimens at the atlantoaxial junction and reflect the same cell types as found peripherally. Atlantoaxial subluxation is ascribed to erosive synovitis in the atlantoaxial, atlantoodontoid, and atlantooccipital joints as well as the synovium-lined bursa between the odontoid and the transverse ligament. In the figure (fig 10-1) contained in the text there are flexion and extension views depicting a widening of the space between the odontoid and the posterior aspect of the anterior ring. Atlantoaxial impaction (upward translocation of the odontoid, pseudobasilar invagination, cranial settling, vertical subluxation) describes the settling of the skull on the atlas and the atlas on the axis, resulting from erosion and bone loss in the occipitoatlantal and atlantoaxial joints. In the figure (10-2) Atlantoaxial impaction is seen on a lateral x-ray. The dens is noted above the clivus and is circumferentially eroded by synovitis. The ring of the atlas lies low on the body of C2.
In the context of viewing a lateral cervical spine to evaluate cranial setting, multiple lines can be used to assess anatomic relationships (i.e. McRae’s Chamberlin’s, or McGregor’s) McRae’s and Chamberlin’s use the foramen magnum as one land mark. Commonly, however, the margins of the foramen magnum are difficult to precisely identify. McGregor’s line connects the posterior margin of the hard palate to the most caudal point of the occiput and is easier to use. The tip of the odontoid should not project more than 4.5 mm above this line.
Anterior subluxation of more than 10-12 mm implies destruction of the entire ligamentous complex.
An atlantoaxial distance greater than 3.5mm is considered abnormal in an adult. The subaxial cervical spine is affected through involvement of the facets, interspinous ligaments, and intervertebral discs (spondylodiscitis). The initial site of destruction has been postulated to be through synovitis of the neurocentral joints with erosion of the adjacent disc and bone causing subluxation, or through primary facetal arthritis and ligamentous laxity causing secondary chronic discovertebraltrauma and destructive hypermobile segmentsis associated with disc destruction and toward the C2-C3 and C3-C4 segments, typically lack osteophytes, and often are at multiple levels, giving a stepladder appearance.

Question 66

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

Explanation

DISCUSSION: Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult.
REFERENCES: Gerber C, Lambert SM: Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376-382.
Spencer EE Jr, Brems JJ: A simple technique for management of locked posterior shoulder dislocations: Report of two cases. J Shoulder Elbow Surg 2005;14:650-652.
Sperling JW, Pring M, Antuna SA, et al: Shoulder arthroplasty for locked posterior dislocation of the shoulder. J Shoulder Elbow Surg 2004;13:522-527.
Hawkins RJ, Neer CS II, Pianta RM, et al: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
McLaughlin HL: Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;34:584-590.

Question 67

-Which gene correlates with severity of disease in spinal muscular atrophy (SMA)?

Explanation

produce higher levels of SMN protein.
The other choices are not associated with spinal muscular atrophy.Defects in PMP22 are the cause of 70% to 80% of cases of Charcot-Marie-Tooth disease. Mutations in the dystrophin gene cause Duchenne muscular dystrophy.

Question 68

A 61-year-old right-hand-dominant woman falls down the stairs, resulting in a left anteroinferior dislocation and noncomminuted greater tuberosity fracture. A closed glenohumeral reduction with intravenous sedation is performed in the emergency department. After reduction, the greater tuberosity fragment remains displaced by 2 mm. What is the most appropriate treatment?

Explanation

Greater tuberosity fractures and rotator cuff tears associated with a traumatic dislocation are more commonly seen in women >60 years. Greater tuberosity fractures that are displaced <5 mm in the general population and
<3 mm in laborers and professional athletes can be treated successfully without surgery. Early passive range
of motion is important to avoid stiffness.

Question 69

This condition is most prevalent in people of which ancestry?

Explanation

DISCUSSION
The radiograph of the lateral lumbosacral spine reveals an isthmic spondylolysis with a Meyerding grade 1 spondylolisthesis. The incidence of spondylolysis in the general population is around 5%, and grade 1 or 2 slips are present in the majority of children with a spondylolysis. Many cases of spondylolysis are painless and discovered incidentally, but, when painful, hyperextension of the lumbar spine may stress the area of the pars defect and exacerbate a patient’s symptoms. A diagnosis can usually be determined with a lateral radiograph of the lumbar spine. Although oblique lumbar radiographs are frequently ordered, several studies have shown that they do not increase diagnostic or prognostic accuracy. Progression of an isthmic spondylolysis, with or without a grade 1 or 2 listhesis, to a serious slip that might
necessitate surgical intervention is rare and occurs in fewer than 5% of patients. Chance for progression diminishes with age, with patients at highest risk prior to the adolescent growth spurt. Spondylolysis may have a genetic component; an increased prevalence has been found in some families and in some ethnic groups, especially among the Native American population.

Question 70

Figures 20a and 20b show the sagittal and coronal T1-weighted MRI scans of a patient’s left knee. Abnormal findings include

Explanation

DISCUSSION: The MRI scans show meniscal tissue extending across the entire lateral compartment, revealing a discoid lateral meniscus. The increased signal within the lateral meniscal tissue indicates a tear. Discoid lateral menisci are congenital variants that often present with mechanical symptoms in adolescents. The other structures in the knee are normal.
REFERENCES: Ahn JH, Shim JS, Hwang CH, et al: Discoid lateral meniscus in children: Clinical manifestations and morphology. J Pediatr Orthop 2001;21:812-816.
Andrish JT: Meniscal injuries in children and adolescents: Diagnosis and management.

J Am Acad Orthop Surg 1996;4:231-237.

Question 71

A 17-year-old pitcher reports pain over the medial aspect of the elbow that occurs during the acceleration phase of throwing, and it prevents him from throwing at the velocity needed to be competitive. What structure is most likely injured in this patient? Review Topic

Explanation

The anterior bundle of the ulnar collateral ligament of the elbow is the primary constraint to valgus force of the elbow. In pitchers and in overhead athletes, injury to this portion of the ligament results in valgus instability. Reconstruction of the anterior band of the ulnar collateral ligament is necessary in many elite athletic throwers to allow them to return to this competitive activity.

Question 72

Figures 42a and 42b shows the radiographs of a 20-year-old man who sustained a hyperextension injury to his little finger. Multiple attempts at closed reduction have been unsuccessful. Management should now consist of

Explanation

DISCUSSION: The radiographs show a complex dislocation of the little finger metacarpophalangeal joint. This is characterized by obvious dislocation on the AP and lateral views and a type of bayonet apposition best visualized on the lateral view. Irreducibility of this injury is caused by displacement of the volar plate that has been traumatically avulsed from its origin on the metacarpal, with subsequent displacement into the metacarpophalangeal joint. This abnormal position of the volar plate causes irreducibility that can be corrected only by open reduction. This can be effected either by dorsal or palmar approaches.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,

pp 711-771.
Becton JL, Christian JD Jr, Goodwin HN, Jackson JG III: A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg Am 1975;57:698-700.
Green DP, Terry GC: Complex dislocation of the metacarpophalangeal joint: Correlative pathological anatomy. J Bone Joint Surg Am 1973;55:1480-1486.

Question 73

Figures 1 and 2 show the radiographs obtained from a 68-year-old morbidly obese man who underwent left total hip replacement 7 years ago and did well, with no symptoms prior to the current presentation. He recently rose from a seated position and felt a pop in the hip, with immediate pain and inability to bear weight. Any pressure on the left foot now produces a painful, grinding sensation with loss of left hip stability. What is the best next step?

Explanation

DISCUSSION:
The modular femoral stem has fractured. Changing the liner to a constrained design is not warranted at this time based on the information provided. Revision of the acetabular implant is appropriate because of the potential for damage to the existing cup from metal debris and femoral implant contact and to convert from a metal-on-metal articulation. Nonsurgical management would not provide pain relief or improvement; revision of the total hip arthroplasty is recommended. The implant failed in a short time, and retention of the femoral stem is not recommended because of the concern for failure with only a neck exchange. A dual-mobility bearing may be a good option if the surgeon plans to retain the acetabular component. Extended trochanteric osteotomy is a useful technique for the removal of a well-fixed femoral implant. In this patient, femoral stem removal without
osteotomy would be difficult due to the fracture of the implant’s femoral neck and the
inability to gain purchase for extraction.

Question 74

Figure 67 shows the AP radiograph of both knees of a 26-year-old woman. A review of the patient’s medical record will most likely reveal a history of

Explanation

Avascular necrosis of the knee is associated with the use of corticosteroids or alcohol 90% of the time. Radiographically evident lesions progress until the necrotic cancellous bone collapses away from the subchondral plate, resulting in the classic crescent sign; earliest sign of mechanical failure of the condyles. Generally seen in a younger age group (less than 50 years old). Of patients with corticosteroid induced AVN of the knee; 81% have systemic lupus erythematosus, 9.5% inflammatory bowel disease, and 9.5% polymyositis.

Question 75

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

Explanation

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

Question 76

A 34-year-old man sustains an extra-articular fracture of the proximal phalanx of his right index finger in a fall. Examination reveals that the fracture is closed and oblique in orientation. Closed reduction and splinting fail to maintain the reduction. Management should now consist of

Explanation

DISCUSSION: The patient has an unstable oblique fracture of the proximal phalanx that is easily reducible but unstable; therefore, the treatment of choice is closed reduction and percutaneous pin fixation, followed by casting. Closed reduction and percutaneous pin fixation offers a better functional result than open reduction and plate fixation. Repeat closed reduction and buddy taping is inadequate because of the inherently unstable fracture pattern. Buddy taping will allow the dislocation to recur. The other options represent more aggressive surgical techniques than are necessary to treat this fracture.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,

pp 711-771.
Green DP, Anderson JR: Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am 1973;55:1651-1653.

Question 77

Figure 31 is the sagittal MR image of a 30-year-old man with a clear-cell sarcoma of the foot. There is no evidence of disease elsewhere after standard staging of a soft-tissue sarcoma.

Explanation

DISCUSSION
For patients with rapidly enlarging painless masses, particularly those that are either large or deep, the diagnosis of a soft-tissue sarcoma should be entertained. Masses exceeding 5 cm in largest dimension that are subfascial and heterogenous on MRI are concerning. MRI with and without contrast is the preferred imaging modality for evaluation of soft-tissue sarcomas because it can delineate location of the lesion, involvement of neurovascular structures, intra-articular involvement, and underlying signal alteration in the osseous structures. Most patients can relate the onset of their symptoms to a traumatic event, and the interpretation of an MRI may include a hematoma. Ultrasound is more commonly used to confirm the clinical impression of a cyst and to distinguish cystic from solid masses.
A core needle biopsy can easily be performed in an outpatient setting or with image guidance to aid in the diagnosis. Core needle biopsies preserve the architectural relationship of cells, which is important in the diagnosis of mesenchymal lesions. A core needle biopsy is appropriate for soft-tissue lesions and osseous lesions and should be performed in a multidisciplinary setting with a surgeon performing the resection so unnecessary compartmental contamination is not introduced into the needle tract.
A fine-needle aspiration allows cytologic but not histologic analysis and generally is not favored for the diagnosis of a sarcoma. If an open biopsy is performed, the incision must be oriented in line with the long axis of the extremity to minimize contamination of surrounding structures. Meticulous hemostasis and closure of the tumor pseudocapsule must be achieved to minimize local tissue contamination. An open biopsy is commonly used if an initial needle biopsy is nondiagnostic. Transverse biopsy incisions should not be used.
Presurgical radiation for sarcomas is advantageous to decrease the field of radiation and overall radiation dose, but a significant postsurgical wound-healing complication rate (up to 35%) is associated with presurgical radiation therapy.
Staging of sarcomas is important to help predict prognosis. Not all sarcomas are reliably positive on a PET scan, so the preferred staging studies are CT scan of the chest and whole-body bone scan. Hematogenous spread of sarcomas is the most common route of metastatic disease, which speaks to the value of chest CT scans. Clear-cell sarcomas (in addition to synovial sarcoma, angiosarcoma, epithelioid sarcoma, and rhabdomyosarcoma) tend to involve lymphatic nodal metastatic disease, so sentinel node biopsy is considered when assessing these tumors. Evidence supports efficacy of sentinel node biopsy for clear-cell sarcomas in particular.
RECOMMENDED READINGS
Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, eds. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer; 2010.
Arbeit JM, Hilaris BS, Brennan MF. Wound complications in the multimodality treatment of extremity and superficial truncal sarcomas. J Clin Oncol. 1987 Mar;5(3):480-8.View Abstract at PubMed
Luce EA. The irradiated wound. Surg Clin North Am. 1984 Aug;64(4):821-9. PubMed PMID: 6591499. View Abstract at PubMed
Cheng EY, Dusenbery KE, Winters MR, Thompson RC. Soft tissue sarcomas: preoperative versus postoperative radiotherapy. J Surg Oncol. 1996 Feb;61(2):90-9.View Abstract at PubMed
Mankin HJ, Lange TA, Spanier SS. The hazards of biopsy in patients with malignant primary bone and soft-tissue tumors. J Bone Joint Surg Am. 1982 Oct;64(8):1121-7. View Abstract at PubMed
Singer S, Nielsen T, Antonescu CR. Molecular biology of soft tissue sarcoma. In: DeVita VT Jr, Lawrence TS, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1522-1532.
Singer S, Maki RG, O'Sullivan B. Soft tissue sarcoma. In: DeVita VT Jr, Lawrence TS, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1533-1577.
Malawer MM, Helman LJ, O'Sullivan B. Sarcomas of bone. In: DeVita VT Jr, Lawrence TS, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1578-1609.
O'Sullivan B, Davis AM, Turcotte R, Bell R, Catton C, Chabot P, Wunder J, Kandel R, Goddard K, Sadura A, Pater J, Zee B. Preoperative versus postoperative radiotherapy in soft-tissue sarcoma of the limbs: a randomised trial. Lancet. 2002 Jun 29;359(9325):2235-41. View Abstract at PubMed
Andreou D, Boldt H, Werner M, Hamann C, Pink D, Tunn PU. Sentinel node biopsy in soft tissue sarcoma subtypes with a high propensity for regional lymphatic spread--results of a large prospective trial. Ann Oncol. 2013 May;24(5):1400-5. doi: 10.1093/annonc/mds650. Epub 2013 Jan 31. PubMed PMID: 23372051. View Abstract at PubMed

Question 78

Total hip arthroplasty in a patient with a long-standing hip fusion on the contralateral side is most likely to result in

Explanation

DISCUSSION: Contralateral total hip arthroplasty in patients with hip fusions results in a 40% higher rate of mechanical failure and loosening. During gait, motion of the contralateral hip is increased and more time is spent bearing weight on that hip. In patients with hip fusions, gait efficiency is only 53%, with a greater rate of oxygen consumption.
REFERENCES: Garvin KL, Pellicci PM, Windsor RE, et al: Contralateral total hip arthroplasty or ipsilateral total hip arthroplasty in patients who have long-standing fusion of the hip. J Bone Joint Surg Am 1989;71:1355-1362.
Gore DR, Murray MP, et al: Walking patterns of men with unilateral surgical hip fusion. J Bone Joint Surg Am 1975;57:759-765.
Romness DW, Morrey BF: Total knee arthroplasty in patients with prior ipsilateral hip fusion. J Arthroplasty 1992;7:63-70.

Question 79

A patient with Pott's disease, tuberculosis of the spine, is more likely to have which of the following early findings? Review Topic

Explanation

Tuberculosis of the spine typically has an indolent presentation. Unlike pyogenic infections of the spine, the disk space is usually preserved. Most commonly, the thoracic and lumbar spine are affected. Laboratory studies may be nonspecific. Delayed presentation usually results in neurologic compromise and a kyphotic deformity. Treatment includes a multidrug regimen. Surgery is indicated for deformity correction or failure of medical treatment.

Question 80

Lumbar disk replacement has been shown to offer which of the following results?

Explanation

DISCUSSION: There is no clear evidence that disk replacement results in pain relief that is superior to fusion. Pain relief appears to be equivalent with these two procedures. No study has clearly demonstrated that normal segmental motion has been consistently restored. Preexisting facet arthropathy is considered to be a contraindication to disk replacement. Comparative long-term data demonstrating a reduced incidence of adjacent segment disease compared to fusion are not yet available.
REFERENCES: Geisler FH, Blumenthal SL, Guyer RD, et al: Neurological complications of lumbar artificial disc replacement and comparison of clinical results with those related to lumbar arthrodesis in the literature. J Neurosurg Spine 2004;1:143-154.
Tropiano P, Huang RC, Girardi FP, et al: Lumbar total disc replacement: Seven to eleven-year follow-up. J Bone Joint Surg Am 2005;87:490-496.

Question 81

An 11-year-old female gymnast has had gradually increasing right wrist pain for the past 6 months. Examination reveals normal range of motion and strength. Moderate tenderness is present over the distal radius. AP radiographs will most likely show

Explanation

DISCUSSION: Distal radial physeal stress syndrome has been reported in up to 25% of nonelite gymnasts showing premature closure of the distal radial physis and distal ulnar overgrowth, producing positive ulnar variance. The diagnosis should be suspected when there is tenderness at the distal radial physis in a young gymnast. The pathology is thought to be the result of repetitive compressive stresses caused by upper extremity weight-bearing forces. The recommended treatment is 3 to 6 months of rest. Salter-Harris fractures with a distal radial epiphyseal slip are unlikely, especially in the absence of a specific traumatic event.
REFERENCES: Mandelbaum BR, Bartolozzi AR, Davis CA, Teurlings L, Bragonier B: Wrist pain syndrome in the gymnast: Pathogenetic, diagnostic, and therapeutic consideration. Am J Sports Med 1989;17:305-317.
Roy S, Caine D, Singer KM: Stress changes of the distal radial epiphysis in young gymnasts: A report of twenty-one cases and a review of the literature. Am J Sports Med 1985;13:301-308.

Question 82

An 83-year-old right-hand-dominant woman sustains a displaced right extra-articular distal radius fracture and is treated with closed reduction and casting. At her 4-week follow-up visit, radiographs demonstrate a volar tilt of -5 degrees and 4 mm of positive ulnar variance. Which treatment is recommended?

Explanation

DISCUSSION
Studies demonstrate that surgical treatment of distal radius fractures in elderly people does not result in improved outcomes. Although nonsurgical treatment resulted in worse radiographic findings for this patient, these findings did not translate into worse functional outcomes.
RECOMMENDED READINGS
Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011 May;36(5):824-35.e2. doi: 10.1016/j.jhsa.2011.02.005. Review. PubMed PMID: 21527140.
View Abstract at PubMed
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53. doi: 10.2106/JBJS.J.01597. PubMed PMID: 22159849. View Abstract
at PubMed
American Academy of Orthopaedic Surgeons: Treatment of Distal Radius Fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons, March 2013. Available at http://www.aaos.org/research/Appropriate_Use/drfauc.asp Accessed {10/8/14}. Last Accessed on 10/8/14

Question 83

The addition of which of the following food supplements may lead to a decrease in neural tube defects?

Explanation

DISCUSSION: The use of folic acid in developed countries has lead to a decrease in neural tube defects. The incidence of neural tube defects is increased in third world countries.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 111-122.
Lemke L, Dias L: Spina bifida, in Cramer KE, Scherl SA, Einhom TA (eds): Orthopaedic Surgery Essentials: Pediatrics. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 203-210.

Question 84

A 7-year-old boy with spastic diplegia is a limited community ambulator. He has a moderately severe crouched gait. The parents request a treatment that will result in a permanent decrease in lower extremity muscle tone. This is best accomplished with Review Topic

Explanation

Posterior rhizotomy provides a permanent reduction in tone of spastic muscles. Potential drawbacks of the procedure include excessive muscle weakness, hip dislocation, and spinal deformity. Intramuscular botulinum-A toxin results in permanent blockade of presynaptic release of acetylcholine across the neuromuscular junction. The clinical effect usually resolves after 3 to 6 months due to neural regeneration. Tone-reduction AFOs have not been shown to reduce tone. A baclofen pump could offer prolonged reduction in tone, but not a single intrathecal injection.

Question 85

A 73-year-old woman reports a 4-month history of severe left-sided posterior buttock pain and left leg pain. The leg pain radiates into the left lateral thigh and posterior calf with cramping. Examination reveals mild difficulty with a single-leg toe raise on the left side and a diminished ankle reflex. There is also a significant straight leg raise test at 45 degrees which exacerbates symptoms. An MRI scan is shown in Figure 4. What is the most appropriate treatment at this time? Review Topic

Explanation

Lumbar spinal stenosis with lumbar radiculopathy can be commonly caused by a synovial cyst arising from the facet joints. Lyons and associates reported on the surgical treatment of synovial cysts in 194 patients. Of the 147 with follow-up data, 91% reported good pain relief and 82% had improvement of their motor deficits. Epstein reported a 58% to 63% incidence of good/excellent results and a 38 to 42
point improvement on the SF-36 Physical Function Scale. It was also suggested that since the presence of a synovial cyst indicates facet pathology, possible fusion should be considered in these patients, especially those with underlying spondylolisthesis.
(SBQ12SP.20) Amphotericin B is most appropriate for the treatment of which type of spine infection? Review Topic
Fungal osteomyelitis
Bacterial osteomyelitis with a gram-positive organism
Bacterial osteomyelitis with a gram-negative organism
Tuberculous osteomyelitis
Viral meningomyelitis
Amphotericin B would be most appropriate for the treatment of fungal infections of the spine.
Amphotericin B is a broad-spectrum anti-fungal medication. It is commonly used as the first-line agent for treatment of fungal infections of the spine. The most common fungi involving the spine include cryptococcus, candida, and aspergillus. The indications for débridement and stabilization with spinal fusion, includes resistance to antibiotic therapy, spinal instability, and/or neurologic deficits.
Kim et al. reviewed fungal infections of the spine. They comment that fungus infections are most commonly spread by hematogenous or direct spread. Access to the vascular system may include intravenous lines, during implantation of prosthetic devices, or during surgery.
Frazier et al. retrospectively reviewed 11 patients with fungal osteomyelitis of the spine. Nine of the patients were immunocompromised secondary to diabetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrition. All were treated with anti-fungal medication. 10 of 11 patients were also treated with surgical debridement. Paralysis secondary to the spine infection developed in eight patients. After an average of 6.3 years of follow-up, the infection had resolved in all nine surviving patients.
Illustration A shows the mechanism of action of Amphotericin. Illustration B shows T1- (Image A and B) and T2-weighted (Image C) images of the lower thoracic and lumbar spine. There are hypointense signals within the T12 and L1 vertebral bodies (Images A and B) indicative of fungal osteomyelitis.
IncorrectAnswers:

Question 86

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

Explanation

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

Question 87

A 58-year-old woman underwent a left total knee arthroplasty 6 years ago. She initially did well after surgery but sustained a fall 2 months ago while at work. She now describes left knee pain and instability and an inability to straighten her knee since the fall. She has been using a hinged knee brace, which provides partial support. On examination, she has passive range of motion of 0° to 115° and active range of motion of 80° to -115°. Her radiographs are shown in Figures below. What is the best option for the restoration of her function?

Explanation

DISCUSSION:
The patient has an extensor mechanism disruption with patellar tendon rupture. This injury is treated with extensor mechanism reconstruction in the setting of previous total knee arthroplasty. There is a reported high failure rate with attempted repair. Revision to hinge knee arthroplasty would provide implant stability but would not restore the extensor mechanism. The patient is relatively young and is working, so reconstruction would offer better long-term function than a drop lock brace, which can be better used in low-functioning patients with this type of injury. Extensor mechanism reconstruction historically has been accomplished with allograft material, but a novel technique using synthetic mesh also has proved successful in treating this difficult problem.

Question 88

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

Explanation

In the setting of significant anteroinferior glenoid bone deficiency (greater than 20% to 25%), both open and arthroscopic Bankart repairs have demonstrated higher rates of failure. Bony glenoid augmentation procedures such as the Bristow-Latarjet, which describe coracoid transfers to reconstruct the deficient glenoid, have led to decreased rates of recurrent shoulder instability. In this scenario, the patient has a significant loss of glenoid bone. There are also several clues in the history to suspect bone deficiency: multiple recurrences, a long history of recurrence, and instability in the midranges of motion. A bony augmentation procedure such as the Latarjet has been well-described to provide a well functioning and stable shoulder joint. A hemiarthroplasty is not indicated in the absence of arthritis. Subscapularis advancement will not address the bone loss.

Question 89

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

Explanation

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

Question 90

A player on a professional football team sustains a knee injury and is diagnosed with an anterior cruciate ligament rupture. When employed as the team physician, your ethical obligation is to inform

Explanation

When you are employed as a team physician, you are obligated to inform the players and the team organization of all athletically relevant medical issues. This differs significantly from the normal rule of patient confidentiality. If the player came to see you and you were not the team physician, you may not inform the team unless the player so desires. As the team physician, you are not obligated to inform the media.

Question 91

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

Explanation

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

Question 92

When performing elbow arthroscopy, it is often necessary to evaluate the posterior compartment. When entering the posterior compartment of the elbow, what are the two safest and most commonly used portals? Review Topic

Explanation

The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps are the "workhorse" portals of the posterior compartment and although relatively safe, risks exist. The radial nerve proximity averages 4.8 mm (3 to 8 mm) from the posterolateral portal. The central posterior portal is close to 20 mm from the ulnar nerve.

Question 93

-The center of rotation of the knee can be best described as

Explanation

Question 94

A 45-year-old man undergoes an anterior cervical diskectomy and fusion at C5-6 and C6-7 with instrumentation. During the first postoperative visit at 1 week, the patient reports difficulty swallowing and mild anterior cervical tightness. The anterior wound is benign and the patient denies any dyspnea or shortness of breath. A postoperative radiograph is seen in Figure 25. What is the most appropriate management at this time?

Explanation

DISCUSSION: The radiograph shows significant prevertebral soft-tissue swelling following a two-level anterior cervical diskectomy and fusion. The incidence of dysphagia 2 years after anterior cervical spine surgery is 13.6%. Risk factors for long-term dysphagia after anterior cervical spine surgery include gender, revision surgeries, and multilevel surgeries. The use of instrumentation, higher levels, or corpectomy versus diskectomy did not significantly increase the prevalence of dysphagia. Lee and associates demonstrated that while dysphagia after anterior cervical spine surgery is a common early finding, it generally decreases significantly by

6 months with nonsurgical management. A minority of patients experience moderate or severe symptoms by 6 months after the procedure. Female gender and multiple surgical levels have been identified as risk factors for the development of postoperative dysphagia.
REFERENCES: Lee MJ, Bazaz R, Furey CG, et al: Risk factors for dysphagia after anterior cervical spine surgery: A two-year prospective cohort study. Spine J 2007;7:141-147.
Bazaz R, Lee MJ, Yoo JU: Incidence of dysphagia after anterior cervical spine surgery:

A prospective study. Spine 2002;27:2453-2458.

Question 95

All of the following are characteristic of synovium affected by rheumatoid arthritis (RA) EXCEPT:

Explanation

The basement membrane is not disrupted in rheumatoid arthritis-affected synovial tissue, as synovium lacks a true basement membrane.
Normal synovium consists of two layers, the intimal and the sublining, and two types of cells, type A and B. In RA, the following changes to the synovium are seen: 1) hyperplasia, with the intimal lining increasing from two cell layers to 10-20 layers 2) decreased apoptosis of the lining 3) increased angiogenesis and 4) abundant lymphocytes around vessels, forming lymphoid follicles.
The synovial pannus is invasive granulation tissue that contains fibroblast-like synoviocytes, but few inflammatory cells. The synovial cells in the pannus have anchorage-independent growth and invasive capabilities, allowing them to directly attack and destroy articular cartilage.
Koch et al. note that the possible contributions of angiogenesis to the proliferation of the inflammatory synovial pannus and the ingress of inflammatory leukocytes into the synovial tissue in RA have been extensively studied. Relevant angiogenesis inducers seen in RA include FGF-2, VEGF, TGFß, TNFa, IL-1, IL-8, VCAM-1, among others. Modulation of angiogenesis may be a viable therapeutic option for RA in the future.
Incorrect Answers:

Question 96

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

Explanation

Question 97

A 33-year-old female sustains the injury shown in Figure A as the result of a fall off a chair, and subsequently undergoes operative stabilization of her injury. Which of the following is most correlated with positive outcomes when treating this injury?

Explanation

Long-term outcomes after an ankle syndesmotic injury are most correlated with an anatomic reduction of the ankle syndesmosis. Formal open reduction of the syndesmosis has been shown to improve outcomes by improving the reduction quality.
While the importance of anatomic reduction of a syndesmotic injury is clear, controversy exists regarding the ideal method of fixation. No significant differences are reproducibly reported in regards to number of syndesmotic screws, size, or number of cortices. There is emerging data supporting the use of suture button fixation.
Wikeroy et al. reviewed 48 patients at a mean of 8.4 years, and they found that patients with a difference in the syndesmotic width between the operated and the nonoperated ankle of 1.5 mm or more showed inferior results. Posterior malleolar fragments and obese patients also had worse outcomes.
Schepers et al. published a review on the suture button device comparisons to traditional screw fixation, reviewing 6 biomechanical studies and 34 clinical studies. They found that the suture button systems have similar outcomes to screw fixation, but insufficient long-term and high-quality evidence prevented a strong conclusion. Implant removal in the suture button groups averaged 10%, while screw removal averaged 52%.
Sagi et al. reviewed 107 patients with ankle fractures and associated syndesmotic
injuries requiring surgery. They found that 39% were malreduced, but open reduction of the syndesmotic injury cut the malreduction rate by 2/3. They also reported that at a minimum of 2 years follow-up, patients with malreduced syndesmotic injuries demonstrated worse functional outcome scores.
Figure A shows an ankle fracture with obvious syndesmotic injury/widening. Incorrect answers:
1-4: These choices are not correlated with excellent outcomes with treatment of a
syndesmotic injury.

Question 98

The brachialis muscle is innervated by what two nerves?

Explanation

DISCUSSION: The brachialis is innervated by two nerves: medially, the musculocutaneous nerve; laterally, the radial nerve. The muscle is split longitudinally to approach the humerus anteriorly.
REFERENCES: Henry AK: The distal part of the humerus and front of the forearm, in Henry AK (ed): Extensile Exposure, ed 2. Edinburgh, UK, Churchill Livingstone, 1973, pp 90-115.
King A, Johnston GH: A modification of Henry’s anterior approach to the humerus. J Shoulder Elbow Surg 1998;7:210-212.

Question 99

A 19-year-old female field hockey player sustains a right ankle injury last night during a game. The patient is on crutches and reports that she has not been able to put any weight on her right ankle since the injury. She was running alongside with another player when her right ankle “gave out” and she twisted it, falling to the ground. Physical examination reveals discoloration similar to a hematoma and significant swelling around the lateral ankle area. Pain is elicited during palpation of the anterior talofibular ligament. What is the most appropriate course of action for this patient’s condition?

Explanation

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement >15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The
diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization and a guided rehabilitation program that emphasizes proprioceptive stability.

Question 100

Which of the following factors is associated with failure of arthroscopic excision of the distal clavicle?

Explanation

DISCUSSION: Uneven resection of bone, typically leaving a retained posterolateral corner of the distal clavicle, can lead to failure of arthroscopic distal clavicle excision. The amount of bone resected, the gender of the patient, or the diagnosis (osteoarthritis versus osteolysis) does not appear to affect the results.
REFERENCE: Flatow EL, Duralde XA, Nicholson GP, Pollock RG, Bigliani LU: Arthroscopic resection of the distal clavicle with a superior approach. J Shoulder Elbow Surg 1995;4:41-50.

Full Question & Answer Text (for Search Engines)

Question 1:

The radiographic feature seen in Figure 37 that best indicates a slow-growing process is the

Options:

deformity of the fibula.
wide base of the lesion.
lack of joint deformity.
medullary canal extending into the lesion.
lack of periosteal reaction.

Correct Answer: deformity of the fibula.

Explanation:

Question 2:

What is the neoplastic cell of origin for this tumor?

Options:

Lymphocyte
Monocyte
Macrophage
Mononuclear phagocyte

Correct Answer: Mononuclear phagocyte

Explanation:

DISCUSSION
Tenosynovial giant-cell tumors are widely known as pigmented villonodular synovitis (PVNS), although this term is misleading because this tumor type is a clonal neoplasm and does not involve an inflammatory process. It often is shown to have a t(1:2)(p13q37) karyotype resulting in CSF1-COL6A3 gene fusion. There are various amounts of mononuclear cells, osteoclastlike giant cells, foamy histiocytes, hemosiderophages, and chronic inflammatory cells. Local recurrences are common, but CSF1R inhibitors are being investigated in studies involving local control improvement and disease regression.
Targeted therapy trials to assist in control of the diffuse-type tenosynovial giant-cell tumor (formerly called PVNS) involve the use of monoclonal antibodies that inhibit CSF1R activation. CSF1R-expressing mononuclear phagocytes are affected by these monoclonal antibodies.
Infantile fibrosarcoma is associated with the t(12;15)(p13;q25) karyotype and ETV6-NTRK3 gene fusion product. Nodular fasciitis is associated with the t(17;22)(p13;q13.1) karyotype and MYH9-USP6 gene fusion product. Inflammatory myofibroblastic tumor is associated with translocations involving 2p23 resulting in multiple fusion products of ALK with TPM4 (19p13.1), TPM3 (1q21), CLTC (17q23), RANBP2 (2q13), ATIC (2q35), SEC31A (4q21), and CARS (11p15). No
nonpreferred response has a histologic appearance that includes hemosiderin, foamy histiocytes, and osteoclastlike giant cells.
A conformation-specific inhibitor of the juxtamembrane region of CSF1R is a synthetic molecule that is designed to access the autoinhibited state of the receptor through direct interactions with the juxtamembrane residues embedded in the adenosine 5’-triphosphate-binding pocket. It is designed to bind in the regulatory a-helix of the N-terminal lobe of the kinase domain in neoplastic cells of tenosynovial giant-cell tumor that have expression of the CSF1 gene. There is a structural plasticity of the domain of the CSF1R that allows the molecule to directly bind the autoinhibited state of CSF1R.
Another approach involves the development of the anti-CSF1R antibody, emactuzumab, which targets tumor-associated macrophages. A lower percentage of volume reduction has been reported with imatinib, a tyrosine kinase inhibitor. Alkylating agents have not been used in this benign neoplasm.
Tenosynovial giant-cell tumor is characterized by an overexpression of CSF1. CSF1R activation leads to recruitment of CSF1R-expressing cells of the mononuclear phagocyte lineage.
RECOMMENDED READINGS
Cassier PA, Gelderblom H, Stacchiotti S, Thomas D, Maki RG, Kroep JR, van der Graaf WT, Italiano A, Seddon B, Dômont J, Bompas E, Wagner AJ, Blay JY. Efficacy of imatinib mesylate for the treatment of locally advanced and/or metastatic tenosynovial giant cell tumor/pigmented villonodular synovitis. Cancer. 2012 Mar 15;118(6):1649-55. doi: 10.1002/cncr.26409. Epub 2011 Aug 5. PubMed PMID: 21823110.
View Abstract at PubMed
Ladanyi M, Fletcher JA, Dal Cin P. Cytogenetic and molecular genetic pathology of soft tissue tumors. In: Goldblum JR, Folpe AL, Weis SW, eds.
Enzinger & Weiss’s Soft Tissue Tumors
. 6th ed. Philadelphia, PA: Elsevier Saunders; 2014:76-109.
Staals EL, Ferrari S, Donati DM, Palmerini E. Diffuse-type tenosynovial giant cell tumour: Current treatment concepts and future perspectives. Eur J Cancer. 2016 Aug;63:34-40. doi: 10.1016/j.ejca.2016.04.022. Epub 2016 Jun 5. Review.
View Abstract at PubMed
Tap WD, Wainberg ZA, Anthony SP, Ibrahim PN, Zhang C, Healey JH, Chmielowski B, Staddon AP, Cohn AL, Shapiro GI, Keedy VL, Singh AS, Puzanov I, Kwak EL, Wagner AJ, Von Hoff DD, Weiss GJ, Ramanathan RK, Zhang J, Habets G, Zhang Y, Burton EA, Visor G, Sanftner L, Severson P, Nguyen H, Kim MJ, Marimuthu A, Tsang G, Shellooe R, Gee C, West BL, Hirth P, Nolop K, van de Rijn M, Hsu HH, Peterfy C, Lin PS, Tong-Starksen S, Bollag G. Structure-Guided Blockade of CSF1R Kinase in Tenosynovial Giant-Cell Tumor. N Engl J Med. 2015 Jul 30;373(5):428-37. doi:10.1056/NEJMoa1411366. PubMed PMID: 26222558.
View Abstract at PubMed
Ries CH, Cannarile MA, Hoves S, Benz J, Wartha K, Runza V, Rey-Giraud F, Pradel LP, Feuerhake F, Klaman I, Jones T, Jucknischke U, Scheiblich S, Kaluza K, Gorr IH, Walz A, Abiraj K, Cassier PA, Sica A, Gomez-Roca C, de Visser KE, Italiano A, Le Tourneau C, Delord JP, Levitsky H, Blay JY, Rüttinger D. Targeting tumor-associated macrophages with anti-CSF-1R antibody reveals a strategy for cancer therapy. Cancer Cell. 2014 Jun 16;25(6):846-59. doi: 10.1016/j.ccr.2014.05.016. Epub 2014 Jun 2. PubMed PMID: 24898549.
View Abstract at PubMed

Question 3:

Options:

at least two more attempts at closed reduction in the emergency department before the patient’s sedation wears off.
at least two attempts at closed reduction in the operating room under general anesthesia with muscle relaxation.
acceptance of the reduction because the alignment is satisfactory and growth problems are rare with Salter-Harris type I fractures.
open reduction, extraction of any interposed periosteum, and smooth wire fixation to prevent nonunion.
open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

Correct Answer: open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

Explanation:

DISCUSSION: The widening of the physis associated with incomplete reduction of this fracture suggests that periosteum is interposed at the fracture site. Clinical and animal study findings suggest that the interposed periosteum may lead to premature physeal closure. Repeated forceful attempts at reduction may subject the physis to further injury and should be avoided. Growth problems are common in children with Salter-Harris type I fractures of the lower extremities. Nonunions are rare in children with Salter-Harris type I fractures.
REFERENCES: Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibial physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23:733-739.
Gruber HE, Phieffer LS, Wattenbarger JM: Physeal fractures: Part II. Fate of interposed periosteum in a physeal fracture. J Pediatr Orthop 2002;22:710-716.

Question 4:

Options:

minimal activity.
moderate activity compared to the supraspinatus.
significant activity with a supraspinatus tear.
significant activity with an intact supraspinatus.
significant activity with both intact and torn rotator cuffs.

Correct Answer: minimal activity.

Explanation:

Question 5:

Options:

Limb-length discrepancy
Mechanical irritation around the knee
Quadriceps weakness
Malunion
Patellofemoral pain

Correct Answer: Mechanical irritation around the knee

Explanation:

Question 6:

What is the most frequent late complication of cementless fixation in total knee arthroplasty?

Options:

Infection
Subluxation of the patella
Loss of motion
Femoral loosening
Osteolysis

Correct Answer: Osteolysis

Explanation:

Question 7:

- A 31-year-old man who is a recent immigrant from Guatemala has had pain in his back and thighs for the past 12 months. History notes a recent diagnosis of gout, and the patient reports falling a distance of 3 feet on his buttocks immediately before the pain began. Examination reveals that he is neurologically intact. Plain radiographs are shown in Figures 44a and 44b, and T2-weighted MRI scans are shown in Figures 44c and 44d. The most likely cause of the pathologic fracture is

Options:

gout.
osteoporosis.
eosinophilic granuloma.
tuberculosis of the spine.
metastatic disease of the spine.

Correct Answer: tuberculosis of the spine.

Explanation:

Question 8:

Options:

fracture kyphosis.
reduction of retropulsed bone.
pain reduction.
incidence of complications.
return to work.

Correct Answer: incidence of complications.

Explanation:

Question 9:

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

Options:

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

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

Explanation:

Question 10:

-The patient asks if something about her anatomy has resulted in this injury. ACL anatomy differs between men and women in what manner?

Options:

There is no significant difference in ACL anatomy between men and women.
A woman’s ACL has a smaller cross-sectional area.
The cross-sectional area of a woman’s ACL is larger.
The intercondylar notch is wider in women than in men.

Correct Answer: A woman’s ACL has a smaller cross-sectional area.

Explanation:

DISCUSSION FOR QUESTIONS 18 THROUGH 20
This patient has the clinical findings of an ACL rupture that is confirmed on MRI scan. She is a professional athlete and would like to return to her sport. Immediate ACL reconstruction in the setting of a knee with limited motion carries an increased risk for postsurgical stiffness. Delayed surgery after the patient regains range of motion is the preferred response. It has been shown that a woman’s ACL is smaller in the cross-sectional area.

Question 11:

Options:

Joint congruity
Torn anterior tibiofibular ligament
Growth arrest leading to angular deformity
Growth arrest leading to limb-length discrepancy
Osteonecrosis of the talus

Correct Answer: Joint congruity

Explanation:

DISCUSSION: Tillaux and triplane fractures occur in adolescents as the result of an external rotation injury of the ankle. As seen on the CT scan, the growth plate starts to close during adolescence; therefore, growth arrest resulting in limb-length discrepancy or angulation is less of a concern in this age group than achieving joint congruity. The joint should be surgically reduced if displacement is greater than 2 mm to minimize the chances of late arthrosis.
REFERENCES: Kay RM, Matthys GA: Pediatric ankle fractures: Evaluation and treatment.
J Am Acad Orthop Surg 2001;9:268-278.
Kling TF Jr: Operative treatment of ankle fractures in children. Orthop Clin North Am 1990;21:381-392.
Duchesneau S, Fallat LM: The Tillaux fracture. J Foot Ankle Surg 1996;35:127-133.

Question 12:

Options:

Hip revision and implantation of a proximal femoral replacement
Hip revision and implantation of a tapered fluted stem
Open reduction and internal fixation with a locked plate and allograft struts
Erythrocyte sedimentation rate and C-reactive protein laboratory studies

Correct Answer: Erythrocyte sedimentation rate and C-reactive protein laboratory studies

Explanation:

Question 13:

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 14:

Which of the following is considered an important factor in improved cemented femoral stem survivorship?

Options:

Precoated stem with methylmethacrylate
Varus stem position
2 to 3 mm of circumferential cement mantle
Dorr C or “stovepipe” femoral anatomy
Sharp angled corners on the femoral stem

Correct Answer: 2 to 3 mm of circumferential cement mantle

Explanation:

Question 15:

Options:

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

Correct Answer: rest and protected weight bearing with crutches.

Explanation:

Question 16:

Options:

Facet joint injection and lumbosacral orthosis
Posterior stabilization
Revision arthroplasty via far lateral approach
Revision to arthrodesis via far lateral approach
Revision to arthrodesis via retroperitoneal approach

Correct Answer: Facet joint injection and lumbosacral orthosis

Explanation:

Question 17:

Options:

Cephalosporin
Cephalosporin and aminoglycoside
Cephalosporin and penicillin
Cephalosporin and vancomyacin
Cephalosporin, aminoglycoside, and penicillin

Correct Answer: Cephalosporin, aminoglycoside, and penicillin

Explanation:

DISCUSSION: A farm injury is automatically considered a grade III (Gustillo classification) injury regardless of size, energy, or additional soft-tissue injury due to the likelihood of substantial contamination. Antibiotic recommendations for grade III injuries include a first- or second-generation cephalosporin with an aminoglycoside or fluoroquinolone within 3 hours of injury, with penicillin added for farm injuries.
REFERENCES: Okike K, Bhattacharyya T: Trends in the management of open fractures: A critical analysis. J Bone Joint Surg Am 2006;88:2739-2748.
Holtom PD: Antibiotic prophylaxis: Current recommendations. J Am Acad Orthop Surg 2006:14:S98-S100.

Question 18:

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

Options:

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

Correct Answer: Abduction and flexion of the proximal fragment

Explanation:

Question 19:

In articular cartilage, Interleukin 1 (IL-1) increases

Options:

matrix metalloproteinase.
proteoglycan synthesis.
collagen production.
nitric oxide synthetase.

Correct Answer: matrix metalloproteinase.

Explanation:

Question 20:

Options:

release of the latissimus dorsi and teres major.
release of the subscapularis and pectoralis major.
passive range-of-motion exercises.
exploration of the brachial plexus.
functional bracing.

Correct Answer: passive range-of-motion exercises.

Explanation:

DISCUSSION: Injury to the upper trunk of the brachial plexus during birth (Erb’s palsy) occurs in approximately 1 in 3,000 births. In a complete lesion, paralysis of the deltoid, supraspinatus, infraspinatus, teres minor, biceps, and brachioradialis results in the findings described above. Spontaneous recovery may occur for up to 2 years. Passive exercises administered daily by the parents are the initial recommended treatment at this age. If significant contracture results in posterior dislocation, surgical correction may be considered.
REFERENCES: Neer CS: Shoulder Reconstruction. Philadelphia, PA, WB Saunders, 1990,
pp 452-454.
Pearl ML: Arthroscopy release of shoulder contracture secondary to birth palsy: An early report on findings and surgical technique. Arthroscopy 2003;19:577-582.
Pearl ML, Edgerton BW, Kon DS, et al: Comparison of arthroscopic findings with MRI and arthrography in children with GH deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 2003;85:890-898.

Question 21:

When comparing arthroscopic and open rotator cuff repairs, which of the following tears shows a decreased recurrent tear rate in the open versus the arthroscopic group? Review Topic

Options:

Partial-thickness tears
Tears less than 1 cm in width
Tears between 1 and 2 cm in width
Tears greater than 3 cm in width
Tears showing retraction medial to the glenoid

Correct Answer: Tears greater than 3 cm in width

Explanation:

Question 22:

When performing an inside-out lateral meniscal repair, capsule exposure is provided by developing the

Options:

iliotibial band and biceps tendon interval, then retracting the lateral head of the gastrocnemius anteriorly.
iliotibial band and biceps tendon interval, then retracting the lateral head of the gastrocnemius posteriorly.
iliotibial band and biceps tendon interval, then retracting the lateral collateral ligament posteriorly.
iliotibial band and biceps tendon interval, then splitting the lateral head of the gastrocnemius.
lateral head of the gastrocnemius and biceps tendon interval, then retracting the biceps tendon anteriorly.

Correct Answer: iliotibial band and biceps tendon interval, then retracting the lateral head of the gastrocnemius posteriorly.

Explanation:

Question 23:

Options:

Physical therapy for functional rehabilitation
CT/myelography of the spinal axis
MRI with gadolinium
Psychiatric consultation for possible malingering
Lumbar puncture for analysis of cerebrospinal fluid

Correct Answer: MRI with gadolinium

Explanation:

Question 24:

Which of the following substances is least likely to affect the success of bone union after lumbar arthrodesis?

Options:

Ketorolac
Indomethacin
Oxycodone hydrochloride
Ibuprofen
Nicotine

Correct Answer: Oxycodone hydrochloride

Explanation:

Question 25:

Options:

Microfracture
Autologous chondrocyte implantation
Osteochondral allograft transfer
Dejour trochleoplasty

Correct Answer: Osteochondral allograft transfer

Explanation:

The images show a full-thickness cartilage defect with significant bony involvement >4 cm
2
. Microfracture should be considered for lesions <2 cm
2
without an underlying osseous defect. Autologous chondrocyte implantation, although used for lesions between 1 and 10 cm
2
, should be restricted for defects with minimal (<8 mm depth) bone loss. Osteochondral allograft transfer with the mosaicplasty technique (transfer of multiple plugs) would be well-suited for this large defect with significant osseous involvement. Dejour trochleoplasty is performed for patellar instability to correct trochlear dysplasia and
would not be indicated in this case.

Question 26:

Options:

repeat the examination in a few hours.
remove the left knee immobilizer and flex the knee.
apply long leg casts that include the feet.
obtain an electromyogram and nerve conduction velocity studies.
perform peroneal nerve exploration.

Correct Answer: remove the left knee immobilizer and flex the knee.

Explanation:

Question 27:

Options:

Further imaging studies, including MRI
An awake closed reduction with Gardner-Wells traction with neurologic examination
Immobilization in a halo skeletal fixation for definitive treatment
Closed reduction under general anesthesia
Immediate open reduction and internal fixation in the surgical suite

Correct Answer: An awake closed reduction with Gardner-Wells traction with neurologic examination

Explanation:

Question 28:

Type II collagen in nondiseased adult human articular cartilage has a half-life that is generally

Options:

several months.
6 months.
1 year.
10 years.
more than 25 years.

Correct Answer: more than 25 years.

Explanation:

Question 29:

Options:

Torn posterolateral corner
Torn posterior cruciate ligament (PCL) and posterolateral corner
Torn PCL
Rupture of the quadriceps tendon
Rupture of the lateral collateral ligament

Correct Answer: Torn posterolateral corner

Explanation:

Question 30:

Figures 23a and 23b show the radiographs of a 75-year-old woman who sustained an injury to her nondominant hand. Initial treatment should consist of

Options:

closed reduction and splinting.
open reduction and internal fixation through a volar approach.
external fixation and Kirschner wire fixation.
intrafocal pinning and casting.
acceptance of alignment and bracing.

Correct Answer: closed reduction and splinting.

Explanation:

DISCUSSION: Definitive treatment decisions for displaced distal radius fractures in the elderly are based on a number of factors related to the fracture pattern and patient demographics. The first step in any treatment algorithm is a closed reduction and splinting with reassessment of alignment parameters. This is an extra-articular fracture with dorsal angulation. Low-demand elderly patients can be treated well with accepted minor malreduction.
REFERENCES: Handoll HH, Madhok R: Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;2:CD000314.
Young CF, Nanu AM, Checketts RG: Seven-year outcome following Colles’ type distal radial fracture: A comparison of two treatment methods. J Hand Surg Br 2003;28:422-426.

Question 31:

Options:

Posterior stabilization and fusion only
Anterior stabilization and fusion only
Anterior decompression and stabilization
Nonsurgical treatment with mobilization in a thoracolumbosacral brace
Multilevel laminectomy

Correct Answer: Posterior stabilization and fusion only

Explanation:

The CT scans show a burst fracture of L1. In distinction from a fracture-dislocation, the levels above and below the injury (T12 and L2) are reasonably well-aligned, although there is a marked amount of kyphosis. The axial image displays retropulsed bone fragments from the posterior vertebral body that are causing nearly 100% canal compromise. As the patient has an incomplete neurologic injury (evidenced by some motor [toe flexion, S2] and sensory [perianal sensation, S3-5] function below the level of the injury), a decompressive procedure should be strongly considered. Studies have demonstrated that an anterior corpectomy achieves the most complete spinal canal decompression after a burst fracture, and is best performed in concert with a stabilization procedure. Posterior stabilization and fusion without laminectomy could restore alignment and provide stability, but it is unlikely to provide adequate spinal canal decompression. Anterior stabilization and fusion, without decompression, would not maximize neurologic recovery. Nonsurgical treatment in a patient with an incomplete neurologic injury should be considered only for those who are medically unfit for surgery. Multilevel laminectomy will cause further destabilization of the spine and will not adequately decompress the spinal canal because the dural sac is being compressed along its anterior aspect by retropulsed bone fragments.
(SBQ12SP.25) A 63-year-old female undergoes lumbar decompression and instrumented fusion for the condition shown in Figure A and B. Which of the following factors are associated with increased risk of early post-operative complications?
Review Topic
Increasing Age
Intraoperative blood loss
Number of levels fused
All of the above
Age, intraoperative blood loss, and number of spinal levels fused are associated with increased rates of inpatient complication following lumbar decompression and fusion for degenerative spondylolisthesis. Older age correlates with the highest risk for complications.
Lumbar decompression and fusion is well supported in the literature to be effective in the treatment of degenerative spondylolithesis when nonoperative modalities fail. Common complications associated with lumbar decompression and fusion include asymptomatic or symptomatic pseudarthroses (estimated 5-30%), surgical site infection (0.10-2%),and adjacent level degeneration (2-3%). Age, intraoperative blood loss, longer operative times, number of levels fused are associated with increased risk of complication. Smoking is associated with worse outcome after surgery.
Kalanithi et al. reviewed the Nationwide Inpatient Sample adminstrative data on sixty six thousand patients undergoing lumbar laminectomy and fusion. They found the increased age and having 3 or more medical comorbidities was associated with increased risk of complication.
Carreon et al. reviewed cases of ninety eight patients who underwent laminectomy and fusion for lumbar degenerative disease. They found that rates of major and minor complication increased with older age, increased blood loss, longer operative time, number of levels fused.
Figure A is a AP lumbar spine radiograph. Figure B is a lateral lumbar spine radiograph showing degenerative spondylolisthesis at L4-L5. Illustration A shows the postoperative images of the patient treated with an L4-5 fusion with an interbody device.
Incorrect

Question 32:

Options:

Electrical stimulation with an implanted coil
Ultrasound stimulation for 30 minutes per day
Locked intramedullary nailing with bone graft
Ilizarov external fixation with intermittent distraction and compression
Plate and screw fixation with bone graft

Correct Answer: Plate and screw fixation with bone graft

Explanation:

Question 33:

Options:

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

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

Explanation:

DISCUSSION: Excessive internal tibial torsion is a common cause of intoeing in toddlers. In most children, this resolves spontaneously by 3 to 4 years of age. Intoeing in elementary age children is usually the result of excessive femoral anteversion. Studies have shown that active intervention (casting, splinting, and shoe modifications) has no demonstrable effect on the natural history or resolution of tibial torsion. Surgery is rarely indicated in adolescents with severe internal tibial torsion that has not resolved and is resulting in cosmetic and functional problems.
REFERENCES: Canale ST, Beaty JH: Operative Pediatric Orthopaedics. St Louis, MO, Mosby Year Book, 1991, pp 357-385.
Lincoln TL, Suen PW: Common rotational variations in children. J Am Acad Orthop Surg 2003;11:312-320.

Question 34:

Options:

case series.
case-control study.
cohort study.
randomized clinical trial.

Correct Answer: case series.

Explanation:

Question 35:

The palmar cutaneous branch of the median nerve (PCBMN) originates from the

Options:

radial side of the median nerve and travels radial to the palmaris longus and ulnar to the flexor carpi radialis.
radial side of the median nerve and travels distally radial to the palmaris longus and flexor carpi radialis.
ulnar side of the median nerve and travels radial to the palmaris longus and ulnar to the flexor carpi radialis.
ulnar side of the median nerve and travels radial to the flexor carpi radialis.
ulnar side of the median nerve and travels radial to the palmaris longus volar.

Correct Answer: radial side of the median nerve and travels radial to the palmaris longus and ulnar to the flexor carpi radialis.

Explanation:

Question 36:

Options:

Rotator cuff repair and biceps tenodesis
Rotator cuff repair and loose body removal
Latissimus dorsi transfer
Bankart repair

Correct Answer: Rotator cuff repair and biceps tenodesis

Explanation:

DISCUSSION
Video 7 for reference
The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove.
The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer.

Question 37:

Autosomal dominant

Options:

This patient has multiple hereditary exostoses. Widening of the metaphysis is characteristic of multiple hereditary exostoses. Large sessile osteochondromas arise from the metaphysis and a large osteochondroma arises from the medial metaphysis with a characteristic cartilaginous cap. The computed tomography scan shows the widening and abnormal tubulation of the bone.
No evidence of malignancy exists in this large osteochondroma. The cartilage cap is regular with no areas of bone destruction. One should also look for a soft tissue mass, which often shows areas of focal calcifications. No soft tissue masses are present in this patient.
It is important to remember that this condition is autosomal dominant. The putative tumor suppressive gene mutation is EXT1, EXT2. The risk of low-grade chondrosarcoma occurring in this condition is approximately 10%.

Correct Answer: It is important to remember that this condition is autosomal dominant. The putative tumor suppressive gene mutation is EXT1, EXT2. The risk of low-grade chondrosarcoma occurring in this condition is approximately 10%.

Explanation:

slide 1 slide 2 slide 3
A patient presents with a hard leg mass and pain with activity. The anteroposterior and lateral radiographs are shown in Slide 1 and Slide 2. An axial computed tomography scan is shown in Slide 3. Which of the following tumor suppressor genes is most likely involved:

Question 38:

Options:

Debridement of the labral tear plus bony resection of the pincer lesion
Debridement of the labral tear and no bony resection of the pincer lesion
Femoral neck osteoplasty plus labral repair using suture anchor
Resection of the bony pincer lesion plus labral repair using suture anchor

Correct Answer: Resection of the bony pincer lesion plus labral repair using suture anchor

Explanation:

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has
important functions for hip stability and maintenance of the suction seal of the joint.

Question 39:

Options:

Streptococcus pneumoniae
Staphylococcus aureus
Pseudomonas aeruginosa
Staphylococcus epidermis
Propionibacterium acnes

Correct Answer: Streptococcus pneumoniae

Explanation:

Question 40:

Options:

Bucket-handle tear of the lateral meniscus
Medial meniscus tear
Discoid lateral meniscus
Posterior cruciate ligament tear
Normal MRI of the knee

Correct Answer: Discoid lateral meniscus

Explanation:

Question 41:

Which of the following cohorts of patients is at highest risk of a future anterior cruciate ligament (ACL) tear? Review Topic

Options:

Men with a hip abduction moment during landing
Men with a neutral hip abduction-adduction moment during landing
Men with varus knee abduction moment during landing
Women with a hip adduction moment during landing
Women with a knee valgus moment during landing

Correct Answer: Women with a knee valgus moment during landing

Explanation:

Question 42:

Options:

Tibial polyethylene exchange
Revision of the femoral and tibial components and conversion to a posterior stabilized insert
Revision of femoral and tibial components to a constrained rotating hinge prosthesis
Isolated femoral component revision and upsizing the femoral implant with a new PCL-retaining polyethylene insert

Correct Answer: Revision of the femoral and tibial components and conversion to a posterior stabilized insert

Explanation:

DISCUSSION
Video 99 for reference
This patient has valgus knee alignment, and, after undergoing appropriate bone resections and soft-tissue balancing, has demonstrated a tight PCL on trial reduction as evidenced by lift-off of the trial insert as described by Scott and Chmell. The appropriate maneuver is PCL recession with partial release of tight (usually anterolateral) PCL fibers. However, for this patient, instability resulted in increased anterior translation. At this stage, the options are to convert to either a deeper-dish insert with increased sagittal conformity or a posterior stabilized insert. The only appropriate choice among the responses is use of an insert with increased sagittal conformity to prevent excessive anterior translation. Increasing the polyethylene could improve stability in flexion, but, considering there is good stability in extension, this likely would lead to an inability to achieve full extension. The patient’s valgus deformity, flexion contracture, correction with release of the iliotibial band, and posterolateral capsule predispose him to increased risk for peroneal nerve palsy. His symptoms at follow-up suggest knee flexion
instability with pain, swelling, and difficulty descending stairs. Considering his history, an incompetent PCL must be considered. Revision of the knee to a posterior stabilized or nonlinked constrained condylar implant depending on the condition of the ligaments likely is needed to address his symptoms. The difference in extension vs flexion stability makes polyethylene exchange a poor option. There is no reason to believe a constrained rotating hinge design is necessary. Repeat use of a PCL-retaining insert is not recommended.

Question 43:

What structure is most at risk for injury from a retractor against the tracheoesophageal junction during an anterior approach to the cervical spine?

Options:

Esophagus
Trachea
Superior laryngeal nerve
Recurrent laryngeal nerve
Sympathetic chain

Correct Answer: Recurrent laryngeal nerve

Explanation:

DISCUSSION: Although any of these structures can be injured by pressure from the medial blade of a self-retaining retractor, the recurrent laryngeal nerve runs cephalad in the interval between the esophagus and trachea and is vulnerable to pressure if caught between the retractor and an inflated endotracheal tube balloon.
REFERENCES: Ebraheim NA, Lu J, Skie M, et al: Vulnerability of the recurrent laryngeal nerve in the anterior approach to the lower cervical spine. Spine 1997;22:2664-2667.
Kilburg C, Sullivan HG, Mathiason MA: Effect of approach side during anterior cervical discectomy and fusion on the incidence of recurrent laryngeal nerve injury. J Neurosurg Spine 2006;4:273-277.

Question 44:

Options:

cast immobilization.
arthroscopy.
continued physical therapy.
a repeat corticosteroid injection.
a short course of oral steroids.

Correct Answer: arthroscopy.

Explanation:

Question 45:

Options:

Fibrous dysplasia
Enchondroma
Ewing’s sarcoma
Metastatic carcinoma
Aneurysmal bone cyst

Correct Answer: Fibrous dysplasia

Explanation:

Question 46:

Options:

elbow extension motion.
elbow flexion strength.
forearm supination motion.
forearm pronation strength.
forearm supination strength.

Correct Answer: forearm supination strength.

Explanation:

Question 47:

Options:

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

Correct Answer: Lateral ulnar collateral

Explanation:

Question 48:

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 49:

Figures 2a and 2b show the radiographs of a 72-year-old man with aseptic loosening of the tibial component of his total knee arthroplasty. Optimal management should include

Options:

tibial revision only, without stems or augmentations.
tibial revision only, with stems and augmentations.
revision of the tibial and femoral components, without stems or augmentations.
revision of the tibial and femoral components, with stems and augmentations.
primary arthrodesis.

Correct Answer: revision of the tibial and femoral components, with stems and augmentations.

Explanation:

DISCUSSION: The radiographs show massive subsidence of the lateral side of the tibia with severe tibial bone loss and a fractured proximal fibula. Reconstruction should consist of a large metal or bony lateral tibial augmentation, and a stem long enough to bypass the defect is required. The femoral and tibial components are articulating without any remaining polyethylene medially; therefore, the femoral component is damaged and needs revision.
The insertions of the lateral ligaments are absent, thereby rendering the lateral side of the knee predictably unstable. Also, the large valgus deformity compromises the medial collateral ligament. The posterior cruciate ligament is also likely to be deficient with this much tibial bone destruction. The patient requires a posterior stabilized femoral component at the minimum, and possibly a constrained femoral component. Retention of the femoral component, even though it may be well-fixed, jeopardizes the outcome.
REFERENCES: Lotke PA, Garino JP: Revision Total Knee Arthroplasty. New York, NY, Lippincott-Raven, 1999, pp 137-250.
Insall JN, Windsor RE, Scott WN, et al: (eds): Surgery of the Knee, ed 2. New York, NY, Churchill Livingstone, 1993, pp 935-957.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 339-365.

Question 50:

Options:

Radiographs
MRI
Erythrocyte sedimentation rate (ESR)
CBC with differential
C-reactive protein (CRP)

Correct Answer: C-reactive protein (CRP)

Explanation:

Question 51:

Which of the following physical examination findings is most likely present in the condition producing the MRI findings shown in Figure 92?

Options:

Valgus laxity at 30 degrees of knee flexion
Varus laxity at 30 degrees of knee flexion
Posterior drawer
Pivot shift
Patellar apprehension

Correct Answer: Pivot shift

Explanation:

DISCUSSION: The T
2
-weighted sagittal MRI scan shows the classic “bone bruise” pattern seen with an anterior cruciate ligament (ACL) tear. These lesions are thought to represent subcortical trabecular hemorrhages and are manifested as an increase in signal intensity on T
2
-weighted images and diminished signal intensity on T
r
weighted images. They are classically located in the mid-portion of the lateral femoral condyle and posterior aspect of the lateral tibial plateau. This is due to the fact that an ACL tear typically is the result of a valgus-extemal rotation of the femur on the fixed tibia. This places most of the weight-bearing stress on the lateral femoral condyle, which rotates laterally and impacts the posterior lip of the lateral tibial plateau. This may result in an impaction fracture if the force is great enough, but more frequently causes merely a microfracture of the involved subcortical trabeculae.
REFERENCES: Vellet AP, Marks PH, Fowler PJ, et al: Occult posttraumatic osteochondral lesions of the knee: Prevalence, classification, and short-term sequelae evaluated with MR imaging. Radiology 1991;178:271-276.
Cone R: Imaging sports-related injuries of the knee, in DeLee J, Drez D, Miller M (eds): DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 2, pp 1595-1652.

Question 52:

When the data are normally distributed, what statistical test is best used to compare means of three or more independent groups?

Options:

Kaplan-Meier analysis
Analysis of variance
Chi-square test
Meta-analysis
Log rank test

Correct Answer: Analysis of variance

Explanation:

Question 53:

Options:

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

Correct Answer: Ligaments are viscoelastic.

Explanation:

Question 54:

Options:

no difference in terminal range of motion.
a lower functional outcome score. C. a clinically significant reduction in passive forward flexion and external rotation.
a higher retear rate of the rotator cuff repair. Historically, orthopaedic surgeons considered early range-of-motion programs following rotator cuff surgery secondary to concerns about potential postsurgical stiffness. Although this may have been a concern with primary open repair, arthroscopic surgery appears to substantially decrease this risk. More recently, investigators are reporting similar results in terms of range of motion, retear rate, and functional outcome scores among patients who undergo early versus delayed rehabilitation programs.

Correct Answer: no difference in terminal range of motion.

Explanation:

Stemless shoulder arthroplasty prostheses have recently been suggested as an alternative to traditional stemmed replacement. Advantages of the stemless surgical technique would include
A. better glenoid exposure than with stemmed prostheses.
B. reliable use in four-part proximal humerus fracture reconstruction.
C. use in proximal humeral malunion without the need for an osteotomy. D. improved long-term survivorship profile.

Question 55:

What is the primary reason for including the ilium in the distal fixation of long instrumentation constructs in adult scoliosis?

Options:

Better coronal balance
Better pelvic balance
Reduced fretting and corrosion
Improved curve correction
Improved fusion success

Correct Answer: Improved fusion success

Explanation:

DISCUSSION: Studies have shown that when compared with fixation to the sacrum alone, the success rate of fusion across the lumbosacral junction increases when both the sacrum and ilium are included in the posterolateral construct. Curve correction, coronal balance, and pelvic balance are all attended to within the thoracolumbar spine and are not directly related to the pelvic fixation. Fretting and corrosion are a byproduct of metal-to-metal connections.
REFERENCES: Islam NC, Wood KB, Transfeldt EE, et al: Extension of fusions to the pelvis in idiopathic scoliosis. Spine 2001;26:166-173.
Emami A, Deviren V, Berven S, et al: Outcome and complications of long fusions to the sacrum in adult spine deformity: Luque-Galveston, combined iliac and sacral screws, and sacral fixation. Spine 2002;27:776-786.

Question 56:

Options:

Intramedullary screw fixation of the fibula
Plating of the fibula with a one third tubular plate
Subtalar arthrodesis with deformity correction
Varus producing distal tibial osteotomy
Ankle arthrodesis

Correct Answer: Subtalar arthrodesis with deformity correction

Explanation:

Question 57:

Options:

Bed rest for 6 weeks, followed by mobilization in a thoracolumbosacral orthosis (TLSO) until the fracture has healed
Immediate mobilization in a TLSO, continuing until the fracture has healed
Anterior corpectomy with strut grafting and placement of anterior fixation
Anterior corpectomy and strut grafting followed by posterior spinal fusion and instrumentation
Posterior spinal fusion and instrumentation

Correct Answer: Posterior spinal fusion and instrumentation

Explanation:

DISCUSSION: The injury pattern is that of a burst fracture at L1 contiguous with a compression fracture at T12. There is associated kyphosis and slight spondylolisthesis of T12 on L1. Treatment of this type of burst fracture in neurologically intact patients is somewhat controversial, with at least one study demonstrating equal long-term results comparing nonsurgical treatment to surgical treatment. In this study, however, body casts were used initially in the nonsurgical group. Moreover, because this patient has multiple fractures, spinal fracture stabilization should be considered to facilitate early mobilization. Surgical stabilization and fusion via a posterior approach is the best treatment option in this patient. Anterior decompression is not necessary since the patient is neurologically intact.
REFERENCES: McLain RF, Benson DR: Urgent surgical stabilization of spinal fractures in polytrauma patients. Spine 1999;24:1646-1654.
Wood K, Butterman G, Mehbod A, et al: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: A prospective, randomized study.
J Bone Joint Surg Am 2003;85:773-781.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 58:

Which of the following antibiotics is contraindicated in children?

Options:

Penicillin
Cephalexin
Tetracycline
Erythromycin
Ampicillin

Correct Answer: Tetracycline

Explanation:

DISCUSSION: The tetracycline family of medications can stain teeth and bone in skeletally immature patients and as a result should be avoided in those patients. The remaining antibiotics have no known specific contraindication to use in children.
REFERENCE: Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 433-457.

Question 59:

Options:

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

Correct Answer: The child is a victim of neglect

Explanation:

Question 60:

The use of nonsteroidal anti-inflammatory drugs following femoral nailing has been associated with which of the following?

Options:

Increased rate of nonunion
Decreased narcotic requirements
Faster time to union
Increased rate of heterotopic ossification
Decreased rate of revision surgery

Correct Answer: Increased rate of nonunion

Explanation:

Question 61:

Options:

Parosteal osteosarcoma
Classic osteogenic sarcoma
Ewing’s sarcoma
Osteochondroma
Chondrosarcoma

Correct Answer: Parosteal osteosarcoma

Explanation:

Question 62:

Which of the following substances makes up the majority by weight of the extracellular matrix for articular cartilage?

Options:

Keratin sulfate
Collagen type II
Water
Protein
Chondroitin sulfate

Correct Answer: Water

Explanation:

Question 63:

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

Options:

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

Correct Answer: Moving valgus stress test

Explanation:

Question 64:

A 16-year-old boy who is a competitive basketball player (Figure 43)

Options:

Ligamentous reconstruction
Meniscal repair
Meniscectomy 39
Immobilization

Correct Answer: Meniscal repair

Question 65:

Options:

Which of the following conditions associated with rheumatoid arthritis of the cervical spine is shown in the flexion-extension views in figures 45a and 45b?
Cranial setting
Cranial subluxation
Odontoid fracture
Lysis of the arch of the atlas
Atlantoaxial subluxation

Correct Answer: Lysis of the arch of the atlas

Explanation:

Question 66:

Options:

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

Correct Answer: Hemiarthroplasty

Explanation:

DISCUSSION: Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult.
REFERENCES: Gerber C, Lambert SM: Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376-382.
Spencer EE Jr, Brems JJ: A simple technique for management of locked posterior shoulder dislocations: Report of two cases. J Shoulder Elbow Surg 2005;14:650-652.
Sperling JW, Pring M, Antuna SA, et al: Shoulder arthroplasty for locked posterior dislocation of the shoulder. J Shoulder Elbow Surg 2004;13:522-527.
Hawkins RJ, Neer CS II, Pianta RM, et al: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
McLaughlin HL: Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;34:584-590.

Question 67:

-Which gene correlates with severity of disease in spinal muscular atrophy (SMA)?

Options:

Peripheral myelin protein 22 (PMP22)
Survival motor neuron I (SMN1)
Survival motor neuron II (SMN2)
Dystrophin

Correct Answer: Survival motor neuron II (SMN2)

Explanation:

Question 68:

Options:

Open reduction internal fixation with transosseous sutures
Arthroscopic fixation using a suture bridge technique
Nonsurgical treatment with early passive range of motion
Nonsurgical treatment with sling immobilization for 4 weeks

Correct Answer: Nonsurgical treatment with early passive range of motion

Explanation:

Question 69:

This condition is most prevalent in people of which ancestry?

Options:

Northern European
Asian
Native American
Sub-Saharan African

Correct Answer: Native American

Explanation:

Question 70:

Figures 20a and 20b show the sagittal and coronal T1-weighted MRI scans of a patient’s left knee. Abnormal findings include

Options:

enchondroma of the proximal tibia.
a bone bruise of the lateral femoral condyle.
a tear of the lateral collateral ligament.
a tear of the discoid lateral meniscus.
a physeal fracture of the proximal femur.

Correct Answer: a tear of the discoid lateral meniscus.

Explanation:

Question 71:

Options:

Radial collateral ligament
Posterior bundle of the ulnar collateral ligament
Anterior bundle of the ulnar collateral ligament
Flexor carpi ulnaris
Pronation teres

Correct Answer: Anterior bundle of the ulnar collateral ligament

Explanation:

Question 72:

Options:

external traction.
open reduction and internal stabilization.
repeat closed reduction under general anesthesia.
open reduction.
percutaneous pin fixation in the current position.

Correct Answer: open reduction.

Explanation:

DISCUSSION: The radiographs show a complex dislocation of the little finger metacarpophalangeal joint. This is characterized by obvious dislocation on the AP and lateral views and a type of bayonet apposition best visualized on the lateral view. Irreducibility of this injury is caused by displacement of the volar plate that has been traumatically avulsed from its origin on the metacarpal, with subsequent displacement into the metacarpophalangeal joint. This abnormal position of the volar plate causes irreducibility that can be corrected only by open reduction. This can be effected either by dorsal or palmar approaches.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 711-771.
Becton JL, Christian JD Jr, Goodwin HN, Jackson JG III: A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg Am 1975;57:698-700.
Green DP, Terry GC: Complex dislocation of the metacarpophalangeal joint: Correlative pathological anatomy. J Bone Joint Surg Am 1973;55:1480-1486.

Question 73:

Options:

Revision of the acetabular implant to a constrained bearing with modular exchange of the femoral head and neck
Revision of the acetabular and femoral implants
Retention of the acetabular implant with modular exchange of the femoral head and neck
Revision of the femoral component alone with a new ceramic head

Correct Answer: Revision of the acetabular and femoral implants

Explanation:

Question 74:

- Figure 67 shows the AP radiograph of both knees of a 26-year-old woman. A review of the patient’s medical record will most likely reveal a history of

Options:

Trauma
Hemophilia
Reiter’s syndrome
Rheumatoid arthritis
Systemic lupus erythematosus

Correct Answer: Systemic lupus erythematosus

Explanation:

Question 75:

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

Options:

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

Correct Answer: an increased rate of volumetric wear.

Explanation:

Question 76:

Options:

repeat closed reduction and buddy taping.
closed reduction and percutaneous pin fixation, followed by casting.
open reduction and plate fixation, followed by casting.
open reduction and screw fixation, followed by splinting and early motion.
open reduction and intramedullary fixation with absorbable implants.

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

Explanation:

DISCUSSION: The patient has an unstable oblique fracture of the proximal phalanx that is easily reducible but unstable; therefore, the treatment of choice is closed reduction and percutaneous pin fixation, followed by casting. Closed reduction and percutaneous pin fixation offers a better functional result than open reduction and plate fixation. Repeat closed reduction and buddy taping is inadequate because of the inherently unstable fracture pattern. Buddy taping will allow the dislocation to recur. The other options represent more aggressive surgical techniques than are necessary to treat this fracture.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 711-771.
Green DP, Anderson JR: Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am 1973;55:1651-1653.

Question 77:

Figure 31 is the sagittal MR image of a 30-year-old man with a clear-cell sarcoma of the foot. There is no evidence of disease elsewhere after standard staging of a soft-tissue sarcoma.

Options:

Marginal resection
Transverse incisional biopsy centered over the mass
Incisional biopsy centered over the mass in line with the long axis of the limb
Sentinel node biopsy
Core needle biopsy

Correct Answer: Marginal resection

Explanation:

DISCUSSION
For patients with rapidly enlarging painless masses, particularly those that are either large or deep, the diagnosis of a soft-tissue sarcoma should be entertained. Masses exceeding 5 cm in largest dimension that are subfascial and heterogenous on MRI are concerning. MRI with and without contrast is the preferred imaging modality for evaluation of soft-tissue sarcomas because it can delineate location of the lesion, involvement of neurovascular structures, intra-articular involvement, and underlying signal alteration in the osseous structures. Most patients can relate the onset of their symptoms to a traumatic event, and the interpretation of an MRI may include a hematoma. Ultrasound is more commonly used to confirm the clinical impression of a cyst and to distinguish cystic from solid masses.
A core needle biopsy can easily be performed in an outpatient setting or with image guidance to aid in the diagnosis. Core needle biopsies preserve the architectural relationship of cells, which is important in the diagnosis of mesenchymal lesions. A core needle biopsy is appropriate for soft-tissue lesions and osseous lesions and should be performed in a multidisciplinary setting with a surgeon performing the resection so unnecessary compartmental contamination is not introduced into the needle tract.
A fine-needle aspiration allows cytologic but not histologic analysis and generally is not favored for the diagnosis of a sarcoma. If an open biopsy is performed, the incision must be oriented in line with the long axis of the extremity to minimize contamination of surrounding structures. Meticulous hemostasis and closure of the tumor pseudocapsule must be achieved to minimize local tissue contamination. An open biopsy is commonly used if an initial needle biopsy is nondiagnostic. Transverse biopsy incisions should not be used.
Presurgical radiation for sarcomas is advantageous to decrease the field of radiation and overall radiation dose, but a significant postsurgical wound-healing complication rate (up to 35%) is associated with presurgical radiation therapy.
Staging of sarcomas is important to help predict prognosis. Not all sarcomas are reliably positive on a PET scan, so the preferred staging studies are CT scan of the chest and whole-body bone scan. Hematogenous spread of sarcomas is the most common route of metastatic disease, which speaks to the value of chest CT scans. Clear-cell sarcomas (in addition to synovial sarcoma, angiosarcoma, epithelioid sarcoma, and rhabdomyosarcoma) tend to involve lymphatic nodal metastatic disease, so sentinel node biopsy is considered when assessing these tumors. Evidence supports efficacy of sentinel node biopsy for clear-cell sarcomas in particular.
RECOMMENDED READINGS
Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, eds.
AJCC Cancer Staging Manual
. 7th ed. New York, NY: Springer; 2010.
Arbeit JM, Hilaris BS, Brennan MF. Wound complications in the multimodality treatment of extremity and superficial truncal sarcomas. J Clin Oncol. 1987 Mar;5(3):480-8.
View Abstract at PubMed
Luce EA. The irradiated wound. Surg Clin North Am. 1984 Aug;64(4):821-9. PubMed PMID: 6591499.
View Abstract at PubMed
Cheng EY, Dusenbery KE, Winters MR, Thompson RC. Soft tissue sarcomas: preoperative versus postoperative radiotherapy. J Surg Oncol. 1996 Feb;61(2):90-9.
View Abstract at PubMed
Mankin HJ, Lange TA, Spanier SS. The hazards of biopsy in patients with malignant primary bone and soft-tissue tumors. J Bone Joint Surg Am. 1982 Oct;64(8):1121-7.
View Abstract at PubMed
Singer S, Nielsen T, Antonescu CR. Molecular biology of soft tissue sarcoma. In: DeVita VT Jr, Lawrence TS, Rosenberg SA, eds.
Cancer: Principles and Practice of Oncology
. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1522-1532.
Singer S, Maki RG, O'Sullivan B. Soft tissue sarcoma. In: DeVita VT Jr, Lawrence TS, Rosenberg SA, eds.
Cancer: Principles and Practice of Oncology
. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1533-1577.
Malawer MM, Helman LJ, O'Sullivan B. Sarcomas of bone. In: DeVita VT Jr, Lawrence TS, Rosenberg SA, eds.
Cancer: Principles and Practice of Oncology
. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1578-1609.
O'Sullivan B, Davis AM, Turcotte R, Bell R, Catton C, Chabot P, Wunder J, Kandel R, Goddard K, Sadura A, Pater J, Zee B. Preoperative versus postoperative radiotherapy in soft-tissue sarcoma of the limbs: a randomised trial. Lancet. 2002 Jun 29;359(9325):2235-41.
View Abstract at PubMed
Andreou D, Boldt H, Werner M, Hamann C, Pink D, Tunn PU. Sentinel node biopsy in soft tissue sarcoma subtypes with a high propensity for regional lymphatic spread--results of a large prospective trial. Ann Oncol. 2013 May;24(5):1400-5. doi: 10.1093/annonc/mds650. Epub 2013 Jan 31. PubMed PMID: 23372051.
View Abstract at PubMed

Question 78:

Total hip arthroplasty in a patient with a long-standing hip fusion on the contralateral side is most likely to result in

Options:

a higher rate of infection.
a higher rate of mechanical failure and loosening.
a higher rate of myositis ossificans.
a higher rate of dislocation.
improved gait efficiency.

Correct Answer: a higher rate of mechanical failure and loosening.

Explanation:

Question 79:

A patient with Pott's disease, tuberculosis of the spine, is more likely to have which of the following early findings? Review Topic

Options:

Acute onset back pain and neurologic dysfunction
Preservation of the disk space between two affected adjacent end plates
Involvement of the cervical spine and torticollis
Elevated WBC count and markedly elevated erythrocyte sedimentation rate
Lordotic deformity in late stages of the disease

Correct Answer: Preservation of the disk space between two affected adjacent end plates

Explanation:

Question 80:

Lumbar disk replacement has been shown to offer which of the following results?

Options:

Provides long-term pain relief superior to that achieved with lumbar fusion
Provides long-term pain relief equivalent to that achieved with lumbar fusion
Provides long-term pain relief in patients with symptomatic degenerative disk disease and facet arthropathy
Consistently prevents the development of adjacent segment disease
Consistently restores normal segmental motion

Correct Answer: Provides long-term pain relief equivalent to that achieved with lumbar fusion

Explanation:

Question 81:

Options:

overgrowth of the distal radial epiphysis.
premature closure of the distal radial physis.
premature closure of the distal ulnar physis.
a Salter-Harris type I fracture of the distal radius with a volar slip of the epiphysis.
a Salter-Harris type I fracture of the distal radius with a dorsal slip of the epiphysis.

Correct Answer: premature closure of the distal radial physis.

Explanation:

Question 82:

Options:

- No additional reduction and continued treatment in the cast
- Repeat closed reduction and cast application
- Closed reduction and percutaneous skeletal fixation
- Open reduction and internal fixation

Correct Answer: - No additional reduction and continued treatment in the cast

Explanation:

DISCUSSION
Studies demonstrate that surgical treatment of distal radius fractures in elderly people does not result in improved outcomes. Although nonsurgical treatment resulted in worse radiographic findings for this patient, these findings did not translate into worse functional outcomes.
RECOMMENDED READINGS
Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011 May;36(5):824-35.e2. doi: 10.1016/j.jhsa.2011.02.005. Review. PubMed PMID: 21527140.
View Abstract at PubMed
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53. doi: 10.2106/JBJS.J.01597. PubMed PMID: 22159849.
View
Abstract
at PubMed
American Academy of Orthopaedic Surgeons: Treatment of Distal Radius Fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons, March 2013. Available at
http://www.aaos.org/research/Appropriate_Use/drfauc.asp Accessed {10/8/14}. Last Accessed on 10/8/14

Question 83:

The addition of which of the following food supplements may lead to a decrease in neural tube defects?

Options:

Vitamin D-1,25
Vitamin B-12
Niacin
Folic Acid
Thiamine

Correct Answer: Folic Acid

Explanation:

Question 84:

Options:

tone-reduction ankle-foot orthoses (AFOs).
intramuscular injections of botulinum-A toxin.
an intrathecal baclofen injection.
selective posterior rhizotomy.
fractional tendon lengthening of bilateral hamstring and gastrocnemius muscles.

Correct Answer: selective posterior rhizotomy.

Explanation:

Question 85:

Options:

Lumbar laminectomy with synovial cyst excision
Repeat epidural steroid injection
Microdiskectomy at L4-5
Nonsteroidal medication and outpatient physical therapy
Left-sided facet blocks at L4-5 and L5-S1

Correct Answer: Repeat epidural steroid injection

Explanation:

Lumbar spinal stenosis with lumbar radiculopathy can be commonly caused by a synovial cyst arising from the facet joints. Lyons and associates reported on the surgical treatment of synovial cysts in 194 patients. Of the 147 with follow-up data, 91% reported good pain relief and 82% had improvement of their motor deficits. Epstein reported a 58% to 63% incidence of good/excellent results and a 38 to 42
point improvement on the SF-36 Physical Function Scale. It was also suggested that since the presence of a synovial cyst indicates facet pathology, possible fusion should be considered in these patients, especially those with underlying spondylolisthesis.
(SBQ12SP.20) Amphotericin B is most appropriate for the treatment of which type of spine infection?
Review Topic
Fungal osteomyelitis
Bacterial osteomyelitis with a gram-positive organism
Bacterial osteomyelitis with a gram-negative organism
Tuberculous osteomyelitis
Viral meningomyelitis
Amphotericin B would be most appropriate for the treatment of fungal infections of the spine.
Amphotericin B is a broad-spectrum anti-fungal medication. It is commonly used as the first-line agent for treatment of fungal infections of the spine. The most common fungi involving the spine include cryptococcus, candida, and aspergillus. The indications for débridement and stabilization with spinal fusion, includes resistance to antibiotic therapy, spinal instability, and/or neurologic deficits.
Kim et al. reviewed fungal infections of the spine. They comment that fungus infections are most commonly spread by hematogenous or direct spread. Access to the vascular system may include intravenous lines, during implantation of prosthetic devices, or during surgery.
Frazier et al. retrospectively reviewed 11 patients with fungal osteomyelitis of the spine. Nine of the patients were immunocompromised secondary to diabetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrition. All were treated with anti-fungal medication. 10 of 11 patients were also treated with surgical debridement. Paralysis secondary to the spine infection developed in eight patients. After an average of 6.3 years of follow-up, the infection had resolved in all nine surviving patients.
Illustration A shows the mechanism of action of Amphotericin. Illustration B shows T1- (Image A and B) and T2-weighted (Image C) images of the lower thoracic and lumbar spine. There are hypointense signals within the T12 and L1 vertebral bodies (Images A and B) indicative of fungal osteomyelitis.
IncorrectAnswers:

Question 86:

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

Options:

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

Correct Answer: Spondylolysis

Explanation:

Question 87:

Options:

Revision total knee arthroplasty with placement of a hinge constrained device
Patellar tendon repair with nonabsorbable suture and patellar resurfacing
Hinged knee brace with drop lock design to restore stability during ambulation
Extensor mechanism reconstruction using synthetic mesh or allograft

Correct Answer: Extensor mechanism reconstruction using synthetic mesh or allograft

Explanation:

Question 88:

Options:

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

Correct Answer: Bony glenoid augmentation procedure

Explanation:

Question 89:

Options:

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

Correct Answer: Excision of the hook of the hamate

Explanation:

Question 90:

A player on a professional football team sustains a knee injury and is diagnosed with an anterior cruciate ligament rupture. When employed as the team physician, your ethical obligation is to inform

Options:

the player but not the team.
the team but not the player.
neither the team nor the player.
both the team and the player.
the team, the player, and the media

Correct Answer: both the team and the player.

Explanation:

Question 91:

Options:

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

Correct Answer: fasciotomies of the foot.

Explanation:

Question 92:

Options:

The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior medial portal created 3 cm from the tip of the olecranon and medial to the triceps
The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps
The posterior medial portal created 3 cm from the tip of the olecranon and medial to the triceps and the posterior lateral portal created 3 cm from the tip of the olecranon and lateral to the triceps
The posterior medial portal created 3 cm from the tip of the olecranon and the lateral portal made through the anconeus
The posterior portal created at the tip of olecranon and the posterior medial portal just medial to the triceps

Correct Answer: The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps

Explanation:

Question 93:

-The center of rotation of the knee can be best described as

Options:

remaining fixed during flexion.
moving posterior as flexion increases.
shifting forward and then back with flexion.
shifting posterior on the lateral side with flexion.
sliding forward on the medial side with increasing flexion.

Correct Answer: shifting posterior on the lateral side with flexion.

Question 94:

Options:

Admit for observation and reassurance
Surgical exploration and removal of the anterior instrumentation
Esophageal swallowing study
Soft cervical collar and early range-of-motion exercises
CT of the cervical spine

Correct Answer: Admit for observation and reassurance

Explanation:

DISCUSSION: The radiograph shows significant prevertebral soft-tissue swelling following a two-level anterior cervical diskectomy and fusion. The incidence of dysphagia 2 years after anterior cervical spine surgery is 13.6%. Risk factors for long-term dysphagia after anterior cervical spine surgery include gender, revision surgeries, and multilevel surgeries. The use of instrumentation, higher levels, or corpectomy versus diskectomy did not significantly increase the prevalence of dysphagia. Lee and associates demonstrated that while dysphagia after anterior cervical spine surgery is a common early finding, it generally decreases significantly by
6 months with nonsurgical management. A minority of patients experience moderate or severe symptoms by 6 months after the procedure. Female gender and multiple surgical levels have been identified as risk factors for the development of postoperative dysphagia.
REFERENCES: Lee MJ, Bazaz R, Furey CG, et al: Risk factors for dysphagia after anterior cervical spine surgery: A two-year prospective cohort study. Spine J 2007;7:141-147.
Bazaz R, Lee MJ, Yoo JU: Incidence of dysphagia after anterior cervical spine surgery:
A prospective study. Spine 2002;27:2453-2458.

Question 95:

All of the following are characteristic of synovium affected by rheumatoid arthritis (RA) EXCEPT:

Options:

Prominent intimal hyperplasia
Decreased apoptosis
Increased angiogenesis
Disruption of the basement membrane
Abundant lymphocytes

Correct Answer: Prominent intimal hyperplasia

Explanation:

Question 96:

Options:

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

Correct Answer: Open fracture

Question 97:

Options:

Immediate weightbearing
Subchondral debridement of any osteochondral defect
Repair of medial ligamentous structures
Casting or splinting in a neutral position postoperatively
Anatomic reduction of the syndesmosis

Correct Answer: Anatomic reduction of the syndesmosis

Explanation:

Question 98:

The brachialis muscle is innervated by what two nerves?

Options:

Radial and musculocutaneous
Lateral and medial brachial cutaneous
Axillary and medial and lateral pectoral
Radial and ulnar
Ulnar and musculocutaneous

Correct Answer: Radial and musculocutaneous

Explanation:

Question 99:

Options:

Early mobilization and a guided proprioceptive and strengthening
Extended immobilization in a cast
Surgical intervention
Weight bearing as tolerated in an ankle brace for 6 weeks

Correct Answer: Early mobilization and a guided proprioceptive and strengthening

Explanation:

Question 100:

Which of the following factors is associated with failure of arthroscopic excision of the distal clavicle?

Options:

Removal of less than 2 cm of bone
Male gender
Female gender
Diagnosis of osteolysis
Uneven resection of bone

Correct Answer: Uneven resection of bone

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

Orthopedic Board Exam MCQs: Trauma, Oncology & Joint Surgery Part 220

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 220

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index