Orthopedic Board Review: Hip & Shoulder Arthroplasty MCQs

About This Board Review Set

This is Part 228 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Two distinct learning modes are available:

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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 228

This module focuses heavily on: Arthroplasty, Hip, Shoulder.

Sample Questions from This Set

Sample Question 1: Which of the following descriptions is true regarding APC-II (anterior-posterior compression) pelvic injuries as classified by Young and Burgess?...

Sample Question 2: 6 grams each per 40 mg PMMA...

Sample Question 3: A 52-year-old woman reports nagging shoulder pain that has been present for months and is slowly progressive in nature. The patient also reports nocturnal pain and notes that the pain is not activity related. Figures 27a and 27b show the ra...

Sample Question 4: A 30-year-old patient has had severe left hip pain and difficulty ambulating, necessitating the use of a cane, for the past 6 months. A photomicrograph of the femoral head sectioned at the time of surgery is shown in Figure 31. What is the ...

Sample Question 5: A 72-year-old woman with diabetes mellitus who underwent a total shoulder arthroplasty for degenerative arthritis 5 years ago now reports the sudden onset of shoulder pain following recent hospitalization for pneumonia. Laboratory values sh...

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

Which of the following descriptions is true regarding APC-II (anterior-posterior compression) pelvic injuries as classified by Young and Burgess?

Explanation

DISCUSSION: APC II injuries are unstable injuries and occur as a result of high-energy trauma. Anatomic structures which are injured or torn include the pubic symphysis, anterior iliosacral ligaments, and the sacrotuberous ligaments. The posterior sacroiliac ligaments are spared in APC-II injuries, and differentiate an APC-II injury from an APC-III injury, in which the posterior ligaments are also torn.
Burgess et al review the classifications of pelvic ring disruptions and their association with mortality. They concluded that APC injuries required more blood replacement and were related to death more often than lateral compression, vertical shear, or combined mechanism pelvic injuries.
Tile studied the anatomy of anterior to posterior pelvic ring injuries. Although the anterior structures, the symphysis pubis and the pubic rami, contribute to 40% to the stiffness of the pelvis, clinical and biomechanical studies have shown that the posterior sacroiliac complex is more important to pelvic-ring stability. The posterior sacroiliac ligamentous complex is more important to pelvic-ring stability than the anterior structures and therefore, the classification of pelvic fractures is based on the stability of the posterior lesion.

Question 2

6 grams each per 40 mg PMMA

Explanation

DISCUSSION
Vancomycin and tobramycin do not produce systemic toxicity in doses as high as 10.5 grams of vancomycin and 12.5 grams of tobramycin per 40 mg of PMMA.
RECOMMENDED READINGS
Hake ME, Young H, Hak DJ, Stahel PF, Hammerberg EM, Mauffrey C. Local antibiotic therapy strategies in orthopaedic trauma: Practical tips and tricks and review of the literature. Injury. 2015 Aug;46(8):1447-56. doi: 10.1016/j.injury.2015.05.008. Epub 2015 May 14. Review. PubMed PMID: 26007616. View Abstract at PubMed
Springer BD, Lee GC, Osmon D, Haidukewych GJ, Hanssen AD, Jacofsky DJ. Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty. Clin Orthop Relat Res. 2004 Oct;(427):47-51. PubMed PMID: 15552135. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 84 THROUGH 86
Figure 84 is the noncontrast MR image obtained at 2 weeks postinjury for a 52-year-old man who was injured after falling from a ladder. His arm is caught in an abducted, externally rotated
position. There is no sense of dislocation. Initial radiograph findings are normal. The radiologic review reads “Probable superior labral anterior to posterior (SLAP) tear.”

Question 3

A 52-year-old woman reports nagging shoulder pain that has been present for months and is slowly progressive in nature. The patient also reports nocturnal pain and notes that the pain is not activity related. Figures 27a and 27b show the radiograph and bone scan, and Figures 27c through 27e show T 1 -weighted, T 2 -weighted, and gadolinium MRI scans, respectively. Based on these findings, what is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph reveals a metaphyseal lesion with some stippled mineralization suggesting a chondroid tumor. The bone scan shows increased uptake, beyond what is expected for a simple enchondroma, and beyond the limits of the lesion. The MRI sequences shows a lobular lesion on the T₁- and T₂-weighted (bright on the T₂ sequence) images with inhomogeneous uptake of gadolinium; both findings are typical for a chondroid lesion. The history of pain, the positive bone scan, the age of the patient, the size of the lesion, and the central location (enostotic) of the lesion all suggest a malignant cartilage tumor. The images are not consistent with the other diagnoses. In particular, plasmacytoma is more uniformly bright on T₂-weighted images and often has a negative bone scan.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 187-194.
Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, WB Saunders, 2002, pp 3897-3904.

Question 4

A 30-year-old patient has had severe left hip pain and difficulty ambulating, necessitating the use of a cane, for the past 6 months. A photomicrograph of the femoral head sectioned at the time of surgery is shown in Figure 31. What is the most likely diagnosis?

Explanation

DISCUSSION: The photomicrograph demonstrates a wedge-shaped infarct with femoral head collapse; therefore, the diagnosis is osteonecrosis of the femoral head. Perthes disease and osteoarthritis do not involve a wedge-shaped defect. Tuberculosis of the hip joint results in greater destruction of the articular cartilage.
REFERENCES: Basset LW, Mirra JM, Cracchiolo A III: Ischemic necrosis of the femoral head: Correlation between magnetic resonance imaging and histologic sections. Clin Orthop 1987;223:181-187.
Sugano N: Osteonecrosis, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopedics. St Louis, MO, Mosby, 2002, pp 878-887.

Question 5

A 72-year-old woman with diabetes mellitus who underwent a total shoulder arthroplasty for degenerative arthritis 5 years ago now reports the sudden onset of shoulder pain following recent hospitalization for pneumonia. Laboratory values show a WBC count of 11,400/mm3 and an erythrocyte sedimentation rate of 52mm/h. What is the most appropriate action?

Explanation

DISCUSSION: The patient has the preliminary diagnosis of an infected shoulder arthroplasty; therefore, shoulder radiographs and joint aspiration for organism identification should be the first steps in the work-up. The patient is at risk for hematogenous spread given the recent history of pneumonia and her history of diabetes mellitus. Although she has stiffness, a stretching program is not indicated with the possibility of infection. Scheduling for revision arthroplasty, or irrigation and debridement will depend on multiple factors including identification of the infecting organism, the organism’s susceptibility to antibiotics, and implant stability. An MRI scan to evaluate for a rotator cuff tear is not indicated at this time.
REFERENCES: Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 953-954.
Stinchfield FE, Bigliani LU, Neu HC, et al: Late hematogenous infection of total joint replacement. J Bone Joint Surg Am 1980;62:1345-1350.

Question 6

Figures 31a and 31b show the radiograph and MRI scan of an otherwise normal 3-month-old infant who has a spinal deformity. MRI reveals no intraspinal anomalies. What is the next step in management? Review Topic

Explanation

Congenital scoliosis in an infant warrants evaluation of the renal, cardiac, and neurologic systems because frequently there is concurrent pathology. Progression in this instance is possible but not certain; therefore, progression must be documented prior to any surgical intervention. Close observation with serial radiographs every 4 to 6 months is appropriate. All of the surgical options listed may be reasonable choices in the future, but cardiac evaluation is the most important issue at this time.

Question 7

For this patient, which TKA design is most appropriate?

Explanation

DISCUSSION
TKA in the setting of valgus deformities poses different challenges than those encountered when varus deformities are present. Most valgus alignment is attributable to a deformity of the distal femur rather than the proximal tibia, as seen in varus knees. One of the major anatomical differences is a hypoplastic lateral femoral condyle which, when used as a rotational reference point, can lead to internal rotation of the femoral component if not recognized. This malrotation will in turn lead to patellofemoral maltracking or instability, which is a common complication associated with primary TKA. The deformity is too severe to consider a bicruciate-retaining TKA or unicompartmental arthroplasty and does not necessitate a hinged TKA.

Question 8

Articular cartilage is divided in zones with specific arrangements of the collagen framework and proteoglycan content. The superficial zone is characterized by collagen oriented

Explanation

Understanding collagen orientation is important to understand articular cartilage damage and disease. Articular cartilage acts as a fiber-reinforced composite matrix able to withstand and distribute physiologic loads without mechanical failure. Collagen fibers form a complex framework with a distinctive cross-sectional architecture. The superficial zone is characterized by collagen fibers oriented parallel to the joint surface and a relatively low concentration of proteoglycans. The transitional zone is characterized by larger diameter collagen fibers oriented in a more random manner, with a higher concentration of proteoglycans. The deep zone has the largest collagen fibers with a vertical arrangement. It has the highest proteoglycan concentration. Calcification of the matrix is seen in the zone of calcified cartilage.

Question 9

At a minimum 2-year follow-up and compared with the metacarpophalangeal (MCP) joint, pyrolytic carbon resurfacing arthroplasties of the proximal interphalangeal (PIP) joint

Explanation

EXPLANATION:
Wall and Stern published a report on MCP joint pyrolytic carbon arthroplasty for osteoarthritis and another on PIP joint pyrolytic carbon resurfacing arthroplasty for osteoarthritis. They found different outcomes, and MCP joint implants outperformed PIP joint implants. Of eleven MCP joint arthroplasties, two produced asymptomatic squeaking and clicking, whereas eleven of 31 PIP joint implants produced this problem. No dislocations were reported among the MCP joint implants, but five PIP joint dislocations were observed. Outcomes were measured by the Michigan Hand Outcomes Questionnaire in both studies and were satisfactory for the MCP joint implants, with an average score of 80. The PIP implants did not fare as well, showing a higher degree of pain along with an average score of 53. The authors noted that, in the 15 patients in the PIP study who had unilateral surgery, the uninvolved, nonsurgical hand motion was actually statistically significantly (P<0.01) better than the surgical hand. MCP joint motion increased from 62º before surgery to 76º after surgery, whereas PIP joint motion got worse after surgery, with the average motion decreasing from 57º to 31º.

Question 10

An 86-year-old woman sustained a fracture of the humerus and underwent surgical fixation 8 weeks ago. There was no radial nerve function below the elbow after surgery. Radiographs are shown in Figures 51a and 51b. What is the most appropriate management at this time?

Explanation

DISCUSSION: Most radial nerve palsies associated with closed fractures of the humerus resolve spontaneously, including Holstein-Lewis lesions (radial nerve palsy associated with oblique distal third fractures of the humerus). Initial sign of recovery at the brachioradialis may not occur for 4 months. There has been no evidence of deleterious effects occurring during this observation period. There are advocates of early exploration of the nerve. Exploration in the intermediate period between 1 and 4 months is not supported. As overall alignment of the fracture is acceptable, there is no need for hardware exchange until nonunion is clearly identified.
REFERENCES: Shao YC, Harwood P, Grotz MR, et al: Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. J Bone Joint Surg Br 2005;87:1647-1652.
Green DP: Radial nerve palsy, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 112.

Question 11

CLINICAL SITUATION Figures 1 and 2 are the radiographs of a 68-year-old woman who comes to the emergency department after stepping into a hole and twisting her ankle. She is complaining of isolated ankle pain and is unable to bear weight. After closed manipulative reduction and splint placement, she is scheduled for operative treatment. The stability of the syndesmosis should be evaluated after

Explanation

Discussion: The radiographs reveal a trimalleolar ankle fracture dislocation with an associated distal tibiofibular syndesmotic disruption. Medial and lateral malleolar stabilization are consistently agreed upon. The decision to stabilize the posterior malleolus is more controversial. Posterior malleolar stabilization accomplishes the following:
Restores incisura competence thereby reducing the incidence of syndesmotic malreduction by creating containment
Assists in stabilizing the syndesmosis via the posterior inferior tibiofibular ligament, potentially limiting the need for additional syndesmotic stabilization
Maximizes the surface area for ankle joint loading
Enhances posterior translational stability of the talus
The traditional indication for stabilization of the posterior malleolus is based on fragment size. However, fracture orientation varies and makes evaluation of the fragment size challenging with a lateral radiograph alone. The three primary types include the posterolateral oblique, medial extension, and shell. Because of the additive syndesmotic stability which is gained through the deep deltoid ligament and medial malleolar fixation, the anterior talofibular ligament and lateral malleolar fixation, and the posterior inferior tibiofibular ligament and posterior malleolar fixation, syndesmotic stability should only be assessed after all other points of instability that are planned for fixation are fixed.
Syndesmotic instability should be assessed with direct manipulation on both the anteroposterior and lateral views with special attention to the lateral view. Syndesmotic reduction should be assessed either through open visualization or by comparing closed reduction parameters (clear space, overlap, and fibular position on the lateral view) with the patient’s contralateral side (assuming no injury). This is more effective than using population norms secondary to the two types of syndesmotic morphologies which create different absolute values for these parameters.

Question 12

A 19-year-old collegiate baseball player injures the ring finger on his dominant hand while sliding headfirst into second base. He reports that he is unable to actively flex or extend the distal interphalangeal joint of the finger. Radiographs are shown in Figures 19a and 19b. What is the anatomic lesion leading to this injury?

Explanation

DISCUSSION: The radiographs reveal a bony avulsion of the flexor profundus insertion (Jersey finger). The large bony fragment classifies this as a Leddy type III injury. The bony fragment has retracted to the level of the annular pulley (A4).
REFERENCES: Leddy JP, Packer JW: Avulsion of the insertion of the profundus tendon insertion in athletes. J Hand Surg 1977;2:66-69.
Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin 1985;1:77-83.

Question 13

What is the most common complication following metatarsal osteotomy for a bunion deformity in an adolescent?

Explanation

Hallux varus-The question does not specify proximal or distal osteotomies, however it is the most common complication with overcorrection of proximal 1st metatarsal osteotomies. Mann. Pg. 329. “Transfer” 2nd metatarsaglia-most significant, not most common, complication of the Mitchell Osteotomy.Mann pg. 319.
Physeal arrest of the first metatarsal-“While an open epiphysis cannot be considered an absolute contraindication to an osteotomy in either the proximal phalanx, or proximal first metatarsal, it is
important at surgery to determine the exact location of the metaphyseal epiphysis to avoid injury.” Pg. 307 Mann, Surgery of Foot and Ankle.
In studies performed by Blais et. Al. A females full foot growth is usually achieved by 14 years and at 12 years an average less than 1 cm of total foot growth remains with less than 50% of this growth at the proximal epiphysis. Males’ terminal growth expected at 16 years of age with 3cm left at 12 years and approximately 1.5 cm of metatarsal growth.
Most studies show recurrence of Hallux Valgus deformity after surgical correction in the juvenile as inordinately high.

Question 14

A 30-year-old right hand-dominant woman is seen in the trauma unit after a high-speed motor vehicle accident. She sustained a right shoulder anterior dislocation that is gently reduced under sedation. A CT scan is shown in Figure 3. If left untreated, the patient is at greatest risk for

Explanation

DISCUSSION: Large, displaced anterior inferior glenoid rim fractures predispose patients to recurrent anterior instability due to loss of the normal concavity compression effect of the glenoid. These defects require open reduction and internal fixation to reestablish shoulder stability. Although intra-articular fractures may lead to arthrosis, recurrent instability is

more common.
REFERENCES: Robinson CM, Kelly M, Wakefield AE: Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: Risk factors and results of treatment.

J Bone Joint Surg Am 2002;84:1552-1559.
Bigliani LU, Newton PM, Steinmann SP, et al: Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med 1998;26:41-45.

Question 15

Among the options listed below, what is the best treatment for the complication shown in Figure 10c?

Explanation

DISCUSSION
Proximal femur fractures can be treated using a variety of implants including intramedullary nails, blade plates, and locking plates (now precontoured proximal femur plates). The comminution and lack of medial cortical support may predispose these fractures to nonunion.
The recent popularity of locking plates for proximal femur treatment has increased their use for this fracture; however, a disproportionately high rate of failure of these plates, including early implant failure with plate and screw breakage, cut out with varus collapse, and nonunion have been reported.?
Malreduction predisposes these fractures to failure. The initial postoperative radiographs do not reveal a varus malreduction because the tip of the greater trochanter is below the center of the femoral head.
Once failure occurs, the best fixation method among the options detailed is an intramedullary nail (second generation with screws into the femoral head) and restoration of alignment. THA is usually not recommended for treatment of subtrochanteric femur fractures in young patients.
RECOMMENDED READINGS
Wirtz C, Abbassi F, Evangelopoulos DS, Kohl S, Siebenrock KA, Krüger A. High failure rate of trochanteric fracture osteosynthesis with proximal femoral locking compression plate.
Injury. 2013 Jun;44(6):751-6. doi: 10.1016/j.injury.2013.02.020. Epub 2013 Mar 21. PubMed PMID: 23522837. View Abstract at PubMed
Floyd JC, O'Toole RV, Stall A, Forward DP, Nabili M, Shillingburg D, Hsieh A, Nascone JW. Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures. J Orthop Trauma. 2009 Oct;23(9):628-33. doi: 10.1097/BOT.0b013e3181b04835. PubMed PMID: 19897983. View Abstract at PubMed Glassner PJ, Tejwani NC. Failure of proximal femoral locking compression plate: a case series. J Orthop Trauma. 2011 Feb;25(2):76-83. doi: 10.1097/BOT.0b013e3181e31ccc.
PubMed PMID: 21245709. View Abstract at PubMed

Question 16

Ulnar collateral ligament (UCL) reconstruction using a modified Jobe technique

Explanation

DISCUSSION
Certain complications are more strongly associated with the approach and surgical procedure for elbow pathology. With a 2-incision distal biceps repair, heterotopic ossification
with a radial-ulnar synostosis is a concern. This complication can be minimized through irrigation of bone debris and care to avoid dissection between the radius and ulna. With a single-incision distal biceps repair, the lateral antebrachial cutaneous nerve is retracted during the procedure. Numbness on the lateral side of the forearm is common, although often temporary. During arthroscopic debridement for lateral epicondylitis, injury to the radial UCL can occur, leading to posterolateral rotatory instability of the elbow. The modified Jobe technique for UCL reconstruction typically involves an ulnar nerve transposition during the procedure. Numbness and tingling in the fourth and fifth digits are concerns when this procedure is performed.

Question 17

A 32-year-old man notes increasing back pain and progressive paraparesis over the past few weeks. He is febrile, and laboratory studies show a WBC of 12,500/mm3. MRI scans are shown in Figures 6a and 6b. Management should consist of

Explanation

DISCUSSION: Indications for surgery in spinal infections include progressive destruction despite antibiotic treatment, an abscess requiring drainage, neurologic deficit, need for diagnosis, and/or instability. This patient has a progressive neurologic deficit. Debridement performed at the site of the abscess should effect canal decompression. Once the debridement is complete back to viable bone, the defect can be reconstructed with a strut graft. Additional posterior stabilization is used as deemed necessary by the degree of anterior destruction. CT-guided needle aspiration, while occasionally useful in the earliest phases of an infection, produces frequent false-negative results and would provide little useful information in the management of this patient.
REFERENCES: Emery SE, Chan DP, Woodward HR: Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting. Spine 1989;14:284-291.
Lifeso RM: Pyogenic spinal sepsis in adults. Spine 1990;15:1265-1271.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 713-721.

Question 18

5 g/dL and his base deficit is 10mEq/L. What is the most appropriate next step in management?

Explanation

Posteromedial rotatory instability
Capitellum fracture
Radial head fracture and posterolateral ulnohumeral dislocation
Trans-olecranon fracture dislocation
Medial (ulnar) collateral ligament rupture Corrent answer: 3
The clinical presentation is consistent with a coronoid tip fracture. This fracture pattern is associated with a radial head fracture and posterolateral ulnohumeral dislocation - together making up the terrible triad injury.
A terrible triad injury is the result of a valgus and supination injury and involves posterolateral elbow dislocation or lateral collateral ligament injury, radial head fracture, and fracture of the coronoid process. The elbow may dislocate postero-laterally with the anterior bundle of the MCL intact, but if the MCL is injured it is typically the last structure to fail. The coronoid fracture is typically a small fragment isolated to the tip. This is a result of a posteriorly directed force driving the coronoid into the trochlea prior to posterior elbow dislocation. CT scan is a useful modality when small or comminuted fragments are difficult to visualize on plain radiographs.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figures A through D show consecutive 2.00 mm sagittal CT reformats demonstrating a small coronoid fracture fragment which was addressed with suture fixation.
Incorrect Answers:
OrthoCash 2020
A 62-year-old right-hand-dominant school teacher sustains a mechanical fall at home and presents with right shoulder pain. Plain
radiographs of the right shoulder are pictured in Figures A and B. The patient asks you what she can expect in terms of recovery following this injury. Which of the following is the most appropriate statement?

At 1-year post-injury, the right shoulder range of motion will most likely be equal to the contralateral extremity.
At 1-year post-injury, you will most likely have returned to your baseline functional status.
Early range of motion exercises risk fracture displacement and should be avoided until at least 4 weeks post-injury.
Most patients do not return to work following this injury.
One in 5 patients with this fracture go on to nonunion and you may benefit from surgery in the future to address this.
This patient has a minimally displaced (1-part) proximal humerus fracture involving the humeral neck and greater tuberosity. This injury pattern is most commonly managed nonoperatively with the majority of patients returning to their baseline functional status by 1 year.
Proximal humerus fractures (PHF) can be classified by number of parts (Neer classification), with a part defined as a fracture fragment displaced > 1cm (> 5mm for greater tuberosity) or angulated > 45°. One-part PHF comprise ~80% of all PHF and are treated nonoperatively with a sling and early range of motion (ROM).
Tejwani et al performed a prospective study of 67 patients with 1-part PHF. At 1-year follow up the ASES score and functional status was similar to pre-injury status. However, ROM of the affected shoulder was diminished in both external and internal rotation. Forward flexion was preserved.
Hanson et al prospectively analyzed 160 patients with PHF of all types (1-4 parts and head-splitting) managed nonoperatively. At 1-year follow up, 93% showed solid union. Constant and DASH scores improved steadily over time but were still lower compared to the contralateral extremity. Of employed patients, 97.6% returned to work with a median time off of 10 weeks and no difference between manual and nonmanual workers.
Figures A and B are the AP and axillary radiographs of the right shoulder, respectively, demonstrating a 1-part PHF involving the humeral neck and greater tuberosity.
Incorrect Responses:
OrthoCash 2020
A 44-year-old male presents with the isolated injury seen in Figure A after a motor vehicle accident and underwent the operative treatment seen in Figure B within 8 hours from the time of incident. Which of the following complications is this patient at highest risk of developing?

Pulmonary embolus
Periprosthetic fracture
Contralateral hip fracture
Osteonecrosis
Infection
This young male patient has sustained a displaced femoral neck fracture and underwent open reduction internal fixation with 3 cannulated screws. Based on the available options, the patient is most at risk of developing osteonecrosis of the femoral head.
Femoral neck fractures in young patients typically are the result of a high-energy trauma. Fracture displacement has been shown to disrupt vascular supply to the femoral head by interrupting retinacular vessels and ligament teres vascularization, as well as increasing intracapsular pressure, producing a tamponade effect. The incidence of osteonecrosis in patients younger than 60 years with displaced femoral neck fractures has been shown to be between 15-30%. Quality of reduction is one key factor that has been shown to influence outcomes postoperatively.
Loizou et al. prospectively studied 1,023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using standard fixation modalities. They showed that osteonecrosis was less common for undisplaced (4.0%) than for displaced fractures (9.5%). The population at greatest risk were women younger than the age of 60 with displaced fractures.
Barnes et al. review subcapital hip fractures. They found that late segmental collapse was more common in displaced fractures in women younger than age 75 years than in those older than age 75 years treated with internal fixation.
Figure A shows a displaced, Garden 3/Pauwels III hip fracture. Figure B shows anatomical fixation with 3 cannulated screws.
Incorrect Answers:
OrthoCash 2020
A 58-year-old male is involved in a motor vehicle collision and sustains the injury shown in Figure A in addition to right 5th and 6th rib fractures. Upon evaluation in the emergency department, he is noted to have a 2 centimeter laceration over the anterior aspect of his left leg with visible bone. Vitals and labs are normal. Which of the following statements is most accurate regarding surgical management for this patient?

Reamed intramedullary nailing is favored due to increased rates of union
Unreamed intramedullary nailing is favored due to presence of concomitant rib fractures
Reamed intramedullary nailing is favored due to decreased rates of infection
Unreamed intramedullary nailing is favored due to less local trauma
Both unreamed and reamed intramedullary nailing are equivalent Corrent answer: 5
Both unreamed and reamed intramedullary nailing are equivalent treatments in patients with open tibia fractures. Intramedullary nailing is the treatment of choice for stable patients with tibial shaft fractures.
Tibial shaft fractures can be the result of low energy twisting injuries or higher energy axial loads. Closed fractures with acceptable alignment can be often be treated with closed reduction and casting. Intramedullary nailing, unreamed or reamed, is the treatment of choice for open fractures except in the setting of damage control orthopaedics when an external fixator may be more appropriate.
Bhandari et al. investigated reamed and unreamed intramedullary nailing for tibial shaft fractures in a randomized trial ("SPRINT" Trial - Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators). They concluded that reamed nailing was more beneficial (decreased rate of primary outcome event: need for bone grafting, implant exchange or removal for infection, debridement for infection) for closed fractures, but had no benefit in open fractures.
Finkemeier et al. evaluated consecutive patients treated with unreamed and reamed intramedullary nailing and found similar rates of union in both open and closed tibial shaft fractures at six and twelve months.
Figures A shows AP and lateral xrays of the left tibia showing a tibial shaft fracture.
Incorrect Answers:
OrthoCash 2020
A 36-year-old male falls from a 10-ft scaffold and suffers the injuries shown in Figures A and B. The patient is placed in a spanning external fixator and brought back to the operating room once his soft tissues are amenable. Planning to use a dual-incision approach, what is the correct interval to use when approaching the medial side?

Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius Corrent answer: 5
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:

OrthoCash 2020
A 25-year-old male presents to the emergency department with the injury seen in Figure A after a motorcycle collision. The patient has a blood pressure of 70 systolic, elevated lactate and a tense abdomen with positive FAST examination. Trauma surgery will be performing an emergent laparotomy. Orthopaedic surgery is consulted and places a pelvic external fixator intraoperatvely to assist with resuscitation. What is an advantage of supra-acetabular external fixator pins as compared with iliac crest pins?

Less interference with pelvic surgical incisions
Less risk of pin tract infection
Less risk of malreduction
Less control of posterior pelvic ring
No interference with laparotomy Corrent answer: 1
One advantage of supra-acetabular external fixator pins is that they do not interfere or contaminate future approaches to the pelvis or acetabulum involving the lateral window.
In multiply injured patients with pelvic trauma external fixation of the pelvic ring is a valuable tool to assist with resuscitation. Pelvic external fixation should be applied rapidly and allow full access to the abdomen for general surgery intervention. Regardless of the technique used, a pelvic external fixator should form a stable construct that minimizes motion of fracture surfaces and allows for clot formation.
Haidukewych et al evaluated the safety of supra-acetabular pin placement in a cadaveric study. The authors found that the lateral femoral cutaneous nerve (LFCN) was most at risk during pin placement.
Figure A demonstrates a widely displaced symphyseal dislocation with associated bilateral sacroiliac (SI) dislocations (APC 3). Illustration A demonstrates an outlet radiograph of a supra-acetabular external fixtator in conjunction with posterior pelvic ring fixation for an LC3 pelvic ring injury.
Illustration B is an illustration of iliac crest external fixation. The video demonstrates techniques for application of both supra-acetabular and iliac
crest external fixation pins.
Incorrect Answers:

OrthoCash 2020
What physical exam finding is most likely to be found in association with the injury shown in Figures A and B?

Numbness in the small finger and ulnar side of the ring finger
No elbow instability
Varus posteromedial rotatory instability
Valgus posterolateral rotatory instability
An anterior open wound Corrent answer: 3
The x-ray shows a fracture of the anteromedial facet of the coronoid with an intact radial head. Large anteromedial facet fractures are associated with varus posteromedial rotatory instability.
The anteromedial facet of the coronoid provides support to the medial elbow against varus stress. Varus and posteromedial force applied to the elbow results in disruption of the lateral collateral ligament (LCL) from its proximal origin. The coronoid is fractured as it is forced against the medial trochlea.
Coronoid fractures of significant size involving the sublime tubercle (insertion of medial collateral ligament) result in varus instability.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques. He states that when a coronoid fracture is associated with a pattern of varus instability, it requires fixation with either suture, buttress plating or screw fixation. Concomitant LCL repair or reconstruction will also be necessary.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong
associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figure A is an AP view of an elbow with an anteromedial facet of the coronoid fractured. The lateral joint space is widened due to injury to the LCL. The medial joint space is narrowed and collapsed. A lateral view is shown in Figure
B. Illustrations A and B show AP and lateral views of a coronoid fracture fixed with buttress plating. The LCL origin was fixed with a suture anchor. Illustration C shows the O'Driscoll classification of coronoid fractures. Illustration D lists injury patterns that suggest posteromedial versus posterolateral rotatory instability.
Incorrect Answers:

OrthoCash 2020
A 35-year-old man presents to the ED as the restrained driver of a high speed motor vehicle collision complaining of hip, chest, and abdominal pain. He becomes diaphoretic, tachycardic, and hypotensive in the trauma bay and is noted to have diminished lower extremity pulses. He is found on ATLS workup to have mediastinal widening.
Which of the following injuries is most associated with thoracic aortic injury?

Thoracic aortic rupture is associated with posterior hip dislocation in deceleration trauma mechanism of injuries.
Posterior hip dislocations are infrequently associated with local vascular injuries. With bilateral perfusion deficits, more proximal large vessel trauma should be considered, and in this situation, thoracic surgery should be involved emergently. Screening chest x-ray in the trauma bay should be reviewed for widened mediastinum, suggestive of aortic injury, as shown in illustration A. Given the high energy mechanism associated with these injuries, a full ATLS trauma survey must be done for every patient.
Marymont et al. studies the association between posterior hip dislocation and thoracic aortic injury. They performed a retrospective chart review of 89 posterior hip dislocations and found 8% had an aortic injury. Although not statistically significant, they note the importance of evaluation for aortic injury in patients with posterior hip dislocations given its emergent life-threatening nature.
In addition to associated chest injuries, Schmidt et al. highlight the importance of evaluating the ipsilateral knee after high-energy traumatic hip dislocation. In a prospective study, they identified a 93% rate of ipsilateral knee injury on MRI including effusion (37%), bone bruising (33%), and meniscal tear (30%) as the most common. They recommend a thorough exam but also expanded use of knee MRI after hip dislocation.
Illustration A shows an example of chest x-ray with a widened mediastinum, suggestive of thoracic aortic injury.

OrthoCash 2020
A 31-year-old female smoker was involved in a skiing accident approximately 9 months ago and underwent open reduction internal fixation of the radius and ulna at the time of injury. She now returns to the clinic complaining of increasing pain with range of motion and activity. Radiographs from her most recent follow-up can be seen in Figure A. Laboratory tests show ESR, CRP and WBC count to be within normal limits. Which of the following options is the most appropriate next step in management?

Bone scan
Above elbow cast
Removable splint
Reamed intramedullary nail
Iliac crest bone grafting + compression plating Corrent answer: 5
This patient is presenting with an atrophic non-union of the ulna after open reduction internal fixation for a both bone forearm fracture 9 months ago. The most appropriate next step in management would be iliac crest bone grafting and compression plating of the ulna.
The primary issue with an atrophic nonunion is biological. The blood supply is poor and therefore incapable of purposeful fracture healing. Smokers, as in this vignette, are at high risk for nonunion. The treatment of an atrophic nonunion involves improving biology at the fracture site through use of autologous bone graft (e.g. iliac crest) and providing mechanical stability by means of compression plating (e.g. 3.5 mm LC-DCP).
dos Reis et al. reports excellent results of 31 cases of diaphyseal forearm fracture non-unions treated with autologous bone grafting and compression
plating. Thirty of thirty-one patients went on to bony union within 3.5 months of revision surgery.
Nadkarni et al. presented a case series of 11 patients with non-unions of various long bones initially managed with intradmedullary (IM) nail fixation. The authors successfully used locking compression plates while retaining the IM nails in the treatment of the nonunion in all cases.
Figure A shows an AP radiograph of a both bone forearm fracture. Figure B shows an AP and lateral radiograph of an atrophic non-union of the ulnar shaft. Illustration A shows a lateral x-ray of a fully healed radius and ulna after hardware removal 1 year after revision surgery.
Incorrect Answers:

OrthoCash 2020
A 27 year-old patient sustains a fracture-dislocation of the acetabulum. Pelvic radiographs (Figures A and B) are taken at initial presentation and a CT scan (Figures C and D) is performed after reduction of the hip in the emergency room. What is the importance of the finding highlighted in the CT scan cuts?

Comminution indicates a better result with non-operative management
Significant marginal impaction could compromise the results of the surgical reduction if the joint surface is not properly restored
The impacted fracture segment will heal without fixation because it is not gapped or translated
The CT scan finding highlighted indicates osteochondral defects to the femoral head, which can be addressed arthroscopically
Intraarticular fracture fragments should be discarded from the surgical field, as incorporation of the fragments into the fixation construct leads to a high rate of avascular necrosis
The CT images shown in Figures C and D display significant marginal impaction of the joint surface.
Marginal impaction is common in posterior wall fractures and fracture-dislocations. Critical review of CT imaging of posterior wall fractures can help with preoperative planning for identifying impaction of the articular surface of the acetabulum. Restoration of the sphericity of the acetabulum to match that of the femoral head is important for successful outcome following ORIF of posterior wall fractures. A common surgical technique to accomplish joint surface restoration includes freeing the impacted articular segments, bone grafting of the void created to support the articular segments, and buttress plating of the posterior wall fracture fragments.
Patel et al. discuss the challenge of interpreting imaging of the acetabulum for assessing fracture characteristics that may significantly impact success or surgical intervention. These characteristics include: articular displacement, marginal impaction, incongruity of the joint surface, intra-articular fragments, and osteochondral injury to the femoral head. Based on expert review of images, determination of significant marginal impaction had a poor intraobserver reliability, as did each of the other modifiers listed.
Figures A and B are radiographs of the posterior wall fracture and hip dislocation. They do not show the large amount of marginal impaction of the acetabular surface. Figure C (coronal reconstruction) and Figure D (sagittal reconstruction) point out a large a amount of marginal impaction of the acetabular. Note the disruption of the joint surface on the intact portion of the acetabulum.
Incorrect answers:
Comminuted posterior wall fractures still should be surgically stabilized if the joint is unstable
This impacted fragment on the margin of the main fracture line will likely heal regardless of restoration of the articular surface; however, this malreduction will lead to a incongruent joint surface
These CT cuts do not show any osteochondral defects of the femoral head; however if found in other CT cuts or intraoperatively, they should be appropriately addressed
Intraarticular fracture fragments should be removed from the joint, but if they make up a substantial portion of the joint surface, they should be incorporated in the fixation construct to obtain the goal of anatomic reduction of the joint surface
OrthoCash 2020
A 32-year-old female is involved in a motor vehicle collision and suffers a right hip dislocation. She is in the twelfth week of pregnancy.
Evaluation in the emergency department reveals no other injuries and ultrasound reveals a strong fetal heart rate and no abnormalities. She undergoes emergent closed reduction but the hip remains unstable and a traction pin is placed. Post-reduction films are shown in Figure
What is the most appropriate next step in management?

Acute open reduction internal fixation
Exam under anesthesia
Skeletal traction for 6-8 weeks
Fetal monitoring until 15 weeks followed by open reduction internal fixation
Percutaneous pinning
This patient has a large posterior wall fracture of the right acetabulum with an unstable hip. The most appropriate next step in treatment is open reduction and internal fixation.
Fixation of acetabular fractures during pregnancy is not contraindicated in the setting of stable fetal heart rate and no abnormalities on pelvic ultrasound.
There is, however, an increased risk of complications for the mother and fetus. Injury severity and mechanism are most closely associated with increased rate of fetal complications. The trimester of pregnancy is not associated with increased risk of complications.
Leggon et al. reviewed 101 cases of pelvic and acetabular fractures in pregnant patients and found mechanism of injury and injury severity were associated with higher mortality for both mother and fetus. Trimester of pregnancy was not associated with increased mortality.
Flik et al. reviewed orthopaedic trauma in a pregnant patients and recommended fetal ultrasound for assessment of fetal well-being in all pregnant patients.
Desai et al. investigated orthopaedic trauma during pregnancy and reported minimal radiation risk to the fetus when obtaining x-rays. They also advocate for LMWH as one of the safest choices for anticoagulation.
Figure A is an x-ray showing a right posterior wall acetabular fracture. Figures B and C are Judet views of the pelvis focusing on the right hip. A large posterior wall fragment is visible in Figure B.
Incorrect Answers:
OrthoCash 2020
Figure A is radiograph of a 50-year-old male science teacher that was involved in a motor vehicle accident. He underwent closed reduction as seen in Figure B and C. What would be the most appropriate treatment?

Open reduction and internal fixation with medial bridge plate and lateral screw in non-lagging mode
Tibiotalocalcaneal arthrodesis
Open reduction and internal fixation with lateral and medial screw in lagging mode
Closed reduction and internal fixation with medial and lateral screw in non-lagging mode
Closed reduction with percutaneous pins Corrent answer: 1
This patient is presenting with a Hawkins II talar neck fracture with medial wall comminution. The most appropriate treatment of this patient would be open reduction internal fixation with medial plate and lateral screw in non-lagging mode.
The treatment of talar fractures is based on the severity of the fracture, soft-tissues, and patient factors. The fracture and subluxation of the subtalar joint should be reduced and stable anatomical fixation should be obtained. When there is comminution of either the superior, lateral or medial aspects of the talus, one should avoid shortening the medial wall as this will cause a varus malunion. The use of a medial or lateral plate can help to re-establish column length, which can often prevent this potential complication.
Sanders et al. showed significant complications after fixation of talar neck fractures. They showed the incidence of secondary reconstructive procedures following talar neck fractures increased from 24% +/- 5% at 1 year to 48%
+/- 10% at 10 years post-injury.
Vallier et al. retrospectively reviewed the records of 39 fractures of the talar neck treated with open reduction and internal fixation. Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09).
Vallier et al. reviewed 81 talar neck fractures to revisit the rate of osteonecrosis and post-traumatic arthritis based on the Hawkins Classification. They found that delaying definitive internal fixation does not increase the risk of developing osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01).
Figure A shows a Hawkins II talar neck fracture. Figures B and C are saggital and coronal CT images, respectively, of the foot. There is significant comminution of the medial wall of the talus with extension into the subtalar joint.
Incorrect Answers:
There is some research to suggest primarily subtalar arthrodesis with these injuries. However, to date, there is no high level evidence that has conclusively shown subtalar arthrodesis to be better than ORIF.
OrthoCash 2020
A 28-year-old male college student sustains a severe foot injury from gunshot-related violence, and subsequently undergoes a lower-extremity amputation as shown in Figure A. At long-term follow-up, which of the following is the strongest predictor of patient satisfaction as related to his injury?

Age less than 30
Marijuana use
Use of negative pressure wound therapy
Male gender
Ability to return to work Corrent answer: 5
The strongest factor to predict patient-reported outcomes after trauma-related lower extremity amputations is the patient's ability to return to work. This is likely due to the effect of the return to work on the physical, emotional, and financial aspects of the patient's life.
The LEAP study is a multicenter, prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.
O'Toole et al reviewed 463 patients treated for limb-threatening lower-extremity injuries and identified factors associated with patient reported outcomes two years after surgery. They found that return to work was the most associated with outcomes, but that physical functioning, walking speed, pain levels, and presence of depression were also associated to a lesser extent with outcomes.
Bosse et al performed a multicenter, prospective study to assess outcomes of 569 patients with severe lower extremity limb injuries that resulted in either amputation or limb salvage procedures. They found that at two years postoperatively, no significant differences were seen between groups in patient-reported outcome. Worse outcomes were associated with rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), and involvement in disability-compensation litigation.
Figure A shows a clinical photograph of a Pirigoff amputation at early follow-up. This amputation is an end-bearing amputation that utilizes the plantar heel pad for weightbearing, and relies on a tibiocalcaneal arthrodesis.
Incorrect Answers:
4: These options are not as strong of a factor of patient satisfaction in longterm follow up after trauma-induced lower extremity amputation.
OrthoCash 2020
A 34 year-old male falls off of motorcycle on an outstretched hand suffering the injuries shown in Figures A and B. He is brought to the operating room and undergoes radial head replacement and fixation and repair of the coronoid and the lateral collateral ligament (LCL). Prior to closing, the elbow is still unstable upon testing range of motion. What is the next best step in management?

Exchange radial head for larger implant
Complete resection of radial head
Cast at 90 degrees of flexion for 6-8 weeks
Reinforce LCL repair with non-absorbable suture
Repair the ulnar collateral ligament Corrent answer: 5
Following complete fixation and repair of a terrible triad, a final range of motion test should be performed prior to closure. If still unstable, the next step should be to assess and repair the ulnar collateral ligament. Another option
would be to placed a hinged external fixator.
Operative reconstruction of a terrible triad injury should be performed in a systematic fashion, working from deep to superficial. Working through a lateral incision and through the radial head fracture, the coronoid should be fixed first, followed by radial head fixation or replacement and then repair/reconstruction of the LCL. If still unstable, the medial side should be addressed, or the patient placed in a hinged external fixator.
Mathew et al review the anatomic, biomechanic, and operative principles (why the above step-by-step method works) to achieving appropriate stability in order to obtain early range of motion to maximize clinical outcome.
Pugh et al. in this retrospective, multi-center study report outcomes on 36 terrible triad injuries fixed with the standard protocol described above. The authors recommend following this systematic approach to achieve the best results.
Figures A and B are AP and lateral radiographs exhibiting a terrible triad elbow fracture-dislocation.
Incorrect answers:
OrthoCash 2020
When treating the pathology depicted in Figures A through D, which of the following is necessary to preserve the blood supply to the femoral head?

Dissection of the gluteal musculature off the iliac crest
Ligation of the ascending branches of the lateral femoral circumflex artery
Greater trochanteric osteotomy
Identification and detachment of the piriformis tendon
Supine positioning
Figures A-D show a femoral head with associated acetabular fracture (Pipkin IV). Both the posterior wall fracture and the femoral head fracture can be addressed through a surgical dislocation via greater trochanteric osteotomy.
Pipkin IV femoral head fracture (with associated acetabular fractures) are somewhat problematic in that the femoral head fracture is usually anterior, while the acetabular fracture usually involves the posterior wall. A Kocher-Langenbeck approach gives good access to the posterior wall but limited access to the articular surface and femoral head avascular necrosis (AVN) is a concern. A Smith-Peterson approach provides good access to the femoral head
but not to the posterior wall. Combined approaches significantly increase the amount of surgical dissection. Surgical dislocation with trochanteric flip osteotomy provides access to the femoral head and posterior wall while preserving blood supply to the femoral head.
Solberg et al. retrospectively reviewed 12 patients with Pipkin IV injuries treated via a trochanteric flip osteotomy. All patients healed their acetabular fractures. Eleven of 12 patients healed their femoral head fractures and one patient (8.3%) developed osteonecrosis.
Henle et al. likewise treated 12 patients with Pipkin IV injuries through a trochanteric flip osteotomy. Two of 12 patients (16.7%) developed osteonecrosis. The remaining 10 patients (83.3%) had good or excellent results. Heterotopic ossification occurred in five patients, causing significant range of motion loss in four of these.
Figure A is a pre-reduction AP pelvis in which the posterior wall fracture is apparent. Figure B is a post-reduction AP pelvis in which an infra-foveal femoral head fracture is apparent (Pipkin IV). Figure C is an axial CT cut which further characterizes the posterior wall fracture. Figure D is an obturator oblique showing femoral head dislocation and posterior wall fracture. The video shows a surgical hip dislocation technique.
Incorrect Answers:
OrthoCash 2020
A 42-year-old male presents to your clinic for the first time with the radiographs seen in Figure A. He sustained the injury 4 weeks ago while skiing overseas and treatment was provided by the local orthopaedic surgeon. The operative note states that he sustained an Gustilo Type I open fracture. After surgical fixation of this type of injury, what is the most common complication requiring reoperation?

Chronic elbow instability
Post-traumatic arthritis
Infection
Heterotopic ossification
Loss of elbow range of motion Corrent answer: 5
This patient sustained a terrible triad elbow fracture-dislocation. Reduced range of motion of the elbow joint is the most common complication REQUIRING reoperation with these injuries.
Terrible triad elbow fracture-dislocations are characterized by posterolateral dislocation/lateral collateral ligament (LCL) injury, radial head fracture and coronoid fracture. Displaced fractures result in elbow instability. Acute radial head stabilization, coronoid open reduction and internal fixation, and LCL +/-medial collateral ligament (MCL) repair/reconstruction is considered the most appropriate treatment for displaced fractures. Operative complications include elbow stiffness, recurrent instability, arthritis, failure of hardware, heterotopic ossification, posterior interosseous nerve palsy and infection.
Egol et al. looked at the functional outcomes of 27 patients that underwent fixation of terrible triad injuries. At one year follow-up, the average flexion-extension arc of elbow motion was 109 degrees +/- 27 degrees, and the average pronation-supination arc was 128 degrees +/- 44 degrees. Grip strength averaged 72% of the contralateral extremity. Although operative fixation led to functional elbow stability, results were poor.
They included a reference to McKee et al. to highlight that intra-articular fractures of the elbow have high rates of stiffness. While not specific to terrible
triads, they looked at the effectiveness of the posterior elbow approach in 25 patients that underwent internal fixation of intra-articular distal humerus fractures. They showed poor outcomes at a mean follow-up of 36 months with reduced range-of-motion, decreased strength and high re-operation rates.
Figure A shows AP fluoroscopic image of a terrible triad injury that has undergone operative fixation. The radial head and coronoid have undergone open reduction internal fixation, and the MCL bony avulsion has been repaired.
Incorrect Answers:
OrthoCash 2020
Figure A is a radiograph from a 59-year-old male that was transferred to a Level I trauma center five hours after a motor vehicle accident. Closed reduction and skeletal traction was successfully performed in the trauma bay. Which of the following factors has been shown to increase the risk of unsatisfactory clinical outcome for this patient?

Need for skeletal traction
Mechanism of injury
Gender
Age
Time to reduction Corrent answer: 4
Age greater than 55-years-old has been found to be an independent risk factor for inferior clinical outcome in patients with combined acetabular fractures and hip dislocations.
The most important initial step in management following resuscitation involves urgent reduction of the dislocated hip. This should be followed by a preoperative CT scan and ultimately surgical fixation of the combined acetabular fracture. Hip dislocations should be reduced within 6-12 hours for optimal outcome, although different critical times have been cited, particularly for dislocations with concomitant acetabular fractures. Skeletal traction may be required to maintain hip reduction.
Moed et. al. present a Level 3 retrospective review of 100 patients who had been treated with open reduction internal fixation of an acetabular fracture. The authors found that factors associated with unsatisfactory clinical outcomes included age greater than 55, intra-articular comminution, osteonecrosis, and delay of greater than 12 hours for reduction of an associated hip dislocation.
Additionally, they showed that there was a strong association of clinical outcome and final radiographic grade.
Figure A demonstrates an acetabular fracture with concomitant hip dislocation. Incorrect Answers:
injury, male gender, and time to reduction <6 hours have not been shown to be related to unsatisfactory outcomes.
OrthoCash 2020
A 37-year-old male cashier is shot in the leg. He sustains the injury shown in Figures A and B, and is subsequently taken to the operating room for intramedullary nailing. Figure C shows a radiograph of the nail starting point (*). What complication is most likely to result?

Varus malunion
Nonunion
Valgus malunion
Malrotation
Superficial peroneal nerve injury Corrent answer: 3
This patient is presenting with a comminuted fracture of the proximal third of the tibia. He is appropriately undergoing intramedullary nail fixation, however, the start point illustrated in Figure C is too medial and often leads to a valgus malunion.
Intramedullary nail fixation is more technically demanding in proximal tibial fractures than diaphyseal fractures. The valgus deformity is due to imbalanced muscle forces on the proximal fragment, which are then accentuated by a start point that is too medial. An apex anterior (procurvatum) deformity can also occur and results from the pull of the patellar tendon or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment. The ideal starting point for proximal tibial fractures is slightly lateral to the medial aspect of the lateral tibial spine on a true AP x-ray and very proximal and just anterior to the anterior margin of the articular surface.
Nork et al. reported the results of intramedullary nailing of proximal tibial fractures with emphasis on techniques of reduction. Various techniques were found to be successful including attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia.
Lowe et al. describe surgical techniques for complex proximal tibial fractures. They describe the extended leg position, use of a femoral distractor, temporary plate fixation, blocking (Poller) screws, and use of percutaneous clamps as means to achieve reduction during fixation.
Figure A and B show an AP and lateral radiograph of a comminuted extra-articular fracture through the proximal third of the tibia. Figure C demonstrates a start point that is too medial (represented by the asterisk) for intramedullary nail fixation. Illustration A and B show the ideal start point for intramedullary nail fixation of the tibia on AP and lateral radiographs.
Incorrect Answers:
Varus malunion is more likely to occur in midshaft tibia fractures with an intact fibula.
Nonunion after a proximal tibial fracture treated with intramedullary nailing is less common than malunion.
Malrotation occurs most commonly after IM nailing of fractures through the distal third of the tibia.
The superficial peroneal nerve is at risk during distal screw fixation using a LISS plating technique for fracture fixation.

OrthoCash 2020
A 24-year-old motorcyclist is brought in as a polytrauma after striking a tree at 65 mph. He is found to have injuries involving the chest, abdomen, pelvis, as well as a left open femoral shaft fracture. He undergoes resuscitation in the trauma bay. Which of the following parameters best supports proceeding with irrigation, debridement and external fixation as opposed to immediate reamed intramedullary nailing?
Temperature = 35.5°C (95.9°F)
Fractures of ribs 2-3 with left apical pneumothorax
Grade IV liver laceration with SBP = 85 mmHg
Left superior and inferior pubic ramus fractures
Lactate = 2.3 mg/dL
Significant abdominal trauma with evidence of hemorrhagic shock (SBP < 90 mmHg) following resuscitation is an unstable parameter and therefore is an indication to proceed with damage control orthopaedics (irrigation and debridement of open fractures and temporizing external fixation) in a polytraumatized patient.
The management of orthopaedic injuries in a polytrauma patient depends on the physiological stability of the patient. In an unstable patient, damage control orthopaedics (DCO) is preferred over early total care (ETC) to avoid an iatrogenic second hit with development of adult respiratory distress syndrome (ARDS) and/or multiple organ failure. Clinical parameters indicative of instability include shock (BP < 90 mmHg, refractory to blood products, lactate
> 2.5 mg/dL), coagulopathy (platelet count < 90,000 mm3, fibrinogen < 1 g/L), hypothermia (< 35°C), and significant chest, abdomen or pelvis injuries (pulmonary contusions, severe liver/spleen lacerations, pelvic ring disruption).
Pape et al. (2009) authored a review article detailing the management of a multitrauma patient. Polytrauma patients can be classified as stable, borderline, unstable or in extremis using a variety of criteria pertaining to hemodynamic stability, coagulation, temperature and soft tissue injury.
Patients who are stable or borderline can undergo ETC, while patients who are unstable or in extremis should be managed with DCO.
Pape et al. (2008) concluded that all patients who underwent early femoral nailing demonstrated increased systemic inflammatory response compared to external fixation, regardless of clinical stability. However, unstable patients
with a preexisting elevation of inflammatory status are likely more impacted by this additional increase. Improved postoperative clinical status coincided with a less vigorous inflammatory response.
Illustration A is a table from Pape et al (2009) depicting the criteria used to determine clinical condition of a polytraumatized patient. Illustration B is an algorithm from Pape et al (2009) detailing management of the multitrauma patient.
Incorrect Responses:

OrthoCash 2020
A 92-year-old female sustains the injury shown in Figure A to her nondominant extremity as the result of a non-syncopal ground-level fall. She denies any previous injury or pain of the elbow, and her medical history is significant only for osteoporosis and hypothyroidism. What is the most appropriate treatment for her injury?

Immediate range of motion as tolerated with a sling for comfort
Long arm cast for 3 weeks, then physical therapy for motion
Open reduction and internal fixation
Radiocapitellar arthroplasty
Total elbow arthroplasty Corrent answer: 5
Use of total elbow arthroplasty (TEA) in the elderly is a well-recognized method of treatment of complex distal humerus fractures. This procedure allows for improved ROM, improved patient-reported outcomes, and decreased revision rates as compared to fixation.
TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients appear to accommodate to objective limitations in function with time, which is important, as most recommendations list restrictions of lifting no more than 5-10 pounds postoperatively.
McKee et al conducted a prospective, randomized, controlled trial to compare functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary semiconstrained total elbow arthroplasty (TEA). Patients who underwent TEA had a quicker procedure, improved DASH scores at 6 months, improved elbow ROM, and decreased revision rates.
Athwal et al review TEA and the options available at the time of publication. They also report on the techniques and purported advantages of arthroplasty as compared to fixation of complex distal humerus fractures.
Frankle et al reviewed patients >65 years old with distal humerus fractures at a minimum of 2 years follow-up. Outcomes were excellent in 33% of cases undergoing ORIF and 92% excellent with TEA. They recommend TEA in instances of arthritis, osteoporosis, or other diagnoses requiring steroids.
Figure A shows a significantly comminuted distal humerus fracture in an osteoporotic patient. Illustration A shows the same patient after undergoing total elbow arthroplasty.
Incorrect Answers:
1:Immediate range of motion is not recommended for this injury, even with the "bag of bones" treatment method. A brief period of immobilization is generally recommended for this technique.
2: Casting is not indicated for this injury.
3: ORIF of this injury will lead to worse outcomes as compared to arthroplasty. 4: Isolated radiocapitellar replacement is not indicated for this injury.

OrthoCash 2020
A 56-year-old right hand dominant attorney falls from standing and sustains the closed injury shown in Figure A. The treating surgeon elects to fix her fracture using a plate and screw construct. Based on
the available imaging, which of the following fracture characteristics best justifies this fixation choice?

Fracture displacement
Intra-articular fracture extension
The fracture extends distal to the coronoid
Oblique fracture line
Fracture comminution
This patient has a displaced, intra-articular, comminuted olecranon fracture. Comminution is an indication for plate fixation.
Most displaced olecranon fractures are treated operatively. Options include tension band constructs, intramedullary screws, plate and screw fixation or fragment excision with triceps advancement. Any construct relying on interfragmentary compression (tension band, intramedullary screws) requires a non-comminuted fracture pattern. Plate fixation is indicated in the setting of comminution, extension past the coronoid, or in the setting of associated instability.
Bailey et al. retrospectively reviewed 25 patients who underwent plate fixation of displaced olecranon fractures. Twenty-two of 25 patients had good or excellent outcomes. Five of 25 patients (20%) of patients required plate removal for symptomatic hardware. The authors concluded that plate fixation
was an effective treatment for displaced olecranon fractures, with good functional outcomes.
Figure A shows a displaced, comminuted olecranon fracture without evidence of propagation past the coronoid.
Incorrect answers:
OrthoCash 2020
A 35-year-old male was involved in a high speed motorcycle accident. He has a closed head injury, bilateral pulmonary contusions and splenic rupture. His orthopaedic injuries are shown in Figure A. He has a blood pressure of 90/50 mm Hg and a heart rate of 115, despite aggressive resuscitation. An arterial blood gas reveals that his blood lactate is 3.5 and base deficit is -6 mmol/L. Following successful closed reduction of the right hip in the operating room with a percutaneous inserted Schantz pin, what is the next most appropriate treatment for his orthopaedic injuries?

Bilateral open reduction and internal fixation
Open reduction internal fixation on the right, reamed intramedullary nailing on the left
Temporizing external fixation on the right, open reduction and internal fixation on the left
Bilateral reamed intramedullary nailing
Bilateral temporizing external fixation Corrent answer: 5
This patient presents with features of hemodynamic instability and a high injury severity score. The next most appropriate treatment would be temporizing external fixation bilaterally. This patient meets the criteria for damage control orthopaedics.
Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology does not undergo further inflammatory insult. As a result, external fixation of femoral shaft fracture and pelvic stabilization is an effective treatment under this strategy. Other indications include vascular injury and severe open fracture.
Pallister et al. reviewed the effects of surgical fracture fixation on the systemic inflammatory response to major trauma. They show that early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure. However, early fracture surgery increases the post-traumatic inflammatory response, which
carries a higher complication rate compared to temporary fixation.
Tisherman et al. created clinical guidelines for the endpoints of resuscitation. Level I data found that standard hemodynamic parameters do not adequately quantify the degree of physiologic derangement in trauma patients. The initial base deficit, lactate level, or gastric pH should be used to stratify patients with regard to the need for ongoing fluid resuscitation.
Pape et al. retrospectively reviewed the impact of early total care vs. damage control orthopaedics in the treatment of femoral shaft fractures in polytrauma patients. They found a significantly higher incidence of acute respiratory distress syndrome (ARDS) with intramedullary nailing (15.1%) compared to external fixation (9.1%) when DCO subgroups were compared.
Figure A is a pelvic AP radiograph showing a right hip fracture-dislocation with an ipsilateral femoral shaft fracture. On the left side there is a displaced pertrochanteric hip fracture.
Incorrect Answers:
OrthoCash 2020
Which of the following has been shown to be the greatest risk factor for refracture after implant removal from a radial shaft?
Removal of locking screws
Removal of small fragment plates
Removal of metaphyseal implants
Removal of implants less than 1 year after insertion
Removal of protective splinting from limb earlier than 10 weeks postoperatively
Removal of implants earlier than 1 year after insertion is a risk factor for refracture of the bone after implant removal.
The risk of refracture after hardware removal is multifactorial. Multiple
variables have been studied such as protective splinting for 6 weeks after hardware removal, waiting 12 months or more prior to hardware removal, and the location of the fracture. The variable that seems to correlate most with the risk of refracture is a diaphyseal location of the initial fracture. Large fragment plates (4.5 mm), when removed, are also at higher risk for refracture in the forearm.
Deluca et. al reported on a case series of patients who sustained a refracture of a forearm after implant removal. They noted that radiolucency at the site of the original fracture was seen in most refractured patients when the plate was removed. They also recommend delaying implant removal to two years after insertion to minimize risk.
Rumball et. al reported that the incidence of refracture after forearm implant removal is 6% in their series. They found that early removal, lack of postoperative immobilization, and plate size are the most critical risk factors for refracture.
Illustration A shows a forearm with evidence of refracture after implant removal.
Incorrect Answers:

OrthoCash 2020
A 23-year-old male arrives to the trauma bay after a motorcycle crash caused by a drive-by shooting. The patient is awake and alert and following commands. Vital signs include a blood pressure of 145/90 and a heart rate of 117bpm. Initial lactate is reported as 2.4 mmol/L. The patient has 2 rib fractures on the right with a clear chest radiograph. The patient is neurovascularly intact with a 4cm transverse wound over the medial ankle. Figures A, B and C exhibit his orthopaedic injuries. What is the most appropriate management?

Irrigation, debridement and placement external fixator right ankle, external fixation femur and intramedullary fixation tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and external fixation tibia
Irrigation, debridement and placement external fixator right ankle, femur and tibia
Irrigation, debridement and external fixation right ankle and skeletal traction
The patient is relatively hemodynamically stable. In this case the femur and tibia should be definitively fixed while the open ankle fracture can be irrigated and debrided and placed in a spanning external fixator, temporizing for later definitive fixation.
Aside from an elevated heart rate and mildly elevated lactate (normal < 2.5 mmol/L), the patient is relatively stable making him a good candidate for long bone stabilization and temporizing external fixation of the right ankle. Gross contamination of the open injury also supports temporizing fixation, which can be brought back for repeat I&D and possible fixation.
Pape et al. compared outcomes for intramedullary nailing (IMN) versus staged fixation for femur fractures in stable versus borderline patients. Borderline patients were defined as those with multi-system injury (especially to lungs) and exhibited higher lung complications following acute IMN when compared to stable patients with isolated orthopaedic injuries.
O'Brien reviewed the literature regarding early total care in regards to IMN stabilization of femur fractures. Summarized data noted isolated injuries treated with early IMN had good outcomes, whereas those with head or lung injury had worse outcomes and pulmonary complications.
Figure A exhibits a right open ankle fracture dislocation. Figure B exhibits a mid-shaft tibia fracture. Figure C exhibits a ballistic mid-shaft femur fracture.
Incorrect Answers:
OrthoCash 2020
Figure A is an anterior-posterior (AP) radiograph of a 27-year-old male who was a bicyclist struck by a motor vehicle. He was intubated in the field and unresponsive in the trauma slot. Ultrasound of his abdomen is positive for blood and he is brought to the operating room emergently for an exploratory laparotomy. He is found to have ischemic bowel and a grade 4 liver laceration. His lactate is 9.0 mg/dL. Which figure represents the next appropriate step in regard to his pelvic ring injury?

The radiograph exhibits an elevated left hemipelvis with complete sacroiliac disruption, which can be temporized with placement in skeletal traction.
The patient is unstable, as indicated by an elevated lactate level. The most appropriate next step is temporizing skeletal traction to reduce the left hemipelvis.
Langford et al. review the initial diagnosis, evaluation and resuscitation in the management of pelvic fractures. Reduction of pelvic volume can be achieved with pelvic binders and temporizing external fixation for anterior posterior compression (APC) and/or lateral compression (LC) fracture patterns, while skeletal traction can help do the same in vertical shear patterns.
Matullo et al. review the uses of skeletal traction in orthopaedic trauma, where lower extremity skeletal traction can be an efficient, fast, easy way to help reduce pelvic volume in vertical shear injuries, especially when the patient is unstable and not cleared for definitive fixation.
Figure A exhibits an elevated left hemipelvis indicative of a vertical shear injury and complete SI disruption. Figure B is an example of a pelvic binder. Figure C is a pelvic reconstruction plate. Figure D is a schematic of an anterior pelvic external fixator. Figure E is a schematic drawing of a patient in lower extremity
skeletal traction. Figure F is a radiograph exhibiting S1 and S2 sacroiliac (SI) screws.
Incorrect answers:
OrthoCash 2020
A 38-year-old man is involved in a motor vehicle collision and suffers the grossly open injury shown in Figure A. He subsequently undergoes irrigation and debridement and placement of an external fixator. In Figure B, if the proximal pin is placed at the red circle as compared to the black circle, the patient is at increased risk for which of the following?

Foot drop
Injury to the anterior tibial artery
Septic arthritis
Flexion contracture of the knee
Patellar tendon rupture Corrent answer: 3
The patient is at increased risk of septic arthritis when placing the proximal tibial pin too proximal due to penetration of the joint capsule. Pin site flora can track into the joint and lead to a septic knee.
Tibial external fixators can be used to temporize tibial shaft, pilon, and ankle fractures not ready for definitive management due to soft tissue concerns and/or practice of damage control orthopaedics. Intracapsular placement of fixator pins can lead to septic arthritis. The capsular reflection typically extends 14 mm distal to the subchondral line.
DeCoster et al. reported a cadaveric dissection study for safe placement of proximal tibia pins and determined that the capsule inserts 14 mm below the articular surface along the posteromedial and posterolateral surfaces. For fractures requiring extremely proximal pin placement, they recommend
anterior cortex penetration only at least 6 mm distal to articular surface.
Reid et al. investigated safe transtibial pin placement using MRI and cadaveric and volunteer knees. They found that pin placement 14 mm distal to subchondral bone will result in low likelihood of capsular penetration.
Figure A is an AP radiograph showing a segmental middle third tibia/fibula fracture. Figure B is a lateral diagram of the tibia showing potential sites of proximal pin placement.
Incorrect Answers:
OrthoCash 2020
Figures A and B are radiographs of a 43-year-old, right-hand dominant, male that injured his arm in a motor vehicle accident. What would be an absolute indication for surgical fixation of his injury?

Radial nerve palsy
Intra-articular extension
2mm fracture distraction, 5 degrees of rotational malignment
Ipsilateral proximal both bone forearm fracture
Bilateral fracture
This patient has a humeral shaft fracture. An absolute indication for surgery would include a floating elbow, i.e. ipsilateral both bone forearm fracture.
The primary causes of humeral fractures include motor vehicle accidents, falls, or violent injury. Almost all cases are treated non-operatively with functional bracing. The absolute indications for surgical management include: ipsilateral vascular injury, severe soft-tissue injury, open fracture, compartment syndrome, and associated ipsilateral forearm fracture, ie, floating elbow. The relative indications for surgical management include: segmental fracture, intraarticular extension, significant fracture distraction, bilateral humeral fracture, inability to maintain acceptable alignment, and polytrauma.
Klenerman et al. reviewed non-operative treatment of humeral shaft fractures. They showed that acceptable results could be achieved even after 20° of
anterior bowing, 30° of varus angulation, 15° of malrotation, and 3 cm of shortening.
Carroll et al. reviewed the management of humeral shaft fractures. They state the indications for operative fixation to be polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical techniques include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing
Figure A and B shows a comminuted mid-shaft humeral fracture with intraarticular extension.
Incorrect Answers:
OrthoCash 2020
Which of the following findings is a contraindication in retrograde nailing of a periprosthetic distal femur fracture around a total knee arthroplasty?
Posterior-stabilized total knee implant
Cruciate retaining total knee implant
Spiral fracture pattern
Distal femoral replacement
Knee flexion contracture of 15 degrees Corrent answer: 4
A distal femoral replacement (TKA) implant will generally preclude placement of a retrograde nail due to the long stem on the femoral component.
Supracondylar femur fractures above a well-fixed TKA component are increasingly common. These fractures are often treated with a lateral locking plate, but can also be treated with a retrograde nail in certain circumstances. An important factor in determining if nailing is a viable option are knowing the TKA implant and it's design. In addition, if the TKA component is known, the maximum size of reamer head and nail can be determined preoperatively from the size of the femoral 'box'.
Schutz et al report on a prospective multicenter study of 112 patients who underwent fixation of a distal femur fracture with the LISS system. They report that 90% of fractures went on to union and they attribute all of the failures to either the high-energy nature of particular fractures or a lack of experience in applying the plate in an appropriate pattern. They also note that primary grafting of these fractures is not necessary.
Illustration A shows a periprosthetic femur fracture treated with a retrograde nail.
Incorrect Answers:
1: A posterior-stabilized implant can be treated with an intramedullary nail in many circumstances but can be technically challenging, depending on the components.
2: A cruciate retaining TKA is not a contraindication to use of a retrograde nail. 3: A spiral pattern periprosthetic supracondylar femur fracture can be treated with a femoral nail.
5: A knee flexion contracture will often provide the flexion necessary for access to the box of the femoral component. A knee extension contracture, however, can preclude access to this box for placement of a nail.

OrthoCash 2020
A patient falls and sustains the isolated injury seen in Figures A and B. The surgical plan includes open reduction and internal fixation with a small mini-fragment plate using a direct lateral approach. During the approach, the forearm was placed in a fully pronated position. What would be the correct position of the forearm during plate application?

Full pronation
25 degrees pronation
Neutral
25 degrees supination
Full supination
Using the lateral approach (Kocher or Kaplan), the correct placement of the arm should be in a neutral position so that the plate can be placed on the bare area of the proximal radius.
Displaced radial head fractures with less than 3 fragments can be amendable to open reduction internal fixation. The methods of fixation include buried or headless screws, if placed at the articular surface, or posterolateral plating, if placed in the bare area. The safe zone for plating is located at a 90-110 arc from the radial styloid to Lister's tubercle with the arm in neutral rotation. This position helps to avoid impingement of ulna against the plate with forearm rotation. It should be noted that during the approach, that the forearm should be fully pronated to avoid injury to the posterior interosseous nerve.
Mathew et al. reviewed the concepts of terrible triad injuries of the elbow. Radial head fractures are treated conservatively when there is an isolated minimally displaced (less than 2mm) fracture with no mechanical block to motion. Open reduction internal fixation is used for Mason II or III fractures with < 3 fragments. Radial head replacement is considered for comminuted
fractures (Mason Type III) with 3 or more fragments.
Cheung et al. reviewed the surgical approaches to the elbow. The lateral approach (Kocher or Kaplan) is most commonly used with these injuries. The Kocher approach utilizes the intramuscular plane between anconeus and extensor carpi ulnaris. Kaplan utilizes the plane between extensor digitorum commons and extensor carpi radialis brevis.
Figure A and B show AP and lateral radiographs of the left elbow. There is a displaced radial head fracture. Illustration A shows a schematic diagram of the radial head "safe zone" between the radial styloid to Lister's tubercle.
Incorrect Answers:

OrthoCash 2020
A 38-year-old male is involved in a high speed motor vehicle collision. He has a Glasgow Coma Scale of 13 and receives 2 liters of fluid en route to the emergency department. Upon evaluation in the emergency department, he is found to have a bilateral femoral shaft fractures, a right ankle fracture, and a left both bone forearm fracture. He also has 2 left sided rib fracture and a grade II liver laceration. His heart rate is 130 and blood pressure is 85/50. All of the following
would be indications to practice damage control orthopaedics in this patient except:
Bilateral femur fractures
Rib fractures
Lactate of 5.2
Urine output of 20 cc/hr
Heart rate and blood pressure Corrent answer: 2
Rib fractures without evidence of further thoracic trauma would not be an indication to practice damage control orthopaedics. This patient is underresuscitated based on his lactate level, urine output, and vital signs and definitive management should be delayed.
Damage control orthopaedics is the practice of delaying definitive management of fractures and utilizing temporary stabilization (such as an external fixator) until a patient has recovered from the initial physiologic insult of trauma.
Patients are at increased risk for perioperative complications such as ARDS and multi-system organ failure during the acute period after polytrauma. In addition to underresuscitation, other indications to practice damage control orthopaedics include: injury severity score>40 (or >20 with thoracic trauma), bilateral femoral fractures, hypothermia below 35 degrees Celsius, and pulmonary contusions.
Pape et al. (2007) studied the incidence of acute lung injuries in polytrauma patients undergoing either intramedullary nailing or external fixation and later definitive fixation of femoral shaft fractures. They found that patients undergoing immediate intramedullary nailing were nearly 6.7 times more likely to have acute lung injury
The Canadian Orthopedic Trauma Society studied the effect of reamed versus unreamed femoral nailing on incidence of ARDS for femoral shaft fractures in trauma patients using a randomized controlled study. They found no difference between the groups.
Pape et al. also examined the pathophysiological cascades that accompany soft tissue injuries of the extremities, abdomen, and pelvis and recommend a more comprehensive for evaluation of patients with these injuries.
Incorrect Answers:
OrthoCash 2020
The anterior intrapelvic (modified Stoppa) approach is most appropriate for which of the following fractures?

The anterior intrapelvic (AIP) or modified Stoppa approach provides access to the quadrilateral plate, which is a common location for fracture displacement in associated both column acetabulum fractures as seen in Figure D.
Compared to the traditional ilioinguinal approach, the modified Stoppa with a lateral window can offer comparable access to the quadrilateral plate, which can allow for its use in associated both column fracture patterns.
de Peretti et al. prospectively followed 25 patients with both column fractures
treated via an iliofemoral approach. Results led the authors to not recommend the extensile approach for both column fractures due to lack of efficiency and high complication rates.
Alonso et al. compared the extensile iliofemoral and triradiate approaches, and both reported acceptable results. However, concerning were the relatively high rates of heterotopic ossification, despite prophylaxis.
Bible al. performed a cadaver study to quantify the amount of access provided by the modified Stoppa approach. This approach provides access to approximately 80% of both the inner pelvis, and the quadrilateral plate, however, comparison to the ilioinguinal approach was not performed.
Shazar et al., in a cohort comparison between the ilioguinal and Stoppa approaches, noted better visualization and potential improve fracture reduction via the Stoppa approach for both column fractures. However, this study was limited in its retrospective and relative observer bias.
Figure A depicts a posterior wall fracture dislocation with concomitant femoral neck fracture. Figure B is an iliac oblique view which depicts a posterior column fracture. Figure C exhibits a posterior column + posterior wall fracture. Figure D depicts acetabular fracture with protrusio. Figure E exhibits a posterior wall fracture.
Incorrect answers:
OrthoCash 2020
Figure A is a radiograph of a 75-year-old woman that fell onto her non-dominant shoulder from a standing height. She was treated nonoperatively for 9 months but continues to complain of pain when she elevates her arm. In patients with this type of fracture pattern, what factor has the greatest impact on fracture healing?

Hand dominance
Angulation of fracture
Smoking
Early physical therapy
Diet
This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with non-operative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to
impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than non-smokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:
OrthoCash 2020
A 26-year-old male epileptic patients presents with right shoulder pain and deformity after a grand mal seizure. After medical stabilization, he denies previous injury to his shoulder. Pre-reduction and post-reduction radiographs of the shoulder are shown in Figures A-C, respectively; physical examination reveals a normal upper extremity neurovascular examination. After shoulder immobilization, what would be the next most appropriate step in management of this patient?

Abduction brace for three weeks, followed by therapy
Right shoulder MR arthrogram
Open reduction and internal fixation
Hemiarthroplasty
Early range of motion Corrent answer: 3
This patient has presented with a fracture dislocation of the right shoulder. After urgent closed reduction, this patient requires open reduction internal fixation of the proximal humerus, and greater tuberosity fracture fragment in particular.
Isolated greater tuberosity fractures may be associated with shoulder dislocations. Careful review of imaging is critical to identify fracture lines that may extend into the humeral neck and head. If these extensions go undetected, catastrophic propagating fractures may occur during closed reduction maneuvers. Treatment is usually with open reduction internal fixation (ORIF). Young patients with proximal humerus fractures should be treated more aggressively with ORIF as compared to elderly patients. Another example would be a severely impacted valgus proximal humeral fracture in a young patient.
Erasmo et al. examined of 82 cases of humerus fracture dislocations treated with the lateral locking plates. Overall outcomes were excellent to good based on standard scoring systems. Complications included avascular necrosis (12%), varus positioning of the head (4.8%), impingement syndrome (3.6%), secondary screw perforation (3.6%), non-union (2.4%) and infection (1.2%).
Robinson et al. looked at severely impacted valgus proximal humeral fractures treated with open reduction internal fixation in young patients. Anatomic reduction is required with lateral plating to re-establish the normal head/neck angle. Good to excellent results can be achieved with fixation methods.
Figure A shows an anterior fracture-dislocation of the right shoulder. Figure B and C show post-reduction radiographs with a congruent glenohumeral joint. Displacement of the greater tuberosity (GT) fragment is greater than 5mm.
Incorrect Answers:
OrthoCash 2020
Pelvic packing can be performed to temporarily treat a hemodynamically unstable patient with a pelvic ring fracture. Which of the following is the preferred location of the skin incision to perform pelvic packing?
Right anterior superior iliac spine (ASIS) to mid-symphysis, left lateral window incision
Left ASIS to mid-symphysis, right lateral window incision
Subumbilical incision
ASIS to ASIS bilaterally
Pararectus incision
The preferred skin incision location is a subumbilical incision, 6-8cm extending upwards from the pubic symphysis towards the umbilicus; this allows access to all of the appropriate areas for pelvic packing.
Following skin incision, the rectus fascia is then divided in the midline which allows for access to both sides of the bladder for packing deep in the pelvic
brim. On each side, 3 lap pads are placed from sacroiliac joint to the retropubic space, all placed below the level of the pelvic brim.
Hak et al. review the options for emergent treatment in life threatening hemorrhage secondary to pelvic fractures. The authors offer several options for emergent treatment, which includes the use of pelvic binders, the placement of external fixators, pelvic packing and interventional angiography. Goals include reduction of pelvic volume and stopping rapid hemorrhage to save a patient's life. Pelvic packing, properly performed, is done through a subumbilical incision, as described above.
Osborn et al. retrospectively reviewed and compared emergent pelvic packing to angiography in hemorrhagic pelvic fracture clinical scenarios. The authors noted comparable results in mortality with a noted decrease in need for post-procedure transfusions in the pelvic packing group.
Cothren et al. reported their outcomes following an institutional algorithmic change from pelvic ex-fix/angiography to pelvic packing and ex-fix. Since their institutional change, the authors noted a significant decrease in transfusions, need for angiography and mortality.
Incorrect answers:
OrthoCash 2020
A 28-year-old man is brought by ambulance to the emergency department after falling from the roof of his home four hours ago. Upon initial evaluation, he has visible deformities of his bilateral lower extremities and a positive FAST exam. Heart rate is 135, blood pressure 85/58, and urine output is 40 cc over 3 hours. According to ATLS guidelines, what percentage of his blood volume has this patient likely lost?

Question 19

Which of the following is an indication for surgical management of a Weber type B distal fibular fracture?

Explanation

DISCUSSION: A widened medial clear space indicates instability caused by an associated tear of the deltoid ligament; therefore, nonsurgical management is not warranted. Weber type B distal fibular fractures without a deltoid tear have a medial clear space of < 4 mm, even under stress, and may be successfully treated nonsurgically. The presence of medial hindfoot ecchymosis and medial ankle tenderness is not fully indicative of medial soft-tissue instability; however, these findings may indicate a deltoid injury and should raise suspicion of an unstable fracture injury pattern. Stress testing is necessary to demonstrate the presence or absence of instability. A small amount of comminution is also cause for increased suspicion of an unstable pattern; however, it is not a direct contraindication when considering nonsurgical management. Two millimeters of fibular displacement without lateral shift of the talus is an acceptable position when considering nonsurgical management of Weber type B distal fibular fractures.
REFERENCES: Michelson JD, Magid D, Ney DR, et al, Examination of the pathologic anatomy of ankle fractures. J Trauma 1992;32:65-70.
Marsh JL, Saltzman CL: Ankle fractures, in Rockwood & Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 2001-2090.

Question 20

Figures 1 and 2 are the radiographs of a 20-year-old college multisport athlete who has had longstanding pain in his left hip. He denies any specific event that initiated his pain, but he notes that he had hip problems when he was an infant. He denies pain with activities of daily living, but he believes his pain is increasingly limiting his ability to exercise. He localizes the pain to his groin. He denies low-back or buttock pain or pain that radiates down his leg. What examination findings are most consistent with the pathology seen in the radiographs?

Explanation

This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater
trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of longstanding groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement. Surgical treatment for cam impingement can be effective for symptomatic patients. Even among high-level athletes, open surgical dislocation of the hip has been shown to have good results. Most patients with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable with those realized with open surgical dislocation. The literature describes success in terms of athletes returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment. Byrd and Jones described five patients who developed transient neurapraxias that resolved uneventfully. The patients in his series who had concomitant microfracture had a 92% return to sports within the follow-up period. Cam impingement has long been thought to be associated with a history of a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who underwent a periacetabular osteotomy can develop a more retroverted acetabulum as well.

Question 21

Figures below show the radiograph and the MRI scan obtained from a 37-year-old woman with a 2-month history of left hip pain. Which presurgical factor is most commonly associated with a poor outcome after a hip joint salvage procedure?

Explanation

DISCUSSION:
MRI reveals an anterior labral tear, and the radiograph shows minimal arthritis with possible dysplasia. The most common location of pain in patients with a labral tear is the groin, and the most common physical finding is a positive impingement test result. Pain during sitting, clicking, and buttock pain are frequently described by patients with a labral tear, but these symptoms are less common than groin pain. A positive posterior impingement test finding is more common in patients with a posterior labral tear. Although age over 40 years and a body mass index higher than 30 can adversely affect clinical outcomes after joint preservation procedures such as PAO, hip arthroscopy, and femoral acetabular impingement surgery, the presence of hip arthritis on presurgical radiographs is the most commonly mentioned cause of failed hip joint preservation surgery. Tönnis grade is a radiographic measure of hip arthritis. A higher Outerbridge score is associated with more frequent poor outcomes after hip arthroscopy; however, the
Outerbridge cartilage score is determined by direct visualization at the time of surgery. The Outerbridge
score cannot be determined presurgically.

Question 22

A patient with a left-sided C6-7 herniated nucleous pulposis would likely have which of the following constellation of findings?

Explanation

DISCUSSION: A C6-7 herniation affects the C7 root. The C7 root has the middle finger as its predominant sensory distribution. Its motor function is the triceps, wrist extension, and finger metacarpophalangeal extension. The reflex is the triceps.
REFERENCES: Magee D: Principles and concepts, in Orthopedic Physical Assessment, ed 3. Philadelphia, PA, WB Saunders, 1997, pp 1-18.
An H: History and physical examination of the spine, in Principles and Techniques of Spine Surgery. Baltimore, MD, Lippincott Williams & Wilkins, 1998, pp 91-101.

Question 23

A 35-year-old man presents one week after an acute right shoulder posterior dislocation after being electrocuted. He is evaluated in the emergency department and undergoes closed reduction. The patient reports global right shoulder pain and limited active and passive range of motion. He has mild anterior and lateral bruising. He is distally neurovascularly intact. Current radiographs and an MRI scan are shown in Figures 1 through 3. What is the best next step?

Explanation

A 68-year-old man presents with chronic progressive right shoulder pain and loss of motion. He has active shoulder elevation of 120° and 5-/5 shoulder forward flexion strength limited by pain. He has exhausted nonsurgical management over the past year and is now interested in surgical intervention. Figure 1 is the preoperative axial CT scan of his shoulder. During surgical reconstruction, the surgeon should anticipate the location of maximal glenoid erosion to be

Question 24

A 17-year-old high school soccer player sustains an anterior cruciate ligament (ACL) tear at the beginning of the season. An MRI scan confirms a complete ACL tear with no meniscal injuries. The patient plans an early return to play and would like to avoid surgery. Therefore, the patient and family should be advised that nonsurgical management consisting of rehabilitative exercises and the use of a functional knee brace will most likely result in

Explanation

DISCUSSION: While there are athletes who can function at a full level with an ACL tear, they are in the minority. As yet, there is no reliable way to predict the patients who will be able to compensate for the loss of the ACL. Studies have confirmed the risk of recurrent instability and meniscal injury in athletes with an ACL-deficient knee who participate in cutting sports. One study showed that only 12 of 43 patients who attempted rehabilitation and bracing were able to return successfully for the season. Another study showed that 17 of 31 athletes who were able to return to their sport sustained 23 meniscal tears because of recurrent instability.
REFERENCES: Shelton WR, Barrett GR, Dukes A: Early season anterior cruciate ligament tears: A treatment dilemma. Am J Sports Med 1997;25:656-658.
Snyder-Mackler L, Fitzgerald GK, Bartolozzi AR III, Ciccotti MG: The relationship between passive joint laxity and functional outcome after anterior cruciate ligament injury. Am J Sports Med 1997;25:191-195.

Question 25

A 20-year-old college pitcher reports medial elbow pain after 3 innings of hard throwing. He recalls no injury and reports no pain with light throwing. The examination shown in the clinical photograph in Figure 48 reproduces the elbow pain. What is the most likely diagnosis?

Explanation

DISCUSSION: The milking test, as seen in the photograph, elicits pain when a tear is present in the medial collateral ligament. Complete rupture is possible but unlikely when there is no history of trauma and the patient is able to throw pain-free for several innings. Subluxation of the ulnar nerve and triceps tendon subluxation present as a painful snapping over the medial aspect of the elbow.
REFERENCES: Williams RJ III, Urquhart ER, Altchek DW: Medial collateral ligament tears in the throwing athlete. Instr Course Lect 2004;53:579-586.
Cain EL Jr, Dugas JR, Wolf RS, et al: Elbow injuries in throwing athletes: A current concepts review. Am J Sports Med 2003;31:621-635.

Question 26

What is the predominant type of collagen in the tissue resulting from the surgical procedure shown in Figures 40a through 40c?

Explanation

DISCUSSION: The arthroscopic images show a microfracture procedure. Perforation of the subchondral bone results in so-called “marrow stimulation” that results in the formation of fibrocartilage. This reparative tissue is composed predominantly of type I collagen with a disorganized matrix lacking a true tidemark, as opposed to hyaline cartilage which is composed primarily of type II collagen. This operation is indicated for full-thickness chondral defects without associated degenerative arthrosis. Microfracture is most commonly performed in the knee, though it has also been applied to other joints. Type III collagen is not a predominant component of fibrocartilage. Type IX and X are minor collagenous components of cartilage.
REFERENCES: Magnussen RA, Dunn WR, Carey JL, et al: Treatment of focal articular cartilage defects in the knee: A systematic review. Clin Orthop Relat Res 2008;466:952-962.
Williams RJ III, Hamly HW: Microfracture: Indications, technique, and results. Instr Course Lect 2007;56:419-428.
Mithoefer K, Williams RJ III, Warren RF, et al: Chondral resurfacing of articular cartilage defects in the knee with the microfracture technique: Surgical technique. J Bone Joint Surg Am 2006;88:294-304.

Question 27

Figure 37 reveals a periprosthetic fracture around a cemented femoral stem in an 81-year-old patient with Paget’s disease and mild coagulopathy. What is the most appropriate reconstructive management on the femoral side?

Explanation

DISCUSSION: This is an example of a Vancouver B3 periprosthetic fracture that consists of a fracture around a loose femoral stem with poor proximal bone support. Therefore, open reduction and internal fixation is not an option. PFR is an excellent choice for elderly inactive patients with poor femoral bone stock. The surgery can be performed in an expeditious manner, which is very important in a patient with mild coagulopathy. Impaction allografting and APC are both options for younger patients who have bone stock that needs to be restored. The results of revision arthroplasty using proximally coated stems, especially under these circumstances, are poor.
REFERENCES: Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293-304.
Parvizi J, Sim FH: Proximal femoral replacements with megaprostheses. Clin Orthop 2004;420:169-175.
Klein GR, Parvizi J, Rapuri V, et al: Proximal femoral replacement for treatment of periprosthetic fractures. J Bone Joint Surg Am 2005;87:1777-1781.

Question 28

Which of the following is considered the treatment of choice for a chondroblastoma of the proximal tibial epiphysis without intra-articular extension?

Explanation

DISCUSSION: Curettage and bone grafting typically is the preferred method of treatment for chondroblastoma, with local recurrence rates of approximately 10%. Some clinicians advocate the addition of adjuvants such as phenol. Left alone, these lesions can destroy bone and invade the joint. Large intra-articular lesions may require major joint reconstruction. Wide local excision rarely is required to eradicate the tumor. Radiation therapy rarely is indicated and only for unresectable or multiply recurrent lesions.
REFERENCES: Springfield DS, Capanna R, Gherlinzoni F, Picci P, Campanacci M: Chondroblastoma: A review of seventy cases. J Bone Joint Surg Am 1985;67:748-755.
Simon MA, Springfield DS, et al: Chondroblastoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 190.

Question 29

An infected total knee replacement with symptoms occurring within 4 weeks of surgery and no radiographic signs of osteomyelitis would be best managed with

Explanation

Treatment of an early infection demands thorough debridement of the wound and appropriate parenteral antibiotics. Systemic treatment with appropriate antimicrobial agents should continue for a minimum of 4 weeks following debridement for an early infection. An infection diagnosed later than 4 weeks following surgery is less likely to have a successful result without removal of the components. OKU V pg. 490.
Arthroscopic debridement not recommended secondary to missing cutaneous tracks and soft tissue/muscle involvement.

Question 30

A 13-year-old girl with Down syndrome has bilateral chronic patellar dislocations. She denies knee pain. She is able to straighten her knees and walks with a symmetric but awkward gait. She does not flex her knees in midstance. Examination reveals that the patellae cannot be brought into a reduced position. Management should consist of

Explanation

DISCUSSION: Chronic dislocation of the patella is occasionally seen in patients with Down syndrome. In early childhood, patellar realignment may restore stability of the patellae. In later childhood, bony changes in the patellar groove interfere with stability, even if surgical realignment is performed. Realignment can also lead to increased knee pain postoperatively. In asymptomatic patients who are able to extend their knees, continued observation is the management of choice.
REFERENCES: Dugdale TW, Renshaw TS: Instability of the patellofemoral joint in Down syndrome. J Bone Joint Surg Am 1986;68:405-413.
Mendez AA, Keret D, MacEwen GD: Treatment of patellofemoral instability in Down’s syndrome. Clin Orthop 1988;234:148-158.

Question 31

The quadrilateral space in the shoulder contains which of the following structures?

Explanation

DISCUSSION: The quadrilateral or quadrangular space of the shoulder is formed laterally by the humerus, proximally by the subscapularis (and teres minor viewed from posterior), distally by the teres major, and medially by the long head of triceps. The posterior humeral circumflex artery and axillary nerve pass through it. The axillary artery is more proximal. The radial nerve and profunda brachii pass through a triangular space more inferior. The circumflex scapular artery passes through a triangular space more medial.
REFERENCES: Hollinshead WH: Textbook of Anatomy, ed 3. Hagerstown, MD, Harper and Row, 1974, pp 205-206.
Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, pp 61-62.

Question 32

A 12 month old infant has congenital complete absence of the tibia. Examination reveals that the femur in the abnormal limb is 3 cm short, with a normal ipsilateral hip. The patient has an intact fibula, an equinovarus foot with four rays, and moderate popliteal skin webbing. Management should consist of

Explanation

Congenital longitudinal deficiency of the tibia (tibial hemimelia) is a rare anomaly. It is characterized by leg length inequality, malrotation of the extremity, and an equinovarus position of the foot. Currently, the primary treatment option is disarticulation at the knee. Centralization of the fibula has been performed in the past with poor long term results, which have required reoperations leading to amputations. The Syme amputation and prosthetic fitting of the present deformity has led to poor results.

Question 33

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

Explanation

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

Question 34

A 14-year-old girl has had progressive heel pain for the past several months. Based on the radiograph, MRI scan, and biopsy specimens shown in Figures 37a through 37d, treatment should include

Explanation

DISCUSSION: An aneurysmal bone cyst is a benign, locally destructive lesion of bone. Most are seen in patients in the second decade of life. The clinical presentation varies, but most patients have pain, tenderness, swelling, and/or pathologic fracture. Radiographs show a radiolucent lesion sometimes with expansile remodeling of the cortex. MRI best detects the commonly seen fluid-fluid levels associated with this lesion. Histologic findings include

blood-filled spaces with bland fibrous connective tissue septa. The stroma has histiocytes, fibroblasts, scattered giant cells, hemosiderin, and occasional inflammatory cells. Treatment of these lesions consists of extended curettage, plus or minus the use of adjuvants (liquid nitrogen, phenol, argon beam coagulation), and finally filling the bone void (allograft or other bone substitute).
REFERENCES: Gibbs CP Jr, Hefele MC, Peabody TD, et al: Aneurysmal bone cyst of the extremities: Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am 1999;81:1671-1678.
Ramirez AR, Stanton RP: Aneurysmal bone cyst in 29 children. J Pediatr Orthop 2002;22:533-539.

Question 35

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

Explanation

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

Question 36

A 4-year-old girl has knee pain after a fall. Examination reveals tenderness about the proximal tibia with modest deformity. She has no neurovascular deficits. A radiograph is seen in Figure 24. What should her parents be told? 2010 Pediatric Orthopaedic Examination Answer Book • 25

Explanation

DISCUSSION: The patient has a so-called Cozen fracture, and she is at significant risk for a posttraumatic genu valgum deformity. However, long-term studies have shown that when such a deformity occurs, it frequently resolves spontaneously and therefore surgical intervention to try and prevent the deformity is not advised.
REFERENCES: Jordan SE, Alonso JE, Cook FF: The etiology of valgus angulation after metaphyseal fractures of the tibia in children. J Pediatr Orthop 1987;7:450-457.
Tuten HR, Keeler KA, Gabos PG, et al: Posttraumatic tibia valga in children: A long-term follow-up note. J Bone
Joint Surg Am 1999;81:799-810.

Question 37

A 72-year-old woman is scheduled to undergo right total hip arthroplasty. Her preoperative radiograph is shown in Figure below. To avoid increasing this patient’s combined offset while maintaining her leg length, what is the most appropriate surgical plan?

Explanation

DISCUSSION:
The management of patients with proximal femoral deformity can be difficult. Appropriate implant selection and preoperative templating are critical. In this patient, it would be difficult to avoid increasing the combined offset by too much, which could contribute to the overtensioning of the soft tissues and trochanteric pain. By medializing the acetabular component (decreasing the combined offset), using a low offset femoral component or a cemented component placed more valgus (decreasing the combined offset), and making a longer neck cut (to avoid shortening of the lower extremity), restoration of the patient’s native offset and leg length can be achieved.

Question 38

What is the average linear wear rate of a conventional, noncross-linked ultra-high molecular weight polyethylene liner used in total hip arthroplasty?

Explanation

DISCUSSION: Several studies have shown that ultra-high molecular weight polyethylene liners used in total hip arthroplasties wear at a rate of 0.1 to 0.2 mm/yr. The orthopaedic surgeon performing total hip arthroplasties should be aware of the average wear rate so that potential problems can be identified when following patients postoperatively.
REFERENCES: Callaghan JJ, Albright JC, Goetz DD, Olejniczak JP, Johnston RC: Charnley total hip arthroplasty with cement: Minimum twenty-five year follow-up. J Bone Joint Surg Am 2000;82:487-497.
Isaac GH, Wroblewski BM, Atkinson JR, Dowson D: A tribological study of retrieved hip prostheses. Clin Orthop 1992;276:115-125.

Question 39

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 40

When conducted at near physiologic strain rates, tensile studies of the inferior glenohumeral ligament (IGHL) have shown that the

Explanation

DISCUSSION: Tensile testing of the inferior glenohumeral ligament at near physiologic strain rates has shown that the anterior band of the IGHL has the greatest stiffness of the three ligament regions and the glenoid insertion site shows greater strain than the ligament midsubstance.
REFERENCES: Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197.
Ticker JB, Bigliani LU, Soslowsky LJ, Pawluk RJ, Flatow EL, Mow VC: Inferior glenohumeral ligament: Geometric and strain-rate dependent properties. J Shoulder Elbow Surg 1996;5:269-279.

Question 41

A B Figures 45a and 45b are the CT and MR spine images of an 82-year-old man who has a history of ankylosing spondylitis falls onto his back. He has no neurologic deficits upon examination in the emergency department. What is the most appropriate next step?

Explanation

DISCUSSION
Spinal fractures in patients with ankylosing spondylitis are unstable and generally necessitate surgical intervention. In a patient with a spinal fracture in the setting of ankylosing spondylitis, posterior instrumented fusion is an appropriate surgical procedure. Treatment with a thoracolumbar orthosis is not an option for patients with extension distraction injuries in the setting of an ankylosed spine because of risk for displacement. Similarly, simply checking upright radiographs is generally not advocated. Laminectomy alone is inappropriate for this patient because there is no cord compression and neurologic symptoms are absent. Stabilization is the treatment goal.
RECOMMENDED READINGS
Braun J, Sieper J. Ankylosing spondylitis. Lancet. 2007 Apr 21;369(9570):1379-90. Review. PubMed PMID: 17448825.View Abstract at PubMed
Caron T, Bransford R, Nguyen Q, Agel J, Chapman J, Bellabarba C. Spine fractures in patients with ankylosing spinal disorders. Spine (Phila Pa 1976). 2010 May 15;35(11):E458-64. doi: 10.1097/BRS.0b013e3181cc764f. PubMed PMID: 20421858. View Abstract at PubMed Finkelstein JA, Chapman JR, Mirza S. Occult vertebral fractures in ankylosing spondylitis. Spinal Cord. 1999 Jun;37(6):444-7. PubMed PMID: 10432265. View Abstract at PubMed Hitchon PW, From AM, Brenton MD, Glaser JA, Torner JC. Fractures of the thoracolumbar spine complicating ankylosing spondylitis. J Neurosurg. 2002 Sep;97(2 Suppl):218-22. PubMed PMID: 12296682. View Abstract at PubMed

Question 42

The superior glenohumeral ligament primarily restrains

Explanation

DISCUSSION: Several cutting studies have evaluated the primary static restraints and the role of the glenohumeral ligaments in providing static stability. With the arm at the side in adduction, the superior glenohumeral ligament and coracohumeral ligament are the primary restraints to inferior translation. The middle glenohumeral ligament functions with the arm in 45 degrees of abduction and resists anterior translation. The inferior glenohumeral ligament is the primary restraint to anterior translation at 90 degrees of abduction.
REFERENCES: Warner JJ, Deng XH, Warren RF, et al: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685.
Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy Orthopaedic Surgeons, 1994, pp 165-177.

Question 43

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

Explanation

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

Question 44

Which of the following regions in the growth plate is commonly affected in a Salter-Harris type II injury? Review Topic

Explanation

A type II injury consists of a fracture along the hypertrophic zone of the growth plate with an attached metaphyseal bony fragment. The hypertrophic zone is the metaphyseal fragment and is located on the compressive or concave side, whereas periosteum is torn on the tensile or convex side. The reserve and proliferative zones remain with the epiphysis and the circulation is usually preserved.

Question 45

Pulsatile bleeding is encountered after placing a retractor anterior to the acetabulum while exposing for reaming during total hip arthroplasty (THA). What vascular structure is likely affected?

Explanation

After a fall 2 months ago, an 82-year-old woman presents with the inability to straighten her leg. She has had several subsequent falls. She had a successful primary total knee arthroplasty (TKA) 3 years ago. AP and lateral radiographs are shown Figures 1 and 2. On examination, she has a 45° extensor lag, no significant pain and good knee stability. She can flex to 110° without difficulty. A full allograft reconstruction versus synthetic mesh reconstruction are the two options discussed with the patient and family. What is the difference between the two surgical options?

Question 46

Figure 43 shows an arthroscopic view of the posteromedial compartment of a patient’s left knee using a 70-degree arthroscope placed through the intercondylar notch. The arrow is pointing to what structure?

Explanation

DISCUSSION: Passing the 70-degree arthroscope through the intercondylar notch provides excellent visualization of the posteromedial corner of the knee. This view should be part of every knee arthroscopy because these structures are often not well visualized from the anterior portals. If this view is omitted, tears of the peripheral posterior horn of the medial meniscus can be overlooked. The arrow points to the peripheral aspect of the posterior horn of the medial meniscus. With an intact medial meniscus, the medial tibial plateau should not be seen from this view. The semimembranosus and gastrocnemius tendons are extra-articular and not visualized.
REFERENCES: Miller MD: Basic arthroscopic principles, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, Saunders, 2003, pp 224-237.
Gold DI, Schaner PJ, Sapega AA: The posteromedial portal in knee arthroscopy: An analysis of diagnostic and surgical utility. Arthoscopy 1995;11:139-145.

Question 47

What percent of adult patients with rheumatoid arthritis test positive for rheumatoid factor?

Explanation

Rheumatoid factor is present in 80% to 90% of adult patients with rheumatoid arthritis. Although rheumatoid factor is very sensitive, it is not very specific. Antinuclear antibodies (ANA) can be detected in 30% to 40% of patients with rheumatoid arthritis.

Question 48

5cm from the carpometacarpal joint. The attached deep transverse intermetacarpal ligaments are sacrificed. To prevent scissoring of the remaining digits and small objects falling through the gap between index and ring fingers, which of the following procedures should be performed?

Explanation

A 65-year-old man fell and injured his right wrist. Radiographs taken in the emergency room are seen in Figure A. He was treated as a sprain and no further follow-up was planned. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. Recent radiographs are seen in Figure B. Surgical treatment that will best address his symptoms and preserve wrist motion consists of

Anterior and posterior interosseous neurectomy
Scaphotrapezialtrapezoidal (STT) fusion
Complete wrist arthrodesis
Proximal row carpectomy
Four-corner fusion with scaphoidectomy
Four-corner fusion with scaphoidectomy is indicated for Stage III SLAC wrist.
Surgical treatment of SLAC wrist is stage dependent. Stage I disease (scaphoid-radial styloid arthritis) is treated with AIN/PIN neurectomy. This procedure can also be done in addition to other bony procedures for Stages II-III disease. Stage II (scaphoid-entire scaphoid facet) is treated with PRC or scaphoid excision with 4-corner fusion (4CF). Stage III (capitolunate arthritis with proximal migration of the capitate into the scapholunate interval) is treated with either scaphoidectomy with 4CF or total wrist fusion.
Some other conditions exist: If capitolunate arthritis exists, PRC is contraindicated and 4CF is performed. If radiolunate arthritis exists, both PRC and 4CF are contraindicated and total wrist fusion is performed. If both radiolunate and capitolunate surfaces are preserved, then either PRC or a 4CF may be performed.
Cohen et al. compare PRC with 4-corner fusion plus scaphoid excision. PRC is technically easier, but leads to shortening of the carpus with weakness and incongruity exists between the capitate and lunate fossa of the distal radius. Scaphoid excision and four-corner fusion maintains carpal height and preserves the radiolunate relationship, but is more technically demanding, there is risk of nonunion, and it requires longer postop immobilization. Pain relief is more reliable following 4-corner fusion.
Figure A shows scapholunate ligament disruption. Figure B shows late stage SLAC wrist. There is capitolunate arthritis but no radiolunate arthritis.
Illustration A shows an example of PRC. Illustration B shows an example of 4CF and scaphoidectomy.
Incorrect Answers

Which of the following statements is true regarding zone II flexor tendon injuries?
At this level, FDS and FDP are located within separate tendon sheaths
FDS repair has not been shown to improve outcomes
Improved gliding is seen with repair of 1 slip of FDS compared to repairing both slips
Repairing FDS does not affect post-operative digit strength
FDP repair has not been shown to improve outcomes
In zone II flexor tendon injuries, repairing only one slip of FDS has been shown to improve gliding when compared to repair of both slips.
Zone II flexor tendon injuries have notoriously had poor outcomes secondary to high rates of adhesion formation at the pulleys. However, new advances in post-operative rehabilitation have significantly improved outcomes to the point where it is no longer considered "no man's land." Management of the FDS has been a source of controversy. In the past, the FDS was occasionally excised to theoretically make more room for the FDP. This has now been largely abandoned and the FDS is repaired whenever possible. Whether or not to repair both slips of FDS remains controversial, with in vitro data suggesting that gliding resistance is improved if only one slip is repaired.
Zhao et al. review the effect of partial vs. complete FDS excision following repair of FDP for zone II flexor tendon injuries. Preserving the whole FDS resulted in a significantly larger increase in gliding resistance after FDP repair than did full or partial FDS removal, which were not significantly different from each other.
Illustration A shows the zones of flexor tendon injury. Note that zone II injuries occur between the FDS insertion and the distal palmar crease. Illustration B shows the anatomy of the flexor tendons in detail. Video V shows a technique for repair of zone II injuries.
Incorrect Answers:

A 6-year-old girl sustains transverse amputations through her long and ring fingertips after getting her hand caught in a lawn mower. She presents to the emergency room 30 minutes after the injury with the amputated tissue which was placed on ice in a waterproof bag. On physical exam the amputation levels are found to be 6 millimeters distal to the lunula. The wounds are noted to be fairly
contaminated with no evidence of exposed bone. Skin defects are less than 1 centimeter. Which of the following is the most appropriate management at this time?
Emergent replantation of the amputated parts
Revision amputation through the distal interphalangeal joint
Thorough irrigation and debridement followed by elective Moberg advancement flaps
Thorough irrigation and debridement followed by elective Z-plasty reconstruction
Thorough irrigation and debridement, soft dressing application, and followup within 1 week
Distal fingertip amputations can be successfully managed with local wound care and healing by secondary intention if no bone is exposed and the soft tissue defects are minimal. This is especially true in the pediatric population.
Distal fingertip amputations are common injuries seen in the emergency department. If bone is not exposed, the wounds can be successfully treated with local wound care and dressing changes, followed by soaks in a hydrogen-peroxide solution after 7-10 days. Some controversy exists in the pediatric population if the soft tissue loss is > 1 cm, with options for management including a V-Y advancement flap or conservative management with dressing changes.
Quell et al. review the results of 82 patients with fingertip amputations treated conservatively; 31 of the digits were treated with primary closure with or without shortening of bone and 54 digits were treated with semiocclusive dressings. No complications were observed, and all healed fingertips were well padded and painless.
Tupper et al. review sixteen patients with twenty fingertip injuries who underwent V-Y plasty for transverse fingertip amputations. Sensitivity was 73% of normal, with eight patients reporting hypersensitivity. Contrary to popular belief, they believe normal sensation following a V-Y plasty is not a reasonable expectation.
Illustration A shows the three levels of fingertip amputations. Zone I is distal to the phalanx; Zone II is distal to the lunula; and Zone III is proximal to the lunula.
Incorrect Answers:

Which of following malformations is most commonly associated with Poland's syndrome?

Figure E CORRECT ANSWER: 4
Figure D demonstrates symbrachydactyly which is most commonly associated with Poland's syndrome.
Poland's syndrome is a rare birth defect characterized by underdevelopment or absence of the chest muscle in conjunction with ipsilateral symbrachydactyly. Poland syndrome most often affects the right side of the body, and occurs more often in males than in females.
Ireland et al. reviewed 43 consecutive cases of Poland's syndrome, and reviewed the relevant literature up to that point. The authors state that the clinical features are variable but always include congenital aplasia and syndactyly, and the right side is affected more than the left. They also note that although the hand remains hypoplastic and functional capacity is limited by the inherent skeletal anomalies, surgical treatment improves functional capacity and cosmetic appearance in the majority of patients.
Van Heest summarizes normal formation and growth of the upper limb as a basis for understanding malformation, with the goal of providing a basic understanding of the evaluation necessary for appropriate counseling and referrals for treatment of the child with hand and upper extremity congenital deformities.
Incorrect Answers:
A 55-year-old male laborer comes in with a chief complaint of clumsiness with his right hand for the past 3 months including difficulty using a hammer while at work. He has had no injury to the right upper extremity. On physical examination, he has persistent small finger abduction/extension with finger extension and active adduction. An EMG is performed and demonstrates ulnar nerve conduction velocities of 31 m/sec (normal >52m/sec). The patient symptoms are most accurately described as:
Axonotmesis with ischemia origin
Axonotmesis with myelin disruption
Neurapraxia with ischemia origin
Neurapraxia with endoneurium disruption
Neurotmesis CORRECT ANSWER: 3
The history and clinical presentation are consistent with ulnar entrapment neuropathy at the level of the cubital tunnel. This would be classified as a neuropraxia with ischemia origin.
Compression injuries to the peripheral nerves are often the result of microvascular dysfunction as the nerves traverse a high to low pressure gradient. Peripheral nerve injury can be classified as neuropraxia, axonotmesis, and neurotmesis. Compressive neuropathies are typically neuropraxias, with local myelin damage but not compromise of the major components of the nerve. In axonotmesis, there is Wallerian degeneration and myelin loss distal to the site of injury. The most severe type is that of neurotmesis. Neurotmesis is composed of a spectrum of injury in which the endoneurium is always disrupted (perineurium or epineurium may be intact). The worst form of neurotmesis is that of nerve transection.
Elhassan et al. review the pathophysiology of cubital tunnel syndrome. They report nerve dysfunction results from ischemic changes secondary to compression. Compressive effects on the nerves can last greater than 24 hours, even after the source of compression has been removed.
Rempel et al. review the pathophysiology of peripheral nerve compression syndromes. The authors indicate that deforming pressures to nerves are often the result of stenotic soft tissue canal boundaries. This leads to interference with local microvasculature of the nerve itself.
Illustration A demonstrates the Wartenberg sign, where the patient has persistent small finger abduction/extension resulting from weakness of the 3rd palmar interosseous/small finger lumbrical.
Illustration B reveals clawing which results from overpowering of the intrinsic muscles by the extrinsic muscles; a tenodesis effect results in flexion of the PIP/DIP joints. This is more severe in ulnar nerve compression at Guyon’s canal. Illustration C shows the Froment sign, where the FPL attempts to compensate for a deficient pinch, because of weakness of the adductor pollicis. Illustration D demonstrates atrophy of the 1st dorsal webspace from chronic compressive changes. Illustration E demonstrates atrophy of the thenar compartment which is consistent with carpal tunnel syndrome.
Incorrect Answers:

Which of the following hand injuries seen in Figures A-E is most appropriately treated with a first dorsal metacarpal artery flap?

Figure E CORRECT ANSWER: 3
Figure C shows a dorsal thumb laceration with exposed tendon that would be most appropriately treated with a first dorsal metacarpal artery (FDMA) flap.
The first dorsal metacarpal artery is a branch of the radial artery that supplies the dorsal hand skin from the thumb metacarpal to the long metacarpal, as well as the skin on the dorsal surfaces of the thumb and index to the proximal interphalangeal joint. The flap is raised distal to proximal as an island flap containing the FDMA, branches of the radial nerve, fascia of the underlying interosseous muscle of the first web space, and skin overlying the MP joint and proximal phalanx of the finger. It is an excellent option for large soft tissue defects on either side of the thumb. In this case, skin grafting is contraindicated because of exposed tendon without paratenon.
Sherif et al. detail the anatomy of the first dorsal metacarpal artery. They found three consistent branches, including the radial, ulnar, and intermediate branch. In part II of their study, they review the results of 23 patients where the FDMA flap was used as a fasciocutaneous or fascial flap for the coverage of soft tissue hand defects.
Illustration A shows a FDMA flap being raised for coverage of a thumb defect. Incorrect Answers:
bone can be allowed to heal through secondary intention.

Figure A is a radiograph of a 35-year-old women who sustained an isolated left wrist injury after a fall onto an outstretched hand. She has been complaining of left dorsal wrist pain since the fall. Examination reveals a positive Watson's scaphoid shift test. What ligamentous structure is an important secondary stabilizer to prevent dorsal intercalated segment instability (DISI) deformity in this patient?

Transverse carpal ligament
Dorsal intercarpal ligaments
Triangular fibrocartilage complex
Dorsal lunotriquetral ligament
Volar lunotriquetral ligament
The integrity of the dorsal intercarpal ligaments is important in preventing dorsal intercalated segment instability (DISI) deformity and persistent scapholunate instability.
Scapholunate instability is the most common carpal instability. The primary stabilizing structure of the scaphoid and lunate bones is the scapholunate ligament, which is commonly injured with a fall on an outstretched hand.
Secondary stabilizers of the scaphoid and lunate include the dorsal intercarpal ligaments and the dorsal radiocarpal ligaments. Failure to recognize injury of these structures can cause persistent dorsal intercalated segment instability (DISI). This can predispose patients to a SLAC wrist and early wrist osteoarthritis.
Mitsuyasu et al. examined the role of dorsal intercarpal ligaments (DIC) in scapholunate instability. They showed that the DIC had an important role in stabilizing the scaphoid and lunate bones with static and dynamic movements. The authors of this study suggest that the DIC ligament should be assessed intraoperatively and consideration should be given to repair and/or reconstruction with surgical management of scapholunate ligament tears.
Viegas et al. showed that the dorsal intercarpal and the dorsal radiocarpal ligaments form a lateral V configuration over the dorsal wrist. This configuration acts as an indirect dorsal stabilizing effect on the scaphoid
throughout the range of motion of the wrist. Their integrity acts to ensure normal wrist kinematics.
Figure A shows an AP and lateral radiograph of the left hand. There is significant gapping between the scaphoid and lunate articulation. This is indicative of a complete scapholunate dissociation, however both wrists should be imaged as this deformity may exist without injury. Illustration A shows the anatomy of the dorsal intercarpal and the dorsal radiocarpal ligaments.
Incorrect Answers:

A 50-year-old patient presents with stiffness in her hand. A clinical photo is shown in Figure A. During surgical exposure, the neurovascular bundle is identified and dissected. What is the clinically most important pathologic structure to identify and what is its location relative to the neurovascular bundle in the digit?

Spiral cord which is central and superficial to the neurovascular bundle
Central cord which is midline and superficial to the neurovascular bundle
Retrovascular cord which is central and superficial to the neurovascular bundle
Spiral cord which is lateral and deep to the neurovascular bundle
Central cord which is lateral and deep to the neurovascular bundle
Based on clinical findings, the patient has evidence of Dupuytren’s contracture affecting her ring finger. Relative to the neurovascular bundle, the spiral cord will lie lateral and deep.
Dupuytren’s disease is a benign hand condition characterized by pathologic nodules and cords of existing fascial bands. The most clinically relevant structure in Dupuytren's disease, is the spiral cord. The spiral cord is the result of pathology of 4 structures: the middle layer of the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. The spiral cord is found predominantly at the palmodigital transition. The spiral cord displaces the neurovascular bundle centrally and superficially.
Benson et al. review the etiology, pathophysiology and treatment options for Dupuytren’s contracture. They highlight that while the pretendinous band is located volar and central to the neurovascular bundle in the palm, the spiral band and lateral digital sheath cause the neurovascular bundle to be displaced superficially and volarly as they become pathologically affected.
Black et al. review the pathoanatomy, diagnosis and management of Dupuytren's disease. They note that the spiral cord lies superficial to the neurovascular bundle proximal to the MCP joint. Distal to the MCP joint it passes deep to the bundle. At that location, the spiral cord lies lateral to the
neurovascular bundle as the lateral digital sheet becomes involved
Figure A demonstrates the cord formation that is characteristic of the pathologic Dupuytren’s condition. It is the central cord that causes contracture of the MCP, whereas the retrovascular and spiral cords cause contractures of the DIP and PIP respectively. Illustration A shows the relationship of spiral cord formation in Dupuytren's disease relative to the normal anatomy of the palmar fascia. The structures implicated in the formation of the spiral cord are the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. Cleland's ligament, more dorsally located, is spared in Dupuytren's disease. The neurovascular bundle is displaced superficially and towards the midline, as the pathological cord spirals around. Illustration B shows the presence of other affected structures, including the natatory ligament and the central band. The central band is an extension of the pretendinous cord and attaches to the base of the middle phalanx. It may insert onto the tendon sheath of the flexor tendon at this level. Formation of natatory cords cause webspace contractures. Formation of central cords lead to flexion contractures of the PIP. Illustration V is a video that provides an educational overview of Dupuytren's.
Incorrect Answers:

An infant is brought to your office for evaluation of his hands. Clinical photos are shown in Figures A and B. The clinical features are most consistent with a genetic mutation in which of the following:

Sonic Hedgehog (SHH)
FGFR2
FGFR3
PMP22
COL1A1 CORRECT ANSWER: 2
Based on the clinical features seen in the figures provided, the most likely syndrome is that of Apert syndrome, which is consistent with a mutation in FGFR2.
Apert syndrome is an autosomal dominant condition that gives rise to facial dysmorphism and complex syndactyly of the hands. The craniosynostosis that develops causes flattening of the skull and facial features.
Goldberg et al review congenital hand conditions and the malformations associated with them. They indicate that not only does identification allow for natural history to be better elucidated, but also timing of surgical intervention can be better gauged.
Figures A and B demonstrate clinical features consistent with Apert Syndrome. The “rosebud” hand is a complex syndactyly that affects the index, middle and ring fingers most commonly. Hypertelorism is exemplified with increased distance between the eyes; additionally, acrocephaly is noted with forehead broadening and skull flattening.
Incorrect Answers
1: Mutation in sonic hedgehog gene (SHH) is associated with a longitudinal deficiency of the radius. This is seen in conditions like TAR, Holt-Oram and VACTERL syndromes.
3: Mutation in FGFR3 leads to achondroplasia
4: Mutation in PMP22 gives rise to Charcot Marie Tooth syndrome 5: Mutation in COL1A leads to osteogenesis imperfecta
A 45-year-old patient presents with recurrence of radial sided wrist pain after undergoing a first dorsal compartment release about 3 months ago. The surgery was completed by one of your partners; operative reports indicate that the sheath was incised on the dorsal edge. On physical exam she is found to have normal appearing skin, a negative Tinel’s sign, and a positive Finklestein test. What is the most likely cause of the recurrence of her symptoms?
Development of neuroma
Complex regional pain syndrome
Failure to decompress the EPB sub-sheath
Failure to decompress the EPL sub-sheath
Failure to decompress the APB sub-sheath
Based on the history and clinical findings this patient has de Quervain’s tenosynovitis. The recurrence of her symptoms can be attributed to a failure to recognize and decompress the EPB sub-sheath.
De Quervain’s tenosynovitis is a stenosing inflammatory condition of the first dorsal compartment of the wrist (APL/EPB). Surgical release of the compartment is indicated after conservative measures have failed. At the time of the operation, the incision is made on the dorsal side of the sheath to prevent volar subluxation of the tendons. Failure to identify and release a distinct EPB sub-sheath or a separate fibro-osseous compartment of the APL can lead to a recurrence of symptoms.
Alegado et al. report a case of a patient with dysesthesias in the superficial radial nerve distribution 3 months after undergoing first dorsal compartment release for de Quervain’s tenosynovitis. They found a persistent fibrous remnant of the dorsal aspect of the sheath causing elevation of the superficial radial nerve. They recommend sheath excision or incision of the sheath at its dorsal attachment to avoid this complication.
Ashurst et al. report a case of a patient presenting with bilateral de Quervain’s tenosynovitis secondary to excessive text messaging. Conservative measures
afforded the patient complete symptomatic recovery. They recommend limitation of texting, in conjunction with other standard treatments, to treat text messaging- associated de Quervain’s tenosynovitis
Ilyas et al. review the etiology, diagnosis and management of De Quervain’s tenosynovitis. Non-surgical management is largely successful and includes splinting and cortisone injections. In refractory cases, surgical release of the first dorsal compartment is completed. They recommend meticulous care of the radial sensory nerve and identification of all separate sub-sheaths.
Illustration A shows an operative photo in a patient with multiple APL slips and an EPB that is hidden within a sub-sheath. Video V gives a brief overview of de Quervain’s tenosynovitis.
Incorrect Answers

A 28-year-old NFL running back complains of continued hand pain three days following an injury sustained while being tackled. He was splinted on the field. He has tenderness over the long finger metacarpal head, with subluxation of the extensor tendon into the intermetacarpal area during active metacarpophalangeal joint flexion. A representative MRI is shown in Figure A. What is the next best step in management of this patient?

Observation alone
Continued splinting in flexion
Continued splinting in extension
Open repair of the disrupted junctura tendinae
Open repair of the disrupted sagittal band
Based on the history and physical exam findings this patient has sustained a traumatic rupture of the sagittal band. In this professional athlete, the next best step would be to perform an open repair of the sagittal band. This will allow for earlier aggressive rehabilitation and a quicker return to sport.
Sagittal band ruptures may be traumatic (as in this case) or attritional in nature (as in rheumatoid arthritis). A direct blow to the MCP leads to forced flexion of the digit and subsequent stretching/rupture of the affected structure. On physical exam the tendons are most unstable with the wrist flexed; MCP flexion will lead to dislocation of the tendon into the intermetacarpal gutter.
Acute injuries may be treated with extension bracing for 4-6 weeks, but in professional athletes, direct open repair of the sagittal band is indicated.
Catalano et al. review sagittal band injuries treated with a thermally molded
plastic splint that held the MCP in ~25-35 degrees of hyperextension. Patients were evaluated over 14 months; out of 11 sagittal band injuries, splinting was successful in eight of them. They recommend initial nonsurgical management with custom splinting.
Hame et al. review the results of the management of sagittal band injuries in the professional athlete. The lesion commonly found was the disruption of the extensor mechanism with predictable sagittal band tears. In their series, all patients regained full range of motion and returned to their respective sports. They recommend surgical intervention in elite athletes in the form of extensor tendon centralization and sagittal band repair.
Figure A shows a T1 weighted axial cut of the affected hand; subluxation of the tendon (arrow) can be identified with disruption of the sagittal band (arrowhead).
The video provided briefly reviews injury to the sagittal band. Incorrect Answers
Compressive injury to the posterior interosseous nerve will lead to EMG fibrillations in which of the following muscles?
Extensor Carpi Radialis Longus/Extensor Carpi Radialis Brevis/Brachoradialis
Extensor Carpi Radialis Longus/Supinator/Abductor Pollicis Longus
Extensor Pollicis Longus/Supinator/Abductor Pollicis Longus
Brachoradialis/Supinator/Extensor Pollicis Longus
Extensor Pollicis Longus/Supinator/Abductor Pollicis Brevis
Based on the choices above, fibrillations will be seen in the extensor pollicis longus, supinator and abductor pollicis longus muscles.
The radial nerve splits into the superficial radial branch and the posterior interosseous nerve (PIN) at the anterior aspect of the radiocapitellar joint, just proximal to the supinator muscle. The PIN innervates the EDC, EDM, ECU,
EPB, EPL, EIP, APL and sometimes the ECRB. Compressive neuropathy of the PIN leads to motor dysfunction, namely weakness with wrist and finger extension.
Lubhan et al. review uncommon compression neuropathies affecting the upper extremity. They indicate that PIN syndrome may be caused by rheumatoid arthritis and compressive ganglion cysts. Depending on which nerve branch is affected, partial lesions may develop. They recommend use of conservative measures (rest, activity modification and splinting) first. Decompressive procedures may be indicated in symptoms lasting greater than 3 months.
Illustration A shows the course of posterior interosseous nerve from proximal to distal along the course of the supinator. This proximal edge of the supinator (Arcade of Froshe), the fibrous edge of the ECRB and the leash of Henry are three main points of compression of the PIN.
Incorrect Answers

Figure A shows a traumatic laceration of the distal forearm with a 5cm segmental median nerve defect. Which of the following repair or reconstruction techniques would allow for the best recovery of motor function?

Autogenous venous nerve conduit
Collegen synthetic nerve conduit
Biodegradable polyglycolic acid
Processed nerve allograft
Nerve autograft CORRECT ANSWER: 5
Figure A shows a traumatic laceration with 5cm of median nerve defect. The use of nerve autograft for this size defect has been shown to have the best recovery of motor function.
The optimal surgical treatment of nerve laceration is direct tension-free repair. In segmental nerve defects this approach cannot be achieved. The use of interposed autologous nerve grafting remains the gold standard of repair in this setting. The use of alternative techniques, such as processed allografts and synthetic conduits, have not shown to have equivalent recovery of motor function as compared to nerve autograft.
Giusti et al. used a rat model to examine techniques of peripheral nerve repair. They showed that nerve autograft resulted in better motor recovery than did the use of processed allograft or a collagen conduit.
Deal et al. discussed tubular interposition substitutes, or nerve conduits, as an alternative to nerve autograft in segmental nerve defect. Nerve conduits can include autogenous nerve conduits (venous or arterial) and synthetic nerve conduits (collagen, PGA, or caprolactone). In general, there is an upper limit of 3-cm when using nerve conduit.
Figure A is an image of the volar forearm. There is a traumatic laceration to
the anterior compartment tendons as well as the median nerve.
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A 45-year-old man presents with a three-month history of unilateral symptoms in his right wrist and hand. He first noticed a palpable nodule over the volar aspect of his wrist about three months ago. The nodule would become painful after weekends of heavy drinking at which time he noticed tingling sensation in his index and middle fingers. He notes that ibuprofen has helped improve the pain in the past. On clinical examination, he has a palpable, nontender, solid nodule over the volar aspect of his wrist. He has no motor or sensory deficits and negative carpal tunnel provocative tests. An axial CT and MRI image are provided in figures A and B. What would be the most appropriate next step in the management of his symptoms?

Fine needle aspiration
Chemotherapy
Night splints
Establish a tissue diagnosis and referral to a rheumatologist
Surgical excision CORRECT ANSWER: 4
The clinical presentation is consistent with carpal tunnel syndrome caused by an atypical space occupying lesion - in his case, gout. The most appropriate next step in the management of his symptoms would be establishing a tissue diagnosis and referral to a rheumatologist where medical therapy, such as prophylaxis with colchicine, could be initiated.
Carpal tunnel syndrome is the most common compressive neuropathy, affecting up to 10% of the general population. Risk factors include female sex,
advanced age, obesity, and repetitive motion activities. Typically, patients will develop symptoms of median nerve compression including thenar muscle atrophy, numbness in the radial 3.5 digits, night pain, and positive Tinel's and Phalen tests. First line management is non-operative, including NSAIDs, night splints, and activitiy modification. Carpal tunnel release surgery is indicated for those who have failed conservative management.
Chen et al. described 23 unusual cases of CTS in which space-occupying lesions were responsible for the symptoms and signs of median nerve compression. In patients with an atypical presentation, such as male gender, non-middle-aged, or unilateral involvement, space-occupying lesions such as gout, synovial sarcoma, lipoma, and ganglions should be investigated as a cause.
Fitzgerald et al. discussed gout affecting the hand and wrist. The medical treatment of gout includes NSAIDs such as indomethacin or ibuprofen for acute flares, and colchicine and allopurinol for chronic prophylaxis.
Figures A and B represent axial CT and MRI images showing calcification and gouty tophi deposition in the carpal tunnel floor.
Incorrect Answers:
Which statement most accurately describes the physiology of peripheral nerve regeneration following an axonotmesic lesion?
The proximal nerve segment undergoes Wallerian degeneration
Axon growth occurs from the distal segment to proximal segment
Neurotrophic factors direct phagocytic activity
Proximal axon budding allows for antegrade (or distal) axon migration
Axoplasm and myelin are degraded distally predominantly by Schwann cells for the first 12 months following injury
Axonomesis is a disruption of the nerve axon following injury. Repair/regeneration of the nerve occurs via proximal budding, followed by antegrade (or distal) axon migration.
The peripheral nerve regeneration process begins with the distal segment undergoing Wallerian degeneration (axoplasm and myelin are degraded distally by phagocytes). Existing Schwann cells proliferate and line-up along the basement membrane. Proximal budding occurs after a one-month delay. This is followed by sprouting axons that migrate in an antegrade fashion to connect to the distal tube. Repair of the nerve can take months, and often have poor outcomes.
Lee et al. reviewed peripheral never injury and repair. They commented that Wallerian degeneration (i.e., breakdown of the axon distal to the site of injury) is initiated 48 to 96 hours after transection. The Schwann cells then align themselves longitudinally, creating columns of cells called Büngner bands. At the tip of the regenerating axon is the growth cone.
Illustration A shows a chart of peripheral nerve injury. The two main classification systems are Seddon and Sunderland. Video V is a lecture discussing peripheral nerve injury and management.
Incorrect Answers:

A 28-year-old male injures his hand while playing basketball and presents to the emergency room. Closed reduction is performed and is stable. Post-reduction rehabilitation is discussed with the patient.
Which of the following radiographs demonstrates an injury that would be treated best by dorsal extension block splinting?

Figure E CORRECT ANSWER: 2
Dorsal extension-block splinting is the treatment of choice for dorsal proximal interphalangeal joint (PIPJ) fracture dislocations that are stable following reduction and have less than 40% articular surface fracture involvement.
Dorsal PIPJ dislocations are a common injury, often resulting from jamming or hyperextending the finger. In the absence of an associated fracture or presence of a small volar plate avulsion, dorsal PIPJ dislocations are often
treated with closed reduction and buddy-taping to the adjacent digit. Injuries that are unstable following reduction or those associated with an intra-articular fracture of the middle phalanx are stabilized with a dorsal extension-block splint to maintain reduction. It is important to initiate early range of motion exercises within the constraints of the splint to minimize scar formation and subsequent PIPJ contracture.
Elfar et al. reviewed fracture-dislocations of the PIPJ. Dorsal PIPJ fracture-dislocations can be categorized as avulsion or impaction shear injuries.
Avulsion fractures result from hyperextension of the PIPJ, tensioning the volar plate (VP) with eventual VP rupture or avulsion of the volar lip of the middle phalanx. Axial load applied to the digit in PIPJ flexion drives the head of the proximal phalanx across the middle phalangeal base, resulting in a shear fracture or comminuted impaction fracture of the middle phalanx, depending on the amount of energy imparted and the bone quality.
Morgan et al. reviewed hand injuries in athletes. Dorsal PIPJ dislocations without associated fracture that are stable following successful reduction are treated by buddy taping the injured digit to the non-injured digit adjacent to the compromised collateral ligament. Buddy taping with active motion should be continued for 6 weeks. Unstable injuries and those with an intra-articular fracture of the middle phalanx should be treated with dorsal extension-block splinting with incremental extension of the splint on a weekly basis for 4 weeks, followed by buddy-taping for 3 months during sports activities.
Figure A shows a simple dorsal PIPJ dislocation. Figure B shows a dorsal PIPJ fracture dislocation. Figure C shows a simple volar PIPJ dislocation. Figure D shows a volar PIPJ fracture dislocation. Figure E shows a dorsal avulsion fracture at the base of the distal phalanx (bony mallet injury). Illustration A depicts an dorsal extension-block splint that blocks extension of the digit past a set point while allowing full active flexion of the digit. Illustration B is a lateral radiograph of a digit showing a small minimally displaced volar plate avulsion fracture at the PIPJ with minimal intra-articular involvement (as compared to Figure B). This injury may be managed with buddy taping and active range of motion as tolerated.
Incorrect Responses:
extension for 6-8 weeks to limit flexion of the digit and therefore fracture displacement.

A 35-year-old mixed martial arts fighter and recreational cocaine user presents with symptoms concerning for hypothenar hammer syndrome (HHS). Significant ischemia is found on physical exam. Arteriography is shown in Figure A. What is the most appropriate next step in treatment?

Conservative treatment with cocaine abstinence
Conservative treatment with activity modifications and medical management with calcium channel blockers
Therapeutic endovascular fibrinolysis
Excision of involved segment and reconstruction with or without a vein graft
Medical management with coumadin for 6 months
Figure A shows a bilobed aneurysm overlying the ulnar artery with normal appearing distal vasculature. Hypothenar hammer syndrome (HHS) can be associated with an aneurysm and is most appropriately treated with resection of the involved segment and either reconstruction with a primary anastomosis or vein graft.
HHS syndrome consists of two separate entities, thrombosis and aneurysm. In the setting of thrombosis without aneurysm, conservative management is preferred. If the thrombosis is acute (<2 weeks), endovascular fibrinolysis has shown good results. In patients with an HHS and an aneurysm, surgery is required for resection to prevent distal embolization and remove the often painful aneurysmal mass.
Yuen et al. review HHS. In patients with HHS and aneurysms, resection of the involved segment of the ulnar artery prevents distal embolic events, eliminates the painful mass, relieves ulnar nerve compression, and removes the thrombus which initiated the reflex vasospasm and closed off the collateral
vessels in the region.
Lifchez et al. review the long-term outcomes of 11 patients with HHS treated with ulnar artery reconstruction. 2 of the patients underwent excision and direct ulnar artery repair, and the rest underwent reconstruction with a vein graft. All patients had a mean improvement in digital brachial index, decrease in pain and dysesthesia symptoms, and decrease in cold intolerance compared with preoperatively.
Nitecki et al. review a case series of 6 patients with HHS. They state that the treatment of thrombosis should be largely conservative, but thrombolytic treatment could be considered if the event happened <2 weeks prior to presentation.
Illustration A shows an excised ulnar artery aneurysm in a patient with HHS. Note the typical "corkscrew" appearance of the distal segment.
Incorrect Answers:

A 36-year-male was using a high-pressure paint gun when he suffered the injury shown in Figure A. Which of the following variables would have the worst impact on his prognosis?

Delay in surgical treatment
Injected solvent was grease
Injected solvent was water-based paint
An entry wound of greater than 3 cm
Injected solvent was at room temperature
The clinical presentation is consistent for a high-pressure injection injury. Delays in surgical treatment are associated with serious sequelae.
High-pressure injection injuries are characterized by extensive soft tissue damage associated with a benign high-pressure entry wound. They should be treated with irrigation & debridement, foreign body removal and broad-spectrum antibiotics. There is a higher rates of amputation when surgery is delayed.
Bekler et al. looked at the results of 14 surgically treated high-pressure injection injuries of the hand with a minimum of two years follow-up. Ten of the injuries required formal operative debridement and foreign body removal. Six required reconstructive microsurgical procedures and one underwent digital tip amputation. They concluded that high-pressure injection injury to the hand is a significant problem, which can easily lead to serious sequelae and, even, amputation.
Rosenwaser et al. report wide débridement of all involved tissues, decompression of tissue compartments, exploration and incision of tendon sheaths, removal of injected material, and saline irrigation are critical in the management of high-pressure injection injuries to the hand. They emphasize
delayed surgery has been associated with increased incidence of morbidity and amputation.
Figure A shows a typical high-pressure injection injury. Notice the benign looking entry wound.
Incorrect Answers:
A healthy 50-year-old secretary is about to undergo an open carpal tunnel release. Which of the following peri-operative steps will have the greatest influence on minimizing the risk of a surgical site infection in this patient?
Administration of cefazolin within 1 hour before incision
Administration of cefazolin within 1 hour before incision followed by 5 days of cephalexin post-op
Cleanse with bacitracin solution immediately before skin incision
Standard sterilization and prepping
Administration of one dose of cephalexin within 1 hour before incision
The patient is undergoing a clean, elective hand surgery. Prophylactic antibiotics, systemic or local, are not indicated for these procedures.
Carpal tunnel syndrome is the most common compressive neuropathy. Individuals who fail medical management (night splints, NSAIDs, activity modification) are candidates for carpal tunnel release surgery (CTS). The surgery may be performed open or endoscopically. The reported incidence of post-operative infections following CTS varies between studies from 0% to 8%.
Whittaker et al. performed a prospective, randomized, double-blinded, placebo
controlled trial investigating the use of antibiotic prophylaxis in clean, incised hand injuries. They found no significant difference in infection rates between patients who received IV flucloxacillin, IV followed by oral flucloxacillin, and an oral placebo (13% vs. 4% vs. 15%, p=0.19). They did not support the use of routine antibiotic prophylaxis prior to clean hand surgery.
Bykowski et al. retrospectively reviewed 8,850 outpatient elective hand surgeries and found no significant difference in the rate of surgical site infection, including patients with diabetes or history of smoking. They concluded that antibiotics should not be routinely administered prior to clean, elective hand surgeries.
Harness et al. found no statistical difference in the incidence of surgical site infection following CTS without prophylactic antibiotic compared with patients who received prophylactic antibiotics (0.7% vs. 0.4%, p=0.354). They did not recommend routine antibiotic prophylaxis.
Illustration A reviews the anatomic components of the carpal tunnel. Incorrect Answers:
infection in clean, elective hand surgery. Surgeons should consider the potential risks of antibiotics prior to administration, including Clostridium difficile colitis, antibiotic allergies, bacterial resistance, and so on.

A 30-year-old male laborer sustained a right wrist injury 9 months ago. He continues to have symptoms of recurrent ulnar-sided wrist pain that impairs his ability to work. An MRI is performed and
shows a triangular fibrocartilage complex (TFCC) injury. Which of the following is an indication to combine a Wafer procedure with arthroscopic TFCC debridement?
Ulnar styloid fracture
Radial styloid fracture
2 mm of positive ulnar variance and ulnocarpal impingment
2 mm of negative ulnar variance and radiocarpal joint arthritis
Scapholunate ligament injury
A Wafer procedure is indicated for positive ulnar variance and symptomatic ulnocarpal impingement associated with degenerative TFCC tears.
Ulnar impaction syndrome and triangular fibrocartilage complex (TFCC) injuries are relatively common causes of ulnar-sided wrist pain. Positive ulnar variance causes increased contact pressures between the lunate and the ulnar head. The Wafer procedure removes 2-4 mm of distal ulnar head to reduce ulnar variance to neutral or negative. This is thought to reduce ulnar impaction and decrease pain.
Faber et al. examined the role of MRI in wrist injuries. They showed that the sensitivity and specificity to detect TFCC tears using MRI is approximately 80%. They conclude that there is no supporting evidence for routine MRI's for patients with non-specific ulnar-sided wrist pain.
Illustration A is a coronal view MRI (without arthrogram) of the right wrist that shows a TFCC tear (blue arrow) with positive ulnar variance. Illustration B shows a series of images showing a TFCC tear on MRI and intra-operatively.
Incorrect Answers:

A 27-year-old male sustains the injury shown in Figure A. He is taken to the operating room and the lesion is repaired primarily. Two months later, he feels a "pop" while using his hand and is no longer able to flex the distal phalanx of the involved digit. He is taken to the operating room for surgical exploration where 1.8 cm of scar tissue between the tendon ends is identified. The tendon sheath is found to be intact and allows smooth passage of a pediatric urethral catheter. What is the next step in management?

Resection of scar and primary repair of tendon ends.
Resection of scar and adjacent 1cm of tendon, placement of Hunter rod for staged reconstruction.
Debulking of scar, partial excision of 25% of the A2 and A4 pulleys.
Resection of scar, harvest of ipsilateral palmaris longus tendon for tendon reconstruction.
Resection of scar and proximal tendon, tendon transfer from adjacent digit.
This patient sustained an FDP laceration that was treated initially with primary repair. He subsequently re-ruptured the tendon 2 months later. With scar >1 cm, tendon grafting is indicated and primary tendon grafting with palmaris longus is commonly performed as it is the most accessible tendon in the operative field.
Flexor tendon lacerations commonly result from volar lacerations. Concomitant neurovascular injury is common. Partial lacerations <60% of tendon width are treated with debridement and early range of motion. With partial lacerations, the least amount of gliding resistance can be obtained with debridement alone. Lacerations >60% of tendon width are treated with flexor tendon repair and controlled mobilization. Failed primary repair and chronic untreated injuries are indications for flexor tendon reconstruction and intensive postoperative rehabilitation.
Lilly et al. reviewed complications after flexor tendon injuries. Common complications include adhesions, joint contracture, tendon rupture, triggering, pulley failure and bowstringing, quadrigia, swan-neck deformity and lumbrical plus deformity.
Figure A shows a zone II laceration of the left index finger FDP.
Incorrect Answers:
A 55-year-old female patient presents with pain along the thumb ray and increasing deformity of her right hand. Key pinch causes her pain. The appearance of her hand is seen in Figure A. Range of motion of her thumb is seen in Figure B. What is the most likely cause of her deformity?

Type II hypoplastic thumb
Median nerve neuropathy
Lupus thumb deformity
Extensor tendon rupture
Osteoarthritis of the trapeziometacarpal joint
The patient has 1st carpometacarpal (CMC) arthritis.
With 1st CMC arthritis, the patient avoids painful thumb abduction and an adduction deformity gradually develops, with 1st webspace contracture. With progressive 1st CMC stiffness, the thumb metacarpophalangeal joint (MCP) develops hyperextension deformity to compensate for the loss of motion, leading to a secondary "Z" deformity.
Rozental et al. reviewed hand and wrist reconstruction. They believe that arthrosis arises from loss of the anterior oblique ("beak") ligament.
Compensatory MCP hyperextension should be treated with MCP capsulodesis or arthrodesis.
Van Heest et al. reviewed thumb CMC arthritis. Treatment for Eaton stage I/II arthritis is open/arthroscopic debridement, volar ligament reconstruction (with APL or FCR tendons), or metacarpal extension osteotomy. For stage III/IV arthritis, treatment options include implant arthroplasty or resection arthroplasty +/- LRTI (with APL, FCR or palmaris longus), and fusion (young patients).
Figure A shows adduction contracture of the 1st webspace, with hyperextension deformity of the 1st MCP joint. Figure B illustrates decreased thumb abduction because of adduction contracture with decreased palmar abduction (normal, 45deg) and decreased radial abduction (normal, 60deg). Illustration A is a radiograph showing thumb CMC arthritis with Z deformity. Illustration B shows lupus thumb deformity ("hitchhiker thumb"). Illustration C shows hand changes in inflammatory arthritis.
Incorrect Answers:

A 26-year-old man presents with chronic hand weakness. The clinical appearance of his hand, and radiographs are shown in Figures A through C. Surgical exploration and decompression is performed. Besides addressing thumb interphalangeal and index distal interphalangeal joint flexion, which is the most appropriate treatment to restore thumb opposition?

Ring flexor digitorum superficialis transfer to the abductor pollicis brevis
Extensor indicis proprius transfer to the abductor pollicis brevis
Neurotization of thenar muscles
Camitz palmaris longus transfer to the abductor pollicis brevis
Thumb carpometacarpal joint arthrodesis
This patient has a high median nerve neuropathy because of a supracondylar spur and ligament of Struthers. Reconstruction is best performed with extensor indicis proprius (EIP) transfer to the abductor pollicis brevis (APB).
In low median nerve palsy, the primary concern is restoration of thumb opposition. In high median nerve palsy, thumb opposition and IP flexion, and index and middle finger flexion have to be addressed. The four common opposition transfers include (1) ring or long FDS, (2) EIP, (3) Camitz palmaris longus (PL), or the Huber abductor digiti minimi (ADM).
Anderson et al. reviewed EIP transfer vs FDS transfer. They found a higher percentage of excellent results in the EIP group. In their series, complications included index finger extensor lag (EIP transfer if the extensor expansion was not repaired) and limited donor finger extension because of lateral band damage or adhesions between the remaining FDS tendon and flexor sheath (FDS transfer).
Cawrse et al. modified the Huber ADM opponens transfer by releasing the proximal end to prevent compression of the ulnar nerve in Guyon's canal by the rotated ADM belly. They found that this technique successfully restored
opposition and thenar bulk.
Figure A shows thenar wasting. Figures B and C show a supracondylar spur. The ligament of Struthers attaches from this spur to the medial epicondyle, under which median nerve and brachial artery pass. Illustration A shows EIP transfer. Illustration B shows FDS transfer. Illustration C shows Camitz PL transfer. Illustration D shows Huber ADM transfer.
Incorrect Answers:

A 2-year-old child is referred by her pediatrician for fixed flexion deformity of the left thumb. She has been wearing a splint for the last 6 months. She has ventricular septal defect and left renal agenesis. The interphalangeal joint does not extend past 40 degrees of flexion as seen in Figures A and B. There is no triggering. There is a firm, nontender nodule overlying the metacarpophalangeal joint as outlined in blue in Figure C. What is the diagnosis and most appropriate treatment?

Thumb camptodactyly. Therapy including passive stretching exercises.
Congenital clapsed thumb. Percutaneous release of the A1 pulley.
Pediatric trigger thumb. Open release of the A1 pulley.
Pediatric trigger thumb. Open release of the A1 pulley and resection of the tendon nodule.
Blauth Type I hypoplastic thumb. Open release of the A1 pulley and volar plate, and resection of the tendon nodule.
This child has pediatric trigger thumb (PTT). The potential for spontaneous resolution beyond the age of 2 years is limited. Surgical release of the A1
pulley is indicated.
Pediatric trigger thumb presents as fixed flexion at the interphalangeal joint (IPJ) rather than triggering. It is likely to be acquired (rather than congenital). It is associated with the presence of Notta's nodule, a thickening of the FPL tendon and overlying tendon sheath. Treatment involves A1 pulley release.
The role of non-surgical management (splinting/stretching) remains unclear. The duration of non-surgical treatment is long (up to 30 months) and compliance can be difficult.
Shah et al. reviewed pediatric trigger thumb. The condition is associated with MCP hyperextension. The authors note no advantage to percutaneous release as general anesthetic is required anyway.
Marek et al. performed a retrospective review and survey response review of surgery for pediatric trigger thumb. They found that age at the time of surgery influences residual flexion contracture and rate of recovery. They found surgery to be safe and effective, and recommend: (1) surgery for a 2-year-old child with a locked thumb for 6 months, (2) observation for a child <1 year if the thumb is triggering (not locked), and (3) a 6-month observation period if observation is advocated.
Figures A and B show a fixed flexion deformity of the thumb and an attempt at thumb extension. Figure C shows the outlined Notta nodule.
Incorrect Answers:
A 48-year-old hairdresser presents with pain and swelling of his ring finger for 4 days. On examination, there is generalized tenderness along the entire digit. Passive extension of the digit triggers
excruciating pain. The clinical appearance of the digit is shown in Figure A. What is the most appropriate next step in management?

Acyclovir
Intravenous antibiotics, splinting and elevation
Closed tendon sheath irrigation from the level of the A1 pulley (proximal) to the distal interphalangeal joint (distal)
Continuous closed tendon sheath irrigation from the wrist (proximal) to the distal interphalangeal joint (distal)
Open irrigation and debridement
This patient has advanced pyogenic flexor tenosynovitis (PFT) with visible ischemia/necrosis. Open irrigation and debridement is necessary.
Pyogenic flexor tenosynovitis is usually caused by a puncture wound (although it may infrequently arise from hematogenous spread). The most common organism is Staphylococcus aureus. Kanavel signs help differentiate this disease from herpetic whitlow, septic arthritis, gout/pseudogout, and other hand infections such as paronychia, felons, cellulitis, and deep space infections.
Draeger et al. reviewed the treatment of pyogenic flexor tenosynovitis (PFT). They recommend open irrigation and debridement for advanced PFT and atypical or chronic tenosynovial infections where tenosynovectomy may be
indicated. Both midaxial and volar zigzag incisions can be used.
Pang et al. reviewed factors affecting the prognosis of PFT. Of the 4 Kanavel signs, they found that fusiform swelling was most often present (97% of patients), followed by pain on passive extension (72%), semiflexed digit posture (69%), and tenderness along the flexor tendon sheath (64%).
Figure A shows advanced PFT demonstrating subcutaneous purulence and local ischemia in addition to fusiform digital swelling. Illustration A shows the Nevasier technique of closed tendon sheath irrigation. Illustration B shows the setup for continuous tendon sheath irrigation using nested catheters.
Illustration C shows the incision for open irrigation and debridement.
Incorrect Answers:

Madelung's deformity of the distal radius is caused by which of the following?
Premature fusion of the distal radial ulnar joint
Physeal growth mismatch between the distal radius and ulna
Nutritional deficiency affecting the physeal zone of provisional calcification
Impaired growth of the volar and ulnar aspect of the distal radial physis
Unrecognized trauma CORRECT ANSWER: 4
Madelung's deformity is that of excessive ulnar/palmar angulation of the distal radius caused by impaired growth of the volar and ulnar aspect of the distal radial physis. It may be caused by either a bony lesion in the palmar/ulnar corner of the distal radial physis or an abnormal radial-carpal ligament (Vicker's ligament). The other answers do not cause Madelung's deformity.
Leri-Weill dyschondrosteosis is a rare genetic disorder caused by mutation in the SHOX gene that causes mesomelic dwarfism with associated Madelung's defomity of the forearm.
Illustration A is a radiographic example of Madelung's deformity.

A 17-year-old boy presents with pain in his right elbow for 2 years and limitation in elbow motion bilaterally. He denies any pain or discomfort in his left elbow. He reports no history of trauma to either elbow. He has had two courses of physical therapy, but has noted no noticeable improvement in pain or motion. Examination demonstrates no elbow tenderness on palpation, and there are no neurological deficits. Manual reduction is unsuccessful. The range of motion of both elbows is shown in Figure A. Radiographs of left and right elbow are shown in Figure B and C respectively. What is the most appropriate treatment plan for the right and left elbow?

Bilateral open reduction and application of a hinged external fixator to both elbows
Radial head resection of the right elbow and non-operative management of the left elbow.
Bilateral radial head arthroplasty
Physical therapy and splinting to both elbows
Radial head resection and interposition arthroplasty for the right elbow and radial head resection alone for the left elbow
This patient has bilateral congenital radial head dislocation (CRHD). The right side is symptomatic with significant loss of motion. The left is asymptomatic with minimal loss of active motion. Therefore the most appropriate treatment is radial head resection of the right elbow and non-operative management of the left elbow.
It is important to differentiate CRHD from traumatic dislocation. Clinical features of CRHD include bilateral involvement, presence at birth, other congenital anomalies, familial occurrence, irreducible by closed methods, and
lack of a history of trauma. Radiological features include dome-shaped radial head and hypoplastic capitellum, relatively short ulna or long radius, deficient trochlea, prominent medial epicondyle, grooving of the distal radius, and anterior curvature of the posterior outline of the ulna.
Bengard et al. reviewed 10 surgically treated and 6 nonsurgically treated CRHD patients. They found no change in flexion-extension and carrying angle postoperatively, but forearm rotation was improved. Surgically treated patients had significant improvement in elbow pain. Ultimately, >25% of patients had wrist pain postop and this must be weighed in the decision process of treatment. They recommend radial head excision as an effective intervention in selected patients with significant elbow pain.
Figure A is a table showing moderately diminished ROM of the right elbow, and minimally reduced ROM of the left elbow. Figures B and C both show posterior dislocation of the radial head (a line along the long axis of the radius should intersect the capitellum in all views).
Incorrect Answers:
Which of the following muscles provide the primary deforming forces to Bennett and Rolando fractures (base of the 1st metacarpal fractures)?
Pronator quadratus
Flexor pollicis longus
Extensor pollicis longus
Adductor pollicis longus and abductor pollicis
Abductor pollicis longus and adductor pollicis
The primary deforming forces in Bennett and Rolando fractures are the Abductor pollicis longus and adductor pollicis.
In a Bennet's or Rolando fracture-dislocation the volar-ulnar fracture fragment is held reduced by the anterior oblique ligament while strong deforming forces pull the remaining metacarpal shaft proximally and dorsally, angulate the shaft ulnarly and supinate the shaft. Most important in these deforming forces are the abductor pollicis longus (APL) inserting on the base of the metacarpal which pulls the metacarpal shaft proximally and dorsally and the adductor pollicis (AP) which inserts on the ulnar base of the proximal phalanx and angulates the metacarpal shaft ulnarly and supinates the shaft. Less important is the extensor pollicis longus (EPL) which inserts on the base of the distal phalanx and also adds to the ulnar angulation of the distal fragment.
Soyer reviews the diagnosis, pathoanatomy, and treatment for fractures at the base of the 1st metacarpal. Understanding the biomechanics, anatomical deforming forces, and the exact fracture pattern aids the treating surgeon in determining the most appropriate method of fixation. The most essential factor for obtaining a good functional result is anatomic restoration of the articular surface.
Elgafy et al. examined the terminal anatomy of the posterior interosseous nerve in their cadaver study - identifing six terminal branches and describing methods to avoid injury. They describe how treating surgeons can maximize function and recovery after base of the 1st metacarpal fractures by understanding these nervous branches and specific fracture pattern treatment to avoid iatrogenic injury to the PIN.

A 28-year-old man sustained a complete laceration of the flexor digitorum profundus of his index finger while cutting a watermelon 3 days ago. A clinical photograph is shown in Figure A. The surgeon plans to repair the tendon using a 4-strand core suture technique. Which method of tendon repair will give him the best results in terms of load to failure and gliding resistance?

Repair with core suture purchase 5mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 10mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 5mm from the cut edge. Circumferential
simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential Silfverskiold epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge, coupled with circumferential simple running epitendinous suture will give him the best load to failure and gliding resistance.
The strength of tendon repairs depend on the number of strands crossing the repair site. Ideally, repairs should have 4-6 strands to allow for early active motion. A running epitendinous suture is recommended to improve tendon gliding and repair strength.
Gulihar et al. compared 3 different epitendinous suture techniques. They found that compared with an intact tendon, gliding resistance increased 100% with the Halsted repair, 80% with the Silfverskiold repair and 60% with a running suture. They thus recommend a simple running suture when an epitendinous suture is needed.
Lee et al. compared core suture purchase at 3, 5, 7 and 10mm from the cut edge. The 10mm-repair group had the highest 2-mm gap force and ultimate failure load. They recommend 10-mm suture purchase for optimal performance and to allow early active motion.
Figure A shows a laceration to the volar aspect of the index finger in flexor zone II. Illustration A shows a core suture purchase distance from the cut edge (represented by "X", where 10mm is the ideal distance). Illustration B shows 3 different epitendinous suture techniques (A, simple running; B, Silfverskiold; C, Halsted).
Incorrect Answers:

A 28-year-old professional baseball player injures his middle finger sliding into the catchers shin guard at home plate. He complains of pain and deformity of the middle finger. A radiograph is provided in figure A. All of the following are true EXCEPT:

Anatomic reconstruction of the articular surface is prognostic of clinical function
Proximal interphalangeal joint subluxation precludes a normal gliding flexion arc
Hinging at the fracture site must be avoided
Early motion should be initiated in postoperative therapy
Early degenerative arthritis can be expected if the joint is not adequately reduced.
The radiograph demonstrates a dorsal fracture dislocation of the proximal interphalangeal joint of the middle finger. Kiefhaber and Stern review the presentation, evaluation, and treatment of PIP fractures. Congruent reduction of the joint to allow the middle phalanx to glide around the proximal phalangeal head is paramount to prevent joint subluxation and instability.
Anatomic reconstruction of the articular surface is desirable but not necessary for successful clinical outcome.
A 30-year-old male sustains a 3.5 cm long thumb pulp injury seen in Figure A. He undergoes a procedure to restore the soft tissue envelope. Which treatment option is contraindicated because of increased risk of interphalangeal joint stiffness?

Moberg volar advancement flap
Foucher first dorsal metacarpal artery flap
Littler neurovascular island flap
Free great toe pulp transfer
Holevich first dorsal metacarpal artery flap
This patient has a large thumb pulp defect measuring 3.5 cm in length, extending proximal to the interphalangeal joint (IPJ) crease. Inset of a Moberg flap large enough to cover the defect would necessitate IPJ flexion >45 degrees, increasing the risk of IPJ stiffness.
Thumb pulp defects may be resurfaced by different means, depending on size. The Moberg flap is suited for medium (1.8-3 cm) defects. For defects >1.5 cm, there is increased risk of wound dehiscence, parrot beak nail deformity, and decreased soft tissue padding. Modifications such as V-Y flaps, bilateral Z-plasties, Burrow triangles, 2 lateral triangular flaps at the proximal edge of the flap, or advancement of an island flap with skin grafting of the secondary defect (O’Brien modification), are recommended.
Baumeister et al. reviewed the functional outcome of Moberg flaps. These flaps do not cause marked impairment of active ROM and any reduction in the AROM of the IP joint is because of a loss of hyperextension.
Horta et al. reviewed the use of multiple flaps (Moberg, radial innervated cross-finger, Venkataswami-Subramanian, Foucher, Tezcan, and Littler). They recommended the Foucher flap because of good sensibility, single-stage surgery, and no need for cortical reintegration (unlike the Littler flap)
Figure A shows a large thumb pulp defect. Illustration A shows the options for resurfacing thumb pulp defects of different sizes. Illustration B is a diagram of these options. Illustrations C and D depict the Holevich dorsal metacarpal artery flap (with overlying skin strip). Illustrations E and F depict the Foucher dorsal metacarpal artery flap (islanded).
Incorrect Answers:

Percutaneous screw fixation for non-displaced scaphoid waist fractures has been shown to have which of the following differences compared to closed treatment?
Increased direct and indirect cost
Slower return to work
Higher union rates
Reduced time to fracture union
Improved motion and grip strength after 2 years
Fixation of non-displaced scaphoid fractures with a percutaneous screw has resulted in a shorter time to union (6-7 weeks versus 10-12 weeks) and faster return to work or sports.
Arora et al found the indirect cost reduction by a quicker return to work was shown to offset the direct costs of surgical intervention.The operatively treated group had a better mean DASH-score than the conservative group. Fracture
union was seen in the screw fixation group at a mean of 43 days and in the cast immobilization group at a mean of 74 days.
Bond et al found in active military personnel there was faster healing but no difference in ultimate union rates or final grip strength or range of motion between percutanous screw fixation and non-operative groups. The average time to fracture union in the screw fixation group was seven weeks compared with twelve weeks in the cast immobilization group. There was no significant difference in the range of motion of the wrist or in grip strength at the two-year follow-up evaluation.
Constriction ring syndrome, also known as amniotic band syndrome, is a congenital disorder associated with which paediatric foot condition?
Equinovalgus foot
Clubfoot (Congenital talipes equinovarus)
Tarsal coalition
Congenital vertical talus
Polydactyly CORRECT ANSWER: 2
Constriction ring syndrome is a congenital disorder that is most commonly associated with clubfeet (congenital talipes equinovarus). The reported incidence of clubfeet with concomitant constriction bands ranges from 12-56%.
Constriction ring syndrome is a collection of congenital malformations that occur as a result of intrauterine rings or bands that constrict fetal tissue. The etiology of constrictive ring syndrome remains elusive, though Streeter postulated in 1930 that a germline developmental abnormality is responsible for the development of amniotic constriction bands, hence one of the synomonous terms used to describe the disorder, Streeter’s dysplasia. Normal anatomy is found proximal to the band. Distally, a constrictive band can cause compression of lymphatic and neurovascular structures and result in lymphedema, altered circulation and neuropathy. In severe cases congenital amputation can occur. In terms of other orthopaedic conditions, constrictive ring syndrome is associated with clubfeet, acrosyndactyly and pseudoarthrosis. With respect to clubfeet, surgical treatment is commonly required, which consists of z-plasty releases of the constricted bands, in addition to surgical correction of the clubfoot deformity.
Gomez reviewed 35 children with clubfeet associated with constriction ring syndrome. In this cohort there was a poor response to casting, as 77% of the children required surgical corrections. Z-plasty releases of the deep bands were performed before the clubfoot correction.
Allington et al. examined the outcome of treatment of clubfeet distal to a lower extremity band in 18 patients (21 feet). Sixteen children (88.9%) underwent surgical treatment after manipulation and serial casting were unsuccessful.
Mild initial foot deformities and constriction bands located in the distal aspect of the lower leg were associated with the best outcomes.
Incorrect Answers:
You are consulted on a newborn male inpatient who presents with the clinical sign shown in Figure A. All of the following are commonly associated with this syndrome EXCEPT?

Bronchopulmonary dysplasia
Cardiac defects
Cleft palate
Encephalocele
Rigid talipes equinovarus

Question 49

A 75-year-old woman who fell on her right knee now reports pain and is unable to bear weight. History reveals that she underwent total knee arthroplasty on the right knee 6 years ago. Radiographs are shown in Figure 5. Management should now consist of

Explanation

DISCUSSION: The radiographs show a loose femoral component with an associated medial condyle distal femoral fracture. The treatment of choice is open reduction and internal fixation with revision of the femoral component because of the femoral component loosening.
REFERENCES: Moran MC, Brick GW, Sledge CB, et al: Supracondylar femoral fracture following total knee arthroplasty. Clin Orthop 1996;324:196-209.
McLaren AC, DuPont JA, Schroeber DC: Open reduction internal fixation of supracondylar fractures above total knee arthroplasties using the intramedullary supracondylar rod. Clin Orthop 1994;302:194-198.
Figgie MP, Goldberg VM, Figgie HE III, et al: The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty 1990;5:267-276.

Question 50

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

Explanation

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

Question 51

A 17-year-old high school football player reports wrist pain after being tackled. Radiographs are shown in Figures 22a through 22c. What is the recommended intervention?

Explanation

DISCUSSION: The patient has an acute fracture of the proximal pole. A 100% healing rate has been reported for open reduction and internal fixation of proximal pole fractures via a dorsal approach. This allows for direct viewing of the fracture line, facilitates reduction, and bone grafting can be done through the same incision if necessary. A vascularized or corticocancellous graft is reserved for nonunions. Proximal fractures are very slow to heal with a cast, if they heal at all. As a small fragment, percutaneous fixation is very difficult and has been reported for waist fractures.
REFERENCES: Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210.
Raskin KB, Parisi D, Baker J, et al: Dorsal open repair of proximal pole scaphoid fractures. Hand Clin 2001;17:601-610.

Question 52

Figure 1 shows the radiograph obtained from a 78-year-old woman who has a recent history of increasing thigh pain 12 years after undergoing total hip arthroplasty. Figure 2 depicts the radiograph obtained after she fell and was unable to ambulate. What is the most appropriate treatment?

Explanation

DISCUSSION:
The surgical treatment of periprosthetic fractures of total hip replacement with a loose implant and progressive bone loss is associated with a high complication rate. The recent literature would favor the use of long "Wagner-type" stems, which have a long distal taper that may optimally engage the remaining femoral shaft isthmus. Plating options are problematic, because the intramedullary stem limits the ability to use screws with the plate. Using long distally fixed stems circumvents this problem by enhancing
fracture healing and creating a long-term prosthetic solution in these most difficult cases.

Question 53

At the L4-5 level, what is the location of the S2-5 nerve roots in relationship to the L5 and S1 nerve roots?

Explanation

DISCUSSION: The nerve roots of S2-5 are positioned dorsally and in the midline relative to the L5 and S1 nerve roots. The L5 nerve root is located lateral to S1 as it prepares to exit under the L5 pedicle. The S1 nerve root is located lateral and ventral to the S2-5 nerve roots.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 3-17.
Cohen MS, Wall EJ, Olmarker K, Rydevik BL, Garfin SR: Anatomy of the spinal nerve roots in the lumbar and lower thoracic spine, in Herkowitz HN, Garfin SR, Balderston RA, Eismont FJ, Bell GR, Wiesel SW (eds): Rothman and Simeone The Spine, ed 4. Philadelphia, PA, WB Saunders, 1999, vol 1, pp 84-86.

Question 54

Figures 48a and 48b are the axial and sagittal T1-weighted MR images of the L4-5 disc level of a 38-year-old man. He is symptomatic from the pathology shown. A surgeon would expect the neurological findings to include

Explanation

DISCUSSION
The pathology shown in the MR images is a right-sided far lateral herniated nucleus pulposus at L4-5, which, if symptomatic, would cause a radiculopathy of the exiting root, L4. A more common posterolateral herniation at L4-5 would cause irritation of the traversing root, L5. The L4 root has a sensory distribution over the anterior thigh that extends along the anterior shin but does not tend to reach the toes. The motor distribution is to the quadriceps and anterior tibialis muscles, with the predominant reflex effect being the patella reflex. The L5 root has a sensory distribution to the first dorsal web space of the foot, motor distribution to the EHL, and no specific reflex.
RECOMMENDED READINGS
Standaert CJ, Herring SA, Sinclair JD. The patient history and physical examination: Cervical, thoracic, and lumbar. In: Herkowitz HN, Garfin SR, Eismont FJ, Bell GR, Balderston RA, eds. Rothman-Simeone The Spine. Vol 1. 5th ed. Philadelphia, PA: Saunders Elsevier; 2006:171-186.
Bono CM, Wisneski R, Garfin SR: Lumbar disc herniations. In: Herkowitz HN, Garfin SR, Eismont FJ, Bell GR, Balderston RA, eds. Rothman-Simeone The Spine. Vol 1. 5th ed. Philadelphia, PA: Saunders Elsevier; 2006:967-991.

Question 55

A 19-year old Division 1 offensive lineman sustains an ankle injury during a game. He has pain with weight-bearing and is unable to return to the game. Figures 1 through 5 are his radiographs taken the next day. What is the best next step?

Explanation

The radiographs reveal medial clear space widening and an oblique proximal fibula fracture (best seen on the lateral view overlapping the tibia). This is consistent with an unstable syndesmotic injury. Operative repair of the syndesmosis with reduction and fixation is warranted. Immobilization is the best option for a stable syndesmotic injury. Physical therapy and MRI are not warranted given the findings on the radiographs.

Question 56

EXT1

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 would be the most appropriate treatment:

Question 57

A 72-year-old man with diabetic neuropathy and 5 degrees of valgus talar tilt; he has pursued nonsurgical treatment for 30 years and now has unrelenting pain

Explanation

DISCUSSION
Arthritis of the ankle and hindfoot can pose challenges. Depending upon patient age, comorbidities, and alignment, a variety of surgical interventions may be offered. A total ankle replacement may be considered for patients older than 60 years of age who have minimal misalignment and low-demand lifestyles. In all other cases, ankle fusion must be considered. The nonsurgical care of ankle arthritis includes anti-inflammatory medication, intra-articular steroid injections, bracing with customized products such as the Arizona brace, or a molded foot and ankle orthosis.
Patients with diabetes and Charcot arthropathy may be treated nonsurgically with total-contact casting during acute and active or "hot" phases and accommodative shoes during consolidation and stable or "cool" phases. When the patient has recurrent ulcers or major anatomy changes, surgical intervention must be considered. Tibiotalocalcaneal fusion helps to realign the foot and ankle and make it more braceable in the setting of ankle and hindfoot Charcot disease.
RECOMMENDED READINGS
Queen RM, Adams SB Jr, Viens NA, Friend JK, Easley ME, Deorio JK, Nunley JA. Differences in outcomes following total ankle replacement in patients with neutral alignment compared with tibiotalar joint malalignment. J Bone Joint Surg Am. 2013 Nov 6;95(21):1927-34. doi: 10.2106/JBJS.L.00404. PubMed PMID: 24196462. View Abstract at PubMed
Nunley JA, Caputo AM, Easley ME, Cook C. Intermediate to long-term outcomes of the STAR Total Ankle Replacement: the patient perspective. J Bone Joint Surg Am. 2012 Jan 4;94(1):43-8. doi: 10.2106/JBJS.J.01613. PubMed PMID: 22218381. View Abstract t PubMed
Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, Brodsky JW, Chou LB, Clanton TO, Deland JT, Deorio JK, Horton GA, Lee TH, Mann JA, Nunley JA, Thordarson DB, Walling AK, Wapner KL, Coughlin MJ. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009 Jul;30(7):579-96. doi: 10.3113/FAI.2009.0579. PubMed PMID: 19589303. View Abstract at PubMed
Faraj AA, Loveday DT. Functional outcome following an ankle or subtalar arthrodesis in adults. Acta Orthop Belg. 2014 Jun;80(2):276-9. PubMed PMID: 25090803. View Abstract at PubMed Grear BJ, Rabinovich A, Brodsky JW. Charcot arthropathy of the foot and ankle associated with rheumatoid arthritis. Foot Ankle Int. 2013 Nov;34(11):1541-7. doi: 10.1177/1071100713500490. Epub 2013 Jul 30. PubMed PMID: 23900228. View Abstract at PubMed

Question 58

A 60-year-old man is evaluated in the ICU after a rollover motor vehicle accident 3 days ago. He has multiple upper and lower extremity trauma and was found unresponsive at the accident scene. Surgery is planned for the extremity trauma once the patient is medically stable. He remains intubated and the cervical spine is immobilized in a semi-rigid collar. Examination reveals mild erythema in the posterior occipital cervical region. Initial AP and lateral radiographs of the cervical spine have not revealed any obvious fracture. What is the most appropriate treatment option at this time?

Explanation

DISCUSSION: Ackland and associates demonstrated that the failure to achieve early spinal clearance in an unconscious blunt trauma patient predisposed the patient to increased morbidity secondary to the prolonged used of cervical immobilization. They demonstrated that the four significant predictors of collar-related ulcers were ICU admission, mechanical ventilation, the necessity for cervical MRI, and the time to cervical spine clearance and collar removal. The risk of pressure-related ulceration increased by 66% for every 1-day increase in Philadelphia collar time and this highlights the need for definitive C-spine clearance.
REFERENCES: Ackland HM, Cooper DJ, Malham GM, et al: Factors predicting cervical collar-related decubitus ulceration in major trauma patients. Spine 2007;32:423-428.
Hewitt S: Skin necrosis caused by semi-rigid cervical collar in a ventilated patient with multiple injuries. Injury 1994;25:323-324.

Question 59

A patient has had a locked posterior dislocation of the shoulder for the past 6 months. After undergoing total shoulder arthroplasty that includes adequate anterior releases and posterior capsulorrhaphy, the patient still exhibits posterior instability intraoperatively. The postoperative rehabilitation regimen should include

Explanation

DISCUSSION: Achieving stability in chronic locked posterior dislocations of the shoulder remains a difficult challenge. Intraoperative measures include decreased humeral retroversion, anterior releases, and posterior capsular tightening. Postoperative rehabilitation is of equal importance. Immobilization in an external rotation brace (10 degrees to 15 degrees) with the arm at the side for 4 to 6 weeks is recommended to decrease tension in the posterior capsule. When passive range-of-motion exercises are instituted, they should be performed in the plane of the scapula to avoid stress posteriorly. Internal rotation and supine elevation should be avoided for similar reasons.
REFERENCES: Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
Loebenberg MI, Cuomo F: The treatment of chronic anterior and posterior dislocations of the glenohumeral joint and associated articular surface defects. Orthop Clin North Am 2000;31:23-24.

Question 60

A 40-year old man has limited, painful motion in dorsiflexion at the metatarsophalangeal (MTP) joint of the right great toe, despite nonsurgical treatment. Radiographs show dorsal and medial osteophytes and minimal narrowing of the articular space. Treatment should consist of

Explanation

Cheilectomy, the excision of an irregular osseous rim that interferes with motion of a joint was performed on the distal part of the metatarsal of patients who had hallux rigidus. In this study by Mann, published in JBJS 1988, they were able to conclude that cheilectomy is a better method of treatment for hallux rigidus than arthrodesis, resection arthroplasty, or arthroplasty with the use of a flexible implant. In older adults who present late, with more severe X-Ray changes, Keller procedure is indicated.

Question 61

Radiographs of a 15-year-old girl with knee pain reveal a radiopaque lesion of the distal femoral metaphysis and epiphysis with a small associated soft-tissue mass. A biopsy specimen shows osteoid and pleomorphic cells with multiple mitotic figures. Staging studies show no other sites of disease. Treatment should consist of

Explanation

DISCUSSION: Based on the location and extent of the tumor, most patients are candidates for limb salvage surgery. The patient has an osteosarcoma; therefore, the treatment of choice is preoperative chemotherapy, wide resection, and reconstruction. There is no difference in survival rates between patients who undergo limb salvage surgery and those who undergo amputation. Curettage and placement of methylmethacrylate is used to treat benign lesions of bone and would not be appropriate in this patient.
REFERENCE: Simon MA, Springfield DS, et al: Common Malignant Bone Tumors: Osteosarcoma. Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 265-274.

Question 62

What procedure can eliminate a sulcus sign?

Explanation

DISCUSSION: A sulcus sign represents inferior subluxation of the shoulder. The elimination of this sign and correction of the inferior subluxation is best achieved through either an open or arthroscopic rotator interval closure. A SLAP repair stabilizes the biceps anchor but does not affect the sulcus sign. A Bankart repair, which corrects anterior-inferior laxity, is not sufficient to eliminate a sulcus sign. Subacromial decompression and supraspinatus repairs have no effect on inferior subluxation.
REFERENCES: Field LD, Warren RF, O’Brien SJ, et al: Isolated closure of rotator interval defects for shoulder instability. Am J Sports Med 1995;23:557-563.
Cole BJ, Rodeo SA, O’Brien SJ, et al: The anatomy and histology of the rotator interval capsule of the shoulder. Clin Orthop 2001;390:129-137.

Question 63

The spring ligament of the foot connects what two bones?

Explanation

DISCUSSION: The spring ligament is also known as the calcaneonavicular ligament and connects the calcaneus to the navicular. This ligament supports the talar head and is an important anatomic supporting structure of the medial longitudinal arch of the foot.
REFERENCES: Choi K, Lee S, Otis JC, et al: Anatomical reconstruction of the spring ligament using peroneus longus tendon graft. Foot Ankle Int 2003;24:430-436.
Davis WH, Sobel M, DiCarlo EF, et al: Gross, histological and microvascular anatomy and biomechanical testing of the spring ligament complex. Foot Ankle Int 1996;17:95-102.

Question 64

Which of the following activities can improve posterior capsular contractures?

Explanation

DISCUSSION: Posterior capsule stretching is performed in the cross-chest and behind the back positions. Stretching in internal rotation in the abducted shoulder will further stretch the posterior capsule. Wide grip stretch, and anterior capsule and strengthening exercises will not necessarily stretch the capsule.
REFERENCES: Ellenbacher TS: Shoulder internal and external rotation strength and range of motion of highly-skilled junior tennis players. Isokinetic Exercise Sci 1992;2:1-8.
Kibler WB, McMullen J, Uhl J: Shoulder rehabilitation strategies, guidelines, and practice. Op Tech Sports Med 2000;8:258-267.

Question 65

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Explanation

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.

The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 66

In performing an opening wedge high tibial osteotomy at the tibial tubercle, the osteotome extends 5 mm posteriorly and centrally out of the bone as shown in Figures 17a and 17b. What is the first structure it enters?

Explanation

DISCUSSION: The major risk of performing a high tibial osteotomy is neurovascular injury. The new version of the high tibial osteotomy makes a transverse osteotomy at the level of the tibial tubercle. The osteotome is protected by the oblique belly of the popliteus muscle. The popliteal artery and vein and tibial nerve all lie posterior to the muscle. The soleus muscle originates below this level.
REFERENCES: Clement CD: Anatomy: A Regional Atlas of Human Anatomy, ed 3.

Baltimore, MD, Munich, Germany, Urban and Schwarzberg, 1987, Figure 422.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, plate 480.

Question 67

Figures 5a and 5b show the radiographs of an 11-year-old boy who felt a pop and immediate pain in his right knee as he was driving off his right leg to jam a basketball. Examination reveals that the knee is flexed, and the patient is unable to actively extend it or bear weight on that side. There is also a large effusion. Management should include

Explanation

DISCUSSION: Fractures through the cartilage on the inferior pole of the patella, the so-called sleeve fracture, are often difficult to diagnose because of the paucity of ossified bone visible on the radiographs. If the fracture is missed and the fragments are widely displaced, the patella may heal in an elongated configuration that may result in compromise of the extensor mechanism function. The treatment of choice is open reduction and internal fixation using a tension band wire technique to achieve close approximation of the fragments and restore full active knee extension.
REFERENCES: Heckman JD, Alkire CC: Distal patellar pole fractures: A proposed common mechanism of injury. Am J Sports Med 1984;12:424-428.
Tolo VT: Fractures and dislocations around the knee, in Green NE, Swiontkowski MF (eds): Skeletal Trauma in Children. Philadelphia, Pa, WB Saunders, 1994, vol 3, pp 380-382.

Question 68

The patient is planning on having his contralateral knee replaced as well. He has a mild valgus deformity in his left knee with an overall windswept deformity. Which release is most appropriate in this case if the knee remains tight in extension?

Explanation

DISCUSSION
Balancing a total knee is important for longevity of the device and functional benefit. The surgeon should be systematic in the release of a varus knee. The deep MCL is typically released as part of the approach and osteophytes are then removed. The semimembranosus tendon can then be released from the posterior medial aspect of the tibia. A downsizing osteotomy can be considered for a large deformity if a patient has adequate tibial sizing. If a patient has the smallest implant available prior to the osteotomy, an osteotomy will lead to overhang of the implant and medial impingement on the MCL.
A valgus knee can be treated with pie crusting of the iliotibial band in mild extension deformity. Surgeons should pause prior to taking down the popliteus and lateral collateral
ligament because this can induce posterior rotatory subluxation of a primary knee, especially in the case of a posterior collateral ligament-sacrificing total knee arthroplasty design.

Question 69

A 40-year-old man has a palpable mass over the dorsum of the ankle. He reports no history of direct trauma but notes that he sustained a laceration to the middle of his leg 6 weeks ago. Examination reveals a 4-cm x 1-cm mass. T 1 - and T 2 -weighted MRI scans are shown in Figures 12a and 12b. An intraoperative photograph and biopsy specimen are shown in Figures 12c and 12d. What is the most likely diagnosis?

Explanation

DISCUSSION: The findings are most consistent with a rupture of the anterior tibial tendon. The damaged area of tendon should be resected, followed by tendon reconstruction or tenodesis. The histology is not consistent with giant cell tumor of the tendon sheath, gout, or synovial sarcoma. Fibromatosis is characterized by a large number of spindle cells within the collagen background.
REFERENCES: Otte S, Klinger HM, Loreaz F, Haerer T: Operative treatment in case of closed rupture of the anterior tibial tendon. Arch Orthop Traum Surg 2002;122:188-190.
Kausch T, Rutt J: Subcutaneous rupture of the tibialis anterior tendon: Review of the literature and case report. Arch Orthop Traum Surg 1998;117:290-293.

Question 70

Figures 7a and 7b show the radiographs of a 51-year-old woman who injured her left leg after falling off a stepladder. Surgical reconstruction is performed with a compression screw and side plate; the postoperative radiograph is shown in Figure 7c. Following gradual progression of weight bearing, she reports that she slipped again and placed full weight on the extremity. She now notes a new onset of increased pain in her left thigh and hip region. Follow-up radiographs are shown in Figures 7d and 7e. Reconstruction should consist of

Explanation

DISCUSSION: The initial fracture was an unstable reverse oblique intertrochanteric fracture with subtrochanteric extension. Initial fixation with a high-angled screw and side plate construct may not provide stability as well as a 95 degree fixed-angle device or a intramedullary hip screw device. The follow-up radiographs show loss of fixation and further propagation of the fracture distally. Reconstruction would best be accomplished with hardware removal and conversion to a long intramedullary nail with femoral head fixation or a 95 degree angled plate and screw device. Conversion to a longer plate does not improve the biomechanical situation at the primary fracture site. In situ bone grafting would not provide any additional stability and would not correct the deformity. The proximal femoral fracture is not amenable to retrograde nailing. Cerclage wiring will not sufficiently enhance stability and is not indicated.
REFERENCES: Bridle SH, Patel AD, Bircher M, Calvert PT: Fixation of intertrochanteric fractures of the femur: A randomized prospective comparison of a gamma nail and dynamic hip screw. J Bone Joint Surg Br 1991;73:330-334.
DeLee JC: Fractures and dislocations of the hip, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 1659-1825.
Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.

Question 71

The comparative outcomes of needle aponeurotomy (NA) and collagenase Clostridium histolyticum (CCH) use in the treatment of Dupuytren contracture indicate that patients treated with CCH have

Explanation

A 48-year-old woman presents with an insidious onset of dorsal wrist pain and decreased motion. Her radiographs are unremarkable, showing no carpal collapse or malalignment. MRI reveals avascular necrosis of the capitate. Her condition does not improve with immobilization. What would be the most appropriate surgical intervention?
A. Proximal row carpectomy
B. Vascularized bone graft
C. Radial shortening osteotomy
D. Capitate shortening osteotomy
Osteonecrosis of the capitate is a rare condition that presents with an insidious onset of dorsal wrist pain. When nonsurgical treatment fails to alleviate symptoms, surgical intervention is appropriate. When collapse of the capitate is present, partial excision of the capitate with interposition, partial wrist arthrodesis, or wrist denervation can be considered. In the absence of collapse, capitate-preserving options are available. Vascularized grafting is a mainstay of treatment. Grafting with distal radius vascularized grafts based on the 1,2 intercompartmental supraretinacular artery or the 4 + 5 extensor compartment artery and second metacarpal graft based on the first dorsal metacarpal artery have been described.

Question 72

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 73

Figure 11a shows the clinical photograph of a 46-year old woman who reports a 3-week history of pain and a “lump” at the base of her neck. She is otherwise in good health and denies any trauma. A 3-D reconstruction CT is shown in Figure 11b. What is the most likely diagnosis?

Explanation

DISCUSSION: Spontaneous subluxation of the sternoclavicular joint occurs without any significant trauma. It is usually accentuated by placing the extremity in an overhead position. Discomfort usually resolves within 4 to 6 weeks with nonsurgical management.
REFERENCES: Rockwood CA, Wirth MA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,

WB Saunders, 2004, vol 2, pp 1078-1079.
Rockwood CA, Odor JM: Spontaneous atraumatic anterior subluxation of the sternoclavicular joint. J Bone Joint Surg Am 1989;71:1280-1288.

Question 74

Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

Explanation

Tension band wiring may not provide adequate stability to prevent displacement in a comminuted fracture. Plate fixation is most commonly recommended for comminuted fractures of the olecranon. Additionally, plate fixation is used for oblique fractures distal to the midpoint of the trochlear notch, fractures that involve the coronoid process, and those associated with Monteggia fracture-dislocations. Tension band wiring is best indicated for simple transverse fractures through the midpoint of the trochlear notch.

Question 75

below depict the radiographs obtained from a year-old woman who comes to the emergency department after experiencing a fall. She is an unassisted community ambulator with a history of right hip pain. What is the most appropriate surgical treatment for this fracture?

Explanation

DISCUSSION:
This patient has pre-existing right hip osteoarthritis. The most correct option for the treatment of this active patient is a right total hip arthroplasty. Hemiarthroplasty would not address the patient's pain from osteoarthritis, and open reduction and internal fixation would not fix the femoral head issue or the
osteoarthritis.

Question 76

The diagnosis of an infection after total knee arthroplasty is most reliably proven based on what single study?

Explanation

DISCUSSION: In a study of 52 patients with infected total knee arthroplasties, Windsor and associates showed that the average leukocyte count was 8,300/mm³ and that aspirated knee fluid was positive in all patients except one. Knee radiographs can be unclear in showing infection, which may be present without radiographic signs of loosening. Technetium Tc 99m and gallium bone scans may not conclusively show the presence of infection, particularly in the first 3 years after knee arthroplasty.
REFERENCES: Windsor RE, Bono JV: Infected total knee replacements. J Am Acad Orthop Surg 1994;2:44-53.
Windsor RE, Insall JN, Urs WK, et al: Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection: Further follow-up and refinement of indications. J Bone Joint Surg Am 1990;72:272-278.

Question 77

Figure 24 shows the radiograph of a 36-year-old volleyball player with right hip pain. What is the cause of the pain?

Explanation

DISCUSSION: Femoral acetabular impingement usually presents in active young adults with the slow onset of groin pain that often starts after a minor trauma. Physical examination reveals limitation of motion with a positive impingement test which consists of forceful internal rotation with flexion and adduction. Femoral acetabular impingement is a mechanism for the development of early osteoarthritis in nondysplastic hips. Surgical debridement of the impinging, nonspherical portion of the femoral head restores offset and improves the clearance of the head, thus preventing abutment of the neck against the acetabular rim. The patient has no evidence of osteonecrosis, developmental dysplasia of the hip, rheumatoid arthritis, or femoral neck fracture.
REFERENCES: Ganz R, Parvizi J, Beck M, et al: Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clin Orthop 2003;417:112-120.
Beck M, Leunig M, Parvizi J, et al: Anterior femoroacetabular impingement: Part II. Midterm results of surgical treatment. Clin Orthop 2004;418:67-73.

Question 78

A 72-year-old woman has a painful right hip, and left hip issues are discovered on the radiographs shown in Figures 1 and 2. An arthroplasty was done 24 years previously. Her left hip is pain-free, but she reports occasional clicking and grinding on the left side. She wishes to avoid major revision surgery. Considering this, what is the best next step to address the left hip?

Explanation

A 22-year-old female dancer presents with left hip pain progressing over 6 months. Physical examination reveals pain with hip flexion, adduction and internal rotation and positive external log roll. Radiographs reveal crossover sign with positive posterior wall sign, and positive ischial spine sign. Center- edge angle (CEA) is 19°. MRI scan shows acetabular labral tear. She has failed attempts at nonsurgical management. What is the most appropriate surgical treatment?

Question 79

A 25-year-old man has a mass on the medial aspect of the left knee. He reports that the mass has been present for several years, but a recent increase in physical activity has resulted in periodic tenderness. Radiographs are shown in Figures 13a and 13b. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs reveal a sessile lesion projecting from the medial aspect of the distal femur. The lesion shares the cortex with the bone and the base communicates with the medullary space of the femur. This is the classic appearance of an osteochondroma, the most common benign tumor of bone.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.
Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 80

-Figures 56a and 56b are the MRI scans of a 2-year-old girl who has a fever of 39°C and inability to move her left arm. She has not had any recent injury and is otherwise healthy. Radiograph findings of her left upper extremity are normal. What is the most appropriate treatment?

Explanation

Question 81

Which of the following activities produces greater hip joint contact pressures than full weight bearing during normal gait?

Explanation

Rising from a seated position on a chair on the affected leg has been shown to create the highest contact pressure within the hip, even higher than full weight-bearing during walking.
Limiting activities that create high contact pressures is important in situations such as after internal fixation of an acetabular fracture. Full weight bearing during a normal gait cycle is often considered too much contact pressure and considered a risk for early failure of fixation. During the postoperative period weight bearing and activities are limited to prevent this. It has been shown that the highest contact pressures, even higher than normal walking, are seen when rising from a chair on the affected leg.
Brand et al. analyzed joint reactive forces in patients walking with and without a cane. Compared to age matched controls they estimate that using a cane decreases the contact pressure in the hip to about 60% of normal.
Hodge et al. looked at data from an implanted hip prosthesis with pressure sensors. They found that some activities common to the early rehabilitative period, such as using a bed pan and performing isometric exercises about the hip, can create pressure approaching those of normal walking. The highest pressures recorded were when rising from a chair.
Incorrect answers:

Question 82

A 49-year-old man is seeking a second opinion for continued knee pain and swelling. He went to his primary doctor for swelling "on top of his knee," and he says his doctor drained some clear fluid. He noted that his condition improved for about 1 week before the swelling returned. He now has increasing pain and redness around his kneecap. Examination reveals significant swelling of his prepatellar bursa, with erythema over the bursa that extends to the surrounding skin. His temperature in the office is 101.7°F. What is the next step in treatment for this patient? Review Topic

Explanation

This patient has septic prepatellar bursitis. Padding, cold therapy, compression, nonsteroidal anti-inflammatory drugs, and aspiration are thought to be acceptable treatments for aseptic prepatellar bursitis; they have little role in septic bursitis. Antibiotics along with aspiration or placement of a percutaneous drain have been associated with success in some cases of septic prepatellar bursitis, but the standard treatment is complete bursectomy with systemic antibiotics.

Question 83

Which of the following is considered an inherent problem in using the distal oblique shortening (Weil) metatarsal osteotomy for dorsal metatarsophalangeal subluxation?

Explanation

DISCUSSION: The distal oblique shortening (Weil) metatarsal osteotomy has not been associated with transfer lesions to the extent of other shortening osteotomies, and malunions and nonunions are unusual complications. Recurrent dorsal contracture of the toe has been reported. Recommendations to reduce this problem include release of the dorsal capsule and tendons, as well as a flexor tendon transfer. A potential cause suspected for this phenomenon is the relatively dorsal positioning of the intrinsic tendons after plantar displacement of the metatarsal head.
REFERENCES: Trnka HJ, Nyska M, Parks BG, Myerson MS: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int 2001;22:47-50.
Trnka HJ, Muhlbauer M, Zettl R, Myerson MS, Ritschl P: Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 1999;20:72-79.
Vandeputte G, Dereymaeker G, Steenwerckx A, Peeraer L: The Weil osteotomy of the lesser metatarsals: A clinical and pedobarographic follow-up study. Foot Ankle Int 2000;21:370-374.

Question 84

A 19-year-old football player is taken off the field because of fatigue. Examination reveals a rash shown in Figure A. Oral examination reveals findings shown in Figure B. Posterior cervical glands are palpable. A mass is palpable in the left upper quadrant. Which of the following is true regarding the most likely diagnosis? Review Topic

Explanation

This patient has infectious mononucleosis (IM). Return to play should occur 3 weeks after symptom resolution.
IM is caused by the Epstein-Barr virus (EBV). Annual incidence is 1-3% in college freshmen. It is characterized by Hoagland's triad (fever, pharyngitis, lymphadenopathy). Some have rash and splenomegaly. Splenic rupture is rare (0.1-0.2% of patients). It is caused by sudden increase in portal venous pressure from a simple Valsalva maneuver or from external trauma. The risk of rupture is highest in the first 3 weeks of illness.
Putukian et al. reviewed IM and athletic participation. They recommend return to LIGHT activity after 3 weeks from symptom onset when the athlete is afebrile, has a good energy level, and does not have any significant associated abnormalities. They recommend returning to CONTACT sports after at least 3 weeks when the athlete has no remaining clinical symptoms, is afebrile, and has a normal energy level.
Jaworski et al. discussed infectious diseases in athletes. They state that splenic rupture occurs because of lymphocytic infiltration that distorts the support structure of the spleen, leading to fragility. They recommend return to light, non-contact activities once the athlete is afebrile and appropriately hydrated, fatigue has improved, and a minimum period of 3 weeks has passed from symptom onset.
Figure A shows a petechial rash, which can be seen in IM. Amoxicillin increases the risk of rash. Figure B shows unilateral exudative pharyngitis. The left tonsil is
covered
by
a
white
exudate/pseudomembrane.
Incorrect

Question 85

A 35-year-old woman who is a recreational runner reports posterior knee pain and tightness in the knee with flexion during running. She denies any history of trauma. Examination reveals normal patellar glide and tilt and no patellar apprehension. Range of motion is 5 degrees to 120 degrees, and quadriceps function and knee ligamentous examination are normal. Radiographs are normal. An MRI scan is shown Figure 18. What is the most likely diagnosis?

Explanation

DISCUSSION: Ganglia involving the cruciate ligaments have been recently reported as a cause of knee pain that interferes with knee flexion and extension. The symptoms are poorly localized in this patient and not along the medial joint line, making the diagnosis of a torn medial meniscus less likely. In addition, the MRI findings do not show a significant medial meniscal lesion. A Baker’s cyst is usually posteromedial and extends posterior to the interval between the medial head of the gastrocnemius and semimembranosus. MRI scans show a fluid-filled lesion with an increased signal on T₁- and T₂-weighted images. A lipoma would be bright on the T₁-weighted image only.
REFERENCES: Deutsch A, Veltri DM, Altchek DW, et al: Symptomatic intraarticular ganglia of the cruciate ligaments of the knee. Arthroscopy 1994;10:219-223.
Brown MF, Dandy DJ: Intra-articular ganglia of the knee. Arthroscopy 1990;6:322-323.

Question 86

During total hip arthroplasty, what characteristic of irradiated (10 Mrad) and subsequently melted highly cross-linked polyethylene should provide a more wear-resistant construct than traditional gamma- irradiated (2.5-4 Mrad)-in-air polyethylene mated with the same head?

Explanation

DISCUSSION:
Highly cross-linked polyethylene makes material resistant to adhesive wear. Abrasive wear from third bodies does not decrease wear. The fatigue strength of such material is inferior to that of traditional polyethylene, and its resistance to creep is the same, if not lower, than that of traditional polyethylene.

Question 87

A 45-year-old man reports right shoulder pain with overhead activities only. Figures 47a through 47d show the radiographs, bone scan, and MRI scan of a lesion of the proximal shoulder. What is the most appropriate treatment?

Explanation

DISCUSSION: The figures show a lesion of the proximal humerus consistent with an enchondroma. The lesion is calcified on the radiographs. There is no cortical destruction, significant endosteal scalloping, or soft-tissue mass. The bone scan shows mild uptake in the area of the proximal humerus, and the T₂-weighted MRI scan shows a lesion with high uptake, suggesting a lesion with high water content. A CT scan could also be obtained to rule out bone destruction or periosteal reaction. Pain with overhead activities is likely related to the rotator cuff. A biopsy is unlikely to add information because of inherent difficulties interpreting low-grade cartilaginous lesions. Curettage and grafting and en bloc resection are excessive treatments for a benign lesion that is apparently asymptomatic. Observation with a follow-up radiograph in 3 to 6 months is appropriate.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.
Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.

Question 88

A 6-month-old child is seen in the emergency department with a spiral fracture of the tibia. The parents are vague about the etiology of the injury. There is no family history of a bone disease. In addition to casting of the fracture, initial management should include Review Topic

Explanation

Unwitnessed spiral fractures should raise the possibility of child abuse, especially prior to walking age. With nonaccidental trauma being considered in the differential diagnosis, a skeletal survey is indicated to determine if there are other fractures in various stages of healing.
(SBQ13PE.60) If a child develops dynamic supination after treatment of idiopathic clubfoot with Ponseti casting, at what age would it be appropriate to consider transfer of the tibialis anterior tendon to the lateral dorsum of the foot? Review Topic
In the first six months of life, immediately following failed cast treatment
12 months
4 years
12 years
15 years
Tibialis tendon transfer to the dorsum of the foot should be performed to address dynamic supination when the lateral cuneiform has ossified. This is typically after at least 2 years of age and usually not before age 3.

Question 89

A 40-year-old man with an acetabular chondrosarcoma has a small soft-tissue mass. Treatment should consist of

Explanation

DISCUSSION: The treatment of choice for pelvic chondrosarcoma is wide resection via an internal hemipelvectomy. Chondrosarcoma requires surgical resection for control and does not respond to traditional chemotherapy or external beam radiation. Hip arthroplasty with acetabular reconstruction and curettage and cementation of the lesion are intralesional procedures that result in a higher incidence of local recurrence of tumor.
REFERENCES: Pring M, Weber KL, Unni K, Sim FH: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg Am 2001;83:1630-1642.
Sheth DS, Yasko AW, Johnson ME, Ayala AG, Murray JA, Romsdahl MM: Chondrosarcoma of the pelvis: Prognostic factors for 67 patients treated with definitive surgery. Cancer 1996;78:745-750.

Question 90

Portions of which of the following normal structures help compose the spiral cord seen in Dupuytren’s contracture?

Explanation

DISCUSSION: The normal fascial components that become diseased and compose the spiral cord include the pretendinous band, spiral band, lateral digital sheet, and Grayson’s ligament. Cleland’s ligament lies dorsal and is not involved with spiral cord formation. The intrinsic muscle and tendon, the natatory ligament, and the intermetacarpal ligament are well proximal to the digit and are not involved in spiral cord formation.
REFERENCES: McGrouther D: Dupuytren’s contracture, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone,

1999, vol 1, pp 565-569.
McFarlane R: Patterns of diseased fascia in the fingers in Dupuytren’s contracture.

Plast Reconstr Surg 1974;54:31-44.

Question 91

-Figure is the clinical photograph of a 70-year-old woman with squamous cell cancer on her thumb.Resection and reconstruction is planned and requires soft-tissue coverage. Thumb region coverage is best obtained with

Explanation

Question 92

What acetabular procedure for developmental dysplasia of the hip does not require a concentric reduction of the femoral head in the acetabulum?

Explanation

DISCUSSION: All of the reorientation innominate osteotomies require a concentric reduction of the hip. The Staheli shelf procedure may be performed even with the hip subluxated, but it is a salvage procedure that covers a portion of the femoral head with capsular fibrocartilage rather than hyaline cartilage.
REFERENCES: Staheli LT, Chew DE: Slotted acetabular augmentation in childhood adolescence. J Pediatr Orthop 1992;12:569-580.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 618-650.

Question 93

A patient with deficient anteroinferior bone stock undergoes a Latarjet procedure that transfers a portion of the coracoid to the glenoid rim and secures it with two screws. After surgery, the patient reports numbness on the anterolateral forearm. To verify the diagnosis, what muscle should be tested for strength?

Explanation

DISCUSSION: A Latarjet procedure is similar to a Bristow procedure, but with the Latarjet procedure a larger portion of the coracoid is transferred to the scapular neck at the anteroinferior glenoid. As in a Bristow procedure, if the fragment is pulled or twisted during the dissection or during fixation, the musculocutaneous nerve can be injured. With loss of biceps function, elbow flexion and forearm supination will be weaker.
REFERENCES: Ho E, Cofield RH, Balm MR, Hattrup SJ, Rowland CM: Neurologic complications of surgery for anterior shoulder instability. J Shoulder Elbow Surg 1999;8:266-270.
Boardman ND 3rd, Cofield RH: Neurologic complications of shoulder surgery. Clin Orthop 1999;368:44-53.
Allain J, Goutallier D, Glorion C: Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 1998;80:841-852.

Question 94

Figure 49 shows an acute axial MRI scan of a left knee. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scan shows bone bruises in the medial aspect of the patella and the lateral aspect of the lateral femoral condyle. Both of these signs are typical for a lateral dislocation of the patella with spontaneous reduction. In addition, there may be associated tearing of the medial retinaculum or distal aspect of the vastus medialis.
REFERENCES: Elias DA, White LM, Fithian DC: Acute lateral patellar dislocation at MR imaging: Injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Radiology 2002;225:736-743.
Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the knee. Am J Sports Med 2005;33:131-148.
Miller TT: Magnetic resonance imaging of the knee, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 201-224.

Question 95

Initial management should consist of Review Topic

Explanation

The radiograph shows osteochondritis dissecans (OCD) of the capitellum, one manifestation of “pitcher’s elbow.” The lesion is nondisplaced, and healing is possible if the inciting throwing activities are curtailed. Long arm cast treatment may be reasonable for the noncompliant patient but should not exceed 6 weeks duration. Surgical treatment is indicated for loose bodies or cartilage flaps. Elbow OCD lesions are now being seen in younger children as more participate in organized sports, especially baseball and gymnastics.

Question 96

A 17-year-old basketball player and pole vaulter who has had anterior knee pain for the past 18 months now reports a recent inability to jump. Based on the MRI scan shown in Figure 11, management should consist of

Explanation

DISCUSSION: The MRI scan reveals a partial patellar tendon rupture in conjunction with chronic patellar tendinitis. Mild and moderate patellar tendinitis may be treated nonsurgically with rest, stretching, strengthening, and anti-inflammatory drugs. Severe tendinopathy or extensor mechanism disruption is best treated surgically with tendon debridement and repair.
REFERENCES: Al-Duri ZA, Aichroth PM: Surgical aspects of patella tendonitis: Techniques and results. Am J Knee Surg 2001;14:43-50.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 218-219.

Question 97

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 98

A 16-year-old boy has a symptomatic flatfoot deformity that is causing pain, skin breakdown, and shoe wear problems. Shoe modification and an orthosis have failed to provide relief. Examination reveals hindfoot valgus, talonavicular sag, and forefoot abduction that are all passively correctable. Treatment should consist of

Explanation

DISCUSSION: The patient has a supple planovalgus deformity that is passively fully correctable, and nonsurgical management has failed to provide relief. Lateral column lengthening with medial soft-tissue tightening will correct the deformity and maintain a flexible foot. Arthrodesis is not recommended for a supple, correctable deformity because of loss of motion and long-term degeneration of surrounding joints. Medial displacement calcaneal osteotomy is generally reserved for an adult-acquired flexible flatfoot.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 613-631.
Evans D: Calcaneo-valgus deformity. J Bone Joint Surg Br 1975;57:270-278.
Mosca VS: Calcaneal lengthening for valgus deformity of the hindfoot: Results in children who had severe, symptomatic flatfoot and skewfoot. J Bone Joint Surg Am 1995;77:500-512.

Question 99

In the setting of a proximal tibial plateau fracture and its repair, which of the following materials is an isotropic material?

Explanation

DISCUSSION: An isotropic material is one that has similar mechanical properties regardless of the orientation of the material. Examples of isotropic materials include metals, plastics, and methacrylate. Most biologic tissues are anisotropic, meaning their mechanical properties alter depending on the materials’ orientation to the applied stress.
REFERENCE: Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007, pp 58-59.

Question 100

Figure 26a shows the radiograph of a 55-year-old woman who has pain in her right leg after falling. Laboratory studies reveal an elevated alkaline phosphatase level. A biopsy specimen from the proximal tibia is shown in Figure 26b. What is the most likely diagnosis?

Explanation

DISCUSSION: Paget’s disease of bone is a metabolic disorder of bone remodeling. The normally coupled process of bone resorption and deposition is lost, resulting in excessive localized bone resorption and compensatory increased bone formation. Pagetic bone tends to be more brittle; therefore, it is susceptible to pathologic fractures and subsequent deformities.
REFERENCES: Lander PH, Hadjipavlou AG: A dynamic classification of Paget’s disease. J Bone Joint Surg Br 1986;68:431-438.
Buckwalter JA, Einhorn TA, Simon SR: Orthopaedic Basic Science, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 320-369.

Full Question & Answer Text (for Search Engines)

Question 1:

Which of the following descriptions is true regarding APC-II (anterior-posterior compression) pelvic injuries as classified by Young and Burgess?

Options:

Pubic symphysis diastasis, intact anterior sacroiliac ligaments, intact sacrotuberous ligament, intact posterior sacroiliac ligaments
Pubic symphysis diastasis, torn anterior sacroiliac ligaments, intact sacrotuberous ligament intact posterior sacroiliac ligaments
Pubic symphysis diastasis, intact anterior sacroiliac ligaments, torn sacrotuberous ligament, intact
posterior sacroiliac ligaments
Pubic symphysis diastasis, torn anterior sacroiliac ligaments, torn sacrotuberous ligament, intact posterior sacroiliac ligaments
Pubic symphysis diastasis, intact anterior sacroiliac ligaments, torn sacrotuberous ligament, torn posterior sacroiliac ligaments

Correct Answer: Pubic symphysis diastasis, intact anterior sacroiliac ligaments, intact sacrotuberous ligament, intact posterior sacroiliac ligaments

Explanation:

Question 2:

6 grams each per 40 mg PMMA

Options:

10 grams each per 40 mg PMMA
20 grams each per 40 mg PMMA

Correct Answer: 10 grams each per 40 mg PMMA

Explanation:

DISCUSSION
Vancomycin and tobramycin do not produce systemic toxicity in doses as high as 10.5 grams of vancomycin and 12.5 grams of tobramycin per 40 mg of PMMA.
RECOMMENDED READINGS
Hake ME, Young H, Hak DJ, Stahel PF, Hammerberg EM, Mauffrey C. Local antibiotic therapy strategies in orthopaedic trauma: Practical tips and tricks and review of the literature. Injury. 2015 Aug;46(8):1447-56. doi: 10.1016/j.injury.2015.05.008. Epub 2015 May 14. Review. PubMed PMID: 26007616.
View Abstract at PubMed
Springer BD, Lee GC, Osmon D, Haidukewych GJ, Hanssen AD, Jacofsky DJ. Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty. Clin Orthop Relat Res. 2004 Oct;(427):47-51. PubMed PMID: 15552135.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 84 THROUGH 86
Figure 84 is the noncontrast MR image obtained at 2 weeks postinjury for a 52-year-old man who was injured after falling from a ladder. His arm is caught in an abducted, externally rotated
position. There is no sense of dislocation. Initial radiograph findings are normal. The radiologic review reads “Probable superior labral anterior to posterior (SLAP) tear.”

Question 3:

Options:

Aneurysmal bone cyst
Enchondroma
Plasmacytoma
Giant cell tumor
Chondrosarcoma

Correct Answer: Chondrosarcoma

Explanation:

DISCUSSION: The radiograph reveals a metaphyseal lesion with some stippled mineralization suggesting a chondroid tumor. The bone scan shows increased uptake, beyond what is expected for a simple enchondroma, and beyond the limits of the lesion. The MRI sequences shows a lobular lesion on the T
1
- and T
2
-weighted (bright on the T
2
sequence) images with inhomogeneous uptake of gadolinium; both findings are typical for a chondroid lesion. The history of pain, the positive bone scan, the age of the patient, the size of the lesion, and the central location (enostotic) of the lesion all suggest a malignant cartilage tumor. The images are not consistent with the other diagnoses. In particular, plasmacytoma is more uniformly bright on T
2
-weighted images and often has a negative bone scan.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 187-194.
Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, WB Saunders, 2002, pp 3897-3904.

Question 4:

Options:

Renal osteodystrophy
Pyogenic osteomyelitis
Osteoarthritis
Osteonecrosis
Tuberculosis osteomyelitis

Correct Answer: Osteonecrosis

Explanation:

DISCUSSION: The photomicrograph demonstrates a wedge-shaped infarct with femoral head collapse; therefore, the diagnosis is osteonecrosis of the femoral head. Perthes disease and osteoarthritis do not involve a wedge-shaped defect. Tuberculosis of the hip joint results in greater destruction of the articular cartilage.
REFERENCES: Basset LW, Mirra JM, Cracchiolo A III: Ischemic necrosis of the femoral head: Correlation between magnetic resonance imaging and histologic sections. Clin Orthop 1987;223:181-187.
Sugano N: Osteonecrosis, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopedics. St Louis, MO, Mosby, 2002, pp 878-887.

Question 5:

Options:

Begin a stretching program.
Obtain shoulder radiographs and aspirate the shoulder joint.
Obtain an MRI scan to evaluate for a rotator cuff tear.
Schedule for irrigation and debridement.
Schedule for revision shoulder arthroplasty.

Correct Answer: Obtain shoulder radiographs and aspirate the shoulder joint.

Explanation:

DISCUSSION: The patient has the preliminary diagnosis of an infected shoulder arthroplasty; therefore, shoulder radiographs and joint aspiration for organism identification should be the first steps in the work-up. The patient is at risk for hematogenous spread given the recent history of pneumonia and her history of diabetes mellitus. Although she has stiffness, a stretching program is not indicated with the possibility of infection. Scheduling for revision arthroplasty, or irrigation and debridement will depend on multiple factors including identification of the infecting organism, the organism’s susceptibility to antibiotics, and implant stability. An MRI scan to evaluate for a rotator cuff tear is not indicated at this time.
REFERENCES: Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 953-954.
Stinchfield FE, Bigliani LU, Neu HC, et al: Late hematogenous infection of total joint replacement. J Bone Joint Surg Am 1980;62:1345-1350.

Question 6:

Options:

Posterior spinal fusion with instrumentation
Anterior-posterior hemiepiphysiodesis
Brace management
Cardiac and renal evaluation
Hemivertebrectomy and fusion

Correct Answer: Cardiac and renal evaluation

Explanation:

Question 7:

For this patient, which TKA design is most appropriate?

Options:

Bicruciate-retaining TKA
Unicompartmental arthroplasty
Hinged TKA
Posterior substitution TKA

Correct Answer: Posterior substitution TKA

Explanation:

Question 8:

Articular cartilage is divided in zones with specific arrangements of the collagen framework and proteoglycan content. The superficial zone is characterized by collagen oriented

Options:

randomly, and low proteoglycan content.
randomly, and high proteoglycan content.
parallel to the surface, and low proteoglycan content.
parallel to the surface, and high proteoglycan content.
perpendicular to the surface, and low proteoglycan content.

Correct Answer: parallel to the surface, and low proteoglycan content.

Explanation:

Question 9:

At a minimum 2-year follow-up and compared with the metacarpophalangeal (MCP) joint, pyrolytic carbon resurfacing arthroplasties of the proximal interphalangeal (PIP) joint

Options:

produce less squeaking or clicking.
result in more dislocations.
provide superior pain relief.
result in better motion compared with the preoperative status.

Correct Answer: result in more dislocations.

Explanation:

EXPLANATION:
Wall and Stern published a report on MCP joint pyrolytic carbon arthroplasty for osteoarthritis and another on PIP joint pyrolytic carbon resurfacing arthroplasty for osteoarthritis. They found different outcomes, and MCP joint implants outperformed PIP joint implants. Of eleven MCP joint arthroplasties, two produced asymptomatic squeaking and clicking, whereas eleven of 31 PIP joint implants produced this problem. No dislocations were reported among the MCP joint implants, but five PIP joint dislocations were observed. Outcomes were measured by the Michigan Hand Outcomes Questionnaire in both studies and were satisfactory for the MCP joint implants, with an average score of 80. The PIP implants did not fare as well, showing a higher degree of pain along with an average score of 53. The authors noted that, in the 15 patients in the PIP study who had unilateral surgery, the uninvolved, nonsurgical hand motion was actually statistically significantly (
P
<0.01) better than the surgical hand. MCP joint motion increased from 62º before surgery to 76º after surgery, whereas PIP joint motion got worse after surgery, with the average motion decreasing from 57º to 31º.

Question 10:

Options:

Nerve conduction velocity studies and electromyography
Exploration and grafting of the radial nerve
Tendon transfers
Observation for another 2 months
Removal of the plate, neurolysis of the radial nerve, and intramedullary rodding of the humerus

Correct Answer: Observation for another 2 months

Explanation:

DISCUSSION: Most radial nerve palsies associated with closed fractures of the humerus resolve spontaneously, including Holstein-Lewis lesions (radial nerve palsy associated with oblique distal third fractures of the humerus). Initial sign of recovery at the brachioradialis may not occur for 4 months. There has been no evidence of deleterious effects occurring during this observation period. There are advocates of early exploration of the nerve. Exploration in the intermediate period between 1 and 4 months is not supported. As overall alignment of the fracture is acceptable, there is no need for hardware exchange until nonunion is clearly identified.
REFERENCES: Shao YC, Harwood P, Grotz MR, et al: Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. J Bone Joint Surg Br 2005;87:1647-1652.
Green DP: Radial nerve palsy, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 112.

Question 11:

Options:

fixation of the lateral malleolus.
fixation of the medial malleolus.
fixation of the posterior malleolus.
all planned fixation is completed .

Correct Answer: all planned fixation is completed .

Explanation:

Discussion:
The radiographs reveal a trimalleolar ankle fracture dislocation with an associated distal tibiofibular syndesmotic disruption. Medial and lateral malleolar stabilization are consistently agreed upon. The decision to stabilize the posterior malleolus is more controversial. Posterior malleolar stabilization accomplishes the following:
Restores incisura competence thereby reducing the incidence of syndesmotic malreduction by creating containment
Assists in stabilizing the syndesmosis via the posterior inferior tibiofibular ligament, potentially limiting the need for additional syndesmotic stabilization
Maximizes the surface area for ankle joint loading
Enhances posterior translational stability of the talus
The traditional indication for stabilization of the posterior malleolus is based on fragment size. However, fracture orientation varies and makes evaluation of the fragment size challenging with a lateral radiograph alone. The three primary types include the posterolateral oblique, medial extension, and shell. Because of the additive syndesmotic stability which is gained through the deep deltoid ligament and medial malleolar fixation, the anterior talofibular ligament and lateral malleolar fixation, and the posterior inferior tibiofibular ligament and posterior malleolar fixation, syndesmotic stability should only be assessed after all other points of instability that are planned for fixation are fixed.
Syndesmotic instability should be assessed with direct manipulation on both the anteroposterior and lateral views with special attention to the lateral view. Syndesmotic reduction should be assessed either through open visualization or by comparing closed reduction parameters (clear space, overlap, and fibular position on the lateral view) with the patient’s contralateral side (assuming no injury). This is more effective than using population norms secondary to the two types of syndesmotic morphologies which create different absolute values for these parameters.

Question 12:

Options:

Rupture of the terminal extensor tendon
Avulsion of the volar plate
Rupture of the sagittal bands
Rupture of the spiral oblique retinacular ligaments
Rupture of the profundus insertion

Correct Answer: Rupture of the profundus insertion

Explanation:

DISCUSSION: The radiographs reveal a bony avulsion of the flexor profundus insertion (Jersey finger). The large bony fragment classifies this as a Leddy type III injury. The bony fragment has retracted to the level of the annular pulley (A4).
REFERENCES: Leddy JP, Packer JW: Avulsion of the insertion of the profundus tendon insertion in athletes. J Hand Surg 1977;2:66-69.
Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin 1985;1:77-83.

Question 13:

What is the most common complication following metatarsal osteotomy for a bunion deformity in an adolescent?

Options:

Hallux varus
Osteonecrosis
Recurrence of the hallux valgus
“Transfer” second metatarsalgia
Physeal arrest of the first metatarsal

Correct Answer: Recurrence of the hallux valgus

Explanation:

Question 14:

Options:

axillary neuropathy.
recurrent instability.
shoulder girdle weakness.
luxatio erecta.
biceps tendinitis.

Correct Answer: recurrent instability.

Explanation:

DISCUSSION: Large, displaced anterior inferior glenoid rim fractures predispose patients to recurrent anterior instability due to loss of the normal concavity compression effect of the glenoid. These defects require open reduction and internal fixation to reestablish shoulder stability. Although intra-articular fractures may lead to arthrosis, recurrent instability is
more common.
REFERENCES: Robinson CM, Kelly M, Wakefield AE: Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: Risk factors and results of treatment.
J Bone Joint Surg Am 2002;84:1552-1559.
Bigliani LU, Newton PM, Steinmann SP, et al: Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med 1998;26:41-45.

Question 15:

Among the options listed below, what is the best treatment for the complication shown in Figure 10c?

Options:

- Removal of hardware and bone grafting
- Removal of hardware and total hip arthroplasty (THA)
- Removal of hardware and revision using a first-generation femoral nail
- Removal of hardware and revision using a second-generation femoral nail

Correct Answer: - Removal of hardware and revision using a second-generation femoral nail

Explanation:

DISCUSSION
Proximal femur fractures can be treated using a variety of implants including intramedullary nails, blade plates, and locking plates (now precontoured proximal femur plates). The comminution and lack of medial cortical support may predispose these fractures to nonunion.
The recent popularity of locking plates for proximal femur treatment has increased their use for this fracture; however, a disproportionately high rate of failure of these plates, including early implant failure with plate and screw breakage, cut out with varus collapse, and nonunion have been reported.?
Malreduction predisposes these fractures to failure. The initial postoperative radiographs do not reveal a varus malreduction because the tip of the greater trochanter is below the center of the femoral head.
Once failure occurs, the best fixation method among the options detailed is an intramedullary nail (second generation with screws into the femoral head) and restoration of alignment. THA is usually not recommended for treatment of subtrochanteric femur fractures in young patients.
RECOMMENDED READINGS
Wirtz C, Abbassi F, Evangelopoulos DS, Kohl S, Siebenrock KA, Krüger A. High failure rate of trochanteric fracture osteosynthesis with proximal femoral locking compression plate.
Injury. 2013 Jun;44(6):751-6. doi: 10.1016/j.injury.2013.02.020. Epub 2013 Mar 21. PubMed PMID: 23522837.
View Abstract at PubMed
Floyd JC, O'Toole RV, Stall A, Forward DP, Nabili M, Shillingburg D, Hsieh A, Nascone JW. Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures. J Orthop Trauma. 2009 Oct;23(9):628-33. doi: 10.1097/BOT.0b013e3181b04835. PubMed PMID: 19897983.
View Abstract at PubMed
Glassner PJ, Tejwani NC. Failure of proximal femoral locking compression plate: a case series. J Orthop Trauma. 2011 Feb;25(2):76-83. doi: 10.1097/BOT.0b013e3181e31ccc.
PubMed PMID: 21245709.
View Abstract at PubMed

Question 16:

Ulnar collateral ligament (UCL) reconstruction using a modified Jobe technique

Options:

Paresthesias in the fourth and fifth digits
Numbness on the lateral side of the forearm
Heterotopic ossification
Posterolateral rotatory instability of the elbow
Medial antebrachial cutaneous neuroma

Correct Answer: Paresthesias in the fourth and fifth digits

Explanation:

Question 17:

Options:

CT-guided needle aspiration and organism-appropriate antibiotics.
laminectomy and postoperative bracing.
posterior fusion with instrumentation and IV antibiotics.
anterior debridement and strut graft, with possible posterior instrumentation.
posterior extracavitary decompression alone.

Correct Answer: anterior debridement and strut graft, with possible posterior instrumentation.

Explanation:

Question 18:

5 g/dL and his base deficit is 10mEq/L. What is the most appropriate next step in management?

Options:

Reamed intramedullary nailing bilateral femur fractures, irrigation and debridement followed by reamed intramedullary nailing right tibia, open reduction internal fixation left forearm
Reamed intramedullary nailing bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, splinting left forearm
External fixation bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, open reduction internal fixation left
forearm
External fixation bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, splinting left forearm
External fixation right femur and right tibia following irrigation and debridement, reamed intramedullary nailing left femur, splinting left forearm

Correct Answer: External fixation bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, splinting left forearm

Explanation:

With a base deficit of 10mEq/L, the patient is under-resuscitated and unstable. Thus, damage control orthopedics via external fixation of the long bone injuries with irrigation and debridement of the open tibia is the appropriate next step in management.
Of all of the reported values, the most important predictor of morbidity and mortality is the base deficit (normal range -2 to +2mEq/L), which represents overall resuscitation status. Another representative parameter of resuscitation status is lactate (normal <2mg/dL). Heart rate, blood pressure and hematocrit are not reliable predictors of normalized resuscitation status, morbidity or mortality.
Callaway et al. retrospectively reviewed a large cohort of blunt trauma patients over a 6 year period. Only base deficit and lactate levels were directly correlated with and were reliable predictors of mortality.
Paladino et al. retrospectively reviewed a prospective database of over 1400 patients. Base deficit and lactate were significant and useful predictors of triage upon initial presentation to denote severe versus non-severe injury.
Martin et al. retrospectively analyzed over 2000 sets of laboratory data in 427 ICU patients. Base deficit (anion status), even in ICU patients with normal lactate levels, were predictive of decreased survival.
Incorrect Answers:
OrthoCash 2020
A 26-year-old male sustains an elbow injury after a fall from a skateboard resulting in valgus and supination forces across the left elbow. A CT scan of the left elbow is shown in Figures A through D. This fracture pattern is most commonly associated with what other traumatic elbow pathology?
Posteromedial rotatory instability
Capitellum fracture
Radial head fracture and posterolateral ulnohumeral dislocation
Trans-olecranon fracture dislocation
Medial (ulnar) collateral ligament rupture
Corrent answer: 3
The clinical presentation is consistent with a coronoid tip fracture. This fracture pattern is associated with a radial head fracture and posterolateral ulnohumeral dislocation - together making up the terrible triad injury.
A terrible triad injury is the result of a valgus and supination injury and involves posterolateral elbow dislocation or lateral collateral ligament injury, radial head fracture, and fracture of the coronoid process. The elbow may dislocate postero-laterally with the anterior bundle of the MCL intact, but if the MCL is injured it is typically the last structure to fail. The coronoid fracture is typically a small fragment isolated to the tip. This is a result of a posteriorly directed force driving the coronoid into the trochlea prior to posterior elbow dislocation. CT scan is a useful modality when small or comminuted fragments are difficult to visualize on plain radiographs.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figures A through D show consecutive 2.00 mm sagittal CT reformats demonstrating a small coronoid fracture fragment which was addressed with suture fixation.
Incorrect Answers:
OrthoCash 2020
A 62-year-old right-hand-dominant school teacher sustains a mechanical fall at home and presents with right shoulder pain. Plain
radiographs of the right shoulder are pictured in Figures A and B. The patient asks you what she can expect in terms of recovery following this injury. Which of the following is the most appropriate statement?
At 1-year post-injury, the right shoulder range of motion will most likely be equal to the contralateral extremity.
At 1-year post-injury, you will most likely have returned to your baseline functional status.
Early range of motion exercises risk fracture displacement and should be avoided until at least 4 weeks post-injury.
Most patients do not return to work following this injury.
One in 5 patients with this fracture go on to nonunion and you may benefit from surgery in the future to address this.
This patient has a minimally displaced (1-part) proximal humerus fracture involving the humeral neck and greater tuberosity. This injury pattern is most commonly managed nonoperatively with the majority of patients returning to their baseline functional status by 1 year.
Proximal humerus fractures (PHF) can be classified by number of parts (Neer classification), with a part defined as a fracture fragment displaced > 1cm (> 5mm for greater tuberosity) or angulated > 45°. One-part PHF comprise ~80% of all PHF and are treated nonoperatively with a sling and early range of motion (ROM).
Tejwani et al performed a prospective study of 67 patients with 1-part PHF. At 1-year follow up the ASES score and functional status was similar to pre-injury status. However, ROM of the affected shoulder was diminished in both external and internal rotation. Forward flexion was preserved.
Hanson et al prospectively analyzed 160 patients with PHF of all types (1-4 parts and head-splitting) managed nonoperatively. At 1-year follow up, 93% showed solid union. Constant and DASH scores improved steadily over time but were still lower compared to the contralateral extremity. Of employed patients, 97.6% returned to work with a median time off of 10 weeks and no difference between manual and nonmanual workers.
Figures A and B are the AP and axillary radiographs of the right shoulder, respectively, demonstrating a 1-part PHF involving the humeral neck and greater tuberosity.
Incorrect Responses:
OrthoCash 2020
A 44-year-old male presents with the isolated injury seen in Figure A after a motor vehicle accident and underwent the operative treatment seen in Figure B within 8 hours from the time of incident. Which of the following complications is this patient at highest risk of developing?
Pulmonary embolus
Periprosthetic fracture
Contralateral hip fracture
Osteonecrosis
Infection
This young male patient has sustained a displaced femoral neck fracture and underwent open reduction internal fixation with 3 cannulated screws. Based on the available options, the patient is most at risk of developing osteonecrosis of the femoral head.
Femoral neck fractures in young patients typically are the result of a high-energy trauma. Fracture displacement has been shown to disrupt vascular supply to the femoral head by interrupting retinacular vessels and ligament teres vascularization, as well as increasing intracapsular pressure, producing a tamponade effect. The incidence of osteonecrosis in patients younger than 60 years with displaced femoral neck fractures has been shown to be between 15-30%. Quality of reduction is one key factor that has been shown to influence outcomes postoperatively.
Loizou et al. prospectively studied 1,023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using standard fixation modalities. They showed that osteonecrosis was less common for undisplaced (4.0%) than for displaced fractures (9.5%). The population at greatest risk were women younger than the age of 60 with displaced fractures.
Barnes et al. review subcapital hip fractures. They found that late segmental collapse was more common in displaced fractures in women younger than age 75 years than in those older than age 75 years treated with internal fixation.
Figure A shows a displaced, Garden 3/Pauwels III hip fracture. Figure B shows anatomical fixation with 3 cannulated screws.
Incorrect Answers:
OrthoCash 2020
A 58-year-old male is involved in a motor vehicle collision and sustains the injury shown in Figure A in addition to right 5th and 6th rib fractures. Upon evaluation in the emergency department, he is noted to have a 2 centimeter laceration over the anterior aspect of his left leg with visible bone. Vitals and labs are normal. Which of the following statements is most accurate regarding surgical management for this patient?
Reamed intramedullary nailing is favored due to increased rates of union
Unreamed intramedullary nailing is favored due to presence of concomitant rib fractures
Reamed intramedullary nailing is favored due to decreased rates of infection
Unreamed intramedullary nailing is favored due to less local trauma
Both unreamed and reamed intramedullary nailing are equivalent
Corrent answer: 5
Both unreamed and reamed intramedullary nailing are equivalent treatments in patients with open tibia fractures. Intramedullary nailing is the treatment of choice for stable patients with tibial shaft fractures.
Tibial shaft fractures can be the result of low energy twisting injuries or higher energy axial loads. Closed fractures with acceptable alignment can be often be treated with closed reduction and casting. Intramedullary nailing, unreamed or reamed, is the treatment of choice for open fractures except in the setting of damage control orthopaedics when an external fixator may be more appropriate.
Bhandari et al. investigated reamed and unreamed intramedullary nailing for tibial shaft fractures in a randomized trial ("SPRINT" Trial - Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators). They concluded that reamed nailing was more beneficial (decreased rate of primary outcome event: need for bone grafting, implant exchange or removal for infection, debridement for infection) for closed fractures, but had no benefit in open fractures.
Finkemeier et al. evaluated consecutive patients treated with unreamed and reamed intramedullary nailing and found similar rates of union in both open and closed tibial shaft fractures at six and twelve months.
Figures A shows AP and lateral xrays of the left tibia showing a tibial shaft fracture.
Incorrect Answers:
OrthoCash 2020
A 36-year-old male falls from a 10-ft scaffold and suffers the injuries shown in Figures A and B. The patient is placed in a spanning external fixator and brought back to the operating room once his soft tissues are amenable. Planning to use a dual-incision approach, what is the correct interval to use when approaching the medial side?
Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius
Corrent answer: 5
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:
OrthoCash 2020
A 25-year-old male presents to the emergency department with the injury seen in Figure A after a motorcycle collision. The patient has a blood pressure of 70 systolic, elevated lactate and a tense abdomen with positive FAST examination. Trauma surgery will be performing an emergent laparotomy. Orthopaedic surgery is consulted and places a pelvic external fixator intraoperatvely to assist with resuscitation. What is an advantage of supra-acetabular external fixator pins as compared with iliac crest pins?
Less interference with pelvic surgical incisions
Less risk of pin tract infection
Less risk of malreduction
Less control of posterior pelvic ring
No interference with laparotomy
Corrent answer: 1
One advantage of supra-acetabular external fixator pins is that they do not interfere or contaminate future approaches to the pelvis or acetabulum involving the lateral window.
In multiply injured patients with pelvic trauma external fixation of the pelvic ring is a valuable tool to assist with resuscitation. Pelvic external fixation should be applied rapidly and allow full access to the abdomen for general surgery intervention. Regardless of the technique used, a pelvic external fixator should form a stable construct that minimizes motion of fracture surfaces and allows for clot formation.
Haidukewych et al evaluated the safety of supra-acetabular pin placement in a cadaveric study. The authors found that the lateral femoral cutaneous nerve (LFCN) was most at risk during pin placement.
Figure A demonstrates a widely displaced symphyseal dislocation with associated bilateral sacroiliac (SI) dislocations (APC 3). Illustration A demonstrates an outlet radiograph of a supra-acetabular external fixtator in conjunction with posterior pelvic ring fixation for an LC3 pelvic ring injury.
Illustration B is an illustration of iliac crest external fixation. The video demonstrates techniques for application of both supra-acetabular and iliac
crest external fixation pins.
Incorrect Answers:
OrthoCash 2020
What physical exam finding is most likely to be found in association with the injury shown in Figures A and B?
Numbness in the small finger and ulnar side of the ring finger
No elbow instability
Varus posteromedial rotatory instability
Valgus posterolateral rotatory instability
An anterior open wound
Corrent answer: 3
The x-ray shows a fracture of the anteromedial facet of the coronoid with an intact radial head. Large anteromedial facet fractures are associated with varus posteromedial rotatory instability.
The anteromedial facet of the coronoid provides support to the medial elbow against varus stress. Varus and posteromedial force applied to the elbow results in disruption of the lateral collateral ligament (LCL) from its proximal origin. The coronoid is fractured as it is forced against the medial trochlea.
Coronoid fractures of significant size involving the sublime tubercle (insertion of medial collateral ligament) result in varus instability.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques. He states that when a coronoid fracture is associated with a pattern of varus instability, it requires fixation with either suture, buttress plating or screw fixation. Concomitant LCL repair or reconstruction will also be necessary.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong
associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figure A is an AP view of an elbow with an anteromedial facet of the coronoid fractured. The lateral joint space is widened due to injury to the LCL. The medial joint space is narrowed and collapsed. A lateral view is shown in Figure
B. Illustrations A and B show AP and lateral views of a coronoid fracture fixed with buttress plating. The LCL origin was fixed with a suture anchor. Illustration C shows the O'Driscoll classification of coronoid fractures. Illustration D lists injury patterns that suggest posteromedial versus posterolateral rotatory instability.
Incorrect Answers:
OrthoCash 2020
A 35-year-old man presents to the ED as the restrained driver of a high speed motor vehicle collision complaining of hip, chest, and abdominal pain. He becomes diaphoretic, tachycardic, and hypotensive in the trauma bay and is noted to have diminished lower extremity pulses. He is found on ATLS workup to have mediastinal widening.
Which of the following injuries is most associated with thoracic aortic injury?
Thoracic aortic rupture is associated with posterior hip dislocation in deceleration trauma mechanism of injuries.
Posterior hip dislocations are infrequently associated with local vascular injuries. With bilateral perfusion deficits, more proximal large vessel trauma should be considered, and in this situation, thoracic surgery should be involved emergently. Screening chest x-ray in the trauma bay should be reviewed for widened mediastinum, suggestive of aortic injury, as shown in illustration A. Given the high energy mechanism associated with these injuries, a full ATLS trauma survey must be done for every patient.
Marymont et al. studies the association between posterior hip dislocation and thoracic aortic injury. They performed a retrospective chart review of 89 posterior hip dislocations and found 8% had an aortic injury. Although not statistically significant, they note the importance of evaluation for aortic injury in patients with posterior hip dislocations given its emergent life-threatening nature.
In addition to associated chest injuries, Schmidt et al. highlight the importance of evaluating the ipsilateral knee after high-energy traumatic hip dislocation. In a prospective study, they identified a 93% rate of ipsilateral knee injury on MRI including effusion (37%), bone bruising (33%), and meniscal tear (30%) as the most common. They recommend a thorough exam but also expanded use of knee MRI after hip dislocation.
Illustration A shows an example of chest x-ray with a widened mediastinum, suggestive of thoracic aortic injury.
OrthoCash 2020
A 31-year-old female smoker was involved in a skiing accident approximately 9 months ago and underwent open reduction internal fixation of the radius and ulna at the time of injury. She now returns to the clinic complaining of increasing pain with range of motion and activity. Radiographs from her most recent follow-up can be seen in Figure A. Laboratory tests show ESR, CRP and WBC count to be within normal limits. Which of the following options is the most appropriate next step in management?
Bone scan
Above elbow cast
Removable splint
Reamed intramedullary nail
Iliac crest bone grafting + compression plating
Corrent answer: 5
This patient is presenting with an atrophic non-union of the ulna after open reduction internal fixation for a both bone forearm fracture 9 months ago. The most appropriate next step in management would be iliac crest bone grafting and compression plating of the ulna.
The primary issue with an atrophic nonunion is biological. The blood supply is poor and therefore incapable of purposeful fracture healing. Smokers, as in this vignette, are at high risk for nonunion. The treatment of an atrophic nonunion involves improving biology at the fracture site through use of autologous bone graft (e.g. iliac crest) and providing mechanical stability by means of compression plating (e.g. 3.5 mm LC-DCP).
dos Reis et al. reports excellent results of 31 cases of diaphyseal forearm fracture non-unions treated with autologous bone grafting and compression
plating. Thirty of thirty-one patients went on to bony union within 3.5 months of revision surgery.
Nadkarni et al. presented a case series of 11 patients with non-unions of various long bones initially managed with intradmedullary (IM) nail fixation. The authors successfully used locking compression plates while retaining the IM nails in the treatment of the nonunion in all cases.
Figure A shows an AP radiograph of a both bone forearm fracture. Figure B shows an AP and lateral radiograph of an atrophic non-union of the ulnar shaft. Illustration A shows a lateral x-ray of a fully healed radius and ulna after hardware removal 1 year after revision surgery.
Incorrect Answers:
OrthoCash 2020
A 27 year-old patient sustains a fracture-dislocation of the acetabulum. Pelvic radiographs (Figures A and B) are taken at initial presentation and a CT scan (Figures C and D) is performed after reduction of the hip in the emergency room. What is the importance of the finding highlighted in the CT scan cuts?
Comminution indicates a better result with non-operative management
Significant marginal impaction could compromise the results of the surgical reduction if the joint surface is not properly restored
The impacted fracture segment will heal without fixation because it is not gapped or translated
The CT scan finding highlighted indicates osteochondral defects to the femoral head, which can be addressed arthroscopically
Intraarticular fracture fragments should be discarded from the surgical field, as incorporation of the fragments into the fixation construct leads to a high rate of avascular necrosis
The CT images shown in Figures C and D display significant marginal impaction of the joint surface.
Marginal impaction is common in posterior wall fractures and fracture-dislocations. Critical review of CT imaging of posterior wall fractures can help with preoperative planning for identifying impaction of the articular surface of the acetabulum. Restoration of the sphericity of the acetabulum to match that of the femoral head is important for successful outcome following ORIF of posterior wall fractures. A common surgical technique to accomplish joint surface restoration includes freeing the impacted articular segments, bone grafting of the void created to support the articular segments, and buttress plating of the posterior wall fracture fragments.
Patel et al. discuss the challenge of interpreting imaging of the acetabulum for assessing fracture characteristics that may significantly impact success or surgical intervention. These characteristics include: articular displacement, marginal impaction, incongruity of the joint surface, intra-articular fragments, and osteochondral injury to the femoral head. Based on expert review of images, determination of significant marginal impaction had a poor intraobserver reliability, as did each of the other modifiers listed.
Figures A and B are radiographs of the posterior wall fracture and hip dislocation. They do not show the large amount of marginal impaction of the acetabular surface. Figure C (coronal reconstruction) and Figure D (sagittal reconstruction) point out a large a amount of marginal impaction of the acetabular. Note the disruption of the joint surface on the intact portion of the acetabulum.
Incorrect answers:
Comminuted posterior wall fractures still should be surgically stabilized if the joint is unstable
This impacted fragment on the margin of the main fracture line will likely heal regardless of restoration of the articular surface; however, this malreduction will lead to a incongruent joint surface
These CT cuts do not show any osteochondral defects of the femoral head; however if found in other CT cuts or intraoperatively, they should be appropriately addressed
Intraarticular fracture fragments should be removed from the joint, but if they make up a substantial portion of the joint surface, they should be incorporated in the fixation construct to obtain the goal of anatomic reduction of the joint surface
OrthoCash 2020
A 32-year-old female is involved in a motor vehicle collision and suffers a right hip dislocation. She is in the twelfth week of pregnancy.
Evaluation in the emergency department reveals no other injuries and ultrasound reveals a strong fetal heart rate and no abnormalities. She undergoes emergent closed reduction but the hip remains unstable and a traction pin is placed. Post-reduction films are shown in Figure
What is the most appropriate next step in management?
Acute open reduction internal fixation
Exam under anesthesia
Skeletal traction for 6-8 weeks
Fetal monitoring until 15 weeks followed by open reduction internal fixation
Percutaneous pinning
This patient has a large posterior wall fracture of the right acetabulum with an unstable hip. The most appropriate next step in treatment is open reduction and internal fixation.
Fixation of acetabular fractures during pregnancy is not contraindicated in the setting of stable fetal heart rate and no abnormalities on pelvic ultrasound.
There is, however, an increased risk of complications for the mother and fetus. Injury severity and mechanism are most closely associated with increased rate of fetal complications. The trimester of pregnancy is not associated with increased risk of complications.
Leggon et al. reviewed 101 cases of pelvic and acetabular fractures in pregnant patients and found mechanism of injury and injury severity were associated with higher mortality for both mother and fetus. Trimester of pregnancy was not associated with increased mortality.
Flik et al. reviewed orthopaedic trauma in a pregnant patients and recommended fetal ultrasound for assessment of fetal well-being in all pregnant patients.
Desai et al. investigated orthopaedic trauma during pregnancy and reported minimal radiation risk to the fetus when obtaining x-rays. They also advocate for LMWH as one of the safest choices for anticoagulation.
Figure A is an x-ray showing a right posterior wall acetabular fracture. Figures B and C are Judet views of the pelvis focusing on the right hip. A large posterior wall fragment is visible in Figure B.
Incorrect Answers:
OrthoCash 2020
Figure A is radiograph of a 50-year-old male science teacher that was involved in a motor vehicle accident. He underwent closed reduction as seen in Figure B and C. What would be the most appropriate treatment?
Open reduction and internal fixation with medial bridge plate and lateral screw in non-lagging mode
Tibiotalocalcaneal arthrodesis
Open reduction and internal fixation with lateral and medial screw in lagging mode
Closed reduction and internal fixation with medial and lateral screw in non-lagging mode
Closed reduction with percutaneous pins
Corrent answer: 1
This patient is presenting with a Hawkins II talar neck fracture with medial wall comminution. The most appropriate treatment of this patient would be open reduction internal fixation with medial plate and lateral screw in non-lagging mode.
The treatment of talar fractures is based on the severity of the fracture, soft-tissues, and patient factors. The fracture and subluxation of the subtalar joint should be reduced and stable anatomical fixation should be obtained. When there is comminution of either the superior, lateral or medial aspects of the talus, one should avoid shortening the medial wall as this will cause a varus malunion. The use of a medial or lateral plate can help to re-establish column length, which can often prevent this potential complication.
Sanders et al. showed significant complications after fixation of talar neck fractures. They showed the incidence of secondary reconstructive procedures following talar neck fractures increased from 24% +/- 5% at 1 year to 48%
+/- 10% at 10 years post-injury.
Vallier et al. retrospectively reviewed the records of 39 fractures of the talar neck treated with open reduction and internal fixation. Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09).
Vallier et al. reviewed 81 talar neck fractures to revisit the rate of osteonecrosis and post-traumatic arthritis based on the Hawkins Classification. They found that delaying definitive internal fixation does not increase the risk of developing osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01).
Figure A shows a Hawkins II talar neck fracture. Figures B and C are saggital and coronal CT images, respectively, of the foot. There is significant comminution of the medial wall of the talus with extension into the subtalar joint.
Incorrect Answers:
There is some research to suggest primarily subtalar arthrodesis with these injuries. However, to date, there is no high level evidence that has conclusively shown subtalar arthrodesis to be better than ORIF.
OrthoCash 2020
A 28-year-old male college student sustains a severe foot injury from gunshot-related violence, and subsequently undergoes a lower-extremity amputation as shown in Figure A. At long-term follow-up, which of the following is the strongest predictor of patient satisfaction as related to his injury?
Age less than 30
Marijuana use
Use of negative pressure wound therapy
Male gender
Ability to return to work
Corrent answer: 5
The strongest factor to predict patient-reported outcomes after trauma-related lower extremity amputations is the patient's ability to return to work. This is likely due to the effect of the return to work on the physical, emotional, and financial aspects of the patient's life.
The LEAP study is a multicenter, prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.
O'Toole et al reviewed 463 patients treated for limb-threatening lower-extremity injuries and identified factors associated with patient reported outcomes two years after surgery. They found that return to work was the most associated with outcomes, but that physical functioning, walking speed, pain levels, and presence of depression were also associated to a lesser extent with outcomes.
Bosse et al performed a multicenter, prospective study to assess outcomes of 569 patients with severe lower extremity limb injuries that resulted in either amputation or limb salvage procedures. They found that at two years postoperatively, no significant differences were seen between groups in patient-reported outcome. Worse outcomes were associated with rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), and involvement in disability-compensation litigation.
Figure A shows a clinical photograph of a Pirigoff amputation at early follow-up. This amputation is an end-bearing amputation that utilizes the plantar heel pad for weightbearing, and relies on a tibiocalcaneal arthrodesis.
Incorrect Answers:
4: These options are not as strong of a factor of patient satisfaction in longterm follow up after trauma-induced lower extremity amputation.
OrthoCash 2020
A 34 year-old male falls off of motorcycle on an outstretched hand suffering the injuries shown in Figures A and B. He is brought to the operating room and undergoes radial head replacement and fixation and repair of the coronoid and the lateral collateral ligament (LCL). Prior to closing, the elbow is still unstable upon testing range of motion. What is the next best step in management?
Exchange radial head for larger implant
Complete resection of radial head
Cast at 90 degrees of flexion for 6-8 weeks
Reinforce LCL repair with non-absorbable suture
Repair the ulnar collateral ligament
Corrent answer: 5
Following complete fixation and repair of a terrible triad, a final range of motion test should be performed prior to closure. If still unstable, the next step should be to assess and repair the ulnar collateral ligament. Another option
would be to placed a hinged external fixator.
Operative reconstruction of a terrible triad injury should be performed in a systematic fashion, working from deep to superficial. Working through a lateral incision and through the radial head fracture, the coronoid should be fixed first, followed by radial head fixation or replacement and then repair/reconstruction of the LCL. If still unstable, the medial side should be addressed, or the patient placed in a hinged external fixator.
Mathew et al review the anatomic, biomechanic, and operative principles (why the above step-by-step method works) to achieving appropriate stability in order to obtain early range of motion to maximize clinical outcome.
Pugh et al. in this retrospective, multi-center study report outcomes on 36 terrible triad injuries fixed with the standard protocol described above. The authors recommend following this systematic approach to achieve the best results.
Figures A and B are AP and lateral radiographs exhibiting a terrible triad elbow fracture-dislocation.
Incorrect answers:
OrthoCash 2020
When treating the pathology depicted in Figures A through D, which of the following is necessary to preserve the blood supply to the femoral head?
Dissection of the gluteal musculature off the iliac crest
Ligation of the ascending branches of the lateral femoral circumflex artery
Greater trochanteric osteotomy
Identification and detachment of the piriformis tendon
Supine positioning
Figures A-D show a femoral head with associated acetabular fracture (Pipkin IV). Both the posterior wall fracture and the femoral head fracture can be addressed through a surgical dislocation via greater trochanteric osteotomy.
Pipkin IV femoral head fracture (with associated acetabular fractures) are somewhat problematic in that the femoral head fracture is usually anterior, while the acetabular fracture usually involves the posterior wall. A Kocher-Langenbeck approach gives good access to the posterior wall but limited access to the articular surface and femoral head avascular necrosis (AVN) is a concern. A Smith-Peterson approach provides good access to the femoral head
but not to the posterior wall. Combined approaches significantly increase the amount of surgical dissection. Surgical dislocation with trochanteric flip osteotomy provides access to the femoral head and posterior wall while preserving blood supply to the femoral head.
Solberg et al. retrospectively reviewed 12 patients with Pipkin IV injuries treated via a trochanteric flip osteotomy. All patients healed their acetabular fractures. Eleven of 12 patients healed their femoral head fractures and one patient (8.3%) developed osteonecrosis.
Henle et al. likewise treated 12 patients with Pipkin IV injuries through a trochanteric flip osteotomy. Two of 12 patients (16.7%) developed osteonecrosis. The remaining 10 patients (83.3%) had good or excellent results. Heterotopic ossification occurred in five patients, causing significant range of motion loss in four of these.
Figure A is a pre-reduction AP pelvis in which the posterior wall fracture is apparent. Figure B is a post-reduction AP pelvis in which an infra-foveal femoral head fracture is apparent (Pipkin IV). Figure C is an axial CT cut which further characterizes the posterior wall fracture. Figure D is an obturator oblique showing femoral head dislocation and posterior wall fracture. The video shows a surgical hip dislocation technique.
Incorrect Answers:
OrthoCash 2020
A 42-year-old male presents to your clinic for the first time with the radiographs seen in Figure A. He sustained the injury 4 weeks ago while skiing overseas and treatment was provided by the local orthopaedic surgeon. The operative note states that he sustained an Gustilo Type I open fracture. After surgical fixation of this type of injury, what is the most common complication requiring reoperation?
Chronic elbow instability
Post-traumatic arthritis
Infection
Heterotopic ossification
Loss of elbow range of motion
Corrent answer: 5
This patient sustained a terrible triad elbow fracture-dislocation. Reduced range of motion of the elbow joint is the most common complication REQUIRING reoperation with these injuries.
Terrible triad elbow fracture-dislocations are characterized by posterolateral dislocation/lateral collateral ligament (LCL) injury, radial head fracture and coronoid fracture. Displaced fractures result in elbow instability. Acute radial head stabilization, coronoid open reduction and internal fixation, and LCL +/-medial collateral ligament (MCL) repair/reconstruction is considered the most appropriate treatment for displaced fractures. Operative complications include elbow stiffness, recurrent instability, arthritis, failure of hardware, heterotopic ossification, posterior interosseous nerve palsy and infection.
Egol et al. looked at the functional outcomes of 27 patients that underwent fixation of terrible triad injuries. At one year follow-up, the average flexion-extension arc of elbow motion was 109 degrees +/- 27 degrees, and the average pronation-supination arc was 128 degrees +/- 44 degrees. Grip strength averaged 72% of the contralateral extremity. Although operative fixation led to functional elbow stability, results were poor.
They included a reference to McKee et al. to highlight that intra-articular fractures of the elbow have high rates of stiffness. While not specific to terrible
triads, they looked at the effectiveness of the posterior elbow approach in 25 patients that underwent internal fixation of intra-articular distal humerus fractures. They showed poor outcomes at a mean follow-up of 36 months with reduced range-of-motion, decreased strength and high re-operation rates.
Figure A shows AP fluoroscopic image of a terrible triad injury that has undergone operative fixation. The radial head and coronoid have undergone open reduction internal fixation, and the MCL bony avulsion has been repaired.
Incorrect Answers:
OrthoCash 2020
Figure A is a radiograph from a 59-year-old male that was transferred to a Level I trauma center five hours after a motor vehicle accident. Closed reduction and skeletal traction was successfully performed in the trauma bay. Which of the following factors has been shown to increase the risk of unsatisfactory clinical outcome for this patient?
Need for skeletal traction
Mechanism of injury
Gender
Age
Time to reduction
Corrent answer: 4
Age greater than 55-years-old has been found to be an independent risk factor for inferior clinical outcome in patients with combined acetabular fractures and hip dislocations.
The most important initial step in management following resuscitation involves urgent reduction of the dislocated hip. This should be followed by a preoperative CT scan and ultimately surgical fixation of the combined acetabular fracture. Hip dislocations should be reduced within 6-12 hours for optimal outcome, although different critical times have been cited, particularly for dislocations with concomitant acetabular fractures. Skeletal traction may be required to maintain hip reduction.
Moed et. al. present a Level 3 retrospective review of 100 patients who had been treated with open reduction internal fixation of an acetabular fracture. The authors found that factors associated with unsatisfactory clinical outcomes included age greater than 55, intra-articular comminution, osteonecrosis, and delay of greater than 12 hours for reduction of an associated hip dislocation.
Additionally, they showed that there was a strong association of clinical outcome and final radiographic grade.
Figure A demonstrates an acetabular fracture with concomitant hip dislocation. Incorrect Answers:
injury, male gender, and time to reduction <6 hours have not been shown to be related to unsatisfactory outcomes.
OrthoCash 2020
A 37-year-old male cashier is shot in the leg. He sustains the injury shown in Figures A and B, and is subsequently taken to the operating room for intramedullary nailing. Figure C shows a radiograph of the nail starting point (*). What complication is most likely to result?
Varus malunion
Nonunion
Valgus malunion
Malrotation
Superficial peroneal nerve injury
Corrent answer: 3
This patient is presenting with a comminuted fracture of the proximal third of the tibia. He is appropriately undergoing intramedullary nail fixation, however, the start point illustrated in Figure C is too medial and often leads to a valgus malunion.
Intramedullary nail fixation is more technically demanding in proximal tibial fractures than diaphyseal fractures. The valgus deformity is due to imbalanced muscle forces on the proximal fragment, which are then accentuated by a start point that is too medial. An apex anterior (procurvatum) deformity can also occur and results from the pull of the patellar tendon or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment. The ideal starting point for proximal tibial fractures is slightly lateral to the medial aspect of the lateral tibial spine on a true AP x-ray and very proximal and just anterior to the anterior margin of the articular surface.
Nork et al. reported the results of intramedullary nailing of proximal tibial fractures with emphasis on techniques of reduction. Various techniques were found to be successful including attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia.
Lowe et al. describe surgical techniques for complex proximal tibial fractures. They describe the extended leg position, use of a femoral distractor, temporary plate fixation, blocking (Poller) screws, and use of percutaneous clamps as means to achieve reduction during fixation.
Figure A and B show an AP and lateral radiograph of a comminuted extra-articular fracture through the proximal third of the tibia. Figure C demonstrates a start point that is too medial (represented by the asterisk) for intramedullary nail fixation. Illustration A and B show the ideal start point for intramedullary nail fixation of the tibia on AP and lateral radiographs.
Incorrect Answers:
Varus malunion is more likely to occur in midshaft tibia fractures with an intact fibula.
Nonunion after a proximal tibial fracture treated with intramedullary nailing is less common than malunion.
Malrotation occurs most commonly after IM nailing of fractures through the distal third of the tibia.
The superficial peroneal nerve is at risk during distal screw fixation using a LISS plating technique for fracture fixation.
OrthoCash 2020
A 24-year-old motorcyclist is brought in as a polytrauma after striking a tree at 65 mph. He is found to have injuries involving the chest, abdomen, pelvis, as well as a left open femoral shaft fracture. He undergoes resuscitation in the trauma bay. Which of the following parameters best supports proceeding with irrigation, debridement and external fixation as opposed to immediate reamed intramedullary nailing?
Temperature = 35.5°C (95.9°F)
Fractures of ribs 2-3 with left apical pneumothorax
Grade IV liver laceration with SBP = 85 mmHg
Left superior and inferior pubic ramus fractures
Lactate = 2.3 mg/dL
Significant abdominal trauma with evidence of hemorrhagic shock (SBP < 90 mmHg) following resuscitation is an unstable parameter and therefore is an indication to proceed with damage control orthopaedics (irrigation and debridement of open fractures and temporizing external fixation) in a polytraumatized patient.
The management of orthopaedic injuries in a polytrauma patient depends on the physiological stability of the patient. In an unstable patient, damage control orthopaedics (DCO) is preferred over early total care (ETC) to avoid an iatrogenic second hit with development of adult respiratory distress syndrome (ARDS) and/or multiple organ failure. Clinical parameters indicative of instability include shock (BP < 90 mmHg, refractory to blood products, lactate
> 2.5 mg/dL), coagulopathy (platelet count < 90,000 mm3, fibrinogen < 1 g/L), hypothermia (< 35°C), and significant chest, abdomen or pelvis injuries (pulmonary contusions, severe liver/spleen lacerations, pelvic ring disruption).
Pape et al. (2009) authored a review article detailing the management of a multitrauma patient. Polytrauma patients can be classified as stable, borderline, unstable or in extremis using a variety of criteria pertaining to hemodynamic stability, coagulation, temperature and soft tissue injury.
Patients who are stable or borderline can undergo ETC, while patients who are unstable or in extremis should be managed with DCO.
Pape et al. (2008) concluded that all patients who underwent early femoral nailing demonstrated increased systemic inflammatory response compared to external fixation, regardless of clinical stability. However, unstable patients
with a preexisting elevation of inflammatory status are likely more impacted by this additional increase. Improved postoperative clinical status coincided with a less vigorous inflammatory response.
Illustration A is a table from Pape et al (2009) depicting the criteria used to determine clinical condition of a polytraumatized patient. Illustration B is an algorithm from Pape et al (2009) detailing management of the multitrauma patient.
Incorrect Responses:
OrthoCash 2020
A 92-year-old female sustains the injury shown in Figure A to her nondominant extremity as the result of a non-syncopal ground-level fall. She denies any previous injury or pain of the elbow, and her medical history is significant only for osteoporosis and hypothyroidism. What is the most appropriate treatment for her injury?
Immediate range of motion as tolerated with a sling for comfort
Long arm cast for 3 weeks, then physical therapy for motion
Open reduction and internal fixation
Radiocapitellar arthroplasty
Total elbow arthroplasty
Corrent answer: 5
Use of total elbow arthroplasty (TEA) in the elderly is a well-recognized method of treatment of complex distal humerus fractures. This procedure allows for improved ROM, improved patient-reported outcomes, and decreased revision rates as compared to fixation.
TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients appear to accommodate to objective limitations in function with time, which is important, as most recommendations list restrictions of lifting no more than 5-10 pounds postoperatively.
McKee et al conducted a prospective, randomized, controlled trial to compare functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary semiconstrained total elbow arthroplasty (TEA). Patients who underwent TEA had a quicker procedure, improved DASH scores at 6 months, improved elbow ROM, and decreased revision rates.
Athwal et al review TEA and the options available at the time of publication. They also report on the techniques and purported advantages of arthroplasty as compared to fixation of complex distal humerus fractures.
Frankle et al reviewed patients >65 years old with distal humerus fractures at a minimum of 2 years follow-up. Outcomes were excellent in 33% of cases undergoing ORIF and 92% excellent with TEA. They recommend TEA in instances of arthritis, osteoporosis, or other diagnoses requiring steroids.
Figure A shows a significantly comminuted distal humerus fracture in an osteoporotic patient. Illustration A shows the same patient after undergoing total elbow arthroplasty.
Incorrect Answers:
1:Immediate range of motion is not recommended for this injury, even with the "bag of bones" treatment method. A brief period of immobilization is generally recommended for this technique.
2: Casting is not indicated for this injury.
3: ORIF of this injury will lead to worse outcomes as compared to arthroplasty. 4: Isolated radiocapitellar replacement is not indicated for this injury.
OrthoCash 2020
A 56-year-old right hand dominant attorney falls from standing and sustains the closed injury shown in Figure A. The treating surgeon elects to fix her fracture using a plate and screw construct. Based on
the available imaging, which of the following fracture characteristics best justifies this fixation choice?
Fracture displacement
Intra-articular fracture extension
The fracture extends distal to the coronoid
Oblique fracture line
Fracture comminution
This patient has a displaced, intra-articular, comminuted olecranon fracture. Comminution is an indication for plate fixation.
Most displaced olecranon fractures are treated operatively. Options include tension band constructs, intramedullary screws, plate and screw fixation or fragment excision with triceps advancement. Any construct relying on interfragmentary compression (tension band, intramedullary screws) requires a non-comminuted fracture pattern. Plate fixation is indicated in the setting of comminution, extension past the coronoid, or in the setting of associated instability.
Bailey et al. retrospectively reviewed 25 patients who underwent plate fixation of displaced olecranon fractures. Twenty-two of 25 patients had good or excellent outcomes. Five of 25 patients (20%) of patients required plate removal for symptomatic hardware. The authors concluded that plate fixation
was an effective treatment for displaced olecranon fractures, with good functional outcomes.
Figure A shows a displaced, comminuted olecranon fracture without evidence of propagation past the coronoid.
Incorrect answers:
OrthoCash 2020
A 35-year-old male was involved in a high speed motorcycle accident. He has a closed head injury, bilateral pulmonary contusions and splenic rupture. His orthopaedic injuries are shown in Figure A. He has a blood pressure of 90/50 mm Hg and a heart rate of 115, despite aggressive resuscitation. An arterial blood gas reveals that his blood lactate is 3.5 and base deficit is -6 mmol/L. Following successful closed reduction of the right hip in the operating room with a percutaneous inserted Schantz pin, what is the next most appropriate treatment for his orthopaedic injuries?
Bilateral open reduction and internal fixation
Open reduction internal fixation on the right, reamed intramedullary nailing on the left
Temporizing external fixation on the right, open reduction and internal fixation on the left
Bilateral reamed intramedullary nailing
Bilateral temporizing external fixation
Corrent answer: 5
This patient presents with features of hemodynamic instability and a high injury severity score. The next most appropriate treatment would be temporizing external fixation bilaterally. This patient meets the criteria for damage control orthopaedics.
Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology does not undergo further inflammatory insult. As a result, external fixation of femoral shaft fracture and pelvic stabilization is an effective treatment under this strategy. Other indications include vascular injury and severe open fracture.
Pallister et al. reviewed the effects of surgical fracture fixation on the systemic inflammatory response to major trauma. They show that early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure. However, early fracture surgery increases the post-traumatic inflammatory response, which
carries a higher complication rate compared to temporary fixation.
Tisherman et al. created clinical guidelines for the endpoints of resuscitation. Level I data found that standard hemodynamic parameters do not adequately quantify the degree of physiologic derangement in trauma patients. The initial base deficit, lactate level, or gastric pH should be used to stratify patients with regard to the need for ongoing fluid resuscitation.
Pape et al. retrospectively reviewed the impact of early total care vs. damage control orthopaedics in the treatment of femoral shaft fractures in polytrauma patients. They found a significantly higher incidence of acute respiratory distress syndrome (ARDS) with intramedullary nailing (15.1%) compared to external fixation (9.1%) when DCO subgroups were compared.
Figure A is a pelvic AP radiograph showing a right hip fracture-dislocation with an ipsilateral femoral shaft fracture. On the left side there is a displaced pertrochanteric hip fracture.
Incorrect Answers:
OrthoCash 2020
Which of the following has been shown to be the greatest risk factor for refracture after implant removal from a radial shaft?
Removal of locking screws
Removal of small fragment plates
Removal of metaphyseal implants
Removal of implants less than 1 year after insertion
Removal of protective splinting from limb earlier than 10 weeks postoperatively
Removal of implants earlier than 1 year after insertion is a risk factor for refracture of the bone after implant removal.
The risk of refracture after hardware removal is multifactorial. Multiple
variables have been studied such as protective splinting for 6 weeks after hardware removal, waiting 12 months or more prior to hardware removal, and the location of the fracture. The variable that seems to correlate most with the risk of refracture is a diaphyseal location of the initial fracture. Large fragment plates (4.5 mm), when removed, are also at higher risk for refracture in the forearm.
Deluca et. al reported on a case series of patients who sustained a refracture of a forearm after implant removal. They noted that radiolucency at the site of the original fracture was seen in most refractured patients when the plate was removed. They also recommend delaying implant removal to two years after insertion to minimize risk.
Rumball et. al reported that the incidence of refracture after forearm implant removal is 6% in their series. They found that early removal, lack of postoperative immobilization, and plate size are the most critical risk factors for refracture.
Illustration A shows a forearm with evidence of refracture after implant removal.
Incorrect Answers:
OrthoCash 2020
A 23-year-old male arrives to the trauma bay after a motorcycle crash caused by a drive-by shooting. The patient is awake and alert and following commands. Vital signs include a blood pressure of 145/90 and a heart rate of 117bpm. Initial lactate is reported as 2.4 mmol/L. The patient has 2 rib fractures on the right with a clear chest radiograph. The patient is neurovascularly intact with a 4cm transverse wound over the medial ankle. Figures A, B and C exhibit his orthopaedic injuries. What is the most appropriate management?
Irrigation, debridement and placement external fixator right ankle, external fixation femur and intramedullary fixation tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and external fixation tibia
Irrigation, debridement and placement external fixator right ankle, femur and tibia
Irrigation, debridement and external fixation right ankle and skeletal traction
The patient is relatively hemodynamically stable. In this case the femur and tibia should be definitively fixed while the open ankle fracture can be irrigated and debrided and placed in a spanning external fixator, temporizing for later definitive fixation.
Aside from an elevated heart rate and mildly elevated lactate (normal < 2.5 mmol/L), the patient is relatively stable making him a good candidate for long bone stabilization and temporizing external fixation of the right ankle. Gross contamination of the open injury also supports temporizing fixation, which can be brought back for repeat I&D and possible fixation.
Pape et al. compared outcomes for intramedullary nailing (IMN) versus staged fixation for femur fractures in stable versus borderline patients. Borderline patients were defined as those with multi-system injury (especially to lungs) and exhibited higher lung complications following acute IMN when compared to stable patients with isolated orthopaedic injuries.
O'Brien reviewed the literature regarding early total care in regards to IMN stabilization of femur fractures. Summarized data noted isolated injuries treated with early IMN had good outcomes, whereas those with head or lung injury had worse outcomes and pulmonary complications.
Figure A exhibits a right open ankle fracture dislocation. Figure B exhibits a mid-shaft tibia fracture. Figure C exhibits a ballistic mid-shaft femur fracture.
Incorrect Answers:
OrthoCash 2020
Figure A is an anterior-posterior (AP) radiograph of a 27-year-old male who was a bicyclist struck by a motor vehicle. He was intubated in the field and unresponsive in the trauma slot. Ultrasound of his abdomen is positive for blood and he is brought to the operating room emergently for an exploratory laparotomy. He is found to have ischemic bowel and a grade 4 liver laceration. His lactate is 9.0 mg/dL. Which figure represents the next appropriate step in regard to his pelvic ring injury?
The radiograph exhibits an elevated left hemipelvis with complete sacroiliac disruption, which can be temporized with placement in skeletal traction.
The patient is unstable, as indicated by an elevated lactate level. The most appropriate next step is temporizing skeletal traction to reduce the left hemipelvis.
Langford et al. review the initial diagnosis, evaluation and resuscitation in the management of pelvic fractures. Reduction of pelvic volume can be achieved with pelvic binders and temporizing external fixation for anterior posterior compression (APC) and/or lateral compression (LC) fracture patterns, while skeletal traction can help do the same in vertical shear patterns.
Matullo et al. review the uses of skeletal traction in orthopaedic trauma, where lower extremity skeletal traction can be an efficient, fast, easy way to help reduce pelvic volume in vertical shear injuries, especially when the patient is unstable and not cleared for definitive fixation.
Figure A exhibits an elevated left hemipelvis indicative of a vertical shear injury and complete SI disruption. Figure B is an example of a pelvic binder. Figure C is a pelvic reconstruction plate. Figure D is a schematic of an anterior pelvic external fixator. Figure E is a schematic drawing of a patient in lower extremity
skeletal traction. Figure F is a radiograph exhibiting S1 and S2 sacroiliac (SI) screws.
Incorrect answers:
OrthoCash 2020
A 38-year-old man is involved in a motor vehicle collision and suffers the grossly open injury shown in Figure A. He subsequently undergoes irrigation and debridement and placement of an external fixator. In Figure B, if the proximal pin is placed at the red circle as compared to the black circle, the patient is at increased risk for which of the following?
Foot drop
Injury to the anterior tibial artery
Septic arthritis
Flexion contracture of the knee
Patellar tendon rupture
Corrent answer: 3
The patient is at increased risk of septic arthritis when placing the proximal tibial pin too proximal due to penetration of the joint capsule. Pin site flora can track into the joint and lead to a septic knee.
Tibial external fixators can be used to temporize tibial shaft, pilon, and ankle fractures not ready for definitive management due to soft tissue concerns and/or practice of damage control orthopaedics. Intracapsular placement of fixator pins can lead to septic arthritis. The capsular reflection typically extends 14 mm distal to the subchondral line.
DeCoster et al. reported a cadaveric dissection study for safe placement of proximal tibia pins and determined that the capsule inserts 14 mm below the articular surface along the posteromedial and posterolateral surfaces. For fractures requiring extremely proximal pin placement, they recommend
anterior cortex penetration only at least 6 mm distal to articular surface.
Reid et al. investigated safe transtibial pin placement using MRI and cadaveric and volunteer knees. They found that pin placement 14 mm distal to subchondral bone will result in low likelihood of capsular penetration.
Figure A is an AP radiograph showing a segmental middle third tibia/fibula fracture. Figure B is a lateral diagram of the tibia showing potential sites of proximal pin placement.
Incorrect Answers:
OrthoCash 2020
Figures A and B are radiographs of a 43-year-old, right-hand dominant, male that injured his arm in a motor vehicle accident. What would be an absolute indication for surgical fixation of his injury?
Radial nerve palsy
Intra-articular extension
2mm fracture distraction, 5 degrees of rotational malignment
Ipsilateral proximal both bone forearm fracture
Bilateral fracture
This patient has a humeral shaft fracture. An absolute indication for surgery would include a floating elbow, i.e. ipsilateral both bone forearm fracture.
The primary causes of humeral fractures include motor vehicle accidents, falls, or violent injury. Almost all cases are treated non-operatively with functional bracing. The absolute indications for surgical management include: ipsilateral vascular injury, severe soft-tissue injury, open fracture, compartment syndrome, and associated ipsilateral forearm fracture, ie, floating elbow. The relative indications for surgical management include: segmental fracture, intraarticular extension, significant fracture distraction, bilateral humeral fracture, inability to maintain acceptable alignment, and polytrauma.
Klenerman et al. reviewed non-operative treatment of humeral shaft fractures. They showed that acceptable results could be achieved even after 20° of
anterior bowing, 30° of varus angulation, 15° of malrotation, and 3 cm of shortening.
Carroll et al. reviewed the management of humeral shaft fractures. They state the indications for operative fixation to be polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical techniques include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing
Figure A and B shows a comminuted mid-shaft humeral fracture with intraarticular extension.
Incorrect Answers:
OrthoCash 2020
Which of the following findings is a contraindication in retrograde nailing of a periprosthetic distal femur fracture around a total knee arthroplasty?
Posterior-stabilized total knee implant
Cruciate retaining total knee implant
Spiral fracture pattern
Distal femoral replacement
Knee flexion contracture of 15 degrees
Corrent answer: 4
A distal femoral replacement (TKA) implant will generally preclude placement of a retrograde nail due to the long stem on the femoral component.
Supracondylar femur fractures above a well-fixed TKA component are increasingly common. These fractures are often treated with a lateral locking plate, but can also be treated with a retrograde nail in certain circumstances. An important factor in determining if nailing is a viable option are knowing the TKA implant and it's design. In addition, if the TKA component is known, the maximum size of reamer head and nail can be determined preoperatively from the size of the femoral 'box'.
Schutz et al report on a prospective multicenter study of 112 patients who underwent fixation of a distal femur fracture with the LISS system. They report that 90% of fractures went on to union and they attribute all of the failures to either the high-energy nature of particular fractures or a lack of experience in applying the plate in an appropriate pattern. They also note that primary grafting of these fractures is not necessary.
Illustration A shows a periprosthetic femur fracture treated with a retrograde nail.
Incorrect Answers:
1: A posterior-stabilized implant can be treated with an intramedullary nail in many circumstances but can be technically challenging, depending on the components.
2: A cruciate retaining TKA is not a contraindication to use of a retrograde nail. 3: A spiral pattern periprosthetic supracondylar femur fracture can be treated with a femoral nail.
5: A knee flexion contracture will often provide the flexion necessary for access to the box of the femoral component. A knee extension contracture, however, can preclude access to this box for placement of a nail.
OrthoCash 2020
A patient falls and sustains the isolated injury seen in Figures A and B. The surgical plan includes open reduction and internal fixation with a small mini-fragment plate using a direct lateral approach. During the approach, the forearm was placed in a fully pronated position. What would be the correct position of the forearm during plate application?
Full pronation
25 degrees pronation
Neutral
25 degrees supination
Full supination
Using the lateral approach (Kocher or Kaplan), the correct placement of the arm should be in a neutral position so that the plate can be placed on the bare area of the proximal radius.
Displaced radial head fractures with less than 3 fragments can be amendable to open reduction internal fixation. The methods of fixation include buried or headless screws, if placed at the articular surface, or posterolateral plating, if placed in the bare area. The safe zone for plating is located at a 90-110 arc from the radial styloid to Lister's tubercle with the arm in neutral rotation. This position helps to avoid impingement of ulna against the plate with forearm rotation. It should be noted that during the approach, that the forearm should be fully pronated to avoid injury to the posterior interosseous nerve.
Mathew et al. reviewed the concepts of terrible triad injuries of the elbow. Radial head fractures are treated conservatively when there is an isolated minimally displaced (less than 2mm) fracture with no mechanical block to motion. Open reduction internal fixation is used for Mason II or III fractures with < 3 fragments. Radial head replacement is considered for comminuted
fractures (Mason Type III) with 3 or more fragments.
Cheung et al. reviewed the surgical approaches to the elbow. The lateral approach (Kocher or Kaplan) is most commonly used with these injuries. The Kocher approach utilizes the intramuscular plane between anconeus and extensor carpi ulnaris. Kaplan utilizes the plane between extensor digitorum commons and extensor carpi radialis brevis.
Figure A and B show AP and lateral radiographs of the left elbow. There is a displaced radial head fracture. Illustration A shows a schematic diagram of the radial head "safe zone" between the radial styloid to Lister's tubercle.
Incorrect Answers:
OrthoCash 2020
A 38-year-old male is involved in a high speed motor vehicle collision. He has a Glasgow Coma Scale of 13 and receives 2 liters of fluid en route to the emergency department. Upon evaluation in the emergency department, he is found to have a bilateral femoral shaft fractures, a right ankle fracture, and a left both bone forearm fracture. He also has 2 left sided rib fracture and a grade II liver laceration. His heart rate is 130 and blood pressure is 85/50. All of the following
would be indications to practice damage control orthopaedics in this patient except:
Bilateral femur fractures
Rib fractures
Lactate of 5.2
Urine output of 20 cc/hr
Heart rate and blood pressure
Corrent answer: 2
Rib fractures without evidence of further thoracic trauma would not be an indication to practice damage control orthopaedics. This patient is underresuscitated based on his lactate level, urine output, and vital signs and definitive management should be delayed.
Damage control orthopaedics is the practice of delaying definitive management of fractures and utilizing temporary stabilization (such as an external fixator) until a patient has recovered from the initial physiologic insult of trauma.
Patients are at increased risk for perioperative complications such as ARDS and multi-system organ failure during the acute period after polytrauma. In addition to underresuscitation, other indications to practice damage control orthopaedics include: injury severity score>40 (or >20 with thoracic trauma), bilateral femoral fractures, hypothermia below 35 degrees Celsius, and pulmonary contusions.
Pape et al. (2007) studied the incidence of acute lung injuries in polytrauma patients undergoing either intramedullary nailing or external fixation and later definitive fixation of femoral shaft fractures. They found that patients undergoing immediate intramedullary nailing were nearly 6.7 times more likely to have acute lung injury
The Canadian Orthopedic Trauma Society studied the effect of reamed versus unreamed femoral nailing on incidence of ARDS for femoral shaft fractures in trauma patients using a randomized controlled study. They found no difference between the groups.
Pape et al. also examined the pathophysiological cascades that accompany soft tissue injuries of the extremities, abdomen, and pelvis and recommend a more comprehensive for evaluation of patients with these injuries.
Incorrect Answers:
OrthoCash 2020
The anterior intrapelvic (modified Stoppa) approach is most appropriate for which of the following fractures?
The anterior intrapelvic (AIP) or modified Stoppa approach provides access to the quadrilateral plate, which is a common location for fracture displacement in associated both column acetabulum fractures as seen in Figure D.
Compared to the traditional ilioinguinal approach, the modified Stoppa with a lateral window can offer comparable access to the quadrilateral plate, which can allow for its use in associated both column fracture patterns.
de Peretti et al. prospectively followed 25 patients with both column fractures
treated via an iliofemoral approach. Results led the authors to not recommend the extensile approach for both column fractures due to lack of efficiency and high complication rates.
Alonso et al. compared the extensile iliofemoral and triradiate approaches, and both reported acceptable results. However, concerning were the relatively high rates of heterotopic ossification, despite prophylaxis.
Bible al. performed a cadaver study to quantify the amount of access provided by the modified Stoppa approach. This approach provides access to approximately 80% of both the inner pelvis, and the quadrilateral plate, however, comparison to the ilioinguinal approach was not performed.
Shazar et al., in a cohort comparison between the ilioguinal and Stoppa approaches, noted better visualization and potential improve fracture reduction via the Stoppa approach for both column fractures. However, this study was limited in its retrospective and relative observer bias.
Figure A depicts a posterior wall fracture dislocation with concomitant femoral neck fracture. Figure B is an iliac oblique view which depicts a posterior column fracture. Figure C exhibits a posterior column + posterior wall fracture. Figure D depicts acetabular fracture with protrusio. Figure E exhibits a posterior wall fracture.
Incorrect answers:
OrthoCash 2020
Figure A is a radiograph of a 75-year-old woman that fell onto her non-dominant shoulder from a standing height. She was treated nonoperatively for 9 months but continues to complain of pain when she elevates her arm. In patients with this type of fracture pattern, what factor has the greatest impact on fracture healing?
Hand dominance
Angulation of fracture
Smoking
Early physical therapy
Diet
This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with non-operative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to
impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than non-smokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:
OrthoCash 2020
A 26-year-old male epileptic patients presents with right shoulder pain and deformity after a grand mal seizure. After medical stabilization, he denies previous injury to his shoulder. Pre-reduction and post-reduction radiographs of the shoulder are shown in Figures A-C, respectively; physical examination reveals a normal upper extremity neurovascular examination. After shoulder immobilization, what would be the next most appropriate step in management of this patient?
Abduction brace for three weeks, followed by therapy
Right shoulder MR arthrogram
Open reduction and internal fixation
Hemiarthroplasty
Early range of motion
Corrent answer: 3
This patient has presented with a fracture dislocation of the right shoulder. After urgent closed reduction, this patient requires open reduction internal fixation of the proximal humerus, and greater tuberosity fracture fragment in particular.
Isolated greater tuberosity fractures may be associated with shoulder dislocations. Careful review of imaging is critical to identify fracture lines that may extend into the humeral neck and head. If these extensions go undetected, catastrophic propagating fractures may occur during closed reduction maneuvers. Treatment is usually with open reduction internal fixation (ORIF). Young patients with proximal humerus fractures should be treated more aggressively with ORIF as compared to elderly patients. Another example would be a severely impacted valgus proximal humeral fracture in a young patient.
Erasmo et al. examined of 82 cases of humerus fracture dislocations treated with the lateral locking plates. Overall outcomes were excellent to good based on standard scoring systems. Complications included avascular necrosis (12%), varus positioning of the head (4.8%), impingement syndrome (3.6%), secondary screw perforation (3.6%), non-union (2.4%) and infection (1.2%).
Robinson et al. looked at severely impacted valgus proximal humeral fractures treated with open reduction internal fixation in young patients. Anatomic reduction is required with lateral plating to re-establish the normal head/neck angle. Good to excellent results can be achieved with fixation methods.
Figure A shows an anterior fracture-dislocation of the right shoulder. Figure B and C show post-reduction radiographs with a congruent glenohumeral joint. Displacement of the greater tuberosity (GT) fragment is greater than 5mm.
Incorrect Answers:
OrthoCash 2020
Pelvic packing can be performed to temporarily treat a hemodynamically unstable patient with a pelvic ring fracture. Which of the following is the preferred location of the skin incision to perform pelvic packing?
Right anterior superior iliac spine (ASIS) to mid-symphysis, left lateral window incision
Left ASIS to mid-symphysis, right lateral window incision
Subumbilical incision
ASIS to ASIS bilaterally
Pararectus incision
The preferred skin incision location is a subumbilical incision, 6-8cm extending upwards from the pubic symphysis towards the umbilicus; this allows access to all of the appropriate areas for pelvic packing.
Following skin incision, the rectus fascia is then divided in the midline which allows for access to both sides of the bladder for packing deep in the pelvic
brim. On each side, 3 lap pads are placed from sacroiliac joint to the retropubic space, all placed below the level of the pelvic brim.
Hak et al. review the options for emergent treatment in life threatening hemorrhage secondary to pelvic fractures. The authors offer several options for emergent treatment, which includes the use of pelvic binders, the placement of external fixators, pelvic packing and interventional angiography. Goals include reduction of pelvic volume and stopping rapid hemorrhage to save a patient's life. Pelvic packing, properly performed, is done through a subumbilical incision, as described above.
Osborn et al. retrospectively reviewed and compared emergent pelvic packing to angiography in hemorrhagic pelvic fracture clinical scenarios. The authors noted comparable results in mortality with a noted decrease in need for post-procedure transfusions in the pelvic packing group.
Cothren et al. reported their outcomes following an institutional algorithmic change from pelvic ex-fix/angiography to pelvic packing and ex-fix. Since their institutional change, the authors noted a significant decrease in transfusions, need for angiography and mortality.
Incorrect answers:
OrthoCash 2020
A 28-year-old man is brought by ambulance to the emergency department after falling from the roof of his home four hours ago. Upon initial evaluation, he has visible deformities of his bilateral lower extremities and a positive FAST exam. Heart rate is 135, blood pressure 85/58, and urine output is 40 cc over 3 hours. According to ATLS guidelines, what percentage of his blood volume has this patient likely lost?

Question 19:

Which of the following is an indication for surgical management of a Weber type B distal fibular fracture?

Options:

Medial hindfoot ecchymosis
Medial ankle tenderness
Widened medial clear space
Comminution
Two millimeters of fibular displacement

Correct Answer: Widened medial clear space

Explanation:

Question 20:

Options:

Pain with resisted hip flexion
Pain with a half sit-up, plus tenderness at the pubic ramus
Pain with a combination of hip flexion, adduction, and internal rotation
Tenderness to palpation at the greater trochanter

Correct Answer: Pain with a combination of hip flexion, adduction, and internal rotation

Explanation:

This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater
trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of longstanding groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement. Surgical treatment for cam impingement can be effective for symptomatic patients. Even among high-level athletes, open surgical dislocation of the hip has been shown to have good results. Most patients with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable with those realized with open surgical dislocation. The literature describes success in terms of athletes returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment. Byrd and Jones described five patients who developed transient neurapraxias that resolved uneventfully. The patients in his series who had concomitant microfracture had a 92% return to sports within the follow-up period. Cam impingement has long been thought to be associated with a history of a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who underwent a
periacetabular osteotomy can develop a more retroverted acetabulum as well.

Question 21:

Options:

Age older than 40 years
Body mass index higher than 30
Tönnis grade of 2 or higher
Outer bridge grade of III or IV

Correct Answer: Tönnis grade of 2 or higher

Explanation:

Question 22:

A patient with a left-sided C6-7 herniated nucleous pulposis would likely have which of the following constellation of findings?

Options:

Pain into the thumb, triceps weakness, and loss of triceps reflex
Middle finger numbness, wrist extensor weakness, diminished brachioradialis reflex
Thumb numbness, wrist extensor weakness, diminished brachioradialis reflex
Middle finger numbness, triceps weakness, and loss of biceps reflex
Middle finger numbness, triceps weakness, and loss of triceps reflex

Correct Answer: Middle finger numbness, triceps weakness, and loss of triceps reflex

Explanation:

DISCUSSION: A C6-7 herniation affects the C7 root. The C7 root has the middle finger as its predominant sensory distribution. Its motor function is the triceps, wrist extension, and finger metacarpophalangeal extension. The reflex is the triceps.
REFERENCES: Magee D: Principles and concepts, in Orthopedic Physical Assessment, ed 3. Philadelphia, PA, WB Saunders, 1997, pp 1-18.
An H: History and physical examination of the spine, in Principles and Techniques of Spine Surgery. Baltimore, MD, Lippincott Williams & Wilkins, 1998, pp 91-101.

Question 23:

Options:

Open reduction internal fixation (ORIF)
Sling immobilization in external rotation
Bristow-Latarjet
Shoulder hemiarthroplasty The patient has sustained a displaced lesser tuberosity fracture with medial displacement following a posterior shoulder dislocation. Nonoperative management would risk long-term loss of normal subscapularis function, as well as anterior shoulder instability. An ORIF of lesser tuberosity is recommended. The current radiographs do not demonstrate any obvious compromise of glenoid bone stock that would necessitate a coracoid transfer. The humeral head is not compromised; therefore, a hemiarthroplasty is not indicated. Correct answer : A 57 76- A 51-year-old man sustains the injury shown in the MRI scan in Figures 1 and 2 following a fall. After a thorough discussion regarding risks and benefits, he elects to proceed with surgery. What is the most appropriate surgical treatment for his fracture?
Open reduction internal fixation with locking plate
Intramedullary (IM) nail
Hemiarthroplasty
Closed reduction and percutaneous pinning The patient has sustained a complex proximal humerus fracture with head split component and multiple articular fragments. When the articular surface is significantly compromised, arthroplasty procedures are favored. The only procedure listed that addresses the damaged humeral head is hemiarthroplasty, making it the correct response. Although a possible option, ORIF would be difficult due to the fragmented humeral head, and there would be a high risk for fracture collapse or avascular necrosis. IM nailing will not provide enough control of the fracture pieces, nor will it replace the damaged articular surface. Closed reduction is not an option given the complex nature of the fracture.

Correct Answer: Bristow-Latarjet

Explanation:

Question 24:

Options:

recurrent buckling with a probable meniscal tear.
limitation of motion with a delay in recovery.
a full return to activity with no limitations.
an improvement in overall performance.
an uneventful completion of the soccer season.

Correct Answer: recurrent buckling with a probable meniscal tear.

Explanation:

Question 25:

Options:

Flexor-pronator avulsion
Ulnar nerve subluxation
Medial collateral ligament injury
Lateral ulnar collateral ligament rupture
Triceps tendon subluxation

Correct Answer: Medial collateral ligament injury

Explanation:

DISCUSSION: The milking test, as seen in the photograph, elicits pain when a tear is present in the medial collateral ligament. Complete rupture is possible but unlikely when there is no history of trauma and the patient is able to throw pain-free for several innings. Subluxation of the ulnar nerve and triceps tendon subluxation present as a painful snapping over the medial aspect of the elbow.
REFERENCES: Williams RJ III, Urquhart ER, Altchek DW: Medial collateral ligament tears in the throwing athlete. Instr Course Lect 2004;53:579-586.
Cain EL Jr, Dugas JR, Wolf RS, et al: Elbow injuries in throwing athletes: A current concepts review. Am J Sports Med 2003;31:621-635.

Question 26:

What is the predominant type of collagen in the tissue resulting from the surgical procedure shown in Figures 40a through 40c?

Options:

Type I
Type II
Type III
Type IX
TypeX

Correct Answer: Type I

Explanation:

Question 27:

Options:

Open reduction and internal fixation
Impaction allografting
Proximally coated femoral stem
Allograft prosthetic composite (APC)
Proximal femoral replacement (PFR)

Correct Answer: Proximal femoral replacement (PFR)

Explanation:

DISCUSSION: This is an example of a Vancouver B3 periprosthetic fracture that consists of a fracture around a loose femoral stem with poor proximal bone support. Therefore, open reduction and internal fixation is not an option. PFR is an excellent choice for elderly inactive patients with poor femoral bone stock. The surgery can be performed in an expeditious manner, which is very important in a patient with mild coagulopathy. Impaction allografting and APC are both options for younger patients who have bone stock that needs to be restored. The results of revision arthroplasty using proximally coated stems, especially under these circumstances, are poor.
REFERENCES: Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293-304.
Parvizi J, Sim FH: Proximal femoral replacements with megaprostheses. Clin Orthop 2004;420:169-175.
Klein GR, Parvizi J, Rapuri V, et al: Proximal femoral replacement for treatment of periprosthetic fractures. J Bone Joint Surg Am 2005;87:1777-1781.

Question 28:

Which of the following is considered the treatment of choice for a chondroblastoma of the proximal tibial epiphysis without intra-articular extension?

Options:

Observation
Curettage and bone grafting
Wide local excision
Wide local excision and radiation therapy
Radiation therapy only

Correct Answer: Curettage and bone grafting

Explanation:

Question 29:

- An infected total knee replacement with symptoms occurring within 4 weeks of surgery and no radiographic signs of osteomyelitis would be best managed with

Options:

Knee fusion
Open irrigation and debridement
Arthroscopic irrigation and debridement
One-stage exchange arthroplasty
Two-stage exchange arthroplasty

Correct Answer: Open irrigation and debridement

Explanation:

Question 30:

Options:

lateral retinacular release and medial reefing.
patellar tendon transfer medially.
lateral release and patellar tendon transfer.
femoral and tibial derotation osteotomies.
continued observation.

Correct Answer: continued observation.

Explanation:

Question 31:

The quadrilateral space in the shoulder contains which of the following structures?

Options:

Axillary nerve and posterior humeral circumflex artery
Axillary artery and radial nerve
Axillary artery and axillary nerve
Recurrent suprascapular nerve and artery
Profunda brachii artery

Correct Answer: Axillary nerve and posterior humeral circumflex artery

Explanation:

Question 32:

- A 12 month old infant has congenital complete absence of the tibia. Examination reveals that the femur in the abnormal limb is 3 cm short, with a normal ipsilateral hip. The patient has an intact fibula, an equinovarus foot with four rays, and moderate popliteal skin webbing. Management should consist of

Options:

Syme’s amputation
Arthrodesis of the knee
Disarticulation of the knee
Centralization of the fibula
Prosthetic fitting to accommodate the present deformity

Correct Answer: Disarticulation of the knee

Explanation:

Question 33:

Options:

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

Correct Answer: Diminished fatigue strength

Explanation:

Question 34:

A 14-year-old girl has had progressive heel pain for the past several months. Based on the radiograph, MRI scan, and biopsy specimens shown in Figures 37a through 37d, treatment should include

Options:

observation.
wide resection.
radiation therapy.
extended curettage.
chemotherapy.

Correct Answer: extended curettage.

Explanation:

DISCUSSION: An aneurysmal bone cyst is a benign, locally destructive lesion of bone. Most are seen in patients in the second decade of life. The clinical presentation varies, but most patients have pain, tenderness, swelling, and/or pathologic fracture. Radiographs show a radiolucent lesion sometimes with expansile remodeling of the cortex. MRI best detects the commonly seen fluid-fluid levels associated with this lesion. Histologic findings include
blood-filled spaces with bland fibrous connective tissue septa. The stroma has histiocytes, fibroblasts, scattered giant cells, hemosiderin, and occasional inflammatory cells. Treatment of these lesions consists of extended curettage, plus or minus the use of adjuvants (liquid nitrogen, phenol, argon beam coagulation), and finally filling the bone void (allograft or other bone substitute).
REFERENCES: Gibbs CP Jr, Hefele MC, Peabody TD, et al: Aneurysmal bone cyst of the extremities: Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am 1999;81:1671-1678.
Ramirez AR, Stanton RP: Aneurysmal bone cyst in 29 children. J Pediatr Orthop 2002;22:533-539.

Question 35:

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

Options:

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

Correct Answer: No differences in motion and strength

Explanation:

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

Question 36:

Options:

The injury will do well with treatment in a knee immobilizer.
The injury will do well with immobilization in a long leg cast.
Long leg cast immobilization and reduction is recommended but she may develop a deformity that always requires surgical correction.
Long leg cast immobilization and reduction is recommended but she may develop a deformity; however, if the deformity develops there is a significant chance it will resolve spontaneously.
Surgery is indicated to prevent deformity that may follow with this injury.

Correct Answer: Long leg cast immobilization and reduction is recommended but she may develop a deformity; however, if the deformity develops there is a significant chance it will resolve spontaneously.

Explanation:

Question 37:

Options:

Lateralize the acetabular component, use a low offset femoral component, and make a shorter neck cut
Medialize the acetabular component, use a low offset femoral component, and make a longer neck cut
Lateralize the acetabular component, use a high offset femoral component, and make a shorter neck cut
Medialize the acetabular component, use a high offset femoral component, and make a longer neck cut

Correct Answer: Medialize the acetabular component, use a low offset femoral component, and make a longer neck cut

Explanation:

Question 38:

What is the average linear wear rate of a conventional, noncross-linked ultra-high molecular weight polyethylene liner used in total hip arthroplasty?

Options:

01 to 0.05 mm/yr
1 to 0.2 mm/yr
5 to 1 mm/yr
1 to 2 mm/yr
Greater than 2 mm/yr

Correct Answer: 1 to 0.2 mm/yr

Explanation:

Question 39:

Options:

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

Correct Answer: Bony glenoid augmentation procedure

Explanation:

Question 40:

When conducted at near physiologic strain rates, tensile studies of the inferior glenohumeral ligament (IGHL) have shown that the

Options:

anterior band of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.
anterior band of the IGHL has the greatest stiffness and the ligament midsubstance shows greater strain than the glenoid insertion site.
axillary pouch of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.
axillary pouch of the IGHL has the greatest stiffness and the ligament midsubstance shows greater strain than the glenoid insertion site.
posterior portion of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.

Correct Answer: anterior band of the IGHL has the greatest stiffness and the glenoid insertion site shows greater strain than the ligament midsubstance.

Explanation:

Question 41:

Options:

Obtain upright radiographs
Thoracolumbar orthosis
Posterior stabilization and fusion
Laminectomy

Correct Answer: Posterior stabilization and fusion

Explanation:

DISCUSSION
Spinal fractures in patients with ankylosing spondylitis are unstable and generally necessitate surgical intervention. In a patient with a spinal fracture in the setting of ankylosing spondylitis, posterior instrumented fusion is an appropriate surgical procedure. Treatment with a thoracolumbar orthosis is not an option for patients with extension distraction injuries in the setting of an ankylosed spine because of risk for displacement. Similarly, simply checking upright radiographs is generally not advocated. Laminectomy alone is inappropriate for this patient because there is no cord compression and neurologic symptoms are absent. Stabilization is the treatment goal.
RECOMMENDED READINGS
Braun J, Sieper J. Ankylosing spondylitis. Lancet. 2007 Apr 21;369(9570):1379-90. Review. PubMed PMID: 17448825.
View Abstract at PubMed
Caron T, Bransford R, Nguyen Q, Agel J, Chapman J, Bellabarba C. Spine fractures in patients with ankylosing spinal disorders. Spine (Phila Pa 1976). 2010 May 15;35(11):E458-64. doi: 10.1097/BRS.0b013e3181cc764f. PubMed PMID: 20421858.
View Abstract at PubMed
Finkelstein JA, Chapman JR, Mirza S. Occult vertebral fractures in ankylosing spondylitis. Spinal Cord. 1999 Jun;37(6):444-7. PubMed PMID: 10432265.
View Abstract at PubMed
Hitchon PW, From AM, Brenton MD, Glaser JA, Torner JC. Fractures of the thoracolumbar spine complicating ankylosing spondylitis. J Neurosurg. 2002 Sep;97(2 Suppl):218-22. PubMed PMID: 12296682.
View Abstract at
PubMed

Question 42:

The superior glenohumeral ligament primarily restrains

Options:

posterior translation of the humeral head with the arm in 90 degrees of abduction.
inferior translation of the humeral head with the arm in adduction.
anterior translation of the humeral head in 90 degrees of abduction.
anterior translation of the humeral head with the arm in 45 degrees of abduction.
anterior translation of the humeral head with the arm in 90 degrees of abduction and external rotation.

Correct Answer: inferior translation of the humeral head with the arm in adduction.

Explanation:

Question 43:

Options:

Alendronate
Indomethacin
Radiotherapy
Excision

Correct Answer: Alendronate

Explanation:

Question 44:

Which of the following regions in the growth plate is commonly affected in a Salter-Harris type II injury? Review Topic

Options:

Reserve zone
Proliferative zone
Hypertrophic zone
Primary spongiosa
Epiphyseal zone

Correct Answer: Hypertrophic zone

Explanation:

Question 45:

Pulsatile bleeding is encountered after placing a retractor anterior to the acetabulum while exposing for reaming during total hip arthroplasty (THA). What vascular structure is likely affected?

Options:

Ascending branches of the lateral femoral circumflex artery
Obturator artery
Superior gluteal artery
External iliac artery Intraoperative vascular injuries during THA can be a catastrophic complication, and knowledge of the practical vascular anatomy is critical to complication avoidance. The external iliac artery travels along the medial border of the psoas muscle and is at risk when placing screws in the anterosuperior quadrant, and further distal when placing retractors over the anterior column, before branching into the femoral vessels at the inguinal ligament. The superior gluteal artery is at risk when placing screws in the sciatic notch, and also during the direct lateral approach as it runs between the gluteus medius and minimus about 5 cm superior to the greater trochanter. The obturator artery is located along the quadrilateral surface of the acetabulum and can be injured when placing an inferior retractor under the transverse acetabular ligament. The ascending branches of the lateral femoral circumflex artery are routinely isolated and cauterized during the anterior approach as they run in the interval between the tensor fascia lata and sartorius.

Correct Answer: External iliac artery Intraoperative vascular injuries during THA can be a catastrophic complication, and knowledge of the practical vascular anatomy is critical to complication avoidance. The external iliac artery travels along the medial border of the psoas muscle and is at risk when placing screws in the anterosuperior quadrant, and further distal when placing retractors over the anterior column, before branching into the femoral vessels at the inguinal ligament. The superior gluteal artery is at risk when placing screws in the sciatic notch, and also during the direct lateral approach as it runs between the gluteus medius and minimus about 5 cm superior to the greater trochanter. The obturator artery is located along the quadrilateral surface of the acetabulum and can be injured when placing an inferior retractor under the transverse acetabular ligament. The ascending branches of the lateral femoral circumflex artery are routinely isolated and cauterized during the anterior approach as they run in the interval between the tensor fascia lata and sartorius.

Explanation:

Question 46:

Options:

Posterior horn of the medial meniscus
Semimembranosus tendon
Medial tibial plateau
Medial head of the gastrocnemius tendon
Medial plica

Correct Answer: Posterior horn of the medial meniscus

Explanation:

Question 47:

What percent of adult patients with rheumatoid arthritis test positive for rheumatoid factor?

Options:

Less than 20%
20% to 40%
50%
80% to 90%
More than 95%

Correct Answer: 80% to 90%

Explanation:

Question 48:

Options:

iliac crest bone grafting
ring metacarpal transposition
second toe transfer
index metacarpal transposition
suture of deep transverse intermetacarpal ligaments

Correct Answer: iliac crest bone grafting

Explanation:

Index metacarpal transposition is indicated to reduce the space left between the index and ring finger. In this case, the middle ray is amputated because of malignancy.
With amputation of the middle or ring metacarpals, small objects fall through the gap and the adjacent fingers scissor. For single central ray defects, techniques to reduce the gap include transposition of the index finger (for middle ray amputation), small finger (for ring ray amputation), complete removal of the metacarpal (without leaving a proximal metacarpal base stump) to allow the bases of index and ring metacarpals to migrate together and reconstruction of the deep transverse metacarpal ligament. The technique of index transposition may vary depending on the osteotomy (straight vs step-cut) and fixation (K wires vs plate) as seen in the illustrations below.
Muramatsu et al. describe bony transposition for reconstruction after ray amputation for malignancy. The advantage is immediate closure of the space. The disadvantages include prolonged postoperative immobilization until union, malrotation (leading to scissoring), mal-tension of tendon (because of different metacarpal heights), and delayed or nonunion.
Lyall et al. advocate total middle ray amputation. They believe that leaving the metacarpal base behind leads to difficulty in aligning the adjacent rays as the index and ring must angulate over the bony obstruction to close the distal gap, leading to scissoring. They believe that index transposition leaves an abnormally wide 1st web space and a remnant 2nd metacarpal stump that can protrude dorsally.
Figure A is an AP radiograph of the right hand showing a destructive lesion of the proximal phalanx of the middle finger abutting the metacarpophalageal joint. Figure B is a STIR coronal MRI image showing the tumor mass extending into surround soft tissue. Illustration A is a diagram showing index transposition for middle ray amputation using a straight osteotomy and crossed K-wires. Illustration B is a diagram showing index transposition using a step-cut osteotomy and multiple K-wire fixation to the adjacent metacarpals. Illustration C is a diagram showing index transposition using a straight osteotomy and plate fixation. Illustration D is a diagram showing an alternative technique of suturing deep transverse metacarpal ligaments together to close the gap.
Incorrect Answers
A 65-year-old man fell and injured his right wrist. Radiographs taken in the emergency room are seen in Figure A. He was treated as a sprain and no further follow-up was planned. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. Recent radiographs are seen in Figure B. Surgical treatment that will best address his symptoms and preserve wrist motion consists of
Anterior and posterior interosseous neurectomy
Scaphotrapezialtrapezoidal (STT) fusion
Complete wrist arthrodesis
Proximal row carpectomy
Four-corner fusion with scaphoidectomy
Four-corner fusion with scaphoidectomy is indicated for Stage III SLAC wrist.
Surgical treatment of SLAC wrist is stage dependent. Stage I disease (scaphoid-radial styloid arthritis) is treated with AIN/PIN neurectomy. This procedure can also be done in addition to other bony procedures for Stages II-III disease. Stage II (scaphoid-entire scaphoid facet) is treated with PRC or scaphoid excision with 4-corner fusion (4CF). Stage III (capitolunate arthritis with proximal migration of the capitate into the scapholunate interval) is treated with either scaphoidectomy with 4CF or total wrist fusion.
Some other conditions exist: If capitolunate arthritis exists, PRC is contraindicated and 4CF is performed. If radiolunate arthritis exists, both PRC and 4CF are contraindicated and total wrist fusion is performed. If both radiolunate and capitolunate surfaces are preserved, then either PRC or a 4CF may be performed.
Cohen et al. compare PRC with 4-corner fusion plus scaphoid excision. PRC is technically easier, but leads to shortening of the carpus with weakness and incongruity exists between the capitate and lunate fossa of the distal radius. Scaphoid excision and four-corner fusion maintains carpal height and preserves the radiolunate relationship, but is more technically demanding, there is risk of nonunion, and it requires longer postop immobilization. Pain relief is more reliable following 4-corner fusion.
Figure A shows scapholunate ligament disruption. Figure B shows late stage SLAC wrist. There is capitolunate arthritis but no radiolunate arthritis.
Illustration A shows an example of PRC. Illustration B shows an example of 4CF and scaphoidectomy.
Incorrect Answers
Which of the following statements is true regarding zone II flexor tendon injuries?
At this level, FDS and FDP are located within separate tendon sheaths
FDS repair has not been shown to improve outcomes
Improved gliding is seen with repair of 1 slip of FDS compared to repairing both slips
Repairing FDS does not affect post-operative digit strength
FDP repair has not been shown to improve outcomes
In zone II flexor tendon injuries, repairing only one slip of FDS has been shown to improve gliding when compared to repair of both slips.
Zone II flexor tendon injuries have notoriously had poor outcomes secondary to high rates of adhesion formation at the pulleys. However, new advances in post-operative rehabilitation have significantly improved outcomes to the point where it is no longer considered "no man's land." Management of the FDS has been a source of controversy. In the past, the FDS was occasionally excised to theoretically make more room for the FDP. This has now been largely abandoned and the FDS is repaired whenever possible. Whether or not to repair both slips of FDS remains controversial, with in vitro data suggesting that gliding resistance is improved if only one slip is repaired.
Zhao et al. review the effect of partial vs. complete FDS excision following repair of FDP for zone II flexor tendon injuries. Preserving the whole FDS resulted in a significantly larger increase in gliding resistance after FDP repair than did full or partial FDS removal, which were not significantly different from each other.
Illustration A shows the zones of flexor tendon injury. Note that zone II injuries occur between the FDS insertion and the distal palmar crease. Illustration B shows the anatomy of the flexor tendons in detail. Video V shows a technique for repair of zone II injuries.
Incorrect Answers:
A 6-year-old girl sustains transverse amputations through her long and ring fingertips after getting her hand caught in a lawn mower. She presents to the emergency room 30 minutes after the injury with the amputated tissue which was placed on ice in a waterproof bag. On physical exam the amputation levels are found to be 6 millimeters distal to the lunula. The wounds are noted to be fairly
contaminated with no evidence of exposed bone. Skin defects are less than 1 centimeter. Which of the following is the most appropriate management at this time?
Emergent replantation of the amputated parts
Revision amputation through the distal interphalangeal joint
Thorough irrigation and debridement followed by elective Moberg advancement flaps
Thorough irrigation and debridement followed by elective Z-plasty reconstruction
Thorough irrigation and debridement, soft dressing application, and followup within 1 week
Distal fingertip amputations can be successfully managed with local wound care and healing by secondary intention if no bone is exposed and the soft tissue defects are minimal. This is especially true in the pediatric population.
Distal fingertip amputations are common injuries seen in the emergency department. If bone is not exposed, the wounds can be successfully treated with local wound care and dressing changes, followed by soaks in a hydrogen-peroxide solution after 7-10 days. Some controversy exists in the pediatric population if the soft tissue loss is > 1 cm, with options for management including a V-Y advancement flap or conservative management with dressing changes.
Quell et al. review the results of 82 patients with fingertip amputations treated conservatively; 31 of the digits were treated with primary closure with or without shortening of bone and 54 digits were treated with semiocclusive dressings. No complications were observed, and all healed fingertips were well padded and painless.
Tupper et al. review sixteen patients with twenty fingertip injuries who underwent V-Y plasty for transverse fingertip amputations. Sensitivity was 73% of normal, with eight patients reporting hypersensitivity. Contrary to popular belief, they believe normal sensation following a V-Y plasty is not a reasonable expectation.
Illustration A shows the three levels of fingertip amputations. Zone I is distal to the phalanx; Zone II is distal to the lunula; and Zone III is proximal to the lunula.
Incorrect Answers:
Which of following malformations is most commonly associated with Poland's syndrome?
Figure E
CORRECT ANSWER: 4
Figure D demonstrates symbrachydactyly which is most commonly associated with Poland's syndrome.
Poland's syndrome is a rare birth defect characterized by underdevelopment or absence of the chest muscle in conjunction with ipsilateral symbrachydactyly. Poland syndrome most often affects the right side of the body, and occurs more often in males than in females.
Ireland et al. reviewed 43 consecutive cases of Poland's syndrome, and reviewed the relevant literature up to that point. The authors state that the clinical features are variable but always include congenital aplasia and syndactyly, and the right side is affected more than the left. They also note that although the hand remains hypoplastic and functional capacity is limited by the inherent skeletal anomalies, surgical treatment improves functional capacity and cosmetic appearance in the majority of patients.
Van Heest summarizes normal formation and growth of the upper limb as a basis for understanding malformation, with the goal of providing a basic understanding of the evaluation necessary for appropriate counseling and referrals for treatment of the child with hand and upper extremity congenital deformities.
Incorrect Answers:
A 55-year-old male laborer comes in with a chief complaint of clumsiness with his right hand for the past 3 months including difficulty using a hammer while at work. He has had no injury to the right upper extremity. On physical examination, he has persistent small finger abduction/extension with finger extension and active adduction. An EMG is performed and demonstrates ulnar nerve conduction velocities of 31 m/sec (normal >52m/sec). The patient symptoms are most accurately described as:
Axonotmesis with ischemia origin
Axonotmesis with myelin disruption
Neurapraxia with ischemia origin
Neurapraxia with endoneurium disruption
Neurotmesis
CORRECT ANSWER: 3
The history and clinical presentation are consistent with ulnar entrapment neuropathy at the level of the cubital tunnel. This would be classified as a neuropraxia with ischemia origin.
Compression injuries to the peripheral nerves are often the result of microvascular dysfunction as the nerves traverse a high to low pressure gradient. Peripheral nerve injury can be classified as neuropraxia, axonotmesis, and neurotmesis. Compressive neuropathies are typically neuropraxias, with local myelin damage but not compromise of the major components of the nerve. In axonotmesis, there is Wallerian degeneration and myelin loss distal to the site of injury. The most severe type is that of neurotmesis. Neurotmesis is composed of a spectrum of injury in which the endoneurium is always disrupted (perineurium or epineurium may be intact). The worst form of neurotmesis is that of nerve transection.
Elhassan et al. review the pathophysiology of cubital tunnel syndrome. They report nerve dysfunction results from ischemic changes secondary to compression. Compressive effects on the nerves can last greater than 24 hours, even after the source of compression has been removed.
Rempel et al. review the pathophysiology of peripheral nerve compression syndromes. The authors indicate that deforming pressures to nerves are often the result of stenotic soft tissue canal boundaries. This leads to interference with local microvasculature of the nerve itself.
Illustration A demonstrates the Wartenberg sign, where the patient has persistent small finger abduction/extension resulting from weakness of the 3rd palmar interosseous/small finger lumbrical.
Illustration B reveals clawing which results from overpowering of the intrinsic muscles by the extrinsic muscles; a tenodesis effect results in flexion of the PIP/DIP joints. This is more severe in ulnar nerve compression at Guyon’s canal. Illustration C shows the Froment sign, where the FPL attempts to compensate for a deficient pinch, because of weakness of the adductor pollicis. Illustration D demonstrates atrophy of the 1st dorsal webspace from chronic compressive changes. Illustration E demonstrates atrophy of the thenar compartment which is consistent with carpal tunnel syndrome.
Incorrect Answers:
Which of the following hand injuries seen in Figures A-E is most appropriately treated with a first dorsal metacarpal artery flap?
Figure E
CORRECT ANSWER: 3
Figure C shows a dorsal thumb laceration with exposed tendon that would be most appropriately treated with a first dorsal metacarpal artery (FDMA) flap.
The first dorsal metacarpal artery is a branch of the radial artery that supplies the dorsal hand skin from the thumb metacarpal to the long metacarpal, as well as the skin on the dorsal surfaces of the thumb and index to the proximal interphalangeal joint. The flap is raised distal to proximal as an island flap containing the FDMA, branches of the radial nerve, fascia of the underlying interosseous muscle of the first web space, and skin overlying the MP joint and proximal phalanx of the finger. It is an excellent option for large soft tissue defects on either side of the thumb. In this case, skin grafting is contraindicated because of exposed tendon without paratenon.
Sherif et al. detail the anatomy of the first dorsal metacarpal artery. They found three consistent branches, including the radial, ulnar, and intermediate branch. In part II of their study, they review the results of 23 patients where the FDMA flap was used as a fasciocutaneous or fascial flap for the coverage of soft tissue hand defects.
Illustration A shows a FDMA flap being raised for coverage of a thumb defect. Incorrect Answers:
bone can be allowed to heal through secondary intention.
Figure A is a radiograph of a 35-year-old women who sustained an isolated left wrist injury after a fall onto an outstretched hand. She has been complaining of left dorsal wrist pain since the fall. Examination reveals a positive Watson's scaphoid shift test. What ligamentous structure is an important secondary stabilizer to prevent dorsal intercalated segment instability (DISI) deformity in this patient?
Transverse carpal ligament
Dorsal intercarpal ligaments
Triangular fibrocartilage complex
Dorsal lunotriquetral ligament
Volar lunotriquetral ligament
The integrity of the dorsal intercarpal ligaments is important in preventing dorsal intercalated segment instability (DISI) deformity and persistent scapholunate instability.
Scapholunate instability is the most common carpal instability. The primary stabilizing structure of the scaphoid and lunate bones is the scapholunate ligament, which is commonly injured with a fall on an outstretched hand.
Secondary stabilizers of the scaphoid and lunate include the dorsal intercarpal ligaments and the dorsal radiocarpal ligaments. Failure to recognize injury of these structures can cause persistent dorsal intercalated segment instability (DISI). This can predispose patients to a SLAC wrist and early wrist osteoarthritis.
Mitsuyasu et al. examined the role of dorsal intercarpal ligaments (DIC) in scapholunate instability. They showed that the DIC had an important role in stabilizing the scaphoid and lunate bones with static and dynamic movements. The authors of this study suggest that the DIC ligament should be assessed intraoperatively and consideration should be given to repair and/or reconstruction with surgical management of scapholunate ligament tears.
Viegas et al. showed that the dorsal intercarpal and the dorsal radiocarpal ligaments form a lateral V configuration over the dorsal wrist. This configuration acts as an indirect dorsal stabilizing effect on the scaphoid
throughout the range of motion of the wrist. Their integrity acts to ensure normal wrist kinematics.
Figure A shows an AP and lateral radiograph of the left hand. There is significant gapping between the scaphoid and lunate articulation. This is indicative of a complete scapholunate dissociation, however both wrists should be imaged as this deformity may exist without injury. Illustration A shows the anatomy of the dorsal intercarpal and the dorsal radiocarpal ligaments.
Incorrect Answers:
A 50-year-old patient presents with stiffness in her hand. A clinical photo is shown in Figure A. During surgical exposure, the neurovascular bundle is identified and dissected. What is the clinically most important pathologic structure to identify and what is its location relative to the neurovascular bundle in the digit?
Spiral cord which is central and superficial to the neurovascular bundle
Central cord which is midline and superficial to the neurovascular bundle
Retrovascular cord which is central and superficial to the neurovascular bundle
Spiral cord which is lateral and deep to the neurovascular bundle
Central cord which is lateral and deep to the neurovascular bundle
Based on clinical findings, the patient has evidence of Dupuytren’s contracture affecting her ring finger. Relative to the neurovascular bundle, the spiral cord will lie lateral and deep.
Dupuytren’s disease is a benign hand condition characterized by pathologic nodules and cords of existing fascial bands. The most clinically relevant structure in Dupuytren's disease, is the spiral cord. The spiral cord is the result of pathology of 4 structures: the middle layer of the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. The spiral cord is found predominantly at the palmodigital transition. The spiral cord displaces the neurovascular bundle centrally and superficially.
Benson et al. review the etiology, pathophysiology and treatment options for Dupuytren’s contracture. They highlight that while the pretendinous band is located volar and central to the neurovascular bundle in the palm, the spiral band and lateral digital sheath cause the neurovascular bundle to be displaced superficially and volarly as they become pathologically affected.
Black et al. review the pathoanatomy, diagnosis and management of Dupuytren's disease. They note that the spiral cord lies superficial to the neurovascular bundle proximal to the MCP joint. Distal to the MCP joint it passes deep to the bundle. At that location, the spiral cord lies lateral to the
neurovascular bundle as the lateral digital sheet becomes involved
Figure A demonstrates the cord formation that is characteristic of the pathologic Dupuytren’s condition. It is the central cord that causes contracture of the MCP, whereas the retrovascular and spiral cords cause contractures of the DIP and PIP respectively. Illustration A shows the relationship of spiral cord formation in Dupuytren's disease relative to the normal anatomy of the palmar fascia. The structures implicated in the formation of the spiral cord are the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. Cleland's ligament, more dorsally located, is spared in Dupuytren's disease. The neurovascular bundle is displaced superficially and towards the midline, as the pathological cord spirals around. Illustration B shows the presence of other affected structures, including the natatory ligament and the central band. The central band is an extension of the pretendinous cord and attaches to the base of the middle phalanx. It may insert onto the tendon sheath of the flexor tendon at this level. Formation of natatory cords cause webspace contractures. Formation of central cords lead to flexion contractures of the PIP. Illustration V is a video that provides an educational overview of Dupuytren's.
Incorrect Answers:
An infant is brought to your office for evaluation of his hands. Clinical photos are shown in Figures A and B. The clinical features are most consistent with a genetic mutation in which of the following:
Sonic Hedgehog (SHH)
FGFR2
FGFR3
PMP22
COL1A1
CORRECT ANSWER: 2
Based on the clinical features seen in the figures provided, the most likely syndrome is that of Apert syndrome, which is consistent with a mutation in FGFR2.
Apert syndrome is an autosomal dominant condition that gives rise to facial dysmorphism and complex syndactyly of the hands. The craniosynostosis that develops causes flattening of the skull and facial features.
Goldberg et al review congenital hand conditions and the malformations associated with them. They indicate that not only does identification allow for natural history to be better elucidated, but also timing of surgical intervention can be better gauged.
Figures A and B demonstrate clinical features consistent with Apert Syndrome. The “rosebud” hand is a complex syndactyly that affects the index, middle and ring fingers most commonly. Hypertelorism is exemplified with increased distance between the eyes; additionally, acrocephaly is noted with forehead broadening and skull flattening.
Incorrect Answers
1: Mutation in sonic hedgehog gene (SHH) is associated with a longitudinal deficiency of the radius. This is seen in conditions like TAR, Holt-Oram and VACTERL syndromes.
3: Mutation in FGFR3 leads to achondroplasia
4: Mutation in PMP22 gives rise to Charcot Marie Tooth syndrome 5: Mutation in COL1A leads to osteogenesis imperfecta
A 45-year-old patient presents with recurrence of radial sided wrist pain after undergoing a first dorsal compartment release about 3 months ago. The surgery was completed by one of your partners; operative reports indicate that the sheath was incised on the dorsal edge. On physical exam she is found to have normal appearing skin, a negative Tinel’s sign, and a positive Finklestein test. What is the most likely cause of the recurrence of her symptoms?
Development of neuroma
Complex regional pain syndrome
Failure to decompress the EPB sub-sheath
Failure to decompress the EPL sub-sheath
Failure to decompress the APB sub-sheath
Based on the history and clinical findings this patient has de Quervain’s tenosynovitis. The recurrence of her symptoms can be attributed to a failure to recognize and decompress the EPB sub-sheath.
De Quervain’s tenosynovitis is a stenosing inflammatory condition of the first dorsal compartment of the wrist (APL/EPB). Surgical release of the compartment is indicated after conservative measures have failed. At the time of the operation, the incision is made on the dorsal side of the sheath to prevent volar subluxation of the tendons. Failure to identify and release a distinct EPB sub-sheath or a separate fibro-osseous compartment of the APL can lead to a recurrence of symptoms.
Alegado et al. report a case of a patient with dysesthesias in the superficial radial nerve distribution 3 months after undergoing first dorsal compartment release for de Quervain’s tenosynovitis. They found a persistent fibrous remnant of the dorsal aspect of the sheath causing elevation of the superficial radial nerve. They recommend sheath excision or incision of the sheath at its dorsal attachment to avoid this complication.
Ashurst et al. report a case of a patient presenting with bilateral de Quervain’s tenosynovitis secondary to excessive text messaging. Conservative measures
afforded the patient complete symptomatic recovery. They recommend limitation of texting, in conjunction with other standard treatments, to treat text messaging- associated de Quervain’s tenosynovitis
Ilyas et al. review the etiology, diagnosis and management of De Quervain’s tenosynovitis. Non-surgical management is largely successful and includes splinting and cortisone injections. In refractory cases, surgical release of the first dorsal compartment is completed. They recommend meticulous care of the radial sensory nerve and identification of all separate sub-sheaths.
Illustration A shows an operative photo in a patient with multiple APL slips and an EPB that is hidden within a sub-sheath. Video V gives a brief overview of de Quervain’s tenosynovitis.
Incorrect Answers
A 28-year-old NFL running back complains of continued hand pain three days following an injury sustained while being tackled. He was splinted on the field. He has tenderness over the long finger metacarpal head, with subluxation of the extensor tendon into the intermetacarpal area during active metacarpophalangeal joint flexion. A representative MRI is shown in Figure A. What is the next best step in management of this patient?
Observation alone
Continued splinting in flexion
Continued splinting in extension
Open repair of the disrupted junctura tendinae
Open repair of the disrupted sagittal band
Based on the history and physical exam findings this patient has sustained a traumatic rupture of the sagittal band. In this professional athlete, the next best step would be to perform an open repair of the sagittal band. This will allow for earlier aggressive rehabilitation and a quicker return to sport.
Sagittal band ruptures may be traumatic (as in this case) or attritional in nature (as in rheumatoid arthritis). A direct blow to the MCP leads to forced flexion of the digit and subsequent stretching/rupture of the affected structure. On physical exam the tendons are most unstable with the wrist flexed; MCP flexion will lead to dislocation of the tendon into the intermetacarpal gutter.
Acute injuries may be treated with extension bracing for 4-6 weeks, but in professional athletes, direct open repair of the sagittal band is indicated.
Catalano et al. review sagittal band injuries treated with a thermally molded
plastic splint that held the MCP in ~25-35 degrees of hyperextension. Patients were evaluated over 14 months; out of 11 sagittal band injuries, splinting was successful in eight of them. They recommend initial nonsurgical management with custom splinting.
Hame et al. review the results of the management of sagittal band injuries in the professional athlete. The lesion commonly found was the disruption of the extensor mechanism with predictable sagittal band tears. In their series, all patients regained full range of motion and returned to their respective sports. They recommend surgical intervention in elite athletes in the form of extensor tendon centralization and sagittal band repair.
Figure A shows a T1 weighted axial cut of the affected hand; subluxation of the tendon (arrow) can be identified with disruption of the sagittal band (arrowhead).
The video provided briefly reviews injury to the sagittal band. Incorrect Answers
Compressive injury to the posterior interosseous nerve will lead to EMG fibrillations in which of the following muscles?
Extensor Carpi Radialis Longus/Extensor Carpi Radialis Brevis/Brachoradialis
Extensor Carpi Radialis Longus/Supinator/Abductor Pollicis Longus
Extensor Pollicis Longus/Supinator/Abductor Pollicis Longus
Brachoradialis/Supinator/Extensor Pollicis Longus
Extensor Pollicis Longus/Supinator/Abductor Pollicis Brevis
Based on the choices above, fibrillations will be seen in the extensor pollicis longus, supinator and abductor pollicis longus muscles.
The radial nerve splits into the superficial radial branch and the posterior interosseous nerve (PIN) at the anterior aspect of the radiocapitellar joint, just proximal to the supinator muscle. The PIN innervates the EDC, EDM, ECU,
EPB, EPL, EIP, APL and sometimes the ECRB. Compressive neuropathy of the PIN leads to motor dysfunction, namely weakness with wrist and finger extension.
Lubhan et al. review uncommon compression neuropathies affecting the upper extremity. They indicate that PIN syndrome may be caused by rheumatoid arthritis and compressive ganglion cysts. Depending on which nerve branch is affected, partial lesions may develop. They recommend use of conservative measures (rest, activity modification and splinting) first. Decompressive procedures may be indicated in symptoms lasting greater than 3 months.
Illustration A shows the course of posterior interosseous nerve from proximal to distal along the course of the supinator. This proximal edge of the supinator (Arcade of Froshe), the fibrous edge of the ECRB and the leash of Henry are three main points of compression of the PIN.
Incorrect Answers
Figure A shows a traumatic laceration of the distal forearm with a 5cm segmental median nerve defect. Which of the following repair or reconstruction techniques would allow for the best recovery of motor function?
Autogenous venous nerve conduit
Collegen synthetic nerve conduit
Biodegradable polyglycolic acid
Processed nerve allograft
Nerve autograft
CORRECT ANSWER: 5
Figure A shows a traumatic laceration with 5cm of median nerve defect. The use of nerve autograft for this size defect has been shown to have the best recovery of motor function.
The optimal surgical treatment of nerve laceration is direct tension-free repair. In segmental nerve defects this approach cannot be achieved. The use of interposed autologous nerve grafting remains the gold standard of repair in this setting. The use of alternative techniques, such as processed allografts and synthetic conduits, have not shown to have equivalent recovery of motor function as compared to nerve autograft.
Giusti et al. used a rat model to examine techniques of peripheral nerve repair. They showed that nerve autograft resulted in better motor recovery than did the use of processed allograft or a collagen conduit.
Deal et al. discussed tubular interposition substitutes, or nerve conduits, as an alternative to nerve autograft in segmental nerve defect. Nerve conduits can include autogenous nerve conduits (venous or arterial) and synthetic nerve conduits (collagen, PGA, or caprolactone). In general, there is an upper limit of 3-cm when using nerve conduit.
Figure A is an image of the volar forearm. There is a traumatic laceration to
the anterior compartment tendons as well as the median nerve.
Incorrect Answers:
A 45-year-old man presents with a three-month history of unilateral symptoms in his right wrist and hand. He first noticed a palpable nodule over the volar aspect of his wrist about three months ago. The nodule would become painful after weekends of heavy drinking at which time he noticed tingling sensation in his index and middle fingers. He notes that ibuprofen has helped improve the pain in the past. On clinical examination, he has a palpable, nontender, solid nodule over the volar aspect of his wrist. He has no motor or sensory deficits and negative carpal tunnel provocative tests. An axial CT and MRI image are provided in figures A and B. What would be the most appropriate next step in the management of his symptoms?
Fine needle aspiration
Chemotherapy
Night splints
Establish a tissue diagnosis and referral to a rheumatologist
Surgical excision
CORRECT ANSWER: 4
The clinical presentation is consistent with carpal tunnel syndrome caused by an atypical space occupying lesion - in his case, gout. The most appropriate next step in the management of his symptoms would be establishing a tissue diagnosis and referral to a rheumatologist where medical therapy, such as prophylaxis with colchicine, could be initiated.
Carpal tunnel syndrome is the most common compressive neuropathy, affecting up to 10% of the general population. Risk factors include female sex,
advanced age, obesity, and repetitive motion activities. Typically, patients will develop symptoms of median nerve compression including thenar muscle atrophy, numbness in the radial 3.5 digits, night pain, and positive Tinel's and Phalen tests. First line management is non-operative, including NSAIDs, night splints, and activitiy modification. Carpal tunnel release surgery is indicated for those who have failed conservative management.
Chen et al. described 23 unusual cases of CTS in which space-occupying lesions were responsible for the symptoms and signs of median nerve compression. In patients with an atypical presentation, such as male gender, non-middle-aged, or unilateral involvement, space-occupying lesions such as gout, synovial sarcoma, lipoma, and ganglions should be investigated as a cause.
Fitzgerald et al. discussed gout affecting the hand and wrist. The medical treatment of gout includes NSAIDs such as indomethacin or ibuprofen for acute flares, and colchicine and allopurinol for chronic prophylaxis.
Figures A and B represent axial CT and MRI images showing calcification and gouty tophi deposition in the carpal tunnel floor.
Incorrect Answers:
Which statement most accurately describes the physiology of peripheral nerve regeneration following an axonotmesic lesion?
The proximal nerve segment undergoes Wallerian degeneration
Axon growth occurs from the distal segment to proximal segment
Neurotrophic factors direct phagocytic activity
Proximal axon budding allows for antegrade (or distal) axon migration
Axoplasm and myelin are degraded distally predominantly by Schwann cells for the first 12 months following injury
Axonomesis is a disruption of the nerve axon following injury. Repair/regeneration of the nerve occurs via proximal budding, followed by antegrade (or distal) axon migration.
The peripheral nerve regeneration process begins with the distal segment undergoing Wallerian degeneration (axoplasm and myelin are degraded distally by phagocytes). Existing Schwann cells proliferate and line-up along the basement membrane. Proximal budding occurs after a one-month delay. This is followed by sprouting axons that migrate in an antegrade fashion to connect to the distal tube. Repair of the nerve can take months, and often have poor outcomes.
Lee et al. reviewed peripheral never injury and repair. They commented that Wallerian degeneration (i.e., breakdown of the axon distal to the site of injury) is initiated 48 to 96 hours after transection. The Schwann cells then align themselves longitudinally, creating columns of cells called Büngner bands. At the tip of the regenerating axon is the growth cone.
Illustration A shows a chart of peripheral nerve injury. The two main classification systems are Seddon and Sunderland. Video V is a lecture discussing peripheral nerve injury and management.
Incorrect Answers:
A 28-year-old male injures his hand while playing basketball and presents to the emergency room. Closed reduction is performed and is stable. Post-reduction rehabilitation is discussed with the patient.
Which of the following radiographs demonstrates an injury that would be treated best by dorsal extension block splinting?
Figure E
CORRECT ANSWER: 2
Dorsal extension-block splinting is the treatment of choice for dorsal proximal interphalangeal joint (PIPJ) fracture dislocations that are stable following reduction and have less than 40% articular surface fracture involvement.
Dorsal PIPJ dislocations are a common injury, often resulting from jamming or hyperextending the finger. In the absence of an associated fracture or presence of a small volar plate avulsion, dorsal PIPJ dislocations are often
treated with closed reduction and buddy-taping to the adjacent digit. Injuries that are unstable following reduction or those associated with an intra-articular fracture of the middle phalanx are stabilized with a dorsal extension-block splint to maintain reduction. It is important to initiate early range of motion exercises within the constraints of the splint to minimize scar formation and subsequent PIPJ contracture.
Elfar et al. reviewed fracture-dislocations of the PIPJ. Dorsal PIPJ fracture-dislocations can be categorized as avulsion or impaction shear injuries.
Avulsion fractures result from hyperextension of the PIPJ, tensioning the volar plate (VP) with eventual VP rupture or avulsion of the volar lip of the middle phalanx. Axial load applied to the digit in PIPJ flexion drives the head of the proximal phalanx across the middle phalangeal base, resulting in a shear fracture or comminuted impaction fracture of the middle phalanx, depending on the amount of energy imparted and the bone quality.
Morgan et al. reviewed hand injuries in athletes. Dorsal PIPJ dislocations without associated fracture that are stable following successful reduction are treated by buddy taping the injured digit to the non-injured digit adjacent to the compromised collateral ligament. Buddy taping with active motion should be continued for 6 weeks. Unstable injuries and those with an intra-articular fracture of the middle phalanx should be treated with dorsal extension-block splinting with incremental extension of the splint on a weekly basis for 4 weeks, followed by buddy-taping for 3 months during sports activities.
Figure A shows a simple dorsal PIPJ dislocation. Figure B shows a dorsal PIPJ fracture dislocation. Figure C shows a simple volar PIPJ dislocation. Figure D shows a volar PIPJ fracture dislocation. Figure E shows a dorsal avulsion fracture at the base of the distal phalanx (bony mallet injury). Illustration A depicts an dorsal extension-block splint that blocks extension of the digit past a set point while allowing full active flexion of the digit. Illustration B is a lateral radiograph of a digit showing a small minimally displaced volar plate avulsion fracture at the PIPJ with minimal intra-articular involvement (as compared to Figure B). This injury may be managed with buddy taping and active range of motion as tolerated.
Incorrect Responses:
extension for 6-8 weeks to limit flexion of the digit and therefore fracture displacement.
A 35-year-old mixed martial arts fighter and recreational cocaine user presents with symptoms concerning for hypothenar hammer syndrome (HHS). Significant ischemia is found on physical exam. Arteriography is shown in Figure A. What is the most appropriate next step in treatment?
Conservative treatment with cocaine abstinence
Conservative treatment with activity modifications and medical management with calcium channel blockers
Therapeutic endovascular fibrinolysis
Excision of involved segment and reconstruction with or without a vein graft
Medical management with coumadin for 6 months
Figure A shows a bilobed aneurysm overlying the ulnar artery with normal appearing distal vasculature. Hypothenar hammer syndrome (HHS) can be associated with an aneurysm and is most appropriately treated with resection of the involved segment and either reconstruction with a primary anastomosis or vein graft.
HHS syndrome consists of two separate entities, thrombosis and aneurysm. In the setting of thrombosis without aneurysm, conservative management is preferred. If the thrombosis is acute (<2 weeks), endovascular fibrinolysis has shown good results. In patients with an HHS and an aneurysm, surgery is required for resection to prevent distal embolization and remove the often painful aneurysmal mass.
Yuen et al. review HHS. In patients with HHS and aneurysms, resection of the involved segment of the ulnar artery prevents distal embolic events, eliminates the painful mass, relieves ulnar nerve compression, and removes the thrombus which initiated the reflex vasospasm and closed off the collateral
vessels in the region.
Lifchez et al. review the long-term outcomes of 11 patients with HHS treated with ulnar artery reconstruction. 2 of the patients underwent excision and direct ulnar artery repair, and the rest underwent reconstruction with a vein graft. All patients had a mean improvement in digital brachial index, decrease in pain and dysesthesia symptoms, and decrease in cold intolerance compared with preoperatively.
Nitecki et al. review a case series of 6 patients with HHS. They state that the treatment of thrombosis should be largely conservative, but thrombolytic treatment could be considered if the event happened <2 weeks prior to presentation.
Illustration A shows an excised ulnar artery aneurysm in a patient with HHS. Note the typical "corkscrew" appearance of the distal segment.
Incorrect Answers:
A 36-year-male was using a high-pressure paint gun when he suffered the injury shown in Figure A. Which of the following variables would have the worst impact on his prognosis?
Delay in surgical treatment
Injected solvent was grease
Injected solvent was water-based paint
An entry wound of greater than 3 cm
Injected solvent was at room temperature
The clinical presentation is consistent for a high-pressure injection injury. Delays in surgical treatment are associated with serious sequelae.
High-pressure injection injuries are characterized by extensive soft tissue damage associated with a benign high-pressure entry wound. They should be treated with irrigation & debridement, foreign body removal and broad-spectrum antibiotics. There is a higher rates of amputation when surgery is delayed.
Bekler et al. looked at the results of 14 surgically treated high-pressure injection injuries of the hand with a minimum of two years follow-up. Ten of the injuries required formal operative debridement and foreign body removal. Six required reconstructive microsurgical procedures and one underwent digital tip amputation. They concluded that high-pressure injection injury to the hand is a significant problem, which can easily lead to serious sequelae and, even, amputation.
Rosenwaser et al. report wide débridement of all involved tissues, decompression of tissue compartments, exploration and incision of tendon sheaths, removal of injected material, and saline irrigation are critical in the management of high-pressure injection injuries to the hand. They emphasize
delayed surgery has been associated with increased incidence of morbidity and amputation.
Figure A shows a typical high-pressure injection injury. Notice the benign looking entry wound.
Incorrect Answers:
A healthy 50-year-old secretary is about to undergo an open carpal tunnel release. Which of the following peri-operative steps will have the greatest influence on minimizing the risk of a surgical site infection in this patient?
Administration of cefazolin within 1 hour before incision
Administration of cefazolin within 1 hour before incision followed by 5 days of cephalexin post-op
Cleanse with bacitracin solution immediately before skin incision
Standard sterilization and prepping
Administration of one dose of cephalexin within 1 hour before incision
The patient is undergoing a clean, elective hand surgery. Prophylactic antibiotics, systemic or local, are not indicated for these procedures.
Carpal tunnel syndrome is the most common compressive neuropathy. Individuals who fail medical management (night splints, NSAIDs, activity modification) are candidates for carpal tunnel release surgery (CTS). The surgery may be performed open or endoscopically. The reported incidence of post-operative infections following CTS varies between studies from 0% to 8%.
Whittaker et al. performed a prospective, randomized, double-blinded, placebo
controlled trial investigating the use of antibiotic prophylaxis in clean, incised hand injuries. They found no significant difference in infection rates between patients who received IV flucloxacillin, IV followed by oral flucloxacillin, and an oral placebo (13% vs. 4% vs. 15%, p=0.19). They did not support the use of routine antibiotic prophylaxis prior to clean hand surgery.
Bykowski et al. retrospectively reviewed 8,850 outpatient elective hand surgeries and found no significant difference in the rate of surgical site infection, including patients with diabetes or history of smoking. They concluded that antibiotics should not be routinely administered prior to clean, elective hand surgeries.
Harness et al. found no statistical difference in the incidence of surgical site infection following CTS without prophylactic antibiotic compared with patients who received prophylactic antibiotics (0.7% vs. 0.4%, p=0.354). They did not recommend routine antibiotic prophylaxis.
Illustration A reviews the anatomic components of the carpal tunnel. Incorrect Answers:
infection in clean, elective hand surgery. Surgeons should consider the potential risks of antibiotics prior to administration, including Clostridium difficile colitis, antibiotic allergies, bacterial resistance, and so on.
A 30-year-old male laborer sustained a right wrist injury 9 months ago. He continues to have symptoms of recurrent ulnar-sided wrist pain that impairs his ability to work. An MRI is performed and
shows a triangular fibrocartilage complex (TFCC) injury. Which of the following is an indication to combine a Wafer procedure with arthroscopic TFCC debridement?
Ulnar styloid fracture
Radial styloid fracture
2 mm of positive ulnar variance and ulnocarpal impingment
2 mm of negative ulnar variance and radiocarpal joint arthritis
Scapholunate ligament injury
A Wafer procedure is indicated for positive ulnar variance and symptomatic ulnocarpal impingement associated with degenerative TFCC tears.
Ulnar impaction syndrome and triangular fibrocartilage complex (TFCC) injuries are relatively common causes of ulnar-sided wrist pain. Positive ulnar variance causes increased contact pressures between the lunate and the ulnar head. The Wafer procedure removes 2-4 mm of distal ulnar head to reduce ulnar variance to neutral or negative. This is thought to reduce ulnar impaction and decrease pain.
Faber et al. examined the role of MRI in wrist injuries. They showed that the sensitivity and specificity to detect TFCC tears using MRI is approximately 80%. They conclude that there is no supporting evidence for routine MRI's for patients with non-specific ulnar-sided wrist pain.
Illustration A is a coronal view MRI (without arthrogram) of the right wrist that shows a TFCC tear (blue arrow) with positive ulnar variance. Illustration B shows a series of images showing a TFCC tear on MRI and intra-operatively.
Incorrect Answers:
A 27-year-old male sustains the injury shown in Figure A. He is taken to the operating room and the lesion is repaired primarily. Two months later, he feels a "pop" while using his hand and is no longer able to flex the distal phalanx of the involved digit. He is taken to the operating room for surgical exploration where 1.8 cm of scar tissue between the tendon ends is identified. The tendon sheath is found to be intact and allows smooth passage of a pediatric urethral catheter. What is the next step in management?
Resection of scar and primary repair of tendon ends.
Resection of scar and adjacent 1cm of tendon, placement of Hunter rod for staged reconstruction.
Debulking of scar, partial excision of 25% of the A2 and A4 pulleys.
Resection of scar, harvest of ipsilateral palmaris longus tendon for tendon reconstruction.
Resection of scar and proximal tendon, tendon transfer from adjacent digit.
This patient sustained an FDP laceration that was treated initially with primary repair. He subsequently re-ruptured the tendon 2 months later. With scar >1 cm, tendon grafting is indicated and primary tendon grafting with palmaris longus is commonly performed as it is the most accessible tendon in the operative field.
Flexor tendon lacerations commonly result from volar lacerations. Concomitant neurovascular injury is common. Partial lacerations <60% of tendon width are treated with debridement and early range of motion. With partial lacerations, the least amount of gliding resistance can be obtained with debridement alone. Lacerations >60% of tendon width are treated with flexor tendon repair and controlled mobilization. Failed primary repair and chronic untreated injuries are indications for flexor tendon reconstruction and intensive postoperative rehabilitation.
Lilly et al. reviewed complications after flexor tendon injuries. Common complications include adhesions, joint contracture, tendon rupture, triggering, pulley failure and bowstringing, quadrigia, swan-neck deformity and lumbrical plus deformity.
Figure A shows a zone II laceration of the left index finger FDP.
Incorrect Answers:
A 55-year-old female patient presents with pain along the thumb ray and increasing deformity of her right hand. Key pinch causes her pain. The appearance of her hand is seen in Figure A. Range of motion of her thumb is seen in Figure B. What is the most likely cause of her deformity?
Type II hypoplastic thumb
Median nerve neuropathy
Lupus thumb deformity
Extensor tendon rupture
Osteoarthritis of the trapeziometacarpal joint
The patient has 1st carpometacarpal (CMC) arthritis.
With 1st CMC arthritis, the patient avoids painful thumb abduction and an adduction deformity gradually develops, with 1st webspace contracture. With progressive 1st CMC stiffness, the thumb metacarpophalangeal joint (MCP) develops hyperextension deformity to compensate for the loss of motion, leading to a secondary "Z" deformity.
Rozental et al. reviewed hand and wrist reconstruction. They believe that arthrosis arises from loss of the anterior oblique ("beak") ligament.
Compensatory MCP hyperextension should be treated with MCP capsulodesis or arthrodesis.
Van Heest et al. reviewed thumb CMC arthritis. Treatment for Eaton stage I/II arthritis is open/arthroscopic debridement, volar ligament reconstruction (with APL or FCR tendons), or metacarpal extension osteotomy. For stage III/IV arthritis, treatment options include implant arthroplasty or resection arthroplasty +/- LRTI (with APL, FCR or palmaris longus), and fusion (young patients).
Figure A shows adduction contracture of the 1st webspace, with hyperextension deformity of the 1st MCP joint. Figure B illustrates decreased thumb abduction because of adduction contracture with decreased palmar abduction (normal, 45deg) and decreased radial abduction (normal, 60deg). Illustration A is a radiograph showing thumb CMC arthritis with Z deformity. Illustration B shows lupus thumb deformity ("hitchhiker thumb"). Illustration C shows hand changes in inflammatory arthritis.
Incorrect Answers:
A 26-year-old man presents with chronic hand weakness. The clinical appearance of his hand, and radiographs are shown in Figures A through C. Surgical exploration and decompression is performed. Besides addressing thumb interphalangeal and index distal interphalangeal joint flexion, which is the most appropriate treatment to restore thumb opposition?
Ring flexor digitorum superficialis transfer to the abductor pollicis brevis
Extensor indicis proprius transfer to the abductor pollicis brevis
Neurotization of thenar muscles
Camitz palmaris longus transfer to the abductor pollicis brevis
Thumb carpometacarpal joint arthrodesis
This patient has a high median nerve neuropathy because of a supracondylar spur and ligament of Struthers. Reconstruction is best performed with extensor indicis proprius (EIP) transfer to the abductor pollicis brevis (APB).
In low median nerve palsy, the primary concern is restoration of thumb opposition. In high median nerve palsy, thumb opposition and IP flexion, and index and middle finger flexion have to be addressed. The four common opposition transfers include (1) ring or long FDS, (2) EIP, (3) Camitz palmaris longus (PL), or the Huber abductor digiti minimi (ADM).
Anderson et al. reviewed EIP transfer vs FDS transfer. They found a higher percentage of excellent results in the EIP group. In their series, complications included index finger extensor lag (EIP transfer if the extensor expansion was not repaired) and limited donor finger extension because of lateral band damage or adhesions between the remaining FDS tendon and flexor sheath (FDS transfer).
Cawrse et al. modified the Huber ADM opponens transfer by releasing the proximal end to prevent compression of the ulnar nerve in Guyon's canal by the rotated ADM belly. They found that this technique successfully restored
opposition and thenar bulk.
Figure A shows thenar wasting. Figures B and C show a supracondylar spur. The ligament of Struthers attaches from this spur to the medial epicondyle, under which median nerve and brachial artery pass. Illustration A shows EIP transfer. Illustration B shows FDS transfer. Illustration C shows Camitz PL transfer. Illustration D shows Huber ADM transfer.
Incorrect Answers:
A 2-year-old child is referred by her pediatrician for fixed flexion deformity of the left thumb. She has been wearing a splint for the last 6 months. She has ventricular septal defect and left renal agenesis. The interphalangeal joint does not extend past 40 degrees of flexion as seen in Figures A and B. There is no triggering. There is a firm, nontender nodule overlying the metacarpophalangeal joint as outlined in blue in Figure C. What is the diagnosis and most appropriate treatment?
Thumb camptodactyly. Therapy including passive stretching exercises.
Congenital clapsed thumb. Percutaneous release of the A1 pulley.
Pediatric trigger thumb. Open release of the A1 pulley.
Pediatric trigger thumb. Open release of the A1 pulley and resection of the tendon nodule.
Blauth Type I hypoplastic thumb. Open release of the A1 pulley and volar plate, and resection of the tendon nodule.
This child has pediatric trigger thumb (PTT). The potential for spontaneous resolution beyond the age of 2 years is limited. Surgical release of the A1
pulley is indicated.
Pediatric trigger thumb presents as fixed flexion at the interphalangeal joint (IPJ) rather than triggering. It is likely to be acquired (rather than congenital). It is associated with the presence of Notta's nodule, a thickening of the FPL tendon and overlying tendon sheath. Treatment involves A1 pulley release.
The role of non-surgical management (splinting/stretching) remains unclear. The duration of non-surgical treatment is long (up to 30 months) and compliance can be difficult.
Shah et al. reviewed pediatric trigger thumb. The condition is associated with MCP hyperextension. The authors note no advantage to percutaneous release as general anesthetic is required anyway.
Marek et al. performed a retrospective review and survey response review of surgery for pediatric trigger thumb. They found that age at the time of surgery influences residual flexion contracture and rate of recovery. They found surgery to be safe and effective, and recommend: (1) surgery for a 2-year-old child with a locked thumb for 6 months, (2) observation for a child <1 year if the thumb is triggering (not locked), and (3) a 6-month observation period if observation is advocated.
Figures A and B show a fixed flexion deformity of the thumb and an attempt at thumb extension. Figure C shows the outlined Notta nodule.
Incorrect Answers:
A 48-year-old hairdresser presents with pain and swelling of his ring finger for 4 days. On examination, there is generalized tenderness along the entire digit. Passive extension of the digit triggers
excruciating pain. The clinical appearance of the digit is shown in Figure A. What is the most appropriate next step in management?
Acyclovir
Intravenous antibiotics, splinting and elevation
Closed tendon sheath irrigation from the level of the A1 pulley (proximal) to the distal interphalangeal joint (distal)
Continuous closed tendon sheath irrigation from the wrist (proximal) to the distal interphalangeal joint (distal)
Open irrigation and debridement
This patient has advanced pyogenic flexor tenosynovitis (PFT) with visible ischemia/necrosis. Open irrigation and debridement is necessary.
Pyogenic flexor tenosynovitis is usually caused by a puncture wound (although it may infrequently arise from hematogenous spread). The most common organism is Staphylococcus aureus. Kanavel signs help differentiate this disease from herpetic whitlow, septic arthritis, gout/pseudogout, and other hand infections such as paronychia, felons, cellulitis, and deep space infections.
Draeger et al. reviewed the treatment of pyogenic flexor tenosynovitis (PFT). They recommend open irrigation and debridement for advanced PFT and atypical or chronic tenosynovial infections where tenosynovectomy may be
indicated. Both midaxial and volar zigzag incisions can be used.
Pang et al. reviewed factors affecting the prognosis of PFT. Of the 4 Kanavel signs, they found that fusiform swelling was most often present (97% of patients), followed by pain on passive extension (72%), semiflexed digit posture (69%), and tenderness along the flexor tendon sheath (64%).
Figure A shows advanced PFT demonstrating subcutaneous purulence and local ischemia in addition to fusiform digital swelling. Illustration A shows the Nevasier technique of closed tendon sheath irrigation. Illustration B shows the setup for continuous tendon sheath irrigation using nested catheters.
Illustration C shows the incision for open irrigation and debridement.
Incorrect Answers:
Madelung's deformity of the distal radius is caused by which of the following?
Premature fusion of the distal radial ulnar joint
Physeal growth mismatch between the distal radius and ulna
Nutritional deficiency affecting the physeal zone of provisional calcification
Impaired growth of the volar and ulnar aspect of the distal radial physis
Unrecognized trauma
CORRECT ANSWER: 4
Madelung's deformity is that of excessive ulnar/palmar angulation of the distal radius caused by impaired growth of the volar and ulnar aspect of the distal radial physis. It may be caused by either a bony lesion in the palmar/ulnar corner of the distal radial physis or an abnormal radial-carpal ligament (Vicker's ligament). The other answers do not cause Madelung's deformity.
Leri-Weill dyschondrosteosis is a rare genetic disorder caused by mutation in the SHOX gene that causes mesomelic dwarfism with associated Madelung's defomity of the forearm.
Illustration A is a radiographic example of Madelung's deformity.
A 17-year-old boy presents with pain in his right elbow for 2 years and limitation in elbow motion bilaterally. He denies any pain or discomfort in his left elbow. He reports no history of trauma to either elbow. He has had two courses of physical therapy, but has noted no noticeable improvement in pain or motion. Examination demonstrates no elbow tenderness on palpation, and there are no neurological deficits. Manual reduction is unsuccessful. The range of motion of both elbows is shown in Figure A. Radiographs of left and right elbow are shown in Figure B and C respectively. What is the most appropriate treatment plan for the right and left elbow?
Bilateral open reduction and application of a hinged external fixator to both elbows
Radial head resection of the right elbow and non-operative management of the left elbow.
Bilateral radial head arthroplasty
Physical therapy and splinting to both elbows
Radial head resection and interposition arthroplasty for the right elbow and radial head resection alone for the left elbow
This patient has bilateral congenital radial head dislocation (CRHD). The right side is symptomatic with significant loss of motion. The left is asymptomatic with minimal loss of active motion. Therefore the most appropriate treatment is radial head resection of the right elbow and non-operative management of the left elbow.
It is important to differentiate CRHD from traumatic dislocation. Clinical features of CRHD include bilateral involvement, presence at birth, other congenital anomalies, familial occurrence, irreducible by closed methods, and
lack of a history of trauma. Radiological features include dome-shaped radial head and hypoplastic capitellum, relatively short ulna or long radius, deficient trochlea, prominent medial epicondyle, grooving of the distal radius, and anterior curvature of the posterior outline of the ulna.
Bengard et al. reviewed 10 surgically treated and 6 nonsurgically treated CRHD patients. They found no change in flexion-extension and carrying angle postoperatively, but forearm rotation was improved. Surgically treated patients had significant improvement in elbow pain. Ultimately, >25% of patients had wrist pain postop and this must be weighed in the decision process of treatment. They recommend radial head excision as an effective intervention in selected patients with significant elbow pain.
Figure A is a table showing moderately diminished ROM of the right elbow, and minimally reduced ROM of the left elbow. Figures B and C both show posterior dislocation of the radial head (a line along the long axis of the radius should intersect the capitellum in all views).
Incorrect Answers:
Which of the following muscles provide the primary deforming forces to Bennett and Rolando fractures (base of the 1st metacarpal fractures)?
Pronator quadratus
Flexor pollicis longus
Extensor pollicis longus
Adductor pollicis longus and abductor pollicis
Abductor pollicis longus and adductor pollicis
The primary deforming forces in Bennett and Rolando fractures are the Abductor pollicis longus and adductor pollicis.
In a Bennet's or Rolando fracture-dislocation the volar-ulnar fracture fragment is held reduced by the anterior oblique ligament while strong deforming forces pull the remaining metacarpal shaft proximally and dorsally, angulate the shaft ulnarly and supinate the shaft. Most important in these deforming forces are the abductor pollicis longus (APL) inserting on the base of the metacarpal which pulls the metacarpal shaft proximally and dorsally and the adductor pollicis (AP) which inserts on the ulnar base of the proximal phalanx and angulates the metacarpal shaft ulnarly and supinates the shaft. Less important is the extensor pollicis longus (EPL) which inserts on the base of the distal phalanx and also adds to the ulnar angulation of the distal fragment.
Soyer reviews the diagnosis, pathoanatomy, and treatment for fractures at the base of the 1st metacarpal. Understanding the biomechanics, anatomical deforming forces, and the exact fracture pattern aids the treating surgeon in determining the most appropriate method of fixation. The most essential factor for obtaining a good functional result is anatomic restoration of the articular surface.
Elgafy et al. examined the terminal anatomy of the posterior interosseous nerve in their cadaver study - identifing six terminal branches and describing methods to avoid injury. They describe how treating surgeons can maximize function and recovery after base of the 1st metacarpal fractures by understanding these nervous branches and specific fracture pattern treatment to avoid iatrogenic injury to the PIN.
A 28-year-old man sustained a complete laceration of the flexor digitorum profundus of his index finger while cutting a watermelon 3 days ago. A clinical photograph is shown in Figure A. The surgeon plans to repair the tendon using a 4-strand core suture technique. Which method of tendon repair will give him the best results in terms of load to failure and gliding resistance?
Repair with core suture purchase 5mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 10mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 5mm from the cut edge. Circumferential
simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential Silfverskiold epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge, coupled with circumferential simple running epitendinous suture will give him the best load to failure and gliding resistance.
The strength of tendon repairs depend on the number of strands crossing the repair site. Ideally, repairs should have 4-6 strands to allow for early active motion. A running epitendinous suture is recommended to improve tendon gliding and repair strength.
Gulihar et al. compared 3 different epitendinous suture techniques. They found that compared with an intact tendon, gliding resistance increased 100% with the Halsted repair, 80% with the Silfverskiold repair and 60% with a running suture. They thus recommend a simple running suture when an epitendinous suture is needed.
Lee et al. compared core suture purchase at 3, 5, 7 and 10mm from the cut edge. The 10mm-repair group had the highest 2-mm gap force and ultimate failure load. They recommend 10-mm suture purchase for optimal performance and to allow early active motion.
Figure A shows a laceration to the volar aspect of the index finger in flexor zone II. Illustration A shows a core suture purchase distance from the cut edge (represented by "X", where 10mm is the ideal distance). Illustration B shows 3 different epitendinous suture techniques (A, simple running; B, Silfverskiold; C, Halsted).
Incorrect Answers:
A 28-year-old professional baseball player injures his middle finger sliding into the catchers shin guard at home plate. He complains of pain and deformity of the middle finger. A radiograph is provided in figure A. All of the following are true EXCEPT:
Anatomic reconstruction of the articular surface is prognostic of clinical function
Proximal interphalangeal joint subluxation precludes a normal gliding flexion arc
Hinging at the fracture site must be avoided
Early motion should be initiated in postoperative therapy
Early degenerative arthritis can be expected if the joint is not adequately reduced.
The radiograph demonstrates a dorsal fracture dislocation of the proximal interphalangeal joint of the middle finger. Kiefhaber and Stern review the presentation, evaluation, and treatment of PIP fractures. Congruent reduction of the joint to allow the middle phalanx to glide around the proximal phalangeal head is paramount to prevent joint subluxation and instability.
Anatomic reconstruction of the articular surface is desirable but not necessary for successful clinical outcome.
A 30-year-old male sustains a 3.5 cm long thumb pulp injury seen in Figure A. He undergoes a procedure to restore the soft tissue envelope. Which treatment option is contraindicated because of increased risk of interphalangeal joint stiffness?
Moberg volar advancement flap
Foucher first dorsal metacarpal artery flap
Littler neurovascular island flap
Free great toe pulp transfer
Holevich first dorsal metacarpal artery flap
This patient has a large thumb pulp defect measuring 3.5 cm in length, extending proximal to the interphalangeal joint (IPJ) crease. Inset of a Moberg flap large enough to cover the defect would necessitate IPJ flexion >45 degrees, increasing the risk of IPJ stiffness.
Thumb pulp defects may be resurfaced by different means, depending on size. The Moberg flap is suited for medium (1.8-3 cm) defects. For defects >1.5 cm, there is increased risk of wound dehiscence, parrot beak nail deformity, and decreased soft tissue padding. Modifications such as V-Y flaps, bilateral Z-plasties, Burrow triangles, 2 lateral triangular flaps at the proximal edge of the flap, or advancement of an island flap with skin grafting of the secondary defect (O’Brien modification), are recommended.
Baumeister et al. reviewed the functional outcome of Moberg flaps. These flaps do not cause marked impairment of active ROM and any reduction in the AROM of the IP joint is because of a loss of hyperextension.
Horta et al. reviewed the use of multiple flaps (Moberg, radial innervated cross-finger, Venkataswami-Subramanian, Foucher, Tezcan, and Littler). They recommended the Foucher flap because of good sensibility, single-stage surgery, and no need for cortical reintegration (unlike the Littler flap)
Figure A shows a large thumb pulp defect. Illustration A shows the options for resurfacing thumb pulp defects of different sizes. Illustration B is a diagram of these options. Illustrations C and D depict the Holevich dorsal metacarpal artery flap (with overlying skin strip). Illustrations E and F depict the Foucher dorsal metacarpal artery flap (islanded).
Incorrect Answers:
Percutaneous screw fixation for non-displaced scaphoid waist fractures has been shown to have which of the following differences compared to closed treatment?
Increased direct and indirect cost
Slower return to work
Higher union rates
Reduced time to fracture union
Improved motion and grip strength after 2 years
Fixation of non-displaced scaphoid fractures with a percutaneous screw has resulted in a shorter time to union (6-7 weeks versus 10-12 weeks) and faster return to work or sports.
Arora et al found the indirect cost reduction by a quicker return to work was shown to offset the direct costs of surgical intervention.The operatively treated group had a better mean DASH-score than the conservative group. Fracture
union was seen in the screw fixation group at a mean of 43 days and in the cast immobilization group at a mean of 74 days.
Bond et al found in active military personnel there was faster healing but no difference in ultimate union rates or final grip strength or range of motion between percutanous screw fixation and non-operative groups. The average time to fracture union in the screw fixation group was seven weeks compared with twelve weeks in the cast immobilization group. There was no significant difference in the range of motion of the wrist or in grip strength at the two-year follow-up evaluation.
Constriction ring syndrome, also known as amniotic band syndrome, is a congenital disorder associated with which paediatric foot condition?
Equinovalgus foot
Clubfoot (Congenital talipes equinovarus)
Tarsal coalition
Congenital vertical talus
Polydactyly
CORRECT ANSWER: 2
Constriction ring syndrome is a congenital disorder that is most commonly associated with clubfeet (congenital talipes equinovarus). The reported incidence of clubfeet with concomitant constriction bands ranges from 12-56%.
Constriction ring syndrome is a collection of congenital malformations that occur as a result of intrauterine rings or bands that constrict fetal tissue. The etiology of constrictive ring syndrome remains elusive, though Streeter postulated in 1930 that a germline developmental abnormality is responsible for the development of amniotic constriction bands, hence one of the synomonous terms used to describe the disorder, Streeter’s dysplasia. Normal anatomy is found proximal to the band. Distally, a constrictive band can cause compression of lymphatic and neurovascular structures and result in lymphedema, altered circulation and neuropathy. In severe cases congenital amputation can occur. In terms of other orthopaedic conditions, constrictive ring syndrome is associated with clubfeet, acrosyndactyly and pseudoarthrosis. With respect to clubfeet, surgical treatment is commonly required, which consists of z-plasty releases of the constricted bands, in addition to surgical correction of the clubfoot deformity.
Gomez reviewed 35 children with clubfeet associated with constriction ring syndrome. In this cohort there was a poor response to casting, as 77% of the children required surgical corrections. Z-plasty releases of the deep bands were performed before the clubfoot correction.
Allington et al. examined the outcome of treatment of clubfeet distal to a lower extremity band in 18 patients (21 feet). Sixteen children (88.9%) underwent surgical treatment after manipulation and serial casting were unsuccessful.
Mild initial foot deformities and constriction bands located in the distal aspect of the lower leg were associated with the best outcomes.
Incorrect Answers:
You are consulted on a newborn male inpatient who presents with the clinical sign shown in Figure A. All of the following are commonly associated with this syndrome EXCEPT?
Bronchopulmonary dysplasia
Cardiac defects
Cleft palate
Encephalocele
Rigid talipes equinovarus

Question 49:

Options:

closed reduction and casting for 6 weeks.
open reduction and internal fixation, using a locked intramedullary rod.
open reduction and internal fixation, using two cancellous screws.
open reduction and internal fixation, using a locked plate and screws.
open reduction and internal fixation and revision of the femoral component.

Correct Answer: open reduction and internal fixation and revision of the femoral component.

Explanation:

DISCUSSION: The radiographs show a loose femoral component with an associated medial condyle distal femoral fracture. The treatment of choice is open reduction and internal fixation with revision of the femoral component because of the femoral component loosening.
REFERENCES: Moran MC, Brick GW, Sledge CB, et al: Supracondylar femoral fracture following total knee arthroplasty. Clin Orthop 1996;324:196-209.
McLaren AC, DuPont JA, Schroeber DC: Open reduction internal fixation of supracondylar fractures above total knee arthroplasties using the intramedullary supracondylar rod. Clin Orthop 1994;302:194-198.
Figgie MP, Goldberg VM, Figgie HE III, et al: The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty 1990;5:267-276.

Question 50:

Options:

Abscess
Ganglion cyst
Nerve sheath tumor
Lymphoma
Metastatic cancer

Correct Answer: Ganglion cyst

Explanation:

Question 51:

A 17-year-old high school football player reports wrist pain after being tackled. Radiographs are shown in Figures 22a through 22c. What is the recommended intervention?

Options:

Pedicled vascularized bone graft
Long arm thumb spica cast
Percutaneous screw fixation
Corticocancellous bone grafting via a volar approach (Matti-Russe)
Open reduction and differential pitch screw placement via a dorsal approach

Correct Answer: Open reduction and differential pitch screw placement via a dorsal approach

Explanation:

DISCUSSION: The patient has an acute fracture of the proximal pole. A 100% healing rate has been reported for open reduction and internal fixation of proximal pole fractures via a dorsal approach. This allows for direct viewing of the fracture line, facilitates reduction, and bone grafting can be done through the same incision if necessary. A vascularized or corticocancellous graft is reserved for nonunions. Proximal fractures are very slow to heal with a cast, if they heal at all. As a small fragment, percutaneous fixation is very difficult and has been reported for waist fractures.
REFERENCES: Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210.
Raskin KB, Parisi D, Baker J, et al: Dorsal open repair of proximal pole scaphoid fractures. Hand Clin 2001;17:601-610.

Question 52:

Options:

Application of a femoral cable plate
Application of cerclage-wired double allograft femoral struts
Femoral revision with an uncemented long stem
Femoral revision with a cemented long-stem prosthesis

Correct Answer: Femoral revision with an uncemented long stem

Explanation:

Question 53:

At the L4-5 level, what is the location of the S2-5 nerve roots in relationship to the L5 and S1 nerve roots?

Options:

They are lateral and dorsal to L5 and S1.
They are lateral and ventral to L5 and S1.
They are in the midline and dorsal to L5 and S1.
They are in the midline and ventral to L5 and S1.
There is no clear anatomic arrangement.

Correct Answer: They are in the midline and dorsal to L5 and S1.

Explanation:

Question 54:

Options:

Right extensor hallucis longus (EHL) weakness, anterior shin numbness, and diminished patella reflex
Right quadriceps weakness, anterior shin pain, and diminished patella reflex
Right dorsal foot first web numbness, EHL weakness, and normal reflexes
Left quadriceps weakness, anterior shin pain, and diminished patella reflex

Correct Answer: Right quadriceps weakness, anterior shin pain, and diminished patella reflex

Explanation:

Question 55:

Options:

Immobilization
Syndesmotic fixation
Physical therapy
Obtain an MRI scan

Correct Answer: Syndesmotic fixation

Explanation:

Question 56:

EXT1

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 would be the most appropriate treatment:

Question 57:

A 72-year-old man with diabetic neuropathy and 5 degrees of valgus talar tilt; he has pursued nonsurgical treatment for 30 years and now has unrelenting pain

Options:

Ankle replacement
Ankle fusion
Tibiotalocalcaneal fusion
Total contact cast
Intra-articular steroid injection

Correct Answer: Ankle fusion

Explanation:

DISCUSSION
Arthritis of the ankle and hindfoot can pose challenges. Depending upon patient age, comorbidities, and alignment, a variety of surgical interventions may be offered. A total ankle replacement may be considered for patients older than 60 years of age who have minimal misalignment and low-demand lifestyles. In all other cases, ankle fusion must be considered. The nonsurgical care of ankle arthritis includes anti-inflammatory medication, intra-articular steroid injections, bracing with customized products such as the Arizona brace, or a molded foot and ankle orthosis.
Patients with diabetes and Charcot arthropathy may be treated nonsurgically with total-contact casting during acute and active or "hot" phases and accommodative shoes during consolidation and stable or "cool" phases. When the patient has recurrent ulcers or major anatomy changes, surgical intervention must be considered. Tibiotalocalcaneal fusion helps to realign the foot and ankle and make it more braceable in the setting of ankle and hindfoot Charcot disease.
RECOMMENDED READINGS
Queen RM, Adams SB Jr, Viens NA, Friend JK, Easley ME, Deorio JK, Nunley JA. Differences in outcomes following total ankle replacement in patients with neutral alignment compared with tibiotalar joint malalignment. J Bone Joint Surg Am. 2013 Nov 6;95(21):1927-34. doi: 10.2106/JBJS.L.00404. PubMed PMID: 24196462.
View Abstract at PubMed
Nunley JA, Caputo AM, Easley ME, Cook C. Intermediate to long-term outcomes of the STAR Total Ankle Replacement: the patient perspective. J Bone Joint Surg Am. 2012 Jan 4;94(1):43-8. doi: 10.2106/JBJS.J.01613. PubMed PMID: 22218381.
View Abstract t
PubMed
Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, Brodsky JW, Chou LB, Clanton TO, Deland JT, Deorio JK, Horton GA, Lee TH, Mann JA, Nunley JA, Thordarson DB, Walling AK, Wapner KL, Coughlin MJ. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009 Jul;30(7):579-96. doi: 10.3113/FAI.2009.0579. PubMed PMID: 19589303.
View Abstract at
PubMed
Faraj AA, Loveday DT. Functional outcome following an ankle or subtalar arthrodesis in adults. Acta Orthop Belg. 2014 Jun;80(2):276-9. PubMed PMID: 25090803.
View Abstract at PubMed
Grear BJ, Rabinovich A, Brodsky JW. Charcot arthropathy of the foot and ankle associated with rheumatoid arthritis. Foot Ankle Int. 2013 Nov;34(11):1541-7. doi: 10.1177/1071100713500490. Epub 2013 Jul 30. PubMed PMID: 23900228.
View Abstract at
PubMed

Question 58:

Options:

Continued semi-rigid immobilization until the extremity surgeries are completed
Halo skeletal fixation prior to the extremity surgery
Definitive clearance of the cervical spine with CT and/or MRI
Removal of the semi-rigid collar and physical examination when the patient is responsive
Soft collar immobilization and local wound care

Correct Answer: Definitive clearance of the cervical spine with CT and/or MRI

Explanation:

DISCUSSION: Ackland and associates demonstrated that the failure to achieve early spinal clearance in an unconscious blunt trauma patient predisposed the patient to increased morbidity secondary to the prolonged used of cervical immobilization. They demonstrated that the four significant predictors of collar-related ulcers were ICU admission, mechanical ventilation, the necessity for cervical MRI, and the time to cervical spine clearance and collar removal. The risk of pressure-related ulceration increased by 66% for every 1-day increase in Philadelphia collar time and this highlights the need for definitive C-spine clearance.
REFERENCES: Ackland HM, Cooper DJ, Malham GM, et al: Factors predicting cervical collar-related decubitus ulceration in major trauma patients. Spine 2007;32:423-428.
Hewitt S: Skin necrosis caused by semi-rigid cervical collar in a ventilated patient with multiple injuries. Injury 1994;25:323-324.

Question 59:

Options:

use of a sling with no range-of-motion exercises until the condition is stable.
use of a sling and passive range-of-motion exercises within the limits of the repair.
no sling and supine passive range-of-motion exercises.
an internal rotation brace holding the arm at the side.
an external rotation brace holding the arm at the side.

Correct Answer: an external rotation brace holding the arm at the side.

Explanation:

Question 60:

- A 40-year old man has limited, painful motion in dorsiflexion at the metatarsophalangeal (MTP) joint of the right great toe, despite nonsurgical treatment. Radiographs show dorsal and medial osteophytes and minimal narrowing of the articular space. Treatment should consist of

Options:

Arthrodesis of the MTP joint
A Silastic implant of the MTP joint
Resection arthroplasty of the MTP joint
Cheilctomy of the MTP joint
Osteotomy of the base of the proximal phalanx

Correct Answer: Cheilctomy of the MTP joint

Explanation:

Question 61:

Options:

above-knee amputation.
preoperative chemotherapy, wide resection of the distal femur, and reconstruction.
preoperative chemotherapy and above-knee amputation.
wide resection of the distal femur and subsequent reconstruction, followed by chemotherapy.
curettage and placement of methylmethacrylate.

Correct Answer: preoperative chemotherapy, wide resection of the distal femur, and reconstruction.

Explanation:

Question 62:

What procedure can eliminate a sulcus sign?

Options:

Rotator interval closure
SLAP repair
Bankart repair
Supraspinatus repair
Subacromial decompression

Correct Answer: Rotator interval closure

Explanation:

Question 63:

The spring ligament of the foot connects what two bones?

Options:

Tibia and talus
Talus and navicular
Talus and calcaneus
Calcaneus and cuboid
Calcaneus and navicular

Correct Answer: Calcaneus and navicular

Explanation:

DISCUSSION: The spring ligament is also known as the calcaneonavicular ligament and connects the calcaneus to the navicular. This ligament supports the talar head and is an important anatomic supporting structure of the medial longitudinal arch of the foot.
REFERENCES: Choi K, Lee S, Otis JC, et al: Anatomical reconstruction of the spring ligament using peroneus longus tendon graft. Foot Ankle Int 2003;24:430-436.
Davis WH, Sobel M, DiCarlo EF, et al: Gross, histological and microvascular anatomy and biomechanical testing of the spring ligament complex. Foot Ankle Int 1996;17:95-102.

Question 64:

Which of the following activities can improve posterior capsular contractures?

Options:

Theraband exercises to strengthen the external rotator
Latissimus pull-down exercises to the chest
Seated rows
Internal rotation stretch at 90 degrees abduction with scapular stabilization
Bench press with wide grip

Correct Answer: Internal rotation stretch at 90 degrees abduction with scapular stabilization

Explanation:

Question 65:

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Options:

within 1 standard deviation of aged-matched normals.
within 1 and 2.5 standard deviations below aged-matched normals.
within 1 standard deviation of young normals.
within 1 and 2.5 standard deviations below young normals.
more than 2.5 standard deviations below aged-matched normals.

Correct Answer: within 1 and 2.5 standard deviations below young normals.

Explanation:

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.
The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 66:

Options:

Popliteal artery
Popliteal vein
Tibial nerve
Popliteus muscle
Soleus muscle

Correct Answer: Popliteus muscle

Explanation:

DISCUSSION: The major risk of performing a high tibial osteotomy is neurovascular injury. The new version of the high tibial osteotomy makes a transverse osteotomy at the level of the tibial tubercle. The osteotome is protected by the oblique belly of the popliteus muscle. The popliteal artery and vein and tibial nerve all lie posterior to the muscle. The soleus muscle originates below this level.
REFERENCES: Clement CD: Anatomy: A Regional Atlas of Human Anatomy, ed 3.
Baltimore, MD, Munich, Germany, Urban and Schwarzberg, 1987, Figure 422.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, plate 480.

Question 67:

Options:

ice and elevation, followed by graduated range-of-motion exercises.
a long leg cast.
excision of the fragment.
open reduction and internal fixation.
observation until maturity, followed by anterior cruciate ligament repair.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 68:

Options:

Semimembranosis release
Medial gastrocnemius release
Medial tibial plateau downsizing osteotomy
Iliotibial band pie crusting
Popliteus tendon release
Cruciate release of the capsule posterior lateral corner

Correct Answer: Iliotibial band pie crusting

Explanation:

Question 69:

Options:

Giant cell tumor of the tendon sheath
Gouty tophi
Aggressive fibromatosis
Tendon rupture
Synovial cell sarcoma

Correct Answer: Tendon rupture

Explanation:

Question 70:

Options:

conversion to a longer side plate with the same compression screw and tube angle.
in situ bone grafting.
hardware removal and reconstruction with an intramedullary device that provides fixation into the femoral head and neck.
hardware removal and retrograde femoral nailing.
revision reconstruction with cerclage wiring.

Correct Answer: hardware removal and reconstruction with an intramedullary device that provides fixation into the femoral head and neck.

Explanation:

Question 71:

The comparative outcomes of needle aponeurotomy (NA) and collagenase Clostridium histolyticum (CCH) use in the treatment of Dupuytren contracture indicate that patients treated with CCH have

Options:

greater direct costs.
better range of motion at 2 years.
a higher reintervention rate at 5 years.
better metacarpophalangeal (MCP) contracture correction at 12 months. NA and CCH are the treatment options for Dupuytren contracture. The treatments of MCP contractures with NA and CCH were compared in two randomized trials that showed equivalent outcomes at 12 months, based on correction and Unité Rhumatologique des Affections de Main (URAM) scores. A recent retrospective study showed reintervention rates at 2 years of 24% for NA and 41% for CCH. At 5 years, the rates were 61% for NA and 55% for CCH. Standardized direct costs for NA and CCH were $624 and $4,189, respectively. Including all reinterventions, the cumulative costs per digit at 5 years after NA and CCH were $1,540 and $5,952, respectively. A 2-year follow-up by Strömberg showed no difference in range of motion or patient- reported outcomes.

Correct Answer: greater direct costs.

Explanation:

Question 72:

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 73:

Options:

Unreduced posterior sternoclavicular dislocation
Congenital hypoplasia of the medial clavicle
Postmenopausal arthritis of the sternoclavicular joint
Sternoclavicular hyperostosis
Spontaneous subluxation of the right sternoclavicular joint

Correct Answer: Spontaneous subluxation of the right sternoclavicular joint

Explanation:

DISCUSSION: Spontaneous subluxation of the sternoclavicular joint occurs without any significant trauma. It is usually accentuated by placing the extremity in an overhead position. Discomfort usually resolves within 4 to 6 weeks with nonsurgical management.
REFERENCES: Rockwood CA, Wirth MA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,
WB Saunders, 2004, vol 2, pp 1078-1079.
Rockwood CA, Odor JM: Spontaneous atraumatic anterior subluxation of the sternoclavicular joint. J Bone Joint Surg Am 1989;71:1280-1288.

Question 74:

Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

Options:

Comminuted fractures
Fractures that involve the coronoid process
Fractures associated with Monteggia fracture-dislocations
Oblique fractures distal to the midpoint of the trochlear notch
Transverse fractures through the midpoint of the trochlear notch

Correct Answer: Transverse fractures through the midpoint of the trochlear notch

Explanation:

Question 75:

Options:

Cemented unipolar hemiarthroplasty B. Cemented bipolar hemiarthroplasty C. Total hip replacement
Open reduction and internal fixation

Correct Answer: Cemented unipolar hemiarthroplasty B. Cemented bipolar hemiarthroplasty C. Total hip replacement

Explanation:

Question 76:

The diagnosis of an infection after total knee arthroplasty is most reliably proven based on what single study?

Options:

Leukocyte count and C-reactive protein
Radiographs
Technetium Tc 99m and gallium bone scans
Aspiration of joint fluid
MRI

Correct Answer: Aspiration of joint fluid

Explanation:

DISCUSSION: In a study of 52 patients with infected total knee arthroplasties, Windsor and associates showed that the average leukocyte count was 8,300/mm
3
and that aspirated knee fluid was positive in all patients except one. Knee radiographs can be unclear in showing infection, which may be present without radiographic signs of loosening. Technetium Tc 99m and gallium bone scans may not conclusively show the presence of infection, particularly in the first 3 years after knee arthroplasty.
REFERENCES: Windsor RE, Bono JV: Infected total knee replacements. J Am Acad Orthop Surg 1994;2:44-53.
Windsor RE, Insall JN, Urs WK, et al: Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection: Further follow-up and refinement of indications. J Bone Joint Surg Am 1990;72:272-278.

Question 77:

Figure 24 shows the radiograph of a 36-year-old volleyball player with right hip pain. What is the cause of the pain?

Options:

Osteonecrosis
Rheumatoid arthritis
Developmental dysplasia of the acetabulum
Femoral neck fracture
Femoral acetabular impingement

Correct Answer: Femoral acetabular impingement

Explanation:

DISCUSSION: Femoral acetabular impingement usually presents in active young adults with the slow onset of groin pain that often starts after a minor trauma. Physical examination reveals limitation of motion with a positive impingement test which consists of forceful internal rotation with flexion and adduction. Femoral acetabular impingement is a mechanism for the development of early osteoarthritis in nondysplastic hips. Surgical debridement of the impinging, nonspherical portion of the femoral head restores offset and improves the clearance of the head, thus preventing abutment of the neck against the acetabular rim. The patient has no evidence of osteonecrosis, developmental dysplasia of the hip, rheumatoid arthritis, or femoral neck fracture.
REFERENCES: Ganz R, Parvizi J, Beck M, et al: Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clin Orthop 2003;417:112-120.
Beck M, Leunig M, Parvizi J, et al: Anterior femoroacetabular impingement: Part II. Midterm results of surgical treatment. Clin Orthop 2004;418:67-73.

Question 78:

Options:

Repeat radiographs at age 75
Intra-articular injection with bone marrow aspirate
Cementation of a modern liner into the existing socket
Cemented femoral stem revision Radiographs show severe wear of the polyethylene with likely wear through and with massive pelvic osteolysis. Modular revision is an option If there are liners available, the locking mechanism is undamaged (unlikely with the mechanical symptoms) and intraoperative stability is adequate. Cementing a modern liner with good technique is a durable option along with bone grafting of the periacetabular defects. Delayed follow-up would likely result in catastrophic failure.

Correct Answer: Cementation of a modern liner into the existing socket

Explanation:

Question 79:

Options:

Osteochondroma
Enchondroma
Myositis ossificans
Parosteal osteosarcoma
Prior bony trauma

Correct Answer: Osteochondroma

Explanation:

DISCUSSION: The radiographs reveal a sessile lesion projecting from the medial aspect of the distal femur. The lesion shares the cortex with the bone and the base communicates with the medullary space of the femur. This is the classic appearance of an osteochondroma, the most common benign tumor of bone.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.
Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 80:

Options:

Incision and drainage of the humerus
Sling immobilization of the left upper extremity
Total body bone scan
A course of oral antibiotics and recheck in 1 week DISCUSSION-The MRI scan shows a large abscess along most of the humerus. Incision and drainage of the abscess is indicated. A bone scan will not add any additional information regarding location of the problem.Immobilization will not address the origin of the problem. Oral antibiotics are not adequate for this abscess.

Correct Answer: Incision and drainage of the humerus

Question 81:

Which of the following activities produces greater hip joint contact pressures than full weight bearing during normal gait?

Options:

Performing isometric hip exercises
Getting on a bed pan
Ambulating with a cane
Rising from a chair using the affected leg
Toe-touch weight bearing with passive hip abduction

Correct Answer: Performing isometric hip exercises

Explanation:

Question 82:

Options:

Initiate oral antibiotics for 7 days.
Reaspirate the bursa and inject a corticosteroid.
Recommend padding the patella for kneeling and ice.
Perform an open bursectomy and start intravenous antibiotics.

Correct Answer: Perform an open bursectomy and start intravenous antibiotics.

Explanation:

Question 83:

Which of the following is considered an inherent problem in using the distal oblique shortening (Weil) metatarsal osteotomy for dorsal metatarsophalangeal subluxation?

Options:

Nonunion of the osteotomy
Malunion of the osteotomy
Excessive shortening that results in transfer lesions to the adjacent toes
Plantar translation that results in metatarsalgia
Dorsal positioning of the intrinsic tendons and recurrent dorsal contracture of the toe

Correct Answer: Dorsal positioning of the intrinsic tendons and recurrent dorsal contracture of the toe

Explanation:

Question 84:

Options:

There is a risk of splenic abscess
Blood-borne transmission results in more severe symptoms
He can return to play 3 weeks after he is asymptomatic
Amoxicillin will allow faster return to play
He should be isolated for 48 hours after symptom onset

Correct Answer: Amoxicillin will allow faster return to play

Explanation:

Question 85:

Options:

Baker’s cyst
Torn medial meniscus
Patellofemoral pain syndrome
Lipoma
Ganglion cyst of the cruciates

Correct Answer: Ganglion cyst of the cruciates

Explanation:

DISCUSSION: Ganglia involving the cruciate ligaments have been recently reported as a cause of knee pain that interferes with knee flexion and extension. The symptoms are poorly localized in this patient and not along the medial joint line, making the diagnosis of a torn medial meniscus less likely. In addition, the MRI findings do not show a significant medial meniscal lesion. A Baker’s cyst is usually posteromedial and extends posterior to the interval between the medial head of the gastrocnemius and semimembranosus. MRI scans show a fluid-filled lesion with an increased signal on T
1
- and T
2
-weighted images. A lipoma would be bright on the T
1
-weighted image only.
REFERENCES: Deutsch A, Veltri DM, Altchek DW, et al: Symptomatic intraarticular ganglia of the cruciate ligaments of the knee. Arthroscopy 1994;10:219-223.
Brown MF, Dandy DJ: Intra-articular ganglia of the knee. Arthroscopy 1990;6:322-323.

Question 86:

Options:

Resistance to adhesive wear B. Resistance to abrasive wear C. Resistance to fatigue wear
Resistance to creep

Correct Answer: Resistance to creep

Explanation:

Question 87:

Options:

Needle biopsy
Incisional biopsy
Curettage and grafting
Observation
En bloc resection

Correct Answer: Observation

Explanation:

DISCUSSION: The figures show a lesion of the proximal humerus consistent with an enchondroma. The lesion is calcified on the radiographs. There is no cortical destruction, significant endosteal scalloping, or soft-tissue mass. The bone scan shows mild uptake in the area of the proximal humerus, and the T
2
-weighted MRI scan shows a lesion with high uptake, suggesting a lesion with high water content. A CT scan could also be obtained to rule out bone destruction or periosteal reaction. Pain with overhead activities is likely related to the rotator cuff. A biopsy is unlikely to add information because of inherent difficulties interpreting low-grade cartilaginous lesions. Curettage and grafting and en bloc resection are excessive treatments for a benign lesion that is apparently asymptomatic. Observation with a follow-up radiograph in 3 to 6 months is appropriate.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.
Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.

Question 88:

Options:

a skeletal survey to rule out other fractures.
a punch biopsy of the skin for collagen analysis to rule out osteogenesis imperfecta.
DNA testing for osteogenesis imperfecta.
blood studies for calcium, phosphorus, and alkaline phosphate levels.
blood studies for parathyroid hormone levels.

Correct Answer: DNA testing for osteogenesis imperfecta.

Explanation:

Unwitnessed spiral fractures should raise the possibility of child abuse, especially prior to walking age. With nonaccidental trauma being considered in the differential diagnosis, a skeletal survey is indicated to determine if there are other fractures in various stages of healing.
(SBQ13PE.60) If a child develops dynamic supination after treatment of idiopathic clubfoot with Ponseti casting, at what age would it be appropriate to consider transfer of the tibialis anterior tendon to the lateral dorsum of the foot?
Review Topic
In the first six months of life, immediately following failed cast treatment
12 months
4 years
12 years
15 years
Tibialis tendon transfer to the dorsum of the foot should be performed to address dynamic supination when the lateral cuneiform has ossified. This is typically after at least 2 years of age and usually not before age 3.

Question 89:

A 40-year-old man with an acetabular chondrosarcoma has a small soft-tissue mass. Treatment should consist of

Options:

chemotherapy with ifosfamide and doxorubicin hydrochloride.
external beam radiation.
wide resection.
curettage and cementation of the pelvic lesion.
cemented total hip arthroplasty with acetabular reconstruction.

Correct Answer: wide resection.

Explanation:

Question 90:

Portions of which of the following normal structures help compose the spiral cord seen in Dupuytren’s contracture?

Options:

Lateral digital sheet and Grayson’s ligament
Lateral digital sheet and Cleland’s ligament
Lateral digital sheet and the transverse intermetacarpal ligament
Pretendinous band and Cleland’s ligament
Intrinsic muscle and the natatory ligament

Correct Answer: Lateral digital sheet and Grayson’s ligament

Explanation:

DISCUSSION: The normal fascial components that become diseased and compose the spiral cord include the pretendinous band, spiral band, lateral digital sheet, and Grayson’s ligament. Cleland’s ligament lies dorsal and is not involved with spiral cord formation. The intrinsic muscle and tendon, the natatory ligament, and the intermetacarpal ligament are well proximal to the digit and are not involved in spiral cord formation.
REFERENCES: McGrouther D: Dupuytren’s contracture, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone,
1999, vol 1, pp 565-569.
McFarlane R: Patterns of diseased fascia in the fingers in Dupuytren’s contracture.
Plast Reconstr Surg 1974;54:31-44.

Question 91:

Options:

the Moberg flap.
a third dorsal metacarpal artery flap.
a first dorsal metacarpal artery flap.
a full-thickness skin grafting.
a reverse cross-finger flap from the index finger with full-thickness skin grafting.

Correct Answer: a first dorsal metacarpal artery flap.

Question 92:

What acetabular procedure for developmental dysplasia of the hip does not require a concentric reduction of the femoral head in the acetabulum?

Options:

Salter innominate osteotomy
Pemberton innominate osteotomy
Dega innominate osteotomy
Triple innominate osteotomy
Staheli shelf procedure

Correct Answer: Staheli shelf procedure

Explanation:

DISCUSSION: All of the reorientation innominate osteotomies require a concentric reduction of the hip. The Staheli shelf procedure may be performed even with the hip subluxated, but it is a salvage procedure that covers a portion of the femoral head with capsular fibrocartilage rather than hyaline cartilage.
REFERENCES: Staheli LT, Chew DE: Slotted acetabular augmentation in childhood adolescence. J Pediatr Orthop 1992;12:569-580.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 618-650.

Question 93:

Options:

Axillary
Abductor pollicis brevis
Supinator
Triceps
Biceps

Correct Answer: Biceps

Explanation:

Question 94:

Figure 49 shows an acute axial MRI scan of a left knee. What is the most likely diagnosis?

Options:

Patellar tendon rupture
Lateral dislocation of the patella
Quadriceps tendon rupture
Anterior cruciate ligament rupture
Posterior cruciate ligament rupture

Correct Answer: Lateral dislocation of the patella

Explanation:

DISCUSSION: The MRI scan shows bone bruises in the medial aspect of the patella and the lateral aspect of the lateral femoral condyle. Both of these signs are typical for a lateral dislocation of the patella with spontaneous reduction. In addition, there may be associated tearing of the medial retinaculum or distal aspect of the vastus medialis.
REFERENCES: Elias DA, White LM, Fithian DC: Acute lateral patellar dislocation at MR imaging: Injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Radiology 2002;225:736-743.
Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the knee. Am J Sports Med 2005;33:131-148.
Miller TT: Magnetic resonance imaging of the knee, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 201-224.

Question 95:

Initial management should consist of Review Topic

Options:

cessation of throwing activities.
a long arm cast for 3 months.
a corticosteroid injection into the elbow joint.
excision of the fragment.
arthroscopic drilling of the lesion.

Correct Answer: cessation of throwing activities.

Explanation:

Question 96:

Options:

debridement and repair.
cast immobilization.
aggressive overload eccentric strengthening.
ice massage and continued athletic participation.
steroid injection.

Correct Answer: debridement and repair.

Explanation:

Question 97:

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 98:

Options:

medial soft-tissue tightening.
medial soft-tissue tightening with lateral column lengthening.
medial soft-tissue tightening with talonavicular fusion.
medial displacement osteotomy with flexor digitorum longus transfer into the tarsal navicular.
triple arthrodesis with lateral column lengthening.

Correct Answer: medial soft-tissue tightening with lateral column lengthening.

Explanation:

Question 99:

In the setting of a proximal tibial plateau fracture and its repair, which of the following materials is an isotropic material?

Options:

Proximal tibial cortical bone
Articular cartilage of the tibial plateau
Stainless steel tibial plate
Medial or lateral meniscus
Calcium phosphate cement

Correct Answer: Stainless steel tibial plate

Explanation:

DISCUSSION: An isotropic material is one that has similar mechanical properties regardless of the orientation of the material. Examples of isotropic materials include metals, plastics, and methacrylate. Most biologic tissues are anisotropic, meaning their mechanical properties alter depending on the materials’ orientation to the applied stress.
REFERENCE: Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007, pp 58-59.

Question 100:

Options:

Metastatic breast cancer
Fibrous dysplasia
Paget’s disease
Hyperparathyroidism
Rheumatoid arthritis

Correct Answer: Paget’s disease

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

Orthopedic Board Exam MCQs: Arthroplasty, Hip & Shoulder Surgery | Part 228

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 228

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index