Orthopedic Board Review MCQs: Arthroplasty, Fracture & Spine | Practice Part 230

Six weeks after open reduction internal fixation of a closed tibial pilon fracture, a patient has a draining wound with surrounding erythema and swelling. Radiographs show lucency around screws. What is the most appropriate treatment sequence?

Figure 42 shows the radiograph of a 70-year-old woman who has had a painful near ankylosis of her dominant elbow for 1 year. Treatment should consist of

A 63-year-old man has a feeling of generalized clumsiness in his arms and hands, difficulty buttoning his shirt, and gradually worsening gait instability. During examination, his neck is gently passively flexed to end range while he is seated. The patient describes an electric shock-like sensation that radiates down the spine and into the extremities. This describes which of the following? Review Topic

A 59-year-old man underwent interposition arthroplasty for osteoarthritis of the elbow 9 years ago. Over the past year the patient has had

A 54-year-old man undergoes total shoulder arthroplasty for osteoarthritis. Despite compliance with an early passive range-of-motion exercise program, he does not regain more than 90 degrees of elevation, 10 degrees of external rotation, and has internal rotation to the fifth lumbar vertebra. At 6 months, his motion fails to improve. Radiographs are shown in Figures 18a and 18b. What is the best course of action?

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

What proteinaceous compound binds to hyaluronic acid to function as an effective boundary molecular layer in articular cartilage?

A 10-year-old girl has been referred for evaluation of a prominence at the lower cervical spine. The patient is asymptomatic, and the examination reveals no evidence of neurologic abnormality. A radiograph and CT scans are shown in Figures 12a through 12c. What is the most likely diagnosis?

Which of the following factors has been shown to increase mortality in poly-trauma patients with severe head injuries?

A 23-year-old man cut the dorsal and ulnar aspects of his long finger on a table saw. The dorsal and ulnar skin over the middle phalanx is missing, with a 2-cm x 2-cm area of loss. There is a 50% loss of the extensor tendon (ulnar), and the remaining tendon has no tenosynovium. The physician should recommend irrigation and debridement and

Which of the following is accurate regarding low-molecular-weight heparin used for deep venous thrombosis (DVT) prophylaxis in total joint arthroplasty?

A 26-year-old weight lifter has had increasing pain in his left shoulder for 4 months. His symptoms do not improve with nonsurgical treatment that included activity modification, anti-inflammatory medication, and corticosteroid injections. He undergoes arthroscopic distal clavicle excision with resection of the distal 2.5 cm of clavicle. Three months after surgery, he reports persistent pain and popping in his shoulder. An examination demonstrates anterior and posterior instability of the distal clavicle without gross deformity. Radiographs are unremarkable. What is the most likely cause of distal clavicle instability after surgery?

A mother brings in her 6-month-old infant with a knee deformity. The child had previously been treated with serial casting in flexion for 3 month at an outside facility. Examination reveals passive hyperextension to 25° and passive flexion to 15° as shown in Figures A and B respectively. A lateral radiograph of the knee is shown in Figure C. What is the most appropriate next step in treatment? Review Topic

A 66-year-old male sustains an open crush injury to his right lower leg with significant skin loss. His history is significant for COPD, diabetes controlled with an insluin pump, and testicular cancer treated with bleomycin twenty years ago. A radiograph of the chest shows a pneumothorax which is treated with a thoracostomy tube. Which of the following is not a contraindication to hyperbaric oxygen treatment for this patient?

03 Which of the following findings is one of the diagnostic criteria for diffuse idiopathic skeletal hyperostosis?

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?

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

In a polytraumatized patient with a high lactate level, large base deficit, and pulmonary injury, what is the best initial treatment for a femoral shaft fracture?

A 2-year-old child is being evaluated for limb-length and girth discrepancy. As a newborn, the patient was large for gestational age and had hypoglycemia. Current examination shows enlargement of the entire right side of the body, including the right lower extremity and foot. The skin shows no abnormal markings, and the neurologic examination is normal. The spine appears normal.

A 30-year-old man who sustained a tibial fracture with a peroneal nerve palsy 2 years ago now has a drop foot and weak eversion of the foot. He reports success with stretching exercises, but he catches his toes when his foot tires. Examination reveals that the foot is plantigrade and supple. What is the next most appropriate step in management?

A 55-year-old male sustained a Sanders IV intra-articular calcaneus fracture two years ago that was treated nonoperatively. He presents to your office with a mechanical block preventing his ankle from dorsiflexing to neutral, continued severe pain and a widened heel. Radiographs show significant loss of calcaneal height and an incongruous subtalar joint. What is the most appropriate surgical treatment at this time?

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

Which statement is true with respect to acetabular fracture surgery as the time between injury and surgery increases?

The clinical photograph in Figure 27 shows a palsy of what nerve/associated muscle?

-T1-weighted, fat-saturated MRI scans are shown in Figures 37a and 37b. What is the next step intreatment?

A 6-year-old boy with severe spastic quadriplegic cerebral palsy is nonambulatory. Examination reveals 10° of hip abduction on the left and 30° on the right with the hips and knees extended. The Thomas test shows 20° of flexion bilaterally, and Ely test results are 3+/4 bilaterally. Radiographs show a center edge angle of 0° on the left and -10° on the right. The neck shaft angles are 170° bilaterally. Which of the following procedures would offer the best results?

A 17-year-old girl is involved in a motor vehicle collision and sustains the injury shown in Figures 46a through 46c. She is neurologically intact in her bilateral lower extremities. Definitive treatment should consist of A B C

Figure below shows the standing AP radiograph obtained from a 55-year-old man who has a 5-year history of daily left knee medial joint line pain with weight-bearing activities. He denies night pain or symptoms of instability. On examination, his range of motion is 0° to 140°. He has a mild, fully correctable varus deformity and a negative Lachman test result. Nonsurgical treatment has failed. What is the UKA survivorship for a 55- year-old patient, compared with the survivorship for total knee arthroplasty?

When performing a Green transfer for cerebral palsy—flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB)—in addition to improving wrist extension, what other motion may be improved if the FCU is routed around the ulna instead of through the interosseous membrane?

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

Steroids are thought to prevent neurologic deterioration after traumatic spinal cord injury by which of the following mechanisms? Review Topic

A 30-year-old elite marathon runner reports chronic pain over the lateral aspect of the distal right leg and dysesthesia over the dorsum of the foot with active plantar flexion and inversion of the foot. Examination reveals a tender soft-tissue fullness approximately 10 cm proximal to the lateral malleolus. The pain is exacerbated by passive plantar flexion and inversion of the ankle. There is also a positive Tinel’s sign over the site of maximal tenderness. There is no motor weakness, and deep tendon reflexes are normal. Radiographs and MRI of the leg are normal. What is the next most appropriate step in management?

A 68-year-old man with no significant medical history underwent a total knee arthroplasty 4 years ago. A radiograph is shown in Figure 55. He reports that he had no problems with the knee until 6 weeks ago when he noted the gradual onset of pain following a colonoscopy. Examination reveals a painful, swollen knee. Knee aspiration reveals a WBC count of 40,000/mm 3 . Management should consist of

A 36-year-old woman with familial neurofibromatosis has an enlarging mass in the posterior thigh. The lesion has slowly increased in size and is now constantly painful. Pressure on the mass causes dysesthesias in the foot. Figures 44a through 44c show T 1 -weighted, STIR, and T 1 -weighted fat-saturated gadolinium scans, respectively. Figure 44d shows a PET scan. What does this lesion most likely represent?

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

The bone avulsion shown in Figure 32 has a high correlation with tearing of the

What risk factor is most associated with progression of idiopathic scoliosis to a curve requiring surgery? Review Topic

All of the following are true statements regarding compartment syndrome in the pediatric patient EXCEPT:

Stability at the atlanto-occipital joint is provided mainly by

A 58-year-old man has a painful, warm, erythematous and fluctuant area over his left olecranon. An aspiration would be most likely to reveal

Figure 99 is the radiograph of an 18-year-old National Collegiate Athletic Association Division I basketball player who jumped for a basket. After landing, he was unable to put weight on his left great toe. He developed pain, swelling, and ecchymosis maximally around the sesamoids. When assessing stability of the first metatarsophalangeal joint, he appears to have more laxity on the left. What is the best next step?

Ulnohumeral distraction interposition arthroplasty is considered the most appropriate treatment for which of the following patients?

-Video 3 shows the physical examination of the right hip of a 14-day-old full-term female infant. There is no history of breech presentation, she was born vaginally, and is the second child born to her mother. She is otherwise healthy and has been eating and gaining weight appropriately. What is the most appropriate course of action at this time?

A patient with severe rheumatoid arthritis reports progressive hip pain. Serial hip radiographs will most likely show which of the following findings?

An 18-year-old collegiate football player injures his right shoulder during a tackle. He reports pain and numbness in the shoulder and numbness radiating to his fingers. His symptoms improve within 15 minutes and he has no residual symptoms. This condition is best known as

In Charcot-Marie-Tooth disease a progressive deformity develops in the foot. Which functional muscles predominate in deformity formation?

Figure 11 shows the radiograph of a 3-year-old girl who sustained a proximal radius injury. Appropriate initial management should include

When performing a bunionectomy with a release of the lateral soft-tissue structures, the surgeon is cautioned against releasing the conjoined tendon that inserts along the lateral base of the proximal phalanx of the great toe. This conjoined tendon is made up of what two muscles?

Refers to the effectiveness of various antibiotics against a particular microorganism.

Figures 1 and 2 are the radiographs of a 55-year-old man who has a 3-year history of right shoulder pain. He has maximized nonoperative management and is interested in operative treatment. He had an open Bankart repair 20 years ago and did well until a few years ago. What is most important to know when deciding on the best surgical treatment for this patient?

Figures 26a through 26c show the MRI scans of a 47-year-old man who underwent arthroscopic shoulder surgery 6 months ago and continues to have pain despite a prolonged course of rehabilitation. Management should now consist of Review Topic

During a transperitoneal approach to the L5-S1 interspace, care must be taken to protect the superior hypogastric plexus from injury. Which of the following techniques reduces the risk of neurologic injury?

Talar compression syndrome in ballet dancers typically involves injury to which of the following structures?

A 62-year-old active man returns for routine follow-up 16 years after hip replacement. He has no hip pain. Radiographs reveal a well-circumscribed osteolytic lesion around a single acetabular screw. All hip components are perfectly positioned. Comparison radiographs obtained 6 months later show an increase in the size of the osteolytic lesion. CT depicts a well-described lesion that is 3 cm at its largest diameter and is localized around one screw hole with an eccentric femoral head. What treatment is appropriate, assuming that well-fixed cementless total hip components are in place?

A 44-year-old man sustains the injury shown in Figures 1 through 3. What is the most appropriate treatment?

Figures 1 and 2 show the intraoperative photographs obtained from a man who is undergoing open reduction and internal fixation of a fifth carpometacarpal joint fracture dislocation. If the structure marked with an arrow in Figure 2 is cut, the patient can expect to experience

A previously asymptomatic 40-year-old man injures his shoulder in a fall. Examination shows that he is unable to lift the hand away from his back while maximally internally rotated. An axial MRI scan of the shoulder is shown in Figure 14. What is the most likely diagnosis?

An 82-year-old man is seen in consultation after being admitted for a fall from ground level. There was no loss of consciousness and the patient recalls striking his head and sustaining a hyperextension-type injury to the cervical spine. Examination reveals an 8-cm head laceration with only mild axial neck tenderness. He has generalized weakness throughout the upper extremities and maintained motor function of the lower extremities. There are no obvious sensory deficits, and the bulbocavernous reflex and deep tendon reflexes are maintained. What is the most appropriate diagnosis at this time?

A 20-year-old-man sustained a scapular fracture after attempting to grab a beam as he fell through a ceiling at a job site 3 months ago. A clinical photograph is shown in Figure 36. He now reports pain in the anterior shoulder and difficulty with overhead activities. What nerve roots make up the involved peripheral nerve?

Hamstring lengthening and posterior transfer of the rectus femoris will be most successful in a patient with cerebral palsy who has which of the following gait abnormalities?

A B C Figures 91a through 91c are CT images of a 76-year-old man who was involved in a motor vehicle collision. Which of the following scenarios would pose a contraindication to closed reduction of this injury prior to MR imaging?

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

Botulinum toxin is used to treat vasospastic disorders of the hand such as the Raynaud phenomenon to improve digital perfusion and reduce pain. Botulinum toxin enables which transmitter to be unopposed, resulting in vasodilation?

below show the radiographs, MRI, and MR arthrogram obtained from a year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has competed or practiced 5 to 6 times per week since the age of He denies any specific hip injury that necessitated treatment, but his trainer contends that he had a groin pull. He reports groin pain with passive flexion and internal rotation of the left hip, and his hip has less internal rotation than his asymptomatic right hip. He is otherwise healthy. What is the primary cause of a cam deformity?

A 50-year-old patient underwent multiple débridements for an open radial shaft fracture with bone loss. The bed currently shows no evidence of infection but has a 14-cm diaphyseal bone defect. The most appropriate treatment includes open reduction and internal fixation along with

A 45-year-old woman with a history of rheumatoid arthritis has C1-C2 instability with neurologic deterioration. Her posterior atlanto-dens interval is 10 mm. Which fixation technique will be the most biomechanically sound to facilitate fusion across the atlanto-axial junction?

When comparing arthroscopic lavage and knee debridement with placebo in patients with chronic symptomatic osteoarthritis, what outcome has been demonstrated?

Limited weight bearing usually is recommended following open reduction and internal fixation of intra-articular lower extremity fractures. A bone graft, or bone graft substitute is often placed in the metaphyseal void beneath the reduced articular fragments. Which of the following bone grafts or bone graft substitutes will most likely permit earlier weight bearing without subsidence of the articular reduction?

A 35-year-old man reports forefoot pain with weight-bearing activities. He reports that he has had high arches since adolescence but has never been treated. Examination reveals stiff cavus feet. He has no plantar callus or hammer toe formation. The ankle can be passively dorsiflexed 10°. Initial management should consist of

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

A 21-year-old man who was injured in a snowboarding accident 18 months ago now reports wrist pain. An MRI scan is shown in Figure 37. Based on the image findings, what is the most likely diagnosis?

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

What is the preferred treatment of a symptomatic curly toe deformity in a 6-year-old child?

Figures 1 through 5 are the MR images of a 12-year-old boy with left lateral-sided knee pain following a football injury. He has a several-year history of recurrent knee pain that improves with rest. An examination reveals a moderate effusion. Range of motion is 0° to 90° and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted. What other finding may be noted in patients with this diagnosis?

Figure 88 is the radiograph of a 68-year-old man who fell 3 weeks after undergoing a successful left primary total hip arthroplasty. He is experiencing a substantial increase in pain and an inability to bear weight. What is an appropriate treatment plan?

A 68-year-old man reports a 4-week history of progressive left-sided lower back and hip pain. The pain is in the posterior buttock region with radiation to the groin and to the left anterior knee region. The pain is aggravated with walking and improves with rest. There is no history of previous trauma. Radiographs are seen in Figures 14a and 14b, and MRI scans are seen in Figures 14c through 14e. What is the most appropriate treatment option at this time?

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

A 19-year-old running back lands directly on his anterior knee after being tackled. He has mild anterior knee pain, a trace effusion, a 2+ posterior drawer, a grade 1A Lachman, no valgus laxity, and negative dial tests at 30° and 90°. What is the best treatment strategy at this time?

A year-old patient fell 3 weeks after undergoing a total hip arthroplasty using cementless fixation of the femoral component. She sustained a comminuted Vancouver type B-2 fracture with displacement of the calcar fragment. What is the best treatment option?

An otherwise healthy 32-year-old man who underwent an uneventful L5-S1 lumbar microdiskectomy 6 weeks ago now reports increasing and severe back pain that awakens him from sleep. Examination reveals a benign-appearing wound, and the neurologic examination is normal. Laboratory studies show an erythrocyte sedimentation rate (ESR) of 90 mm/h and a WBC of 9,000/mm3. Plain radiographs are normal. What is the next most appropriate step in management?

A 5-year-old boy reports intermittent left elbow pain. History reveals that he injured his elbow 4 months ago, but had no treatment. He is now using his arm normally but reports pain almost daily. Examination reveals tenderness over the lateral epicondyle and a prominence is evident. Range of motion is from -5 degrees to 120 degrees. Radiographs are shown in Figure 67. Management should include

…The patient underwent an uneventful arthroscopic repair and did well until 1 year later when she crashed during a race. She tore her anterior cruciate ligament (ACL) and underwent reconstruction. Followup after her successful ACL reconstruction reveals complaints of new shoulder pain and posterior instability from using crutches after her ACL surgery. A new MRI scan is shown in Figure 24. What factors are most likely associated with this patient’s recurrence?

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

A 45-year-old man reports a history of a popping sensation and pain in the right shoulder while lifting boxes 6 months ago. The pain has persisted with loss of motion of the shoulder. Radiographs and MRI scans are shown in Figures 47a through 47d. Which of the following studies is likely to produce a significant positive result? Review Topic

Figure 10 shows the AP radiograph of an ambulatory 76-year-old patient. What is the most appropriate surgical treatment option for this patient?

A 17-year-old high school football player is seen for follow-up after sustaining an injury 3 days ago. He reports that he tackled a player, felt numbness throughout his body, and could not move for approximately 15 seconds. A spinal cord injury protocol was initiated on the field. Evaluation in the emergency department revealed a normal neurologic examination and full painless neck motion. He states that he has no history of a similar injury. An MRI scan of the cervical spine is normal. During counseling, the patient and his family should be informed that he has sustained

A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out with his left arm to prevent the defensive player from getting around him, and, as he grabbed the player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.” He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook test result is abnormal at the elbow. Which type of contraction of the involved muscle most likely resulted in this lineman's injury?

A 28-year-old woman has had pain in her hand and mild swelling of the little finger for the past 2 months. A radiograph is shown in Figure 41a, and the biopsy specimen is shown in Figures 41b and 41c. What is the most likely diagnosis?

Reconstruction of the injured structure is performed. After surgery, the patient initially notes limitation in motion, and later develops recurrent instability of the knee. Which factor most likely contributed to the development of instability?

An MRI scan

Which of the following structures are found in the anterior tarsal tunnel?

A 60-year-old right hand-dominant women fell on her outstretched arm and sustained an anterior shoulder dislocation. The shoulder is reduced in the emergency department and she is seen for follow-up 1 week later wearing a sling. Examination reveals that she has significant difficulty raising her arm in forward elevation and has excessive external rotation compared to the contralateral shoulder. What is the next most appropriate step in management? Review Topic

The mother of a 2-year-old boy reports that he had pain in the right hip all night and refuses to walk on the leg this morning. He is afebrile. Examination reveals pain on hip extension and adduction, but he is able to internally and externally rotate the hip approximately 20 degrees in each direction without pain. Laboratory studies reveal a WBC count of 7,400/mm 3 , with 62% polymorphonuclear neutrophil leukocytes. The AP radiograph shown in Figure 15 reveals a left teardrop distance of 8 mm, while the right side measures 10 mm. Which of the following diagnostic studies will best help confirm the diagnosis?

-An otherwise healthy 15-year-old wrestler has a 6-cm cutaneous lesion on the posterior aspect of his right elbow that he reports as a spider bite. What is the most likely diagnosis?

1mg/L (normal 1-3mg/L). Knee aspiration yields WBC of 673 cells/mm(3) with 30% polymorphonucleocytes, and a negative gram stain. There is no surrounding erythema but there is a 1cm area at the inferior aspect of the wound that has a large amount of serous drainage able to be expressed. She has a painless range of motion is 0° to 117°. What would be the next most appropriate step in management?