OITE Orthopedic Board MCQs: Fracture, Infection, Trauma

About This Board Review Set

This is Part 236 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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

Topics Covered in Part 236

This module focuses heavily on: Fracture, Infection, Trauma.

Sample Questions from This Set

Sample Question 1: A 21-year-old college defensive lineman sustains a minimally displaced (less than 1 mm) midthird scaphoid fracture during the first game of the season. Management should consist of...

Sample Question 2: Which of the following types of exercise used to increase flexibility is considered most beneficial in increasing joint range of motion?...

Sample Question 3: All of the following are factors associated with transfer of patients to Level 1 trauma centers EXCEPT:...

Sample Question 4: A 30-year-old woman has had pain in her right leg for the past 6 months. A lytic lesion is noted in the anterior cortex of the midtibia, extending 5 cm in length without a soft-tissue mass. A radiograph and a biopsy specimen are shown in Fi...

Sample Question 5: A 3-year-old girl developed torticollis eight months ago after a severe respiratory tract infection. A initial trial of halter traction was attempted without success. A trial of halo traction was then performed for 3 weeks and then a dynami...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

A 21-year-old college defensive lineman sustains a minimally displaced (less than 1 mm) midthird scaphoid fracture during the first game of the season. Management should consist of

Explanation

DISCUSSION: The union rate for minimally displaced midthird scaphoid fractures is quite high with cast immobilization while allowing a return to sports. Inadequate immobilization results in a much higher nonunion rate. Early fixation and rehabilitation have been proposed for sports or positions that are not amenable to cast immobilization. While immobilization of a nondisplaced fracture results in an acceptably high union rate, there is no advantage to fixation in conjunction with immobilization in the course of healing. With adequate immobilization and protection, play restrictions until healing has occurred are unnecessary.
REFERENCES: Rettig AC, Kollias SC: Internal fixation of acute stable scaphoid fractures in the athlete. Am J Sports Med 1996;24:182-186.
Rettig AC, Weidenbener EJ, Gloyeske R: Alternative management in midthird scaphoid fractures in the athlete. Am J Sports Med 1994;22:711-714.
Riester JN, Baker BE, Mosher JF, Lowe D: A review of scaphoid fracture healing in competitive athletes. Am J Sports Med 1985;13:159-161.

Question 2

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

Explanation

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

Question 3

All of the following are factors associated with transfer of patients to Level 1 trauma centers EXCEPT:

Explanation

DISCUSSION: Caucasian race has not been found to be a predictor for transfer to a Level 1 trauma center. The retrospective case-control study by Koval et al found that African-American race, presence of medical comorbidity, medicaid insurance, and male gender are predictors for transfer of patients to a trauma center that have ISS scores less than 9. The article by Nathens et al found that lack of insurance was an independent predictor for transfer to a trauma center after adjusting for differences in injury severity. An injury severity score of 36 represents a patient that has sustained life-threatening polytrauma and should be transferred to a Level 1 trauma center.

Question 4

A 30-year-old woman has had pain in her right leg for the past 6 months. A lytic lesion is noted in the anterior cortex of the midtibia, extending 5 cm in length without a soft-tissue mass. A radiograph and a biopsy specimen are shown in Figures 35a and 35b. What is the preferred treatment?

Explanation

DISCUSSION: In an adult with an anterior cortical tibial lesion, this is the classic histologic appearance and anatomic location for an adamantinoma. The histology reveals areas of epithelial cells (in a glandular pattern) within a fibrous stroma. The epithelial cells are shown in nests. They would stain positively for keratin. Adamantinoma is a rare malignant bone tumor with a propensity for late metastasis. It has a high incidence of local recurrence unless resected with a wide margin. Chemotherapy and radiation therapy are not helpful in the treatment of this disease. Amputation generally is not necessary because a diaphyseal resection is usually possible.
REFERENCES: McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 263.
Moon NF, Mori H: Adamantinoma of the appendicular skeleton: Updated. Clin Orthop Relat Res 1986;204:215-237.

Question 5

A 3-year-old girl developed torticollis eight months ago after a severe respiratory tract infection. A initial trial of halter traction was attempted without success. A trial of halo traction was then performed for 3 weeks and then a dynamic computed tomographic (CT) was obtained and shown in Figure A. Panel (a) shows an axial image with maximal rotation to the left. Panel (b) shows an axial image with maximal rotation to the right. What is the most appropriate next step in management? Review Topic

Explanation

Lumbar epidural injection
Physical therapy with core strengthening and anti-inflammatory medications as needed
Lumbar decompression
Lumbar decompression and fusion
MRI of the cervical and thoracic spine
The clinical scenario is consistent with a patient with symptoms of degenerative spondylolisthesis AND symptoms of myelopathy. Myelopathy must be ruled out by performing an MRI of the cervical and thoracic spine.
Tandem stenosis occurs in approximately 5 to 25% of patients. Because of the stepwise progressive nature of myelopathy, treatment of myelopathy often takes precedence over lumbar spinal stenosis.
Rhee et al. found that the sensitivity and specificity of specific physical exam findings varies. Both the upward babinski reflex and the presence of clonus were found to be very non-sensitive (13%). The most sensitive provacative test was found to be the Hoffman sign (59%).
Salvi et al. reviewed the classic presentations for cervical myelopathy including demographics, history, and physical exam findings (the inability to preform a tandem gait, hyperreflexia, an abnormal babinksi and hoffman reflex, the inability to preform rapid movements and bilateral muscle weakness). Additionally they identify other potential causes for myelopathy, including multiple sclerosis, amyotrophic lateral sclerosis, multifocal motor neuropathy, and Guillain-Barre´syndrome.
Maezawa et al. showed that gait analysis can identify a pattern in patients with myelopathy. Patients with severe myelopathy have a characteristic gait with hyperextension of the knee in the stance phase without plantar flexion of the ankle in the swing phase. They also have decreased walking speed and stride length with a prolonged stance phase.
Figure A and B show a classic degenerative spondylolisthesis.
Incorrect Answers:

Question 6

A 12-year-old girl has progressive development of cavus feet. Examination reveals slightly diminished vibratory sensation on the bottom of the foot. Reflexes are 1+ at the knees and ankles. Motor examination shows that all muscles are 5/5 in the foot, except the peroneal and anterior tibial muscles are rated as 4+/5. Which of the following studies is considered most diagnostic?

Explanation

DISCUSSION: The patient most likely has a form of Charcot-Marie-Tooth disease, or hereditary motor sensory neuropathy (HMSN). The most common varieties can now be diagnosed by DNA testing. Mutations have been detected in the peripheral myelin protein-22 (PMP-22) gene in HMSN type IA and in the connexin gene in the x-linked HMSN. Specific DNA diagnosis is useful in genetic counseling. Routine chromosomal testing most likely would not detect these mutations. Nerve conduction velocity study results are normal in some types of HMSN, and delayed nerve conduction, when found, indicates a peripheral neuropathy but does not specify the type or inheritance pattern. Biopsy of the sural nerve or of the quadriceps can be informative in some patients, but is not as specific as DNA testing. These procedures are most often reserved for patients with negative DNA test results.
REFERENCES: Chance PF: Molecular genetics of hereditary neuropathies. J Child Neurol 1999;14:43-52.
Bell C, Haites N: Genetic aspects of Charcot-Marie-Tooth disease. Arch Dis Child 1998;78:296-300.

Question 7

Figure 242 is the anteroposterior radiograph of a 28-year-old man who underwent resection and reconstruction for an Ewing sarcoma. What is the most common functional deficit encountered during rehabilitation?

Explanation

Question 8

What complication is most likely to occur following proximal humeral fixation with a locked plate-and-screw construct?

Explanation

Proximal humeral locking plates have been associated with screw penetration (incidence 23%). The rotator cuff injury is not due to the plate or its application and is associated with dislocations in the elderly. Axillary nerve damage, while possible, has a low reported incidence from open reduction and internal fixation of the proximal humerus with locking constructs. Impingement and fracture of the humeral shaft are also unlikely. More likely but not offered as a choice is the problem of varus
reduction which can result in failure. However, penetration of the screws remains the most commonly reported complication.

Question 9

If the structure marked by the tip of the probe in Figure 94 is repaired to the bony glenoid with suture anchors during an arthroscopic stabilization procedure, what is the most likely result? Review Topic

Explanation

The probe is on the middle glenohumeral ligament (MGHL), which, in this case, is a cord-like and robust structure, commonly known as a Buford complex. The space between the bony glenoid and the MGHL (in this case, a cord-like Buford complex) is a normal variant and should not be repaired or tightened to the bony glenoid with a soft-tissue anchor or other repair. If this structure is inadvertently repaired, the most common scenario is loss of external rotation with the arm at the side, as the MGHL/Buford complex becomes tight with the arm in this position. The loss of external rotation is more pronounced with the arm at the side than abducted at 90 degrees as the MGHL/Buford complex becomes tighter with the arm at the side than abducted.

Question 10

-This boy’s parents are eager to get him back on the field as soon as possible. What is the most appropriate treatment option?

Explanation

DISCUSSION FOR QUESTIONS 60 AND 61
Although a recent increase in the number of pitches may have contributed to this patient’s development of little leaguer’s shoulder, the most significant overall factor is age. Little leaguer’s shoulder is caused by rotational stress placed on the proximal humeral epiphysis during overhead throwing. The growth plate is weakest to torsion stress, and is most susceptible to injury during periods of rapid growth commonly seen during puberty. Most chronic shoulder injuries occur in throwing athletes between 13 and 16 years of age. Genetic factors and gender have not been studied in association with little leaguer’s shoulder. An initial 3-month period of rest and activity modification will typically result in resolution of symptoms.Nonsteroidal anti-inflammatory drugs may be used as needed. After the rest period, a gradual return to baseline pitching is implemented until the patient is back to baseline. This protocol has a long-term success rate exceeding 90%.

Question 11

A 27-year-old man now reports dorsiflexion and inversion weakness after an automobile collision 6 months ago in which compartment syndrome developed isolated to the anterior and deep posterior compartments. Examination reveals the development of a progressive cavovarus deformity, but the ankle and hindfoot remain flexible. In addition to Achilles tendon lengthening, which of the following procedures is most likely to improve the motor balance of his foot and ankle?

Explanation

DISCUSSION: Compartment syndrome of the anterior and deep posterior compartments results in anterior tibialis and posterior tibialis tendon weakness, respectively. Furthermore, the long flexors to the hallux and lesser toes will be weak as well. The intact peroneus longus overpowers the weak anterior tibialis tendon, resulting in plantar flexion of the first metatarsal, cavus, and hindfoot varus. Therefore, transferring the peroneus longus to the dorsolateral midfoot reduces the first metatarsal plantar flexion torque, and possibly augments ankle dorsiflexion torque.
REFERENCES: Hansen ST: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott, Williams & Wilkins, 2000, pp 433-435.
Vienne P, Schoniger R, Helmy N, et al: Hindfoot instability in cavovarus deformity: Static and dynamic balancing. Foot Ankle Int 2007;28:96-102.

Question 12

Which radiographic abnormality most accurately serves as a predictor of ankle syndesmosis disruption?

Explanation

DISCUSSION
Normal syndesmotic relationships include a tibiofibular clear space smaller than 6 mm on both AP and mortise views. In a 1989 cadaveric study by Harper and Keller, a tibiofibular clear space exceeding 6 mm on both the AP and mortise views was the most reliable predictor of early syndesmotic widening. Tibiofibular overlap is measured 1 cm proximal to the plafond. Normal values exceed 6 mm or 42% of the width of the fibula on the AP view, or 1 mm on the mortise view. Proximal fibula fracture can occur in isolation without syndesmotic injury, frequently after direct trauma. The medial clear space is the distance between the lateral border of the medial malleolus and the medial border of the talus and is measured at the level of the talar dome. In the mortise view with the ankle in neutral dorsiflexion, the medial clear space should be equal to or smaller than the superior clear space between the talar dome and the tibial plafond. ?A normal medial clear space may be present with syndesmotic injury and consequently lacks sensitivity and specificity.
RECOMMENDED READINGS
Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg. 2007 Jun;15(6):330-9. Review. PubMed PMID: 17548882. View Abstract at PubMed
Wuest TK. Injuries to the Distal Lower Extremity Syndesmosis. J Am Acad Orthop Surg. 1997 May;5(3):172-181. PubMed PMID: 10797219. View Abstract at PubMed
Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989 Dec;10(3):156-60. PubMed PMID: 2613128. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 40
A 41-year-old man sustained a twisting injury while running up stairs 4 weeks ago. He was treated in an ankle brace and has been bearing weight since the injury occurred. He has no history of ankle problems, but he now has ankle pain, swelling, and instability. The pain is aggravated by stairs, and the instability is worse on unlevel ground. Radiographs do not show a fracture.

Question 13

A normal functioning posterior tibialis tendon is best confirmed by which of the following physical findings?

Explanation

The main function of the Tib. Post. Tendon is inversion of the subtalar joint and adduction of the forefoot. This initial inversion stabilizes the subtalar joint allowing the gastrosoleus complex to forcibly invert the joint while plantarflexing the ankle. Heel inversion begins during flatfoot when the Tib Post. fires at 7% of the walking cycle. The gastrosoleus kicks in at 30% of the cycle to maintain inversion, which locks the midfoot for push-off.

Question 14

A 58-year-old woman has had a slowly progressing mass over the distal interphalangeal (DIP) joint of her dominant hand with a worsening deformity of her nail. She has no significant medical history but underwent bilateral knee arthroplasties 1 year ago. Radiographs reveal a small osteophyte at the DIP joint dorsally. A clinical photograph and a biopsy specimen are shown in Figures 76a and 76b. What is the most likely diagnosis?

Explanation

DISCUSSION: A mucous cyst is thought to be a ganglion arising from the DIP joint in patients with osteoarthritis. They are frequently associated with nail deformities. Treatment involves removal of the cyst with debridement of DIP joint osteophytes.
REFERENCES: Fritz GR, Stern PJ, Dickey M: Complications following mucous cyst excision. J Hand Surg Br 1997;22:222-225.
Zook EG, Brown RE: The perionychium, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, vol 2, pp 1353-1380.

Question 15

Local administration of recombinant bone morphogenetic protein-2 (rhBMP-2) to patients with type III-A and III-B open tibial shaft fractures at the time of initial surgery has shown all of the following when compared to standard treatment EXCEPT:

Explanation

DISCUSSION: The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) to improve the healing of open tibial shaft fractures has been the focus of two prospective clinical studies. Swiontkowski et al showed when compared to the control group (intramedullary nail fixation and routine soft-tissue management), the group receiving the rhBMP-2 required fewer bone-grafting procedures (p = 0.0005), fewer invasive secondary interventions (p = 0.0065), and there was a lower rate of infection (p = 0.0234). A shorter-term study by Govender et al showed significantly more patients treated with rhBMP-2 had healing of the fracture at the postoperative visits from ten weeks through twelve months (p = 0.0008). Govender et al found similiar results in regards to a decreased need of secondary procedures, improvement in time to union, improved wound healing and decreased infection rate in those who received BMP-2.

Question 16

This medication, a factor Xa inhibitor, currently is not approved for venous thromboembolism (VTE) prophylaxis.

Explanation

DISCUSSION
Warfarin has a long clinical track record and is well known among most physicians. It is a vitamin K antagonist that can be monitored with prothrombin time (INR) testing and reversed with vitamin K and fresh frozen plasma if needed. Newer oral anticoagulants are becoming more common and offer the advantage of being rapidly active without a need for monitoring. These oral anticoagulants are not reversible, which can complicate the treatment of patients who present with bleeding or require surgery. Dabigatran (Pradaxa) is a direct thrombin inhibitor that is approved for stroke prevention in atrial fibrillation. It is not reversible, and a surgical delay of 24 to 48 hours is recommended for all but emergent surgeries. A longer delay is recommended with renal insufficiency. Rivaroxaban (Xarelto) is an oral factor Xa inhibitor that is approved for atrial fibrillation and the treatment of VTE and deep vein thrombosis prophylaxis. It offers the advantage of daily dosing. It
is not reversible and a surgical delay of 36 to 48 hours is recommended. Apixaban (Eliquis) is another factor Xa inhibitor for which twice-daily dosing is required. It is currently approved for stroke prevention in atrial fibrillation, and a surgical delay of 36 to 48 hours is recommended.
RECOMMENDED READINGS
Gonsalves WI, Pruthi RK, Patnaik MM. The new oral anticoagulants in clinical practice. Mayo Clin Proc. 2013 May;88(5):495-511. doi: 10.1016/j.mayocp.2013.03.006. Review. Erratum in: Mayo Clin Proc. 2013 Jul;88(7):777. PubMed PMID: 23639500. View Abstract at PubMed Alquwaizani M, Buckley L, Adams C, Fanikos J. Anticoagulants: A Review of the Pharmacology, Dosing, and Complications. Curr Emerg Hosp Med Rep. 2013 Apr 21;1(2):83-97. Print 2013 Jun. PubMed PMID: 23687625. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 100 AND 101
A 55-year-old woman slipped on ice while getting out of her car and sustained the injury shown in Figure 100.

Question 17

Figure A shows the 2 bundles of the ACL dissected from a cadaveric knee off their bony attachments. They are labeled Bundle A and Bundle B, respectively. Which of the following is true? Review Topic

Explanation

Bundle A is the anteromedial (AM) bundle, which is longer, and is tight in flexion. Bundle B is the posterolateral (PL) bundle, which is shorter, and is loose in flexion. The AM bundle is attached anterior to the PL bundle on the tibia.
The ACL is comprised of 2 bundles. The AM bundle is longer than the PL bundle.
Their names reflect their relative anatomic positions on the tibial insertion site. On the femur, the AM bundle begins at the proximal-anterior aspect of the femoral insertion site, while the PL bundle begins at the posterior-inferior part. In flexion, the AM bundle is tight and the PL bundle is loose. In extension, the AM bundle is loose and the PL bundle is tight.
Bicer et al. reviewed the anatomy of the ACL. They found that the AM bundle was longer (32mm) compared with the PL bundle (18mm). PL bundle carries greater force near full extension, and the AM bundle carries greater force after 15-45° of flexion. Under combined rotatory loads (valgus and internal tibial torque at knee flexion
>30°), the AM bundle bore more force than the PL bundle.
Figure A shows the 2 bundles of the ACL. The AM bundle is longer than the PL bundle. The oft referred to length of ACL refers mainly to the length of the AM bundle. Illustrations A and B show the spatial relationships of the AM and PL bundles in a cadaveric knee. Illustration C shows the relative positions of the attachments of each bundle.
Incorrect

Question 18

A 42-year-old woman reports that she has low back pain and had a transient loss of consciousness after falling off a horse. She denies having neck pain but notes that she was involved in a motor vehicle accident 2 years ago and had neck pain at that time. Examination reveals full range of motion of the neck and no localized tenderness. The neurologic examination is normal. A lateral radiograph of the cervical spine is obtained. Figures 41a and 41b show CT and MRI scans. What is the most likely diagnosis?

Explanation

DISCUSSION: The examination findings do not correlate with an acute injury (full range of cervical motion and the absence of pain). Radiographically, the fracture appears old based on the smooth contour of the fracture fragments and the absence of soft-tissue swelling. Flexion-extension radiographs can be obtained to determine potential instability; if present, stabilization and fusion should be considered.
REFERENCES: Schatzker J, Rorabeck CH, Waddell JP: Non-union of the odontoid process: An experimental investigation. Clin Orthop 1975;108:127-137.
Clark CR, White AA III: Fractures of the dens: A multicenter study. J Bone Joint Surg Am 1985;67:1340-1348.

Question 19

It is recommended that invasive dental work be completed prior to the initiation of which of the following medications?

Explanation

Bisphosphonate therapy combined with invasive dental work increases the risk for development osteonecrosis of the jaw.
Bisphosphonates are a class of drugs that prevent bone mass loss by inhibiting osteoclast resorption. They are used in the treatment of vertebral compression fractures, non-vertebral fragility fractures, osteogenesis imperfecta, multiple myeloma, and avascular necrosis. Because bisphosphonates have been associated with osteonecrosis of the jaw, it is suggested that all invasive dental work be completed prior to initiation of treatment.
Pazianas et al. (2011) review the safety profile of bisphosphonates. Specifically, they cite gastrointestinal discomfort, atypical femur fractures, osteonecrosis of the jaw, ocular inflammation, and musculoskeletal pain as common side effects. They state there is limited evidence surrounding bisphosphonate's association with esophageal cancer and atrial fibrillation.
Pazianas et al. (2007) reviewed 11 publications that reported 26 cases of osteonecrosis of the jaw following initiation of bisphosphonate treatment. Age >60 years, female sex, and previous invasive dental treatment were the most common characteristics of those who developed ONJ.
Illustration A shows the various bisphosphonates and their mechanisms of action. Illustration B shows an example of osteonecrosis of the jaw, a side effect that has been linked to bisphonphonate treatment.
Incorrect Answers:

Question 20

A 23-year-old woman sustains an injury to her right hand after falling off her snowboard. Examination reveals that she has difficulty moving her fingers. A radiograph and a clinical photograph are shown in Figures 8a and Figure 8b. Management should consist of

Explanation

DISCUSSION: The radiograph reveals oblique fractures of the third and fourth metacarpals. The rotational component of the fracture displacement is well visualized on the clinical photograph, which shows scissoring of the middle finger over the ring finger. The fracture obliquity results in rotational deformity that cannot be adequately maintained and held by closed treatment. The treatment of choice is open reduction and internal fixation.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999, pp 711-771.
Freeland AE, Benoist LA, Melancon KP: Parallel miniature screw fixation of spiral and long oblique hand phalangeal fractures. Orthopedics 1994;17:199-200.
Freeland AE, Geissler WB: Plate fixation of metacarpal shaft fractures, in Blair WF (ed): Techniques in Hand Surgery. Baltimore, MD, Williams and Wilkins, 1996, pp 255-264.

Question 21

-What gene is implicated in spinal muscular atrophy?

Explanation

Question 22

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

Explanation

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

Question 23

Lateral malleolus fractures can be treated with a variety of techniques, including posterior antiglide plating or lateral neutralization plating. What is an advantage of using lateral neutralization plating instead of posterior antiglide plating?

Explanation

DISCUSSION: Posterior antiglide plating is a technique that involves placement of a plate on the posterior aspect of the distal fibula, using the plate as a reduction tool and direct buttress against distal fracture fragment displacement.
Schaffer et al showed from a biomechanical standpoint that posterior antiglide plating was superior to lateral neutralization plating for distal fibula fracture fixation.
Weber et al reported a (30/70) 43% rate of plate removal secondary to peroneal discomfort. In addition, peroneal tendon lesions were found in 9 of the 30 patients.

Question 24

A newborn girl with an isolated unilateral dislocatable hip is placed in a Pavlik harness with the hips flexed 100 degrees and at resting abduction. Figure 23 shows an ultrasound obtained 2 weeks later. What is the next step in management? Review Topic

Explanation

The infant has a well-positioned hip in the Pavlik harness and treatment should be continued in the current position. The success rate is over 90% with the use of this device for a dislocatable hip. Ultrasound is a useful tool to confirm appropriate positioning of the cartilaginous femoral head during treatment. If the femoral head is
not reduced after 2 to 3 weeks in the harness, this mode of treatment should be abandoned. Forceful extreme abduction can cause osteonecrosis of the femoral epiphysis and should be avoided. Closed reduction, arthrography, and spica casting are indicated if the hip cannot be maintained in a reduced position with the harness.

Question 25

A 68-year-old woman had advanced right knee arthritis and total knee replacement was planned. She learned she had primary biliary cirrhosis at age 41 and now has advancing liver failure. Preoperative coagulation tests show a baseline International Normalized Ratio (INR) of 1.36. Appropriate methods to prevent thromboembolic disease as recommended by the 2011 AAOS Clinical Practice Guideline, Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty , include

Explanation

The 2011 AAOS Clinical Practice Guideline, Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty, recommends the use of mechanical prophylaxis for patients at increased risk for bleeding (including those with liver disease or hemophilia). This recommendation is the consensus of the workgroup that established these guidelines because there was insufficient evidence to justify a stronger recommendation in this clinical scenario. The other responses use no prophylaxis or pharmacological prophylaxis. Pharmacological prophylaxis is not recommended in patients who are at increased risk for bleeding.

Question 26

A 23-year-old male is involved in a motor vehicle accident and sustains a left open femur fracture, right open humeral shaft fracture, and an LC-II pelvic ring injury. Which of the following best describes the radiographic findings associated with this pelvic injury pattern using the Young-Burgess Classification system?

Explanation

DISCUSSION: Lateral compression type II fractures (as described by the Young-Burgess Classification System) are associated with a crescent fracture of the iliac wing located on the side of impact. A representative CT scan image and illustration of this injury are shown in Illustration A and B respectively. A table describing each pelvic injury and their associated complications is shown in Illustration C. Illustration D shows each Young-Burgess pelvic injury type.
Burgess et al discuss the effectiveness of a treatment protocol as determined by their pelvic injury classification and hemodynamic status. The injury classification system was based on lateral compression, anteroposterior compression, vertical shear, and combined mechanical injury types. They found that their classification-based treatment protocols reduce the morbidity and mortality related to pelvic ring disruption.
Tile discusses acute pelvic trauma and his classification system for pelvic injuries (ie. Types A, B, and C). He states that any classification system must be seen only as a general guide to treatment, and that the management of each patient requires careful, individualized decision making.
Incorrect
2:
This
describes
an
APC-II
injury
3:
This
describes
an
APC-III
injury
4:
This
describes
and
LC-I
injury

Question 27

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?

Explanation

DISCUSSION: The patient has a global loss of motion that has failed to improve with 6 months of nonsurgical treatment; because he has reached a plateau, further nonsurgical management will likely be ineffective. Revision in the form of an open release is indicated to lyse intra- and extra-articular adhesions; subscapularis lengthening may be done concurrently as needed. Revising to a smaller head can be considered if adequate motion is not achieved. The radiographs reveal an adequate neck cut with appropriate seating of the component. Removing the glenoid component will decrease capsular tension but will probably increase pain because of the lack of glenoid resurfacing. Increasing humeral retroversion will not improve motion.
REFERENCES: Cuomo F, Checroun A: Avoiding pitfalls and complication in total shoulder arthroplasty. Orthop Clin North Am 1998;29:507-518.
Wirth MA, Rockwood CA Jr: Complications of shoulder arthroplasty. Clin Orthop 1994;307:47-69.

Question 28

A 44-year-old woman has bilateral knee pain, and history reveals bilateral hip replacements. Radiographs are seen in Figure 28a, and histopathologic specimens from the total hip replacement are shown in Figures 28b and 28c. Laboratory studies reveal anemia. What is the most likely diagnosis?

Explanation

DISCUSSION: Rheumatoid arthritis is an inflammatory arthritis that usually involves multiple joints. Radiologic findings of periarticular erosion, osteopenia, and minimal osteophyte formation favor rheumatoid arthritis over osteoarthritis. Pigmented villonodular synovitis and Charcot arthropathy are more often considered monoarticular diseases. There are no radiographic findings of Paget’s disease.
REFERENCE: Dutkowsky J: Miscellaneous non traumatic disorders, in Crenshaw A (ed): Campbell’s Operative Orthopaedics. St Louis, MO, Mosby, 1992, pp 2007-2012.

Question 29

Figures 1 and 2 are the clinical photographs of a 36-year-old woman who cannot fully extend the metacarpophalangeal (MP) joints of her long and ring fingers 9 months after the removal of a plate from the proximal radius via a dorsal approach. What is the most likely cause of this problem?

Explanation

EXPLANATION:
Plating of the proximal radius from a dorsal or Thompson approach (between the extensor carpi radialis brevis and extensor digitorum communis) allows complete visualization of the PIN through the supinator. Going through the same incision from proximal to distal produces a scar-filled proximal approach, and it is not uncommon to drift ulnarly and injure an individual nerve to the extensor digitorum communis muscle, resulting in the deformity seen in Figures 1 and 2.Postsurgical tendon adhesions rarely involve only 2 tendons. Complete tendon lacerations are rare at this level in the proximal forearm, as is a complete laceration of the PIN. Neuropraxias are common but usually resolve after 3 months. The gossamer-thin branch of the PIN to the EDC can be easily damaged in scar tissue, resulting in an inability to fully extend the MP joints of the long and ring fingers. The proprius tendons allow the patient to fully extend the index and little finger MP joints. Connecting the EDC of the long finger to the extensor indicis proprius and the EDC of the ring finger to the extensor digiti quinti proprius can correct the deformity. To avoid the problem, the surgeon should start the incision distally in normal anatomy, and the interval between the mobile wad and the digital extensors will be more easily found.

Question 30

The term anorexia athletica refers to a problem whose criteria include all of the following, EXCEPT Review Topic

Explanation

Anorexia athletica is a newer term that may generally replace the "triad" of disordered eating, menstrual dysfunction, and osteoporosis. True osteoporosis is actually relatively uncommon in the female athlete, and thus the traditional diagnostic criteria are rarely met. In anorexia athletica, multiple signs and symptoms are used to reach the diagnosis. Specifically, however, a diagnosis of anorexia athletica requires the absence of any affective disorder, such as depression.

Question 31

Figures 2a and 2b are this patient’s proton density fat-saturated MR images. His tibial tubercle-trochlear groove (TT-TG) distance is 12 mm, and he has normal limb-alignment film findings. Treatment at this stage should include

Explanation

DISCUSSION
This patient’s examination and history indicate recurrent patellar dislocations. Radiographs show an osseous or osteochondral loose fragment. There is no evidence of an obvious nondisplaced fracture or physeal changes. In the setting of suspected patella dislocation or subluxation with loose fragment seen on radiograph, an MRI is indicated. Lateral release alone is seldom indicated in a knee that is normal before injury. The examination and MRI do not indicate a need for medial collateral ligament repair. Treatment should consist of arthroscopy or arthrotomy and attempted internal fixation of this fragment. If fixation is not possible, the loose body can be removed. Normal TT-TG values, an increased lateral patellar glide, and a history of recurrent patellar dislocations after trauma suggest MPFL incompetence and the need for reconstruction.

Question 32

Figure 1 shows the radiograph obtained from a 67-year-old man recently diagnosed with osteoarthritis, 8 years after receiving a left metal-on-metal total hip arthroplasty (THA). The acetabular component has a modular cobalt alloy acetabular liner. The patient states that he did very well postoperatively, but for the last 6 months has noted worsening pain and swelling in his left hip. Serum metal ion testing reveals a chromium level of 12.4 ng/mL, compared with a normal level of less than 0.3 ng/mL, and a cobalt level of 11.8 ng/mL, compared with a normal level less than 0.7 ng/mL. An MRI with metal artefact reduction sequence (MARS) was performed and is shown in Figure 2. What is the most appropriate management at this time?

Explanation

DISCUSSION:
Metal-on-metal THA was initially introduced in the 1990s, with the proposed advantages of decreased wear and improved stability. However, catastrophic adverse local tissue reactions associated with their use has raised numerous concerns. The work-up of a patient with a prior metal-on-metal total hip arthroplasty involves a thorough history and physical examination; blood analysis, including the erythrocyte sedimentation rate, C-reactive protein, and metal ion levels; and secondary imaging, including ultrasonography, CT, and MRI. In a patient with clinical symptoms, elevated metal ion levels, and a large fluid collection seen on MRI, the most appropriate treatment would be removal of the metal-on-metal bearing. Given the presence of an adverse reaction involving cobalt and chromium, a revision ceramic head may be most appropriate to avoid the potential of trunnion-associated corrosion.

Question 33

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

Explanation

DISCUSSION: Symptomatic herniations of the thoracic spine are much less common than those of the cervical or lumbar region. They tend to occur most commonly during the third to fifth decades of life and although they can be found at all levels, they are most common in the lower third near the thoracolumbar region. Posterior laminectomy and disk excision has the highest rate of neurologic deterioration and is not recommended. Multiple studies have shown that herniated thoracic disks can be found at one or more levels in 40% of asymptomatic individuals.
REFERENCES: Shah RP, Grauer JN: Thoracoscopic excision of thoracic herniated disc, in Vaccaro AR, Bono CM (eds): Minimally Invasive Spine Surgery. New York, NY, Informa Healthcare, 2007, pp 73-80.
Bohlman HH, Zdeblick TA: Anterior excision of herniated thoracic discs. J Bone Joint Surg Am 1988;70:1038-1047.

Question 34

A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with Review Topic

Explanation

An isolated avulsion of the lesser tuberosity occurs very rarely and usually is found in 12- and 13-year-old adolescents. The MRI scans reveal a tear of the humeral attachment of the inferior glenohumeral ligament, a so-called HAGL lesion. This injury to the inferior glenohumeral ligament occurs much less commonly than the classic Bankart lesion (anterior inferior labral tear). A tear of the subscapularis occurs with a similar mechanism of injury but generally occurs in older individuals.

Question 35

A 51-year-old female presents with an acute inability to extend her thumb, four months after she was treated with cast immobilization for a minimally-displaced distal radius fracture. What is the most appropriate treatment at this time?

Explanation

DISCUSSION: A rare complication of non-displaced or minimally displaced fractures of the distal radius treated with a cast is a delayed rupture of the extensor pollicis longus (EPL) tendon. The EPL is the primary extensor of the interphalangeal joint of the thumb and also assists with metacarpophalangeal extension. Extensor indicis proprius transfer to the EPL is the most widely used and reported treatment for this condition.
Magnussen et al. reviewed results of EIP transfer following ruptures of the EPL, with 19/21 good results. None of the cases had any loss of independent index finger extension although index extensor strength reduced to half of that of the contralateral side.
Hove et al. reported a similar satisfaction rate following treatment of 15 patients. In his series of 4,400 distal radius fractures treated over a 5 year period, the incidence of delayed tendon rupture following distal radius fracture was 0.3 percent.

Question 36

Disadvantages of anterior-inferior plate fixation for acute clavicular fractures relative to superior plating include

Explanation

Anterior-inferior plate fixation of midshaft clavicular fractures has evolved to be an alternative plate location compared to superior plating. The advantages of anterior-interior plating are reduced prominence of the hardware compared to the subcutaneous superior plates; the potential for placement of longer screws as the clavicle is wider front to back than top to bottom, especially laterally; and a potential for decreased risk to the subclavian structures. A relative disadvantage of anterior-inferior plating is a need to detach a small portion of the deltoid origin. Union rates for anterior-inferior plating are similar to those with superior plating.

Question 37

A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and

Explanation

Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear.

Question 38

A 31-year-old woman has a history of a painful ankle that has failed to respond to conservative management. She has associated night pain that is relieved with nonsteroidal anti-inflammatory drugs. MRI and technetium Tc 99m scans are consistent with an osteoid osteoma. Management should now consist of

Explanation

DISCUSSION: Surgical curettage or en bloc resection is the treatment of choice for osteoid osteoma. Night pain and relief of symptoms with nonsteroidal anti-inflammatory drugs are classic findings for osteoid osteoma.
REFERENCES: Donley BG, Philbin T, Rosenberg GA, Schils JP, Recht M: Percutaneous CT guided resection of osteoid osteoma of the tibial plafond. Foot Ankle Int 2000;21:596-598.
Kenzora JE, Abrams RC: Problems encountered in the diagnosis and treatment of osteoid osteoma of the talus. Foot Ankle 1981;2:172-178.
Shereff MJ, Cullivan WT, Johnson KA: Osteoid-osteoma of the foot. J Bone Joint Surg Am 1983;65:638-641.

Question 39

A patient has a C6 spinal cord injury. Following stabilization of the spine, the patient should be advised that their expected maximum level of function

Explanation

A patient with an injury at the level of: C4 injury needs puffer control; C5 can use hand controls; C6 can use a manual wheelchair and sliding board transfers; C7 allows independent transfers; and no cervical injury routinely allows ambulation with crutches and leg braces.

Question 40

The thickest bone in the occiput is located

Explanation

DISCUSSION: Anatomic studies have shown that the thickest bone of the occiput is at the level of the external occipital protuberance. It ranges from 11.5 mm to 15.1 mm in men and from 9.7 mm to 12 mm in women. In general, the bone thins as it extends distally from the external occipital protuberance and it also moves laterally from the midline. The structures at risk during screw placement include the venous sinuses.
REFERENCES: Nadim Y, Lu J, Sabry FF, et al: Occipital screws in occipitocervical fusion and their relation to the venous sinuses: An anatomic and radiographic study. Orthopedics 2000;23:717-719.
Ebraheim N, Lu J, Biyani A, et al: An anatomic study of the thickness of the occipital bone: Implications for occipitocervical instrumentation. Spine 1996;21:1725-1729.

Question 41

The best indication for a knee fusion after a failed total knee replacement is

Explanation

Knee arthrodesis rather than reimplantation should be considered a) following failure of a primary knee prosthetic arthroplasty when the extensor mechanism is insufficient, b) in the immuno-compromised patient, c) in the knee with poor soft tissue coverage, d) when the causative microorganism in the infected prosthetic knee is particularly virulent which may be sensitive to only toxic antimicrobials. It should also be considered in the relatively young patient with high functional demands, whose arthritic process only involves one joint.

Question 42

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

Explanation

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

Question 43

Bacitracin is a topical antibiotic agent that may be added to solutions and used for intraoperative lavage. What is this agent effective against?

Explanation

DISCUSSION: Bacitracin is a polypeptide obtained from a strain (Tracy strain) of Bacillus subtilis. It is stable and poorly absorbed from the intestinal tract; its only use is for topical application to skin, wounds, or mucous membranes. Concentrations of 500 to 2,000 units per milliliter of solution or gram of ointment are used for topical application. Bacitracin is mainly bactericidal for gram-positive bacteria, including penicillin-resistant staphylococci. In combination with polymixin B or neomycin, bacitracin is useful for suppression of mixed bacterial flora in surface lesions. Bacitracin is toxic for the kidney, causing proteinuria, hematuria, and nitrogen retention; therefore, it has no place in systemic therapy. Bacitracin is said not to induce hypersensivity readily, but reactions to this agent have been described.
REFERENCES: Rosenstein BD, Wilson FC, Funderburk CH: The use of bacitracin irrigation to prevent infection in postoperative skeletal wounds: An experimental study. J Bone Joint Surg Am 1989;71:427-430.
Brooks GF, Butel JS, Morse SA (eds): Jawetz, Melnick, and Adelberg’ s Medical Microbiology: Antimicrobial Chemotherapy. New York, NY, McGraw-Hill, 1995, pp 187-188.

Question 44

A researcher is working on Medication A, a drug FDA-approved for the treatment of osteoporosis in men and women. It is an anti-resorptive agent that inhibits the formation, function and survival of osteoclasts. It does not bind to calcium hydroxyapatite. At 1-year after the initial dose, tissue levels are non-detectable. It can be used in the presence of cancer metastases to bone. What is Medication A? Review Topic

Explanation

Denosumab is FDA-approved for the treatment of osteoporosis in men and women. It inhibits the formation, function and survival of osteoclasts (OC). It does not bind to calcium hydroxyapatite. At 1-year after the initial dose, tissue levels are non-detectable.
Denosumab is a human monoclonal antibody against RANKL. By binding RANKL, it prevents interaction of RANKL with RANK (on OC and osteoclast precursors, OCP), and inhibits OC-mediated bone resorption, and the formation, function and survival of OC. In contrast, bisphosphonates bind to calcium hydroxyapatite in bone, and decrease resorption by decreasing function and survival (but not formation) of OC.
Vaananen et al. reviewed the cell biology of OC. During bone resorption, 3 membrane domains appear: ruffled border, sealing zone and functional secretory domain. The resorption cycle starts with migration, bone attachment, polarization (formation of membrane domains), dissolution of hydroxyapatite, degradation of organic matrix, removal of degradation products from resorption lacuna, and apoptosis of the OC or return to the non-resorbing stage.
Boyce et al. reviewed the regulation of osteoclasts and their functions. OCPs are held in bone marrow by chemokines e.g. stroma-derived factor-1 (SDF1) and attracted to blood by sphingosine-1 phosphate (S1P) (increased in synovial fluid of patients with RA). All aspects of osteoclast formation and functions are regulated by M-CSF and RANKL. More recent studies indicate that osteoclasts and their precursors regulate immune responses and osteoblast formation and functions by means of direct cell-cell contact through ligands and receptors, such as ephrins and Ephs, and semaphorins and plexins, and through expression of clastokines.
Warriner and Saag reviewed the diagnosis and treatment of osteoporosis. They defined osteoporosis as T-score of = -2.5 or a history of fragility fracture. Incident hip and vertebral fractures increase future risk of these fractures (hazard ratio 7.3 and 3.5, respectively).
Cummings et al. compared subcutaneous denosumab (60mg every 6mths) vs placebo in prevention of fractures in 7868 osteoporotic (T-score -2.5 to -4.0) postmenopausal women. They found that denosumab reduced risk of vertebral fracture by 68% (risk ratio, 0.32), hip fracture by 40% (hazard ratio 0.6), nonvertebral fracture by 20% (hazard ratio 0.8). There was no increased risk of cancer, infection, delayed fracture healing, cardiovascular disease, osteonecrosis of the jaw or adverse reactions. They concluded that it was useful for reduction of fractures in osteoporotic women.
The video shows the action of denosumab (prolia). Illustration A shows the different osteoclast zones.
Incorrect Answers:

Question 45

A right-handed, 53 year old man reports pain in the left shoulder following a fall on an abducted externally rotated shoulder 3 months ago. Examination reveals pain on elevation and tenderness localized to the anterior aspect of the shoulder. Results of the lift-off test are inconclusive due to limited internal rotation. Figure 2 shows the T1-weighted axial image from an MRI-arthrogram. Treatment should include

Explanation

Subscapularis repair-Traumatic rupture of the tendon of the subscapularis muscle is caused by forceful hyperextension or external rotation of the adducted arm. A simple clinical maneuver called the "lift-off test", reliably diagnosed or excluded clinically relevant rupture of the subscapularis tendon.

Question 46

A 54-year man has left shoulder pain and weakness after falling while skiing 4 months ago. Examination reveals full range of motion passively, but he has a positive abdominal compression test and weakness with the lift-off test. External rotation strength with the arm at the side and strength with the arm abducted and internally rotated are normal. MRI scans are shown in Figures 1a and 1b. Treatment should consist of

Explanation

DISCUSSION: The examination findings are consistent with subscapularis muscle weakness but normal supraspinatus and infraspinatus strength. The lift-off test and abdominal compression test are specific for subscapularis function. The MRI scan reveals a chronic avulsion and retraction of the subscapularis. The transverse image reveals a normal infraspinatus muscle, and the sagittal image reveals an atrophic subscapularis. Surgical repair of the isolated subscapularis tendon is indicated.
REFERENCES: Iannotti JP, Williams GR: Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 31-56.
Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon: Results of operative treatment. J Bone Joint Surg Am 1996;78:1015-1023.

Question 47

A 56-year-old man with poorly controlled diabetes mellitus has rapidly developing and advancing erythema, warmth and swelling with bullae formation on the left lower extremity. These findings appear to be advancing proximally several millimeters per hour. Culture results are most likely to reveal

Explanation

Discussion: Necrotizing fasciitis (NF) results in the death of the body's soft tissue. It is a severe disease of sudden onset that spreads rapidly. Symptoms include red or purple skin in the affected area, with severe pain, fever, and vomiting. The most commonly affected areas are the limbs and perineum. Early diagnosis is difficult as the disease often looks like a simple superficial skin infection in the early stages. While a number of laboratory and imaging modalities can raise the suspicion for necrotizing fasciitis, the gold standard for diagnosis is a surgical exploration in the setting of high suspicion. When in doubt, a small "keyhole" incision can be made into the affected tissue. If a finger easily separates the tissue along the fascial plane,
the diagnosis is confirmed and an extensive debridement should be performed. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score can be utilized to risk stratify people who have signs of cellulitis and determine the likelihood of necrotizing fasciitis being present. It uses six serologic measures, including C-reactive protein, total white blood cell count, hemoglobin, sodium, creatinine and glucose.
Polymicrobial synergistic infection was the most common cause of necrotizing fasciitis (48 patients; 53.9%) with streptococci and enterobacteriaceae being the most common isolates. Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The most common associated comorbidity was diabetes mellitus (63 patients; 70.8%).

Question 48

An MRI arthrogram of the elbow is shown in Figure 6. Based on these findings, what is the most likely diagnosis? Review Topic

Explanation

Carrino JA, Morrison WB, Zou KH, et al: Noncontrast MR imaging and MR arthrography of the ulnar collateral ligament of the elbow: Prospective evaluation of two-dimensional pulse sequences for detection of complete tears. Skeletal Radiol 2001;30:625-632.

Question 49

A 16-year-old cheerleader reports an ache in the right shoulder and arm that is worse after activity. She denies any history of acute trauma. Examination reveals a positive sulcus sign and an AP glide test with a posterior and anterior apprehension sign. To confirm a diagnosis of multidirectional instability, which of the following imaging studies is most appropriate?

Explanation

DISCUSSION: Multidirectional instability is a common finding in young female athletes. The anatomic structures are all intact but are hypermobile; therefore, CT and bone scans and scapular Y-views are often normal. Obtaining a weighted or AP stress view while applying downward traction on the arm will document instability and hypermobility of the joint. MRI generally is not indicated in this condition. Ultrasound is used primarily for rotator cuff pathology.
REFERENCES: Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908.
Warner JJ, Johnson D, Miller M, Caborn DN: Technique for selecting capsular tightness in repair of anterior-inferior shoulder instability. J Shoulder Elbow Surg 1995;4:352-364.

Question 50

Figures below show the radiographs, and the MRIs obtained from a 32-year-old man with worsening left knee pain. A 3-foot hip-to-ankle radiograph shows a 13-degree varus knee deformity. The patient sustained a major left knee injury 5 years ago and a confirmed complete anterior cruciate ligament (ACL) tear. He managed this injury nonsurgically with a functional brace but experienced worsening pain. He was seen by an orthopaedic surgeon 18 months ago, and a medial meniscus tear was diagnosed; the tear was treated with an arthroscopic partial medial meniscectomy. Since then, his knee has been giving way more often, and he no longer feels safe working on a pitched roof. The patient received 6 months of formal physical therapy and was fitted for a new functional ACL brace, but he still has pain and instability. He believes he has exhausted his nonsurgical options and would like to undergo surgery. What is the most appropriate treatment at this time?

Explanation

DISCUSSION:
Proximal tibial osteotomy is the most appropriate intervention to correct varus malalignment and to reduce stress on the ACL. In some cases, proximal tibial osteotomy alone may address both pain and instability, but if instability persists, particularly in the setting in which instability can be dangerous, subsequent ACL reconstruction can further stabilize the knee with less stress on the graft after the correction of malalignment. Varus alignment places increased stress on the native or reconstructed ACL. ACL reconstruction should be performed only at the same time as or following proximal tibial osteotomy to correct alignment in the setting of varus malalignment. It is not appropriate to perform ACL reconstruction prior to proximal tibial osteotomy in this setting. Distal femoral osteotomy is not indicated to correct varus malalignment. Varus alignment places increased stress on the native or reconstructed ACL, and ACL reconstruction alone is not indicated for this patient.

Question 51

A 28-year-old man sustained numerous injuries in an accident including a dislocation of the elbow and a severe closed head injury that resulted in unconsciousness. The elbow was reduced in the emergency department. After 1 month of rehabilitation, the patient reports pain and stiffness. A radiograph is shown in Figure 23. Management should now consist of

Explanation

DISCUSSION: In a young individual with a chronic dislocation of the elbow and heterotopic bone formation, the treatment of choice is open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a dynamic hinged fixator to begin protected early postoperative range of motion. It is important to understand that the fixator protects the reconstruction and allows early range of motion, but it does not maintain the reduction and should not be expected to do so. Pin fixation across the elbow delays early motion and is not recommended. Total elbow arthroplasty is not indicated, and ulnohumeral arthroplasty is for a primary arthritic condition.
REFERENCES: Garland DE, Hanscom DA, Keenan MA, et al: Resection of heterotopic ossification in the adult with head trauma. J Bone Joint Surg Am 1985;67:1261-1269.
Moor TJ: Functional outcome following surgical excision of heterotopic ossification in patients with traumatic brain injury. J Orthop Trauma 1993;7:11-14.

Question 52

Percutaneous placement of a lateral proximal tibial locking plate that extends down to the distal third of the leg is associated with postoperative decreased sensation of which of the following distributions?

Explanation

DISCUSSION: Placement of long lateral tibial plates have been shown to have a risk of iatrogenic injury to the superficial peroneal nerve, which has a sensory distribution to the dorsal foot. This risk is seen especially with percutaneous approaches, such as those used with the LISS plate. The first reference by Deangelis et al found a risk of superficial peroneal injury with percutaneous screw placement of holes 11-13 in the LISS plate. The second referenced article by Roberts et al noted a slightly increased distance to the neurovascular bundle when interlocking tibial nails in a lateral to medial direction (compared to medial to lateral locking) and slightly increased biomechanical strength when locking in a medial to lateral direction. The third referenced article by Wolinsky et al notes a risk of iatrogenic injury to the deep peroneal nerve and anterior tibial artery with an anterolateral approach to the distal tibia, but notes the superficial peroneal nerve is safe with an appropriate exposure.

Question 53

A 50-year-old woman undergoes an L4-S1 laminectomy and noninstrumented fusion for degenerative spondylolisthesis.

Explanation

DISCUSSION
Complications are numerous in adult spinal deformity surgery. Many complications are related to the patient's sagittal balance following surgery and recognition of the potential to develop sagittal imbalance or flat-back syndrome following spinal fusion. The quality of bone density is important in spinal instrumented fusions, especially among older patients. Patients with osteopenia or osteoporosis have a higher incidence of proximal-level screw cut-out through the vertebral body into the cephalad disk space.
Proximal junctional kyphosis is common in longer instrumented fusions, especially when instrumented to the sacrum/pelvis; when the spine is fixed in a "flat" or hypolordotic position; when the thoracic spine is hyperkyphotic (ie, Scheuermann kyphosis); when the end instrumented vertebrae is kyphotic; or when the sagittal plumb line (measured from C7) is more than 4 cm forward of the posterior corner of the sacrum.
Sagittal imbalance is a common complication when the spine is instrumented in a hypolordotic position. This can occur with degenerative conditions that necessitate multilevel fusions or fusions to sacrum without recognition of the degree of lordosis the patient should have. Pelvic incidence (PI) is a spinopelvic measurement that is a constant that measures an angle from the hips to the midpoint of the sacral end plate. PI correlates to the amount of lumbar lordosis that a patient would typically have in an upright position (+/-10 degrees). If a patient has significant sagittal imbalance, he or she will have a forward lean and lack the ability to extend the spine to stand upright. In an attempt to stand upright, the patient may bend his or her knees or hips in a crouched position. When extending their knees, they again lean forward.
Pseudarthrosis is common with noninstrumented fusions. Deep surgical-site infections are uncommon but can be major complications that are difficult to treat, necessitating formal irrigation and debridement and long-term antibiotics. Patients with diabetes have a higher incidence of infection.
RECOMMENDED READINGS
Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 2005 Sep 15;30(18):2024-

Question 54

Figure 1 shows the radiograph of an 11-year-old boy who stubbed his great toe while playing soccer barefoot. He is able to walk home despite a small amount of bleeding at the nail fold. Management should consist of

Explanation

DISCUSSION: Great toe fractures through the physis should be considered open fractures if there is bleeding at the nail fold. Treatment should include irrigation and debridement and appropriate antibiotics. Immobilization with a cast is usually sufficient for treatment of

the fracture.
REFERENCES: Noonan KJ, Saltzman CL, Dietz FR: Open physeal fractures of the distal phalanx of the great toe: A case report. J Bone Joint Surg Am 1994;76:122-125.
Banks AS, Cain TD, Ruch JA: Physeal fractures of the distal phalanx of the hallux. J Am Podiatr Med Assoc 1988;78:310-313.

Question 55

The authors found that all 9 patients went on to both clinical and radiographic union. They concluded that the Masquelet technique was successful in effectively reconstructing traumatic and posttraumatic bony defects in the forearm with a low incidence of complications.

Explanation

Heterotopic ossification is uncommon
Minifragment screws are sufficient for fracture fixation
Kocher-Langenbeck is the optimal surgical approach for this injury
Fragment excision leads to improved outcomes compared to open reduction and internal fixation
A 2 mm fragment step-off is considered the cut-off for non-surgical management
This patient has sustained a Pipkin II femoral head fracture with associated anterior hip dislocation. An open reduction with internal fixation of the femoral head fragments with direct visualization is indicated to restore stability and congruity of the hip joint. These fractures can be treated with mini-fragment screws with excellent reduction and purchase without risks of extensive chondral injury or screw prominence.
Femoral head fractures are uncommon injuries usually associated with hip dislocations. They are classified using the Pipkin Classification (Illustration B). While resection of small femoral head fracture fragments can be considered (Pipkin I) as sufficient and satisfactory treatment, this fragment is large and displaced and thus should be treated with ORIF for optimal results. Regarding the surgical approach, advocates for the direct anterior approach state direct access to the anterior portion of the femoral head with decreased overall complication rates. Other approaches, including surgical hip dislocation and Kocher-Langenbeck, are also useful depending on associated injuries (acetabulum fractures, etc.) and location of the head fragment. ORIF of these fractures can be performed with the use of countersunk mini-fragment screws, headless screws and even bioabsorbable pins to avoid prominence or extensive chondral injury.
Marecek et al. authored a review article on femoral head fractures. They described these injuries as being generally associated with hip dislocations and require prompt reduction. They noted that the surgical fixation of the femoral head is generally done through the direct anterior approach or via a surgical hip dislocation depending on associated injuries. The authors also discussed the importance of using mini-frag screws to avoid hardware prominence. They also noted that while heterotopic ossification is a common finding after the anterior approach for these injuries, it is rarely proven to be symptomatic.
Giannoudis et al. reviewed femoral head fractures focusing on management, complications and clinical results. They reported on 453 femoral head fractures in 450 patients. Regarding Pipkin Is, they noted that fragment excision gave better results compared to ORIF (p=0.07), while Pipkin IIs showed improved outcomes with ORIF. Regarding complications, they noted the following rates: wound infection (3%), sciatic nerve palsy (4%), AVN (11.9%), post-traumatic OA (20%) and HO (16.8%). They also noted the anterior approach was associated with promising long-term functional results and a lower incidence of major complication rates.
Figure A is an AP pelvis radiograph revealing a left hip dislocation with a large femoral head fracture extending into the weight-bearing zone of hip joint
(Pipkin II). Figures B and C are CT scan images revealing an anteriorly dislocated hip with a large femoral head fracture without associated acetabulum fractures. Illustration A is the post-op fluoroscopy showing ORIF of femoral head with multiple 2.7 cortical screws. Illustration B demonstrates the Pipkin classification for femoral head fractures.
Incorrect Answers:

Which of the following describes the most common organism cultured from septic olecranon bursitis?
Gram positive cocci in chains
Gram positive bacilli in branches
Gram positive cocci in pairs and clusters
Gram negative diplococci
Gram negative bacilli with thin rods Correct answer: 3
The most common cultured organism in the setting of septic olecranon bursitis is Staphylococcus aureus (S. aureus), appearing as gram positive cocci in pairs and clusters.
S. aureus is responsible organism in approximately 80% of cases of septic olecranon and prepatellar bursitis. Mixed flora is also common. Patient demographics in both conditions are similar, more commonly involving middle-aged males. Direct inoculation is presumed to be the primary culprit as opposed to hematogenous seeding, as blood supply to the bursal tissue is poor. Differentiating infectious from non-infectious bursitis can be challenging.
Aaron et al. provide a review article on the four most common types of bursitis: olecranon, prepatellar, trochanteric, and retrocalcaneal. They note that olecranon bursitis is the most common superficial bursitis, and that a careful history and physical exam can help differentiate infectious from noninfectious olecranon bursitis. The authors discuss one series of 46 patients demonstrating that a skin temperature overlying the affected bursa ≥2.2°C than the contralateral, unaffected bursa had a 100% sensitivity and 94% specificity in diagnosing a septic process.
Illustration A shows a patient with olecranon bursitis. Illustration B shows the classic gram stain for S. aureus (gram positive cocci in pairs and clusters).
Incorrect Answers:

During a trauma conference, a hand surgeon presents a case of a 25-year-old male who injured his elbow while roller skating. While describing the patient's radiographs, he reports that this injury is associated with valgus posterolateral rotatory instability. Which of the following images is most likely the patient's radiograph?

Posterolateral rotatory instability (PLRI) can result from a "terrible triad" fracture-dislocation pattern (seen in Figure E), classically involving a radial head fracture, coronoid tip or base fracture, and an elbow dislocation.
Terrible triad injuries typically occur with axial loading, supination, and a valgus directed force through the elbow. In comparison to PLRI which results from a terrible triad injury, posteromedial rotatory instability (PMRI) commonly results from an anteromedial coronoid facet fracture following a varus-directed force. These injuries also very frequently also have a lateral collateral ligament complex injury but often have no radial head fracture. PLRI is far more common than PMRI. Generally with a PLRI pattern, the lateral collateral ligament complex fails first, followed by injury to the anterior capsule or coronoid, and lastly the medial collateral ligament complex is affected. Nonoperative management is possible, but only indicated in small, non-displaced radial head fractures with small coronoid tip fractures. Typically, terrible triad injuries are addressed surgically with radial head fixation or arthroplasty, lateral collateral ligament repair, and, less commonly, coronoid fracture fixation or anterior capsule repair.
Ring et al. reviewed 56 patients who had been treated with an ORIF of the radial head at 48 months after injury. They found unsatisfactory outcomes for patients who had an ORIF of radial head fractures with greater than 3 articular fragments. The authors recommended ORIF of radial head fractures with 3 or few fragments.
Steinmann performed a review of coronoid process fractures. The author reports that with an anteromedial coronoid fracture, the anteroposterior (AP) radiograph of the elbow will demonstrate progressive narrowing of the joint space from lateral to medial. Dr. Steinmann concludes that an important determinant of stability is the involvement of the sublime tubercle (insertion point of the MCL), and that medial instability is likely with involvement of the sublime tubercle.
Mathew et al. review the anatomic, biomechanical, and operative principles of terrible triad injuries. The authors discuss that the primary goal of fixation is to stabilize the elbow and allow early range of motion. They underscore technical improvements and implant developments which have improved outcomes.
Figure A demonstrates a capitellum fracture. Figure B demonstrates an olecranon fracture.
Figure C demonstrates a displaced radial head fracture.
Figure D demonstrates an anteromedial facet coronoid fracture.
Figure E demonstrates a terrible triad injury with a radial head fracture,
coronoid tip fracture, and elbow subluxation.
Incorrect Answers:
A 32-year-old soccer player presents with severe right ankle pain and inability to bear weight after sustaining a slide-tackle injury during a game. Radiographs are shown in Figures A and B. Given the nature of his injury, he is taken for surgical reduction and fixation. Following medial malleolar fixation, the syndesmosis is addressed. All of the following are true regarding the most appropriate intraoperative technique for anatomic syndesmotic reduction EXCEPT:

The axis of the reduction clamp should parallel the anatomic trans-syndesmotic angle
The lateral tine of the clamp should be seated just posterior to the lateral malleolar ridge
The medial tine should be placed on the anterior third of the tibia on a true lateral fluoroscopic view of the ankle
The reduction clamp should be placed 1-2cm proximal to the tibial plafond
The surgeon should apply judicious compression under fluoroscopic visualization to avoid over-compression of the syndesmosis
When placing a clamp across the syndesmosis to facilitate reduction, the lateral tine should be placed directly on the lateral malleolar ridge. Placing the lateral tine either more anteriorly or posteriorly has been shown to result in sagittal malreduction from fibular translation.
Syndesmotic reduction has proven to be technically challenging, with reportedly greater than 50% of cases resulting in malreduction. Provisional reduction is most often attained via a pointed reduction clamp. Placement of the lateral tine is outlined above. The medial tine should be placed at the anatomic midportion of the medial tibia, which can be confirmed
fluoroscopically as the anterior third of the tibia on a true lateral view of the ankle. It is important to maintain the axis of the clamp parallel to the joint line and to the anatomic syndesmotic angle. The clamp should furthermore be maintained 1-2cm proximal to the mortise, at the level of the incisura, to avoid deformation or undue translation of the fibula. Lastly, over-compression of the syndesmosis has been demonstrated, though the clinical implications remain controversial.
Putnam et al. performed a radiographic analysis of the ideal orientation for placement of a syndesmotic reduction clamp. Based on the CT scans of uninjured adult ankles, the authors showed that the trans-syndesmotic axis could be most reliably paralleled by a reduction clamp by placing the lateral tine on the lateral malleolar ridge and the medial tine radiographically within the anterior third of the tibia, anatomically half-way between the anterior and posterior cortices. They further specified that the ideal location was within the central one-third of the distance from the anterior tibial cortex to the anterior fibular cortex.
Cosgrove et al. prospectively evaluated the effect of medial clamp tine positioning on the incidence of syndesmotic malreduction. The authors found that malreduction most often resulted from deviation of the clamp axis from the syndesmotic axis. With the clamp at 1-2cm proximal to the mortise and the lateral tine on the lateral malleolar ridge, the ideal position of the medial tine was within the anterior third of the tibia. The rate of sagittal malreduction increased substantially with increasingly posterior placement of the medial tine. The medial clamp position did not affect coronal plane malreduction.
Gardner et al. review the technical considerations in reduction and fixation of syndesmotic injuries. The authors stress careful positioning of the reduction clamp, advocating that the clamp should be placed from the lateral malleolar ridge to the center of the anteroposterior width of the medial tibia.
Additionally, they note that placement too proximal or distal results in coronal plane deformity of the fibula, and that over-compression of the syndesmosis is certainly possible.
Figure A is the AP radiograph of the left ankle demonstrating a displaced medial malleolar fracture and syndesmotic widening. Figure B is the lateral radiograph of the ipsilateral knee showing an associated proximal fibular fracture.
Illustration A shows the syndesmotic angle and anatomic trans-syndesmotic axis as compared to the AP and lateral fluoroscopic axes. Illustration B shows the ideal positioning of the medial tine within the anterior third of the tibia on a true lateral view of the ankle.
Incorrect answers:

A 45-year-old male injures his wrist during Live Action Role Play in Chicago two weeks ago. He underwent operative fixation by and presents to your clinic for his 2 week follow-up visit. You review his operative note in which the surgeon reports having to apply a volar
locking plate in a distal position to secure the difficult intra-articular fracture. The patient shows you the lateral film in Figure A. You remove his splint, he has no difficulty moving any fingers, very minimal pain, and is not taking any narcotic medication. How do you counsel him about his post-operative period?

The plate may need to removed once the fracture is healed to reduce the chance of flexor pollicis longus injury
The plate may need to removed once the fracture is healed to reduce the chance of flexor carpi radialis injury
The plate may need to removed once the fracture is healed to reduce the chance of flexor digitorum superficialis – index finger injury
The patient should undergo revision fixation as soon as possible
The plate is in appropriate position and will likely never need to be removed Correct answer: 1
This patient’s volar locking plate (VLP) is distal to the "watershed line", extending volarly beyond the most volar aspect of the distal radius. He is at greatest risk for an attritional rupture of the FPL.
A VLP placed this distal and volar is more likely to cause flexor tendon injury.
Up to 12% of all patients undergoing volar plate fixation will experience flexor tendon injury, and the FPL is the most common tendon associated with the VLP (57% of total flexor tendon ruptures). The average time from fixation to flexor tendon rupture has been cited at 9 months. To judge if a plate is volar to the watershed line, a plum line can be made in the proximal direction from the most volar edge of the distal radius. If a plate is volar to this (Soong) line, the patient is thought to be at a higher risk for flexor tendon injury. As a result, this patient should be followed closely and if pain with thumb flexion is present after 3 months, the surgeon should consider plate removal so long as the fracture is healed to reduce the chance of FPL rupture. Ruptured tendons require repair, grafting, or transfer with hardware removal.
Griffin and Chhabra comprehensively reviewed the risk factors and adverse events following VLP fixation of distal radius fractures, including flexor tendonitis and rupture. They found that risk factors for flexor tendon rupture following VLP fixation included plate placement distal to the watershed line and that PQ repair does not seem to affect flexor tendonitis.
Agnew et al. analyzed wrist MRIs to determine the relationship between the flexor tendons and the watershed line. They found that at 3mm proximal to the watershed line, the FPL and FDP to the index finger were 2.6 and 2.2mm anterior to the volar rim of the distal radius. The authors suggested that distally placed plates are incredibly close to the flexor tendons.
Chilelli et al. described 24 of 48 wrists which had VLP following distal radius fracture and went on to experiences loss of FPL flexion post-operatively. They found that FPL ROM generally returned after 52 days, however with an associated average loss of 11° in thumb IPJ ROM. The authors attribute this to stripping of FPL from the bone during the volar approach.
Soong et al. divided patients who underwent VLP fixation for distal radius fractures into three groups according to position of plate relative to a plum line extending proximally from the most volar and distal aspect of the distal radius: those with a VLP dorsal to the Soong line (grade 0), those with the VLP volar to the Soong line but proximal to the rim (grade 1), and those with a VLP volar to the Soong line and at or distal to rim (grade 2). Of the 73 cases reviewed, the authors reported three flexor tendon ruptures, two of which were grade 2 position. The authors concluded that both position of plate and type of plate were contributors to flexor tendon injury following VLP fixation.
Figure A is a lateral radiograph of the wrist demonstrating appropriate reduction and fixation but with the VLP volar to the "watershed" or Soong line.
Illustration A is a lateral radiograph with Soong's line drawn to show that this plate is too volar.
Incorrect Answers:

A 42-year-old construction worker sustains a crush injury to the hand at a job site. He has immediate pain and significant swelling, and is taken to the local emergency department for evaluation. Radiographs do not demonstrate any fracture or dislocation. On exam,
he experiences severe pain with passive motion at the metacarpal phalangeal joints and when the wrist is flexed and extended.
Otherwise he has intact sensation and appropriate capillary refill. What is the next best step in diagnosis or treatment?
Advanced imaging
Arterial Doppler
Admission for overnight observation
Surgical intervention
Pain control
This patient presents with compartment syndrome of the hand. A history and clinical exam are the best tools to identify the diagnosis, and the treatment consists of emergent fasciotomies.
Compartment syndrome of the hand may be secondary to trauma, burn, IV drug use, extravasation of IV fluids, or major limb revascularization. The diagnosis is usually made with pain out of proportion to exam, particularly with passive stretch of the digits. It is possible to have compartment syndrome without neurovascular changes (paresthesia, pallor, pulselessness), particularly earlier in the presentation. Compartment measurements may be obtained and are considered diagnostic with an absolute value greater than 30mmHg or when the compartment pressure is within 30mmHg of the patient's diastolic blood pressure. However pressure testing is not necessary in most cases, but may be particularly important in the patient who is obtunded, intubated, or who had a block, as the physical exam will be confounded. There are ten hand compartments: hypothenar, thenar, adductor pollicis, four dorsal interosseous, and three palmar interosseous; and emergent surgical release of all ten compartments is indicated.
Codding et al. comprehensively reviewed hand compartment syndrome. The authors identify the history and physical exam as the most critical aspect of the diagnosis. More specifically, they noted that pain with passive stretch of the MCPJ is the most sensitive clinical sign on physical exam. The authors conclude the short comings of the research on hand compartment syndrome, but note the potential morbidity of a missed diagnosis is so great that the threshold for surgical intervention should be very low.
Lipschitz et al. reviewed the measurement of compartment pressures in the hand. The authors discussed technical pearls including leveling the monitor at the level of the heart, using local analgesia on the skin only, inserting the needle perpendicular to the skin, and measuring all 10 hand compartments.
They noted that any measurement greater than 30mmHg or within 30mmHg of the diastolic blood pressure may be considered diagnostic.
Illustration A shows the standard incisions utilized to release all ten hand compartments. Incisions are generally placed directly overlaying the thenar musculature, hypothenar musculature, the carpal tunnel, and dorsally over the metacarpals. The radial and ulnar border of each metacarpal are incised through the dorsal incisions to release the interossei compartments.
Incorrect Answers:

A 60-year-old woman with a history of well-controlled diabetes and hypertension sustained a fall into a ditch yesterday and presents with persistent left ankle pain and deformity. The injury is closed, and the patient is neurovascularly intact. Injury films are shown in Figures A and B. An unsuccessful attempt at reduction in the emergency department with sedation was made. What is the cause of failure of closed reduction?

Subacute nature of fracture
Incarceration of the deltoid ligament
Incarceration of the fibula behind the posterolateral ridge of tibia
Entrapment of the flexor hallucis longus (FHL) tendon
Entrapment of the extensor digitorum brevis (EDB) Correct answer: 3
The patient has sustained a Bosworth fracture-dislocation, which is a fixed dislocation of the fractured fibula behind the posterolateral tibial ridge. These fractures are generally irreducible via a closed means and require open reduction.
The initial radiographs in this vignette reveal posterior subluxation of the talus and fibula without significant coronal plane deformity. This deformity should raise the suspicion of a Bosworth fracture-dislocation, especially if closed reduction is unsuccessful. Bosworth fracture-dislocations can often be associated with posterior malleolar fractures, specifically of the posterolateral rim of the distal tibia. These injuries often fail closed reduction, given the engagement of the fibula behind the posterolateral tibial ridge, and frequently require open reduction. In this situation, the most effective method to reduce the fracture is through a posterolateral approach. This is the same approach that can then be utilized for the fixation of the posterolateral fragment and fibula.
Delasotta et al. discussed a case presentation of a 24-year-old male with a Bosworth fracture-dislocation in which the anterior compartment musculature was interposed within the fracture site, impairing both closed and eventual open reduction of the injury. The authors go on to discuss how 3D CT reconstruction of the bone and soft tissues can aid in both the diagnosis and preoperative planning of such injuries. They also note that these injuries should be admitted for compartment and neurovascular checks and undergo urgent surgical treatment.
Gardner et al. performed a cadaveric study directly comparing fixation of posterior malleolar fractures to syndesmotic stabilization in a simulated stage IV pronation-external rotation injury. Compared with the intact specimens, the authors found that fixation of the posterior malleolus restored 70% of the native stiffness, but syndesmosis stabilization only restored 40%. The authors concluded that given the likely integrity of the posterior inferior tibiofibular ligament in the setting of posterior malleolar fractures, anatomic reduction and fixation may be more appropriate than syndesmotic stabilization and better suited to restore stability.
Switaj et al. retrospectively evaluated the incidence of posterior malleolar fractures and posterior pilon variants in a 270 patients with operatively treated ankle fractures. The authors noted a relative frequency of posterior malleolar fractures of 50% and that of the posterior pilon variants of 20% within the entire cohort. While they found no significant difference in frequency of posterior malleolar or posterior pilon variants with regard to either AO/OTA or Lauge-Hansen classification, patients with posterior pilon variants were significantly older.
Figure A and B show the AP and lateral views of an ankle revealing a lateral malleolar fracture with tibiotalar subluxation and posterior dislocation of the fibula with respect to the posterolateral ridge of the tibia, consistent with a
Bosworth fracture-dislocation.
Incorrect answers:
A 42-year-old male who works as a professional clown presents with severe ankle pain and gross deformity after tripping and falling over his props at a children’s birthday party. His radiograph is shown in Figure A. Following fixation of the medial and lateral malleolar fractures, the syndesmosis is assessed and is found to be persistently unstable. All of the following are true regarding posterior malleolar fixation EXCEPT:

Fixation of the posterior malleolus obviates the need for syndesmotic fixation in most cases
Fixation of the posterior malleolus remains biomechanically inferior to trans-articular syndesmotic fixation
Functional and radiographic outcomes following posterior malleolar fixation are at least equivalent if not superior to those following syndesmotic fixation
Non-anatomic fixation of the posterior malleolus will compromise syndesmotic fixation
The syndesmosis is often incompletely injured in the setting of a posterior malleolar fracture
Fixation of the posterior malleolus has been shown to be biomechanically superior to single-screw trans-articular syndesmotic fixation. Anatomic reduction and fixation will most often obviate the need for syndesmotic fixation, as the posterior inferior tibiofibular ligament (PITFL) is typically intact and attached to the fragment.
Posterior malleolar integrity is essential to ankle function and stability. The posterior malleolus not only contains the talus posteriorly but adds to articular congruity for tibiotalar load transfer and contributes to rotatory ankle stability through the PITFL. As a result, posterior malleolar fractures compromise these critical functions. Operative management is therefore aimed at containment of
the talus, restoration of articular congruity, reduction of the incisura, and restoring integrity to the syndesmosis. Functional and radiographic outcomes following posterior malleolar fixation have been shown to be at least equivalent to those following syndesmotic fixation.
Miller et al. compared the need for syndesmotic fixation in bi- and tri-malleolar ankle fractures following anatomic reduction and fixation in the prone position versus initial conservative management in the supine position. The authors found that fixation of the posterior malleolus obviated the need for syndesmotic fixation in 97.9% of cases, while nearly 25% of patients with no initial fixation required stabilization. They concluded that prone positioning and anatomic fixation of the posterior malleolus should be performed as this adequately restored syndesmotic stability in almost all cases.
Gardner et al. performed a radiographic evaluation of syndesmotic integrity in the setting of pronation-external rotation stage 4 ankle fractures with associated posterior malleolar fractures. Based on radiographs and MRI, no complete tears of the posterior-inferior tibiofibular ligament were evident. The fracture pattern was then simulated in cadavers, and posterior malleolar fixation restored 70% of the native stability while syndesmotic fixation alone restored only 40% of the native stability. The authors advocated for posterior malleolar fixation over syndesmotic stabilization.
Miller et al. prospectively compared the outcomes following posterior malleolar and syndesmotic fixation for unstable ankle fractures with partial syndesmotic injury. At a minimum one-year follow-up, the authors found that patients who had undergone open reduction with fixation of posterior malleolar fractures had no difference in outcomes as compared to those who underwent syndesmotic fixation. They concluded that not only was syndesmotic reduction maintained at final follow-up following posterior malleolar fixation, but that functional outcomes were at least equivalent to syndesmotic fixation.
Fitzpatrick et al. evaluated the impact of posterior malleolar fixation toward restoring syndesmotic stability in a cadaveric supination-external rotation stage 4 fracture model. The authors found that failure to fix or anatomically reduce posterior malleolar fragments resulted in non-anatomic translation of the fibula and ultimately in syndesmotic malreduction. They advocated for anatomic reduction and fixation of larger posterior malleolar fractures.
Figure A is an AP radiograph of the right ankle demonstrating a displaced trimalleolar ankle fracture with maintained relationship between the distal fibula and posterior malleolar fragment.
Incorrect Answers:
A 35-year-old morbidly obese female presents with global right ankle pain and significant swelling after a misstep over one of her cats on the stairs. She is unable to bear weight, but the skin is intact. Injury films are shown in Figures A through D. What is the internervous plane through which direct anatomic reduction and fixation of both fractures could best be achieved?

Question 56

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 57

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 58

A 32-year-old man has intense right hand and wrist pain, a deformed wrist, and numbness in his fingers after falling off his motorcycle. This is an isolated injury. Examination reveals a swollen wrist, normal capillary refill to all fingers, and limited flexion of all fingers. Radiographs are shown in Figures 21a and 21b. Neurologic examination of the hand will most likely reveal

Explanation

DISCUSSION: The patient has a perilunate dislocation. A volar dislocation of the lunate is often associated with median nerve dysfunction. This injury to the wrist is often overlooked because of its benign clinical appearance and the presence of other injuries, as it is caused by high-energy mechanisms.
REFERENCES: Ruby LK, Cassidy C: Fractures and dislocations of the carpus, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1297-1300.
Habernek H, Weinstabl R, Kdolsky R, et al: Volar lunate fracture-dislocations of the wrist: Case report for two patients treated with external frame and internal open reduction. J Trauma 1998;45:975-978.

Question 59

A 14-year-old boy is lifting weights and feels a sudden pain in his back, associated with sciatica bilaterally. The sciatica persists for several weeks. The radiograph shown in Figure 7a is negative, and the CT scan shown in Figure 7b is available for evaluation. An MRI scan is read as a disk bulge. Management should consist of

Explanation

DISCUSSION: A limbus or apophyseal fracture caused by heavy lifting or twisting is commonly seen in older children and adolescents. Patients describe feeling a popping sensation and report radicular symptoms. Radiographs usually are not sufficient to diagnose the injury. MRI or CT should be used to determine the exact location of the fracture. Nonsurgical management is rarely successful. A wide laminectomy with surgical excision of the limbus fragment is recommended if neurologic symptoms are present.
REFERENCE: Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, p 694.
2010 Pediatric Orthopaedic Examination Answer Book • 13

Question 60

The radiographs and CT scan seen in Figures 28a through 28d reveal what type of acetabular fracture pattern?

Explanation

DISCUSSION: The AP, obturator oblique, and iliac oblique views of the pelvis reveal a fracture that disrupts the iliopectineal and ilioischial lines, indicating a fracture that involves both anterior and posterior columns. However, it does not have the other features of anterior or posterior column fracture patterns. A displaced posterior wall fracture is also present, best seen on the obturator oblique view. The anterior to posterior directed fracture line on the CT scan indicates a transverse fracture; therefore, the patient has a transverse with posterior wall fracture pattern. A T-type fracture would be similar but would have a break into the obturator ring.
REFERENCES: Tile M: Describing the injury: Classification of acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 427-475.
Brandser E, Marsh JL: Acetabular fractures: Easier classification with a systematic approach. Am J Roentgenol 1998;171:1217-1228.

Question 61

Turf toe typically involves injury to which of the following structures of the great toe?

Explanation

DISCUSSION: The term turf toe includes a range of injuries of the capsuloligamentous complex of the first metatarsophalangeal joint with or without osteochondral fracture of the first metatarsal head or one of the sesamoids. The mechanism of injury is hyperextension.
REFERENCES: Clanton TO, Butler JE, Eggert A: Injuries to the metatarsophalangeal joints in athletes. Foot Ankle 1986;7:162-176.
Sammarco GJ: How I manage turf toe. Phys Sports Med 1988;16:113-118.

Question 62

A 42-year-old man sustained the periprosthetic fracture shown in Figures 19a and 19b. The femoral component is well fixed. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has a periprosthetic fracture below the femoral stem. The component is porous coated and well fixed. Open reduction and internal fixation, leaving the stem in place, can be performed when bone quality is good. Plating with or without allograft struts and supplemental cerclage fixation generally is acceptable. If the component is loose, revision to a longer device is recommended with appropriate stabilization of the fracture using the aforementioned methods. If bone loss has occurred, allograft supplementation or a tumor prosthesis may be indicated. Fractures located well below the stem tip can be treated without regard for the prosthesis. Closed reduction and bracing is not associated with good results for periprosthetic femoral fractures. Retrograde intramedullary nailing is not appropriate for this fracture.
REFERENCES: Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293-304.
Bono JV, McCarthy JC, Thornhill TS, Bierbaum BE, Turner RH (eds): Revision Total Hip Arthroplasty. New York, NY, Springer Verlag, 1999, pp 530-592.

Question 63

Figures 4a and 4b are the radiographs of an isolated injury. What is the next most appropriate step in management?

Explanation

Successful treatment of a pilon fractures requires a complete understanding of the fracture configuration. This information is not available using radiographs alone; therefore, CT is used to define the fracture anatomy but only after stabilization and distraction of the fracture via external fixation. MRI does not adequately show the detail of the bone fragments. Immediate ORIF is contraindicated because of the high rate of soft-tissue complications with this treatment regimen, whereas closed treatment has a high rate of poor outcomes because of arthritis. Delayed ORIF is the recommended treatment, but this occurs after temporary stabilization and CT scanning.

Question 64

In addition to lengthening the achilles, transfer of which tendon is important for functional ambulation after performing a Chopart amputation of the foot?

Explanation

DISCUSSION: The partial foot amputation through the talonavicular and calcaneocuboid joints is also known as the Chopart amputation. The Chopart amputation may result in significant equinovarus deformity with anterior weight bearing through the scar line, predisposing to skin breakdown over time. Therefore, lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck should also be performed in conjunction with this disarticulation. The tib ant transfer results in dorsiflexion and distributes the weight-bearing portion more centrally and the lengthening of the Achilles tendon is necessary to accommodate this posteriorly. Transfer of the tibialis anterior or posterior tibialis to the calcaneous would exacerbate the equinovarus deformity. Shortening of the Achilles tendon would also exacerbate the anterior loading of the scar.

Question 65

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?

Explanation

This patient had an eccentric muscle contraction (muscle lengthening while contracting) of his biceps muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his positive biceps active test finding (supination/pronation of the forearm showing no motion of the biceps muscle belly). Eccentric contractors have the highest potential for building strength but also are at highest risk for injury. Concentric (muscle shortening with contraction), isometric (no change in muscle length with contracture), and isokinetic (constant velocity of muscle contraction with a variable force) do not describe the mechanism detailed. The loss of distal biceps attachment will result in loss of elbow supination strength in flexion (the biceps is the only supinator to cross the elbow) while still retaining elbow flexion (albeit weakened) because of the other elbow flexors (brachioradialis and brachialis). Consequently, treatment should be anatomic repair of the distal biceps insertion, which can be performed with a 2-incision or 1-incision technique. Although all of the listed complications have been reported with these techniques, LABC neuropraxia is by far the most common. Radiographs show that this athlete’s injury was repaired using a 1-incision technique with a cortical fixation device and a radial bone tunnel. This technique has gained favor because of its decreased incidence of heterotopic ossification and radioulnar synostosis compared with the 2-incision technique. The most troubling complication for most surgeons is the development of a posterior interosseous nerve (PIN) palsy, which this patient clearly demonstrates in addition to the more common LABCN upon postsurgical examination. Because the LABCN injury is typically a neuropraxia from retraction, a period of observation is indicated. PIN injury can result from excessive traction during surgical exposure or from entrapment by the fixation button. Considering the anatomy of the PIN, successful recovery of the nerve typically progresses based on the distance from the origin of the nerve to the muscle indicated. The extensor indicis proprius (EIP) muscle is the most distal muscle innervated and can be expected to recover last. First to return would be the EDC
followed by the ECU, EDQ, and, finally, the EIP.

Question 66

The structure that runs just beneath the peroneal tubercle of the calcaneus is the

Explanation

DISCUSSION
The peroneal tubercle is often a good landmark at which to identify the peroneus longus tendon surgically, and a hypertrophic tubercle has been associated with peroneus longus tendinopathy. Both peroneal tendons curve anteriorly around the tip of the fibula, with the peroneal tubercle separating the 2 tendons at the level of the calcaneus. The peroneus brevis runs in front of the tubercle and the longus behind. The flexor hallucis longus runs through a fibro-osseus tunnel posterior to the hindfoot formed by the posterolateral (os trigonum) and posteromedial tubercle of the talus. The calcaneal fibular ligament attaches to the calcaneus below the posterior facet of the subtalar joint and deep to the peroneal tendons.
RECOMMENDED READINGS
Hyer CF, Dawson JM, Philbin TM, Berlet GC, Lee TH. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005 Nov;26(11):947-50. Pub PMID: 16309609.View Abstract at PubMed
Bruce WD, Christofersen MR, Phillips DL. Stenosing tenosynovitis and impingement
of the peroneal tendons associated with hypertrophy of the peroneal tubercle. Foot Ankle Int. 1999 Jul;20(7):464-7. PubMed PMID: 10437932.View Abstract at PubMed

Question 67

Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral

Explanation

DISCUSSION: Nonsurgical management is considered for proximal tears as well as partial tears in some individuals. Surgical management is often not appropriate in older or sedentary patients. However, patients treated nonsurgically will have a significant cosmetic defect, as well as weakness in adduction and internal rotation.
REFERENCES: Schepsis AA, Grafe MW, Jones HP, et al: Rupture of the pectoralis major muscle: Outcome or repair of acute and chronic injuries: Am J Sports Med 2000;28:9-15.
Petilon J, Carr DR, Sekiya JK, et al: Pectoralis major muscle injuries: Evaluation and management. J Am Acad Orthop Surg 2005;13:59-68.

Question 68

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

Explanation

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

Question 69

-What is the mechanism of action of tranexamic acid in controlling traumatic hemorrhage?

Explanation

Question 70

A 21-year-old man sustains multiple gunshot wounds to his right upper extremity. He can not extend his digits or his thumb but can extend and radially deviate his wrist. An injury to the radial nerve or one of its branches has most likely occurred at which of the following locations?

Explanation

DISCUSSION: In this patient, the radial nerve is most likely injured at the level of the radial neck. The radial nerve emerges from the posterior cord of the brachial plexus and travels along the spiral groove of the humerus. At the level of the lateral humeral condyle, the radial nerve branches into the posterior interosseous nerve after giving off two cutaneous branches, the superficial radial and the posterior cutaneous. The posterior interosseous nerve travels through the supinator muscle and winds around the radial neck. At this level, the posterior interosseous nerve is vulnerable to injury, particularly following fracture or penetrating trauma.
REFERENCES: Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System, Part 1: Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy Corporation, 1987, vol 8, p 53.
Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 428-429.

Question 71

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

Explanation

Jehovah’s Witnesses will not accept the transfusion of blood or blood products such as packed red or white cells, platelets, or plasma. However, many Jehovah’s Witnesses will accept the use of a cell saver in a “closed circuit.”

Question 72

During total knee arthroplasty using a posterior cruciate-retaining design, excessive tightness in flexion is noted, while the extension gap is felt to be balanced. Which of the following actions will effectively balance the knee?

Explanation

DISCUSSION: Excessive flexion gap tightness can be addressed with a variety of techniques; including: (a) recess and release the posterior cruciate ligament; (b) resect a posterior slope in the tibia; (c) avoid an oversized femoral component that moves the posterior condyles more distally; (d) resect more posterior femoral condyle and use a smaller femoral component placed more anteriorly; and (e) release the tight posterior capsule and balance the collateral ligaments.
REFERENCE: Ayers DC, Dennis DA, Johanson NA, Pelligrini VD: Common complications of total knee arthroplasty. J Bone Joint Surg Am 1997;79:278-311.

Question 73

A 4-year-old girl who is undergoing chemotherapy for acute lymphocytic leukemia sustains a displaced fracture through an osteolytic lesion in the metaphysis of the distal femur as a result of a fall. Treatment should include

Explanation

In the article by Gallagher, et al, they note a 12% incidence of pathologic fractures associated with acute leukemic lesions. The fracture should be treated using standard methods. Thus, the treatment of displaced fracture through an osteolytic lesion in the metaphysis of the distal femur in a 4-year-old girl would be closed reduction and immobilization in a cast.

Question 74

A 45-year-old woman sustains an injury to her lower leg. Examination reveals that there is a deformity with no neurologic or vascular problems. The skin is intact. Radiographs are shown in Figures 46a and 46b. Which of the following factors would make closed management the least appropriate choice for this injury?

Explanation

DISCUSSION: All the factors listed, with the exception of an ipsilateral femoral fracture, are representative of a low-energy stable tibial shaft fracture that will do well with closed reduction and immobilization in a long leg cast, followed by weight bearing as tolerated and then a functional brace or patellar tendon bearing cast until union is achieved. Shortening will not increase from that seen on these initial radiographs. The spiral fracture provides a broad surface for healing, and the fibular fracture at another level indicates a stable soft-tissue envelope which, with the immobilization device, will stabilize the fracture reduction. An ipsilateral femoral fracture is a strong indication to surgically stabilize both fractures.
REFERENCES: Trafton PG: Tibial shaft fractures, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 2153-2169.
Martinez A, Sarmiento A, Latta LL: Closed fractures of the proximal tibia treated with a functional brace. Clin Orthop 2003;417:293-302.

Question 75

A 45-year-old man reports that he awoke 2 weeks ago with severe pain in his right arm. Examination reveals weakness in the biceps, brachialis, and wrist extensors. There is decreased sensation in the thumb and index finger and a diminished brachioradialis reflex. Assuming this patient has a posterolateral herniated nucleus pulposus, what level is involved?

Explanation

DISCUSSION: This is a classic C6 nerve injury, and it is most likely the result of a herniated nucleus pulposus at C5-6. The C5 nerve root controls the elbow flexors, shoulder abductors, and external rotators. The C7 nerve root controls the elbow extensors, wrist pronators, and the triceps reflex.
REFERENCES: Standaert CJ: The patient history and physical examination: Cervical, thoracic and lumbar, in Herkowitz HN, Garfin SR, Eismont FJ, et al (eds): Rothman-Simeone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, vol 1, pp 171-186.
Bates B: A Guide to Physical Examination and History Taking, ed 5. Philadelphia, PA,

JB Lippincott, 1991.

Question 76

Which of the following methods of treating a vertically oriented (eg, Pauwels III) femoral neck fracture is mechanically optimal?

Explanation

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 nonoperative 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 nonsmokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:

Question 77

A 16-year-old female gymnast reports a 2-month history of back pain since falling off the parallel bars, and she has been unable to return to gymnastics. She has no numbness or tingling. Examination reveals lower back tenderness, some paravertebral muscle spasm, range of motion of the lumbosacral spine is 20 degrees of flexion and 20 degrees of extension, and an equivocal straight leg raise. Lumbosacral spine radiographs demonstrate Schomorl’s nodes but no evidence of spondylolisthesis. What is the next best step in management?

Explanation

DISCUSSION: Injuries to the anterior and middle column in gymnasts occur but are far less common than posterior column injuries such as spondylolysis and spondylolisthesis. The data on injuries to the anterior and middle columns are more limited. Long-term gymnastics exercise is associated with disk degeneration and other anterior and middle column abnormalities as reported by Katz and Scerpella. They identified a series of anterior and middle column abnormalities, including vertebral compression fractures, Schmorl’s nodes, disk degeneration, and disk herniation in young competitive female gymnasts with back pain. Therefore, the differential diagnosis of back pain in these athletes should include abnormalities of the anterior and middle column. Although diagnostic imaging should begin with radiographs, MRI is the best way to diagnosis these abnormalities. A bone scan is more useful for imaging bony abnormalities of the posterior elements. Flexion-extension radiographs are not indicated in this patient. Treatment such as physical therapy or a lumbosacral corset should not be initiated prior to a complete work-up.
REFERENCES: Katz DA, Scerpella TA: Anterior and middle column thoracolumbar spine injuries in young female gymnasts: Report of seven cases and review of the literature. Am J Sports Med 2003;31:611-616.
Tertti M, Paajanen H, Kujala UM, et al: Disc degeneration in young gymnasts: A magnetic resonance imaging study. Am J Sports Med 1990;18:206-208.

Question 78

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

Explanation

In a series reported by Blaine and associates, 12 patients were converted from interposition to total elbow arthroplasty. This procedure was successful in 10 out of 12 patients.

Question 79

What preoperative factor correlates best with the outcome of rotator cuff repair?

Explanation

DISCUSSION: The size of the rotator cuff tear in both anteroposterior and mediolateral dimensions has been found to correlate best with outcome. Older patient age and rupture of the long head of the biceps tend to be associated with larger tears and, therefore, may be associated indirectly with a poorer outcome.
REFERENCES: Iannotti JP: Full-thickness rotator cuff tears: Factors affecting surgical outcome. J Am Acad Orthop Surg 1994;2:87-95.
Iannotti JP, Bernot MP, Kuhlman JR, Kelley MJ, Williams GR: Postoperative assessment of shoulder function: A prospective study of full-thickness rotator cuff tears. J Shoulder Elbow Surg 1996;5:449-457.

Question 80

Which of the following amputations will lead to the greatest oxygen requirement per meter walked following prosthesis fitting?

Explanation

DISCUSSION: The general trend is increasing energy requirement for more proximal amputations. Amputation should be performed at the lowest possible level in order to preserve the most function. Pinzur compared 5 patients with amputations at midfoot, Syme’s, BKA, through knee, and AKA with five controls. Walking speed and cadence decreased while oxygen consumption per meter walked increased with each more proximal amputation. The only exception is the Syme which was the most energy efficient even though it is more proximal to the midfoot amputation.

Question 81

A 67-year-old woman has persistent anterior thigh and knee pain after undergoing total knee arthroplasty 1 year ago. Examination and radiographs reveal no problems in the knee, mild hip flexor weakness (grade 4+), and decreased sensation over the anterior thigh including and proximal to the incision. MRI of the lumbar spine will most likely reveal which of the following findings?

Explanation

DISCUSSION: Degenerative spondylolisthesis at L3-4 is the most likely diagnosis. This spondylolisthesis would result in foraminal stenosis affecting the third lumbar root and leading to anterior thigh and knee pain and hip flexor weakness. L4-5 spondylolisthesis would impinge on the L4 root in the foramen. Degenerative disk disease without hypertrophy is unlikely to have root impingement. Posterolateral herniations typically affect the inferior root and are less common in this age group.
REFERENCES: Hoppenfeld S: Physical Examination of the Spine and Extremities. Upper Saddle River, NJ, Prentice Hall, 1976, p 250.
Lauerman WC, Goldsmith ME: Spine, in Miller MD (ed): Review of Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 353-378.

Question 82

Figures 9a and 9b show the radiographs of a 75-year-old man who underwent a revision total knee arthroplasty with a long-stemmed tibial component. In rehabilitation, he reports fullness and tenderness in the proximal medial leg (at the knee). The strategy that would best limit this postoperative problem is use of

Explanation

DISCUSSION: The problem with this reconstruction is the medial protrusion of the base plate. The use of a base plate with an offset stem can prevent the protrusion and thus the impingement and pain. Allograft bone or smoothing the outline with cement would be just as prominent and likely to cause pain. An ingrowth surface may improve soft-tissue attachment but would still leave the implant protruding medially and likely to cause pain. A nonstemmed tibial base plate would lead to less medial protrusion but at the expense of a smaller area for load carriage on the proximal tibia.
REFERENCE: Gustke K: Cemented tibial stems are not requisite in revision. Orthopedics 2004;27:991-992.

Question 83

A 13-year-old girl who competes in gymnastics reports the insidious onset of lateral left elbow pain over the past 6 months. She also notes occasional catching episodes in the elbow; however, she denies any history of trauma. Examination reveals tenderness over the lateral epicondyle and extensor muscle origin. The elbow is stable and has full flexion, but lacks 10° of full extension. An AP plain radiograph and an MRI scan are shown in Figures 17a and 17b. Management of the elbow should consist of

Explanation

DISCUSSION: The radiograph and MRI scan show osteochondritis dissecans of the capitellum, and the patient’s history suggests a loose body. The treatment of choice is arthroscopic removal of the loose body and microfracture of the crater. Excision of the radial head, a cortisone injection, or tennis elbow release does not treat the pathology in the capitellum. Nonsurgical treatment would not relieve the mechanical symptoms of the loose body or promote healing in the crater.
REFERENCES: Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med

1998;26:520-530.
Jackson DW, Silvino N, Reiman P: Osteochondritis in the female gymnast’s elbow. Arthroscopy 1989;5:129-136.
Ruch DS, Cory JW, Poehling GG: The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 1998;14:797-803.

Question 84

below show the radiographs, and the CT obtained from a year-old woman who underwent cementless left total hip arthroplasty. Nine months after surgery, she continued to have groin pain when actively flexing her hip. She has trouble walking up stairs and getting out of her car. What is the most likely diagnosis?

Explanation

DISCUSSION:
Groin pain after total hip replacement has a number of possible causes, and an exact diagnosis may remain elusive in some patients. Infection should be ruled out with laboratory studies and, if indicated, diagnostic aspiration of the hip joint. Implant loosening should be evaluated by plain radiograph and bone scan, if indicated. Synovitis resulting from wear debris should be considered in patients with polyethylene liners who experience late-onset symptoms or in any patient with a metal-on-metal bearing. This patient's symptoms are classic for iliopsoas tendonitis. Physical examination usually reveals pain and weakness with resisted hip flexion. A cross-table lateral radiograph and CT show that the anterior edge of the acetabulum protrudes beyond the anterior wall, thereby acting as a source of iliopsoas tendon irritation. In such cases, acetabular component revision and repositioning are indicated. Fluoroscope-guided iliopsoas cortisone injection can help to establish the diagnosis and relieve groin pain. If the acetabular component is well positioned, then iliopsoas tenotomy should be considered.

Question 85

-Radiographs are shown in Figures 89a through 89c. What is the most likely diagnosis?

Explanation

Question 86

Figure 35 is the MR image of an 18-year-old man who has had knee pain with running for 5 months. What is the most appropriate treatment?

Explanation

DISCUSSION
The MR image shows an osteochondritis dissecans (OCD), which is an acquired lesion of the subchondral bone. Patients with OCD initially report nonspecific pain and variable amounts of swelling. Initial radiographs help to identify the lesion and establish the physes status. MRI is useful for assessing potential for the lesion to heal with nonsurgical treatment. This lesion is unstable, considering the fluid line between the OCD and the underlying normal bone. Nonsurgical treatment is appropriate for small, stable lesions in patients with open physes and focuses on activity restriction for 3 to 9 months. Surgical treatment is necessary to address unstable or detached lesions. Stable lesions with intact articular cartilage can be treated with subchondral drilling to stimulate vascular ingrowth, with radiographic healing at an average of 4.4 months. Fixation is indicated for unstable or hinged lesions, and stabilization of the fragment can be achieved using a variety of implants through an arthroscopic or open approach. The fragment should be salvaged and the normal articular surface restored whenever possible.

Question 87

A 55-year-old man who runs on the weekends reports a 1-year history of continued pain directly posteriorly in the heel. Management consisting of anti-inflammatory drugs, icing techniques, a heel-counter in his shoe split, and physical therapy consisting of stretching, contrast baths, custom orthotics, and iontophoresis has failed to provide relief. Not only is his lifestyle disrupted with respect to running, but he now has pain with normal ambulation with all forms of shoe wear. He is not necessarily concerned with returning to running; he is primarily seeking pain relief. A lateral radiograph and clinical photograph are shown in Figures 32a and 32b. Treatment should now consist of

Explanation

DISCUSSION: The patient has severe calcifications at the insertion of the Achilles tendon. Failure to address the Haglund’s exostosis and the calcifications will leave the patient with persistent pain. Steroids should not be injected directly into the tendon because of the increased risk of tendon rupture. Shock wave treatment may have some value in treating plantar fasciitis, but its efficacy has not been documented with insertional calcifications and Haglund’s exostosis treatment. Brisement is injection of saline solution around the Achilles tendon in an attempt to decompress the peritenon. This may be valuable in intrasubstance Achilles tendinosis or peritendinitis but has no value with insertional disease. Symptoms persisting beyond 6 months are difficult to treat nonsurgically; therefore, the appropriate treatment protocol is aggressive and must address all pathology. The patient may not be able to run at the level achieved prior to surgery, but the goal of the surgery is pain relief.
REFERENCES: Clain M, Baxter D: Achilles tendinitis. Foot Ankle 1992;13:482-487.
Schepsis A, Wagner C, Leach R: Surgical management of Achilles tendon overuse injuries: A long-term follow-up study. Am J Sports Med 1994;22:611-619.
Schepsis A, Leach R: Surgical management of Achilles tendinitis. Am J Sports Med 1987;15:308-315.
Keck S, Kelly P: Bursitis of the posterior part of the heel: Evaluation of surgical treatment of eighteen patients. J Bone Joint Surg Am 1965;47:267-273.

Question 88

03 A 26-year-old woman has chronic toe pain after hitting a bedpost 3 months ago. A radiograph is shown in Figure 27. Her injury represents an avulsion of the

Explanation

The main function of the EDL is extension of the MTP joints of the lesser toes, so injury results in a claw toe deformity if left unrepaired. The EDL originates on the lateral tibial condyle, the anterior crest of the fibula, and the interosseous membrane and inserts on the base of the terminal phalanges of the four lesser toes. Innervated by the deep peroneal nerve, the EDL functions to extend the toes at the DIP joint and to dorsiflex and evert the foot. The EDL divides into two separate tendons beneath the superior retinaculum and then further divides into two lateral tendons to the fourth and fifth toes and two medial tendons to the second and third toes. The individual tendon of the EDL to each toe is joined on the lateral aspect by the tendon of the EDB. They are anchored at the level of the MTP joint by a fibroaponeurotic structure.
The EDB originates on the distal lateral and superior surface of the calcaneus and inserts on the
lateral aspect of the flexor digitorum longus tendon and also on to the base of the proximal phalanx of the first through fourth toes. There is no EDB tendon to the fifth toe. If an EDB laceration is easily identified at the time of an EDL repair, than it may be repaired as well, otherwise repair of the EDL alone is sufficient.
Heckman JD: Fractures and dislocation of the foot, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds):Rockwood and Green’s Fractures in Adults, ed 3. Philadelphia, PA, JB Lippincott, 1991, pp 2166-2169.
Coughlin MJ: Disorders of tendons, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 787-788.
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Question 89

Iliosacral screws placed for stabilization of posterior pelvic ring injuries (eg, sacroiliac dislocation) that exit the sacrum anteriorly are most likely to injure which of the following structures?

Explanation

DISCUSSION: Iliosacral screws have gained popularity for posterior stabilization of pelvic ring disruptions, but complications attributed to incorrect placement are a clinical problem. The L5 nerve root is at greatest risk and is in closest proximity to a malpositioned screw (exiting the sacrum). The L4 root is more anterior at this level. The S1 root is still intraosseous at this level and is at risk but not from the screw exiting anteriorly at this level. The arteries are at risk but are more anterior and are at less risk than the L5 nerve root.
REFERENCE: Ebraheim NA, Haman SP, Xu R, Stanescu S, Yeasting RA: The lumbosacral nerves in relation to dorsal SI screw placement and their locations on plain radiographs. Orthopedics 2000;23:245-247.

Question 90

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

Explanation

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

Williams and Wilkins, 1998, pp 98-100.

Question 91

In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures?

Explanation

DISCUSSION: The Chaput fragment, highlighted by the arrow in Illustration A, is the anterolateral fragment of the distal tibia. This section of bone attaches to the anterior inferior tibiofibular ligament and is often hinged off this structure due to the fracture. A pilon fracture is often split into three main fragments at the joint level (Illustration B): Chaput fragment (anterolateral), Volkmann fragment (posterolateral), and a medial fragment. The Volkmann fragment is the attachment site of the posterior inferior tibiofibular ligament. The Wagstaff fragment is the fibular corollary to the Chaput fragment, and serves as the other attachment of the anterior inferior tibiofibular ligament

Question 92

A 13-year-old girl presents with back pain for 6 months. Figures A and B are SPECT scan and CT images taken at the time of presentation. What is the most likely diagnosis? Review Topic

Explanation

This
patient
has
spondylolysis.
Spondylolysis is a common cause of back pain in children/adolescents. It is common in sports with repetitive hyperextension (gymnasts, weightlifters, football linemen). It is best seen on lateral and oblique radiographs, CT (best study to diagnose and delineate anatomy), and SPECT.
Saifuddin et al. reviewed the orientation of the pars fracture. They found that only 32% of defects were oriented within 15° of the 45° lateral oblique plane and would be
visible on oblique radiographs. They thus recommend CT scans for spondylolysis.
Cheung et al. reviewed spondylolysis and spondylolisthesis. They advocate pars repair for symptomatic spondylolysis and low-grade, mobile spondylolisthesis with pars defects cephalad to L5 and for those with multiple-level defects.
Figure A is a 99mTc-MDP SPECT scan showing increased uptake at the right L5 pars interarticularis. Figure B is an axial helical CT image showing bilateral spondylolysis at L5. Illustration A is a corresponding sagittal reconstruction image demonstrating right pars fracture into the right L5 superior facet. Illustration B shows the appearance of osteoblastic metastasis (green arrow). Illustration C shows the options for pars repair.
Incorrect

Question 93

Pelvic packing for a hemodynamically unstable patient with a pelvic ring fracture is best described by which of the following techniques?

Explanation

For the technique of pelvic packing patients are placed supine on an operating room table. For rotationally and/or vertically unstable fracture patterns, an external fixator is then placed to stabilize the pelvis so that the volume of the pelvis is decreased and the packing has counterforce acting against it. An approximately 6 cm to 8 cm midline incision is made extending upwards from the pubic symphysis and heading toward the umbilicus. The rectus fascia is then divided in the midline. The bladder is retracted to one side and three lap pads are packed deep to the pelvic brim. The bladder is retracted to the other side and three more lap pads are placed on that side as well. The first sponge is placed at the level of the sacroiliac joint, the second anterior to the first sponge, and the third in the retropubic space lateral and just deep to the bladder. All should be placed below the level of the pelvic brim. The fascia is then closed. If the patient is hemodynamically unstable after stabilization, then packing of the pelvis angiography should be considered.

Question 94

The peroneus tertius is a commonly used landmark for arthroscopic portal placement. What is the function of this tendon?

Explanation

DISCUSSION: The peroneus tertius, although absent in 10% of the population, originates on the distal third of the extensor surface of the fibula and inserts onto the base of the fifth metatarsal, possibly extending to the fascia over the fourth interosseous space. The muscle is located in the anterior compartment of the leg and is innervated by the deep peroneal nerve. The tendon produces dorsiflexion and eversion when walking and can be used as an insertion point during tendon transfers to assist dorsiflexion. This tendon is peculiar to humans and is a proximally migrated deep extensor of the fifth toe.
REFERENCES: Joshi SD, Joshi SS, Athavale SA: Morphology of the peroneus tertius muscle.

Clin Anat 2006;19:611-614.
Williams PL, Bannister LH, Berry MM, et al (eds): Gray’s Anatomy, ed 38. London, Churchill Livingston, 1995, p 883.
Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, p 21.

Question 95

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?

Explanation

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral
discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatment of a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.

Question 96

CLINICAL SITUATION Figure 1 is the radiograph taken 6 weeks ago of a 41-year-old woman with persistent pain in her right leg after sustaining a tibia fracture 12 months ago in a motor vehicle collision. On examination, she has well-healed scars and a well-healed flap on the medial aspect at the level of the fracture. She reports having an infection after the initial surgery, which resulted in debridement of the soft tissue and need for the local rotational flap. There are no changes at the fracture site as shown in the most recent radiograph (Figure 2). She is healthy and has no comorbidities. Assuming her workup is negative for any other causes, what is the best treatment option?

Explanation

Discussion: The patient had an open fracture that was initially treated with what appears to be appropriate irrigation and debridement and intramedullary nail placement. The post-operative infection and need for rotational flap is worrisome, but she has not had any issues since the flap. She has abundant callus formation but the fracture line is still visible and unchanged on 2 sets of radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated. A CT scan is not warranted because the sequential radiographs show persistent fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing. Based on successive radiographs and the lack of healing, observation is probably just delaying the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone non-unions, especially in the femur.

Question 97

An otherwise healthy 54-year-old man who underwent a successful multilevel lumbar decompression and fusion 4 years ago now reports increasingly severe bilateral thigh claudication with paresthesia and severe back pain for the past 12 months. Physical therapy, bracing, and epidural steroids have failed to provide relief. A radiograph and MRI scans are shown in Figures 15a through 15c. He is afebrile, and laboratory studies show an erythrocyte sedimentation rate of 5 mm/h and a normal WBC count. What is the best course of action?

Explanation

DISCUSSION: The patient has degeneration of an adjacent segment with resultant

kyphosis and stenosis. Because he is healthy, has responded well to previous surgery,

|and has a potentially correctable lesion, he is not a good candidate for an end-stage failed

back procedure such as a morphine pump. The stenosis is exacerbated by the deformity; therefore, a simple decompression will contribute to instability. Because of the kyphosis and the patient’s relatively young age, the treatment of choice is restoration of sagittal alignment and posterior decompression.
REFERENCE: Eck JC, Humphreys SC, Hodges SD: Adjacent-segment degeneration after lumbar fusion: A review of clinical, biomechanical, and radiographic studies. Am J Orthop 1999;28:336-340.

Question 98

A B Figures 60a and 60b are the postmyelography CT images of a 62-year-old man who has had low-back and bilateral lower-extremity pain. His pain began approximately 1 year ago and there was no precipitating event. The location of the pain is in the lower lumbar region in the midline and it radiates into the buttocks and thighs bilaterally. The pain is exacerbated by standing and walking and relieved by forward spine flexion. He reports no pain while sitting or lying supine. Upright radiographs demonstrate 4 mm of anterolisthesis of L4 on L5. What is the most appropriate surgical procedure?

Explanation

DISCUSSION
This patient radiographically has L4-5 degenerative stenosis and a low-grade spondylolisthesis. The axial images demonstrate a gap in the facet joint, more on the left than the right, which is highly suggestive of dynamic instability. Thus, this patient would most benefit from a laminectomy and fusion of L4-5. A microdiskectomy would not be helpful as this patient does not have a disk herniation. Patients undergoing posterior decompression alone experience an unacceptably high rate of recurrent stenosis and/or progression of spondylolisthesis. Early studies demonstrated that adding an intertransverse process fusion to posterior decompression significantly improved clinical outcomes. Anterior interbody fusion likely will not decompress the spinal canal sufficiently, though there is some thought that indirect decompression can be effective in some cases.
RECOMMENDED READINGS
Frymoyer JW. Degenerative Spondylolisthesis: Diagnosis and Treatment. J Am Acad Orthop Surg. 1994 Jan;2(1):9-15. PubMed PMID: 10708989. Majid K, Fischgrund JS. Degenerative lumbar spondylolisthesis: trends in management. J Am Acad Orthop Surg. 2008 Apr;16(4):208-15. Review. PubMed PMID: 18390483. View Abstract at PubMed
Carlisle E, Fischgrund JS. Lumbar spinal stenosis and degenerative spondylolisthesis. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006: 299-317.
Puschak TJ, Sasso RC. Spondylolysis-spondylolisthesis. In: Vaccaro AR, ed. Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:553-563.

Question 99

Which of the following conditions associated with a closed fracture of the clavicle indicates the need for open reduction and internal fixation?

Explanation

Injuries to underlying vascular structures associated with clavicle fractures require exploration and stabilization. Brachial plexus injuries recover spontaneously in two thirds of patients. Displaced and segmental fractures may undergo closed reduction. Open treatment of clavicle fractures have been discouraged secondary to technical difficulties and nonunion. A floating shoulder (displaced clavicle and scapular neck fractures is an indication for ORIF but not humeral neck fracture.)

Question 100

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

Explanation

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

Full Question & Answer Text (for Search Engines)

Question 1:

A 21-year-old college defensive lineman sustains a minimally displaced (less than 1 mm) midthird scaphoid fracture during the first game of the season. Management should consist of

Options:

cast immobilization and a return to play as symptoms allow.
cast immobilization and a return to play when union is achieved.
open reduction and internal fixation, followed by early range of motion with a return to play when union is achieved.
open reduction and internal fixation, followed by a return to play with protective casting.
symptomatic treatment, with definitive treatment at the end of the season.

Correct Answer: cast immobilization and a return to play as symptoms allow.

Explanation:

Question 2:

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

Options:

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

Correct Answer: Proprioceptive neuromuscular facilitation (PNF)

Explanation:

Question 3:

All of the following are factors associated with transfer of patients to Level 1 trauma centers EXCEPT:

Options:

Male
Medicaid insurance
Injury severity score of 36
Caucasian race
One or more comorbidity

Correct Answer: Male

Explanation:

Question 4:

Options:

Debridement and IV antibiotics
Wide resection of the lesion
Chemotherapy alone
Observation
Amputation

Correct Answer: Wide resection of the lesion

Explanation:

DISCUSSION: In an adult with an anterior cortical tibial lesion, this is the classic histologic appearance and anatomic location for an adamantinoma. The histology reveals areas of epithelial cells (in a glandular pattern) within a fibrous stroma. The epithelial cells are shown in nests. They would stain positively for keratin. Adamantinoma is a rare malignant bone tumor with a propensity for late metastasis. It has a high incidence of local recurrence unless resected with a wide margin. Chemotherapy and radiation therapy are not helpful in the treatment of this disease. Amputation generally is not necessary because a diaphyseal resection is usually possible.
REFERENCES: McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 263.
Moon NF, Mori H: Adamantinoma of the appendicular skeleton: Updated. Clin Orthop Relat Res 1986;204:215-237.

Question 5:

Options:

No further treatment
Closed reduction under conscious sedation
Closed reduction under general anesthesia in the operating room with neurologic monitoring
Occipitocervical fusion
Posterior atlantoaxial fusion

Correct Answer: No further treatment

Explanation:

The clinical presentation is consistent with chronic torticollis caused by Atlantoaxial rotatory displacement (AARD). Because both halter traction and halo traction were attempted and failed, the next most appropriate next step in management is posterior atlantoaxial fusion.
Common causes of Atlantoaxial rotatory displacement (AARD) include infection, trauma, and recent neck surgery. Diagnosis is challenging and is best confirmed with dynamic CT (CT with the head turned maximally to either side and at neutral). If the symptoms are acute (less than 7 days) then initial treatment with a soft collar and anti-inflammatory medications is indicated. If the condition has been present for more than a week, more aggressive treatment with halter traction (present 1 week to 1 month) or halo traction (present for 1-3 months) is indicated. If nonoperative modalities fail, the condition has been present for > 3 months, or the patient has neurologic deficits, then posterior C1-C2 fusion is indicated.
Copley et al discuss the evaluation and treatment of various congenital and traumatic conditions of the pediatric cervical spine. They report that the underlying mechanism of Atlantoaxial rotatory displacement (AARD) is inflammation and spasm which can be caused by infection, prior surgery, trauma, and rheumatoid arthritis.
Subach et al reviewed at 20 children with atlantoaxial rotatory subluxation. They found that of the 20 patients treated overall, conservative management failed in 6 (30%), and they required posterior fusion because of recurrence of the atlantoaxial rotatory subluxation or unsuccessful reduction. The major factor predicting the failure of conservative management was the duration of subluxation before initial reduction. Patients with long-standing subluxation were more likely to experience recurrence and require surgery.
Figure A shows an asymmetric placed odontoid within the ring of C1. There is an increased distance from the odontoid to the right arch of C1 which is fixed and minimally changes with maximal rotation to the left. This radiographic finding is indicative of fixed subluxation. Illustration A further demonstrates this.
Incorrect
(SBQ12SP.1) A 65-year-old female with a history of breast cancer presents with bilateral buttock and leg pain that is worse with walking and improves with sitting. In addition, she reports that she feels unsteady on her feet and requires holding the railing when going up and down stairs. On physical exam she is unable to complete a tandem gait and has hip flexion weakness, ankle dorsiflexion weakness, and ankle plantar flexion weakness. Her reflex exam shows 3+ bilateral patellar reflexes. Radiographs and an MRI are shown in Figure A and B. What is the next most appropriate step in management.
Review
Topic
Lumbar epidural injection
Physical therapy with core strengthening and anti-inflammatory medications as needed
Lumbar decompression
Lumbar decompression and fusion
MRI of the cervical and thoracic spine
The clinical scenario is consistent with a patient with symptoms of degenerative spondylolisthesis AND symptoms of myelopathy. Myelopathy must be ruled out by performing an MRI of the cervical and thoracic spine.
Tandem stenosis occurs in approximately 5 to 25% of patients. Because of the stepwise progressive nature of myelopathy, treatment of myelopathy often takes precedence over lumbar spinal stenosis.
Rhee et al. found that the sensitivity and specificity of specific physical exam findings varies. Both the upward babinski reflex and the presence of clonus were found to be very non-sensitive (13%). The most sensitive provacative test was found to be the Hoffman sign (59%).
Salvi et al. reviewed the classic presentations for cervical myelopathy including demographics, history, and physical exam findings (the inability to preform a tandem gait, hyperreflexia, an abnormal babinksi and hoffman reflex, the inability to preform rapid movements and bilateral muscle weakness). Additionally they identify other potential causes for myelopathy, including multiple sclerosis, amyotrophic lateral sclerosis, multifocal motor neuropathy, and Guillain-Barre´syndrome.
Maezawa et al. showed that gait analysis can identify a pattern in patients with myelopathy. Patients with severe myelopathy have a characteristic gait with hyperextension of the knee in the stance phase without plantar flexion of the ankle in the swing phase. They also have decreased walking speed and stride length with a prolonged stance phase.
Figure A and B show a classic degenerative spondylolisthesis.
Incorrect Answers:

Question 6:

Options:

Nerve conduction velocity studies
Biopsy of the quadriceps femoris muscle
Biopsy of the sural nerve
DNA testing
Chromosomal analysis

Correct Answer: DNA testing

Explanation:

Question 7:

Options:

Hip instability
Abductor weakness
Adductor weakness
Quadriceps weakness
Leg-length discrepancy

Correct Answer: Abductor weakness

Question 8:

What complication is most likely to occur following proximal humeral fixation with a locked plate-and-screw construct?

Options:

Screw penetration
Rotator cuff injury
Axillary nerve damage
Fracture of the humeral shaft
Impingement

Correct Answer: Screw penetration

Explanation:

Question 9:

Options:

Loss of external rotation with the glenohumeral joint abducted 90 degrees
Loss of external rotation with the arm at the side of the body
Loss of internal rotation with the glenohumeral joint abducted 90 degrees
Loss of internal rotation up the back
Loss of flexion

Correct Answer: Loss of external rotation with the arm at the side of the body

Explanation:

Question 10:

-This boy’s parents are eager to get him back on the field as soon as possible. What is the most appropriate treatment option?

Options:

Screw fixation of the epiphysis
Arthroscopic debridement
A shut-down period until the boy is asymptomatic, and gradual return to pitching via a throwing program
An intra-articular cortisone injection

Correct Answer: A shut-down period until the boy is asymptomatic, and gradual return to pitching via a throwing program

Explanation:

DISCUSSION FOR QUESTIONS 60 AND 61
Although a recent increase in the number of pitches may have contributed to this patient’s development of little leaguer’s shoulder, the most significant overall factor is age. Little leaguer’s shoulder is caused by rotational stress placed on the proximal humeral epiphysis during overhead throwing. The growth plate is weakest to torsion stress, and is most susceptible to injury during periods of rapid growth commonly seen during puberty. Most chronic shoulder injuries occur in throwing athletes between 13 and 16 years of age. Genetic factors and gender have not been studied in association with little leaguer’s shoulder. An initial 3-month period of rest and activity modification will typically result in resolution of symptoms.Nonsteroidal anti-inflammatory drugs may be used as needed. After the rest period, a gradual return to baseline pitching is implemented until the patient is back to baseline. This protocol has a long-term success rate exceeding 90%.

Question 11:

Options:

Anterior tibialis tendon transfer to the dorsolateral midfoot
Posterior tibialis tendon transfer to the dorsolateral midfoot
Peroneus longus tendon transfer to the dorsolateral midfoot
Peroneus brevis tendon transfer to the dorsolateral midfoot
Flexor hallucis longus tendon transfer to the peroneus brevis

Correct Answer: Peroneus longus tendon transfer to the dorsolateral midfoot

Explanation:

DISCUSSION: Compartment syndrome of the anterior and deep posterior compartments results in anterior tibialis and posterior tibialis tendon weakness, respectively. Furthermore, the long flexors to the hallux and lesser toes will be weak as well. The intact peroneus longus overpowers the weak anterior tibialis tendon, resulting in plantar flexion of the first metatarsal, cavus, and hindfoot varus. Therefore, transferring the peroneus longus to the dorsolateral midfoot reduces the first metatarsal plantar flexion torque, and possibly augments ankle dorsiflexion torque.
REFERENCES: Hansen ST: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott, Williams & Wilkins, 2000, pp 433-435.
Vienne P, Schoniger R, Helmy N, et al: Hindfoot instability in cavovarus deformity: Static and dynamic balancing. Foot Ankle Int 2007;28:96-102.

Question 12:

Which radiographic abnormality most accurately serves as a predictor of ankle syndesmosis disruption?

Options:

Medial clear space equal to the superior clear space on the anteroposterior (AP) view
Tibiofibular overlap exceeding 6 mm on the AP view
Tibiofibular clear space exceeding 6 mm on AP view
Talocrural angle symmetric to the opposite side

Correct Answer: Tibiofibular clear space exceeding 6 mm on AP view

Explanation:

DISCUSSION
Normal syndesmotic relationships include a tibiofibular clear space smaller than 6 mm on both AP and mortise views. In a 1989 cadaveric study by Harper and Keller, a tibiofibular clear space exceeding 6 mm on both the AP and mortise views was the most reliable predictor of early syndesmotic widening. Tibiofibular overlap is measured 1 cm proximal to the plafond. Normal values exceed 6 mm or 42% of the width of the fibula on the AP view, or 1 mm on the mortise view. Proximal fibula fracture can occur in isolation without syndesmotic injury, frequently after direct trauma. The medial clear space is the distance between the lateral border of the medial malleolus and the medial border of the talus and is measured at the level of the talar dome. In the mortise view with the ankle in neutral dorsiflexion, the medial clear space should be equal to or smaller than the superior clear space between the talar dome and the tibial plafond. ?A normal medial clear space may be present with syndesmotic injury and consequently lacks sensitivity and specificity.
RECOMMENDED READINGS
Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg. 2007 Jun;15(6):330-9. Review. PubMed PMID: 17548882.
View Abstract at PubMed
Wuest TK. Injuries to the Distal Lower Extremity Syndesmosis. J Am Acad Orthop Surg. 1997 May;5(3):172-181. PubMed PMID: 10797219.
View Abstract at PubMed
Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989 Dec;10(3):156-60. PubMed PMID: 2613128.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 40
A 41-year-old man sustained a twisting injury while running up stairs 4 weeks ago. He was treated in an ankle brace and has been bearing weight since the injury occurred. He has no history of ankle problems, but he now has ankle pain, swelling, and instability. The pain is aggravated by stairs, and the instability is worse on unlevel ground. Radiographs do not show a fracture.

Question 13:

A normal functioning posterior tibialis tendon is best confirmed by which of the following physical findings?

Options:

Pronation of the foot during the stance phase of gait
Heel inversion at the beginning of a single limb heel rise
Active inversion of the nonweightbearing foot
Active plantar flexion of the first ray against resistance
Active plantar flexion of the foot during the push-off phase of gait

Correct Answer: Heel inversion at the beginning of a single limb heel rise

Explanation:

Question 14:

Options:

Metastatic lung carcinoma
Mucous cyst
Synovial sarcoma
Inclusion cyst
Felon abscess

Correct Answer: Mucous cyst

Explanation:

DISCUSSION: A mucous cyst is thought to be a ganglion arising from the DIP joint in patients with osteoarthritis. They are frequently associated with nail deformities. Treatment involves removal of the cyst with debridement of DIP joint osteophytes.
REFERENCES: Fritz GR, Stern PJ, Dickey M: Complications following mucous cyst excision. J Hand Surg Br 1997;22:222-225.
Zook EG, Brown RE: The perionychium, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, vol 2, pp 1353-1380.

Question 15:

Options:

shorter hospital stay
fewer bone-grafting procedures
lower infection rate
fewer secondary invasive interventions
faster early fracture healing

Correct Answer: shorter hospital stay

Explanation:

Question 16:

This medication, a factor Xa inhibitor, currently is not approved for venous thromboembolism (VTE) prophylaxis.

Options:

- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)

Correct Answer: - Apixaban (Eliquis)

Explanation:

DISCUSSION
Warfarin has a long clinical track record and is well known among most physicians. It is a vitamin K antagonist that can be monitored with prothrombin time (INR) testing and reversed with vitamin K and fresh frozen plasma if needed. Newer oral anticoagulants are becoming more common and offer the advantage of being rapidly active without a need for monitoring. These oral anticoagulants are not reversible, which can complicate the treatment of patients who present with bleeding or require surgery. Dabigatran (Pradaxa) is a direct thrombin inhibitor that is approved for stroke prevention in atrial fibrillation. It is not reversible, and a surgical delay of 24 to 48 hours is recommended for all but emergent surgeries. A longer delay is recommended with renal insufficiency. Rivaroxaban (Xarelto) is an oral factor Xa inhibitor that is approved for atrial fibrillation and the treatment of VTE and deep vein thrombosis prophylaxis. It offers the advantage of daily dosing. It
is not reversible and a surgical delay of 36 to 48 hours is recommended. Apixaban (Eliquis) is another factor Xa inhibitor for which twice-daily dosing is required. It is currently approved for stroke prevention in atrial fibrillation, and a surgical delay of 36 to 48 hours is recommended.
RECOMMENDED READINGS
Gonsalves WI, Pruthi RK, Patnaik MM. The new oral anticoagulants in clinical practice. Mayo Clin Proc. 2013 May;88(5):495-511. doi: 10.1016/j.mayocp.2013.03.006. Review. Erratum in: Mayo Clin Proc. 2013 Jul;88(7):777. PubMed PMID: 23639500.
View Abstract at PubMed
Alquwaizani M, Buckley L, Adams C, Fanikos J. Anticoagulants: A Review of the Pharmacology, Dosing, and Complications. Curr Emerg Hosp Med Rep. 2013 Apr 21;1(2):83-97. Print 2013 Jun. PubMed PMID: 23687625.
View Abstract at
PubMed
CLINICAL SITUATION FOR QUESTIONS 100 AND 101
A 55-year-old woman slipped on ice while getting out of her car and sustained the injury shown in Figure 100.

Question 17:

Figure A shows the 2 bundles of the ACL dissected from a cadaveric knee off their bony attachments. They are labeled Bundle A and Bundle B, respectively. Which of the following is true? Review Topic

Options:

The tibial attachment of Bundle A is anterior to Bundle B. In extension, Bundle B is loose and Bundle A is tight.
The tibial attachment of Bundle A is anterior to Bundle B. In flexion, Bundle B is loose and Bundle A is tight.
The tibial attachment of Bundle B is anterior to Bundle A. In flexion, Bundle B is loose and Bundle A is tight.
The tibial attachment of Bundle B is anterior to Bundle A. In flexion, Bundle A is loose and Bundle B is tight.
The tibial attachment of Bundle B is anterior to Bundle A. In extension, Bundle A is loose and Bundle B is tight.

Correct Answer: The tibial attachment of Bundle A is anterior to Bundle B. In extension, Bundle B is loose and Bundle A is tight.

Explanation:

Question 18:

Options:

Cervical sprain
Atlas fracture
Acute displaced odontoid fracture
Odontoid nonunion
Hangman’s fracture

Correct Answer: Odontoid nonunion

Explanation:

Question 19:

It is recommended that invasive dental work be completed prior to the initiation of which of the following medications?

Options:

Glucosamine
Cholecalciferol
Levothyroxine
Teriparatide
Bisphosphonates

Correct Answer: Glucosamine

Explanation:

Question 20:

Options:

closed reduction and buddy taping.
in situ pinning.
open reduction and internal fixation.
casting for 6 weeks.
dynamic extension splinting.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 21:

-What gene is implicated in spinal muscular atrophy?

Options:

Survival motor neuron I (SMN-I)
Peripheral myelin protein 22 (PMP22)
Dystrophin
Androgen receptor DISCUSSION-Deletions in the SMN-I gene are found in 95% to 98% of patients with spinal muscular atrophy. Genetic testing is typically part of the diagnostic workup for spinal muscular atrophy. A positive test result is diagnostic, and, in most cases, eliminates the need for muscle biopsy. The other choices are not associated with spinal muscular atrophy. Defects in PMP22 are the cause of 70% to 80% of cases of Charcot-Marie-Tooth disease. Mutations in the dystrophin gene cause Duchenne muscular dystrophy, and mutations in the androgen receptor cause spinobulbar muscular atrophy (Kennedy’s disease).

Correct Answer: Survival motor neuron I (SMN-I)

Question 22:

Options:

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

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

Explanation:

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

Question 23:

Options:

Decreased joint penetration of distal screws
Increased rigidity
Decreased need for delayed hardware removal
Decreased peroneal irritation
Improved distal fixation

Correct Answer: Decreased joint penetration of distal screws

Explanation:

Question 24:

Options:

Reposition the harness to hold the hips in 70 degrees of abduction
Closed reduction and arthrography under anesthesia
Open reduction and a spica cast
Continued harness treatment in the current position
Spica cast

Correct Answer: Continued harness treatment in the current position

Explanation:

Question 25:

Options:

use of mechanical prophylaxis (eg, pneumatic calf compressors) while in the hospital.
oral warfarin with a goal INR between 2.0 and 3.0.
low-dose warfarin for 3 weeks postsurgically beginning 48 hours after surgery.
no prophylaxis because this patient already is partially anticoagulated secondary to her liver disease.

Correct Answer: use of mechanical prophylaxis (eg, pneumatic calf compressors) while in the hospital.

Explanation:

The 2011 AAOS Clinical Practice Guideline,
Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty
, recommends the use of mechanical prophylaxis for patients at increased risk for bleeding (including those with liver disease or hemophilia). This recommendation is the consensus of the workgroup that established these guidelines because there was insufficient evidence to justify a stronger recommendation in this clinical scenario. The other responses use no prophylaxis or pharmacological prophylaxis. Pharmacological prophylaxis is not recommended in patients who are at increased risk for bleeding.

Question 26:

Options:

Crescent fracture located on the side of impact
Widened anterior SI joint, disrupted sacrotuberous and sacrospinous ligaments with intact posterior SI ligaments
Complete SI disruption with lateral displacement
Sacral compression fracture on side of impact with transverse pubic rami fractures
Open-book injury with contralateral sacral compression fracture

Correct Answer: Open-book injury with contralateral sacral compression fracture

Explanation:

Question 27:

Options:

Continue with a more aggressive passive range-of-motion exercise program.
Perform an open release.
Revise the humeral component and increase retroversion.
Revise the humeral component alone after osteotomizing more of the humeral neck and seating the component lower.
Remove the glenoid component to decrease tension in the rotator cuff.

Correct Answer: Perform an open release.

Explanation:

Question 28:

Options:

Osteoarthritis
Rheumatoid arthritis
Pigmented villonodular synovitis
Charcot arthropathy
Paget’s disease

Correct Answer: Rheumatoid arthritis

Explanation:

Question 29:

Options:

Laceration of a branch of the posterior interosseous nerve (PIN)
Postsurgical tendon adhesion
Laceration of the (EDC) tendons to long and ring fingers
Neuropraxia of the PIN

Correct Answer: Laceration of a branch of the posterior interosseous nerve (PIN)

Explanation:

EXPLANATION:
Plating of the proximal radius from a dorsal or Thompson approach (between the extensor carpi radialis brevis and extensor digitorum communis) allows complete visualization of the PIN through the supinator. Going through the same incision from proximal to distal produces a scar-filled proximal approach, and it is not uncommon to drift ulnarly and injure an individual nerve to the extensor digitorum communis muscle, resulting in the deformity seen in Figures 1 and 2.Postsurgical tendon adhesions rarely involve only 2 tendons. Complete tendon lacerations are rare at this level in the proximal forearm, as is a complete laceration of the PIN. Neuropraxias are common but usually resolve after 3 months. The gossamer-thin branch of the PIN to the EDC can be easily damaged in scar tissue, resulting in an inability to fully extend the MP joints of the long and ring fingers. The proprius tendons allow the patient to fully extend the index and little finger MP joints. Connecting the EDC of the long finger to the
extensor indicis proprius
and the EDC of the ring finger to the
extensor digiti quinti
proprius can correct the deformity. To avoid the problem, the surgeon should start the incision distally in normal anatomy, and the interval between the
mobile wad and the digital extensors will be more easily found.

Question 30:

The term anorexia athletica refers to a problem whose criteria include all of the following, EXCEPT Review Topic

Options:

gastrointestinal complaints.
restriction of caloric intake.
presence of an affective disorder.
weight loss.
menstrual dysfunction.

Correct Answer: presence of an affective disorder.

Explanation:

Question 31:

Options:

hinged knee bracing, protected weight bearing, and physical therapy.
anteromedialization of the tibial tubercle.
internal fixation and medial patellofemoral ligament (MPFL) reconstruction.
arthroscopic lateral retinacular release.

Correct Answer: internal fixation and medial patellofemoral ligament (MPFL) reconstruction.

Explanation:

Question 32:

Options:

Annual monitoring of serum metal ion levels
Repeated MRI with MARS in 6 months
Conversion of the THA to a cobalt alloy femoral head and polyethylene bearing
Conversion of the THA to a ceramic femoral head with an inner titanium sleeve and polyethylene bearing

Correct Answer: Conversion of the THA to a ceramic femoral head with an inner titanium sleeve and polyethylene bearing

Explanation:

Question 33:

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

Options:

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

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

Explanation:

DISCUSSION: Symptomatic herniations of the thoracic spine are much less common than those of the cervical or lumbar region. They tend to occur most commonly during the third to fifth decades of life and although they can be found at all levels, they are most common in the lower third near the thoracolumbar region. Posterior laminectomy and disk excision has the highest rate of neurologic deterioration and is not recommended. Multiple studies have shown that herniated thoracic disks can be found at one or more levels in 40% of asymptomatic individuals.
REFERENCES: Shah RP, Grauer JN: Thoracoscopic excision of thoracic herniated disc, in Vaccaro AR, Bono CM (eds): Minimally Invasive Spine Surgery. New York, NY, Informa Healthcare, 2007, pp 73-80.
Bohlman HH, Zdeblick TA: Anterior excision of herniated thoracic discs. J Bone Joint Surg Am 1988;70:1038-1047.

Question 34:

Options:

an avulsion of the lesser tuberosity.
a midsubstance tear of the capsule.
a tear of the anterior inferior labrum.
a tear of the subscapularis.
a tear of the humeral insertion of the inferior glenohumeral ligament.

Correct Answer: a tear of the humeral insertion of the inferior glenohumeral ligament.

Explanation:

Question 35:

Options:

Occupational therapy for strengthening
Extensor carpi radialis longus transfer to extensor pollicus longus
Extensor pollicis brevis transfer to extensor pollicus longus
Extensor indicis proprius transfer to extensor pollicus longus
Primary repair of extensor pollicus longus

Correct Answer: Occupational therapy for strengthening

Explanation:

Question 36:

Disadvantages of anterior-inferior plate fixation for acute clavicular fractures relative to superior plating include

Options:

more prominent implants leading to higher rate of reoperation for implant removal.
a higher nonunion rate.
inferior fixation due to shorter screw lengths laterally.
an increased need to detach the deltoid origin.
an increased risk for injury to subclavian structures.

Correct Answer: an increased need to detach the deltoid origin.

Explanation:

Question 37:

A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and

Options:

Axillary nerve palsy
Spinal accessory nerve palsy
Deltoid avulsion
Rotator cuff tear
Unreduced posterior glenohumeral dislocation

Correct Answer: Rotator cuff tear

Explanation:

Question 38:

Options:

curettage or en bloc resection.
allograft limb salvage.
injection with 5% phenol.
radiation therapy.
hormonal therapy.

Correct Answer: curettage or en bloc resection.

Explanation:

Question 39:

A patient has a C6 spinal cord injury. Following stabilization of the spine, the patient should be advised that their expected maximum level of function

Options:

An electric wheelchair with puffer control
An electric wheelchair with hand controls
A manual wheelchair and sliding board transfers
A manual wheelchair and independent transfers
Crutches with long leg braces for short distance ambulation

Correct Answer: A manual wheelchair and sliding board transfers

Explanation:

Question 40:

The thickest bone in the occiput is located

Options:

in no predictable pattern.
at the level of the foramen magnum.
at the level of the external occipital protuberance.
4 cm below the external occipital protuberance.
4 cm lateral to the external occipital protuberance.

Correct Answer: at the level of the external occipital protuberance.

Explanation:

Question 41:

The best indication for a knee fusion after a failed total knee replacement is

Options:

Aseptic loosening in a 70-year-old patient
Mechanical failure of a hinged knee prosthesis
Failed knee replacement complicated by reflex sympathetic dystrophy
Infection with soft-tissue deficit
A prior patellectomy

Correct Answer: Infection with soft-tissue deficit

Explanation:

Question 42:

Options:

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

Correct Answer: Physical therapy emphasizing a throwing program

Explanation:

Question 43:

Bacitracin is a topical antibiotic agent that may be added to solutions and used for intraoperative lavage. What is this agent effective against?

Options:

Gram-positive bacteria
Gram-negative bacteria
Mixed flora
Bacterial spores
Fungi

Correct Answer: Gram-positive bacteria

Explanation:

Question 44:

Options:

Denosumab
Alendronate
Abaloparatide
Teriparatide
Strontium ranelate

Correct Answer: Strontium ranelate

Explanation:

Question 45:

- A right-handed, 53 year old man reports pain in the left shoulder following a fall on an abducted externally rotated shoulder 3 months ago. Examination reveals pain on elevation and tenderness localized to the anterior aspect of the shoulder. Results of the lift-off test are inconclusive due to limited internal rotation. Figure 2 shows the T1-weighted axial image from an MRI-arthrogram. Treatment should include

Options:

Labral repair
acromioplasty
excision of the coracoid process
an arthroscopic Bankart procedure
subscapularis repair

Correct Answer: subscapularis repair

Explanation:

Question 46:

Options:

arthroscopy and labral repair.
arthroscopy and supraspinatus repair.
arthroscopy and subscapularis repair.
arthroscopy and supraspinatus and infraspinatus repair.
open repair of the pectoralis major.

Correct Answer: arthroscopy and subscapularis repair.

Explanation:

Question 47:

Options:

group A Streptococcus.
Methicillin-resistant staphylococcus aureus.
Clostridium.
polymicrobial infection.

Correct Answer: polymicrobial infection.

Explanation:

Question 48:

An MRI arthrogram of the elbow is shown in Figure 6. Based on these findings, what is the most likely diagnosis? Review Topic

Options:

Rupture of the medial collateral ligament
Rupture of the lateral collateral ligament
Intra-articular loose body
Flexor-pronator injury
Extensor origin avulsion

Correct Answer: Rupture of the medial collateral ligament

Explanation:

Question 49:

Options:

Ultrasound
CT
Bone scan
Scapular Y-view of the shoulder
Stress views of the shoulder

Correct Answer: Stress views of the shoulder

Explanation:

Question 50:

Options:

ACL reconstruction and subsequent proximal tibial osteotomy
ACL reconstruction alone
Distal femoral osteotomy with simultaneous ACL reconstruction
Proximal tibial osteotomy with subsequent ACL reconstruction

Correct Answer: Proximal tibial osteotomy with subsequent ACL reconstruction

Explanation:

Question 51:

Options:

semiconstrained total elbow arthroplasty.
ulnohumeral arthroplasty and anterior and posterior capsular releases.
closed reduction and external fixation.
open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a hinged elbow fixator.
open reduction, heterotopic excision, anterior and posterior capsular releases, and pin fixation across the joint for 3 weeks.

Correct Answer: open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a hinged elbow fixator.

Explanation:

Question 52:

Options:

Medial hindfoot
Lateral hindfoot
First dorsal webspace
Dorsal midfoot
Plantar foot

Correct Answer: Medial hindfoot

Explanation:

Question 53:

A 50-year-old woman undergoes an L4-S1 laminectomy and noninstrumented fusion for degenerative spondylolisthesis.

Options:

Postoperative deep surgical site infection
Proximal junctional kyphosis
Pedicle screw cut-out
Pseudarthrosis
Sagittal imbalance

Correct Answer: Pseudarthrosis

Explanation:

Question 54:

Options:

a hard-soled shoe for 4 to 6 weeks.
closed reduction and percutaneous pinning.
burning a hole in the nail for relief of the impending hematoma.
digital block and irrigation and debridement of the wound.
repair of the extensor hallucis longus tendon injury and use of a hard-soled shoe.

Correct Answer: digital block and irrigation and debridement of the wound.

Explanation:

DISCUSSION: Great toe fractures through the physis should be considered open fractures if there is bleeding at the nail fold. Treatment should include irrigation and debridement and appropriate antibiotics. Immobilization with a cast is usually sufficient for treatment of
the fracture.
REFERENCES: Noonan KJ, Saltzman CL, Dietz FR: Open physeal fractures of the distal phalanx of the great toe: A case report. J Bone Joint Surg Am 1994;76:122-125.
Banks AS, Cain TD, Ruch JA: Physeal fractures of the distal phalanx of the hallux. J Am Podiatr Med Assoc 1988;78:310-313.

Question 55:

Options:

Azi et al. present a surgical technique article on the Masquelet technique. The authors note that in the setting of infection, the antibiotic specific to the organism from the culture should be added to the cement. In culture-negative or aseptic defects, vancomycin +/- an aminoglycoside was their preferred antibiotic. They also discussed several contraindications to the Masquelet technique to include large osteochondral articular defects, prior irradiation
(given that this would impair adequate pseudomembrane formation), and soft tissue defects not amendable to bony coverage.
Micev et al. review the surgical technique of the Masquelet procedure. The authors noted that at 4 weeks, the induced membrane had the highest expression of vascular endothelial growth factor (VEGF), IL-6, and BMP-2 compared to samples taken at 6, 8 and 12 weeks. They also noted that BMP-2 production peaked at that point and gradually declined over the ensuing month. This led them to conclude that the optimal time of bone grafting to be 4 weeks after the placement of the cement spacer.
Figure A demonstrates a severely comminuted radial shaft fracture with a large bone defect.
Illustration A shows the same patient in Figure A following stage 1 of Masquelet (left) with debridement, placement of a cement spacer and internal fixation; on the right is the same patient following stage 2 with bone grafting.
Incorrect Answers:

Correct Answer: Illustration A shows the same patient in Figure A following stage 1 of Masquelet (left) with debridement, placement of a cement spacer and internal fixation; on the right is the same patient following stage 2 with bone grafting.

Explanation:

A 25-year-old male runs into a tree while going 45 mph on his motorcycle. He presents to your level 1 trauma hospital with the injuries shown in figures A through C. After closed reduction, which of the following is true with respect to treatment for this patient?
Heterotopic ossification is uncommon
Minifragment screws are sufficient for fracture fixation
Kocher-Langenbeck is the optimal surgical approach for this injury
Fragment excision leads to improved outcomes compared to open reduction and internal fixation
A 2 mm fragment step-off is considered the cut-off for non-surgical management
This patient has sustained a Pipkin II femoral head fracture with associated anterior hip dislocation. An open reduction with internal fixation of the femoral head fragments with direct visualization is indicated to restore stability and congruity of the hip joint. These fractures can be treated with mini-fragment screws with excellent reduction and purchase without risks of extensive chondral injury or screw prominence.
Femoral head fractures are uncommon injuries usually associated with hip dislocations. They are classified using the Pipkin Classification (Illustration B). While resection of small femoral head fracture fragments can be considered (Pipkin I) as sufficient and satisfactory treatment, this fragment is large and displaced and thus should be treated with ORIF for optimal results. Regarding the surgical approach, advocates for the direct anterior approach state direct access to the anterior portion of the femoral head with decreased overall complication rates. Other approaches, including surgical hip dislocation and Kocher-Langenbeck, are also useful depending on associated injuries (acetabulum fractures, etc.) and location of the head fragment. ORIF of these fractures can be performed with the use of countersunk mini-fragment screws, headless screws and even bioabsorbable pins to avoid prominence or extensive chondral injury.
Marecek et al. authored a review article on femoral head fractures. They described these injuries as being generally associated with hip dislocations and require prompt reduction. They noted that the surgical fixation of the femoral head is generally done through the direct anterior approach or via a surgical hip dislocation depending on associated injuries. The authors also discussed the importance of using mini-frag screws to avoid hardware prominence. They also noted that while heterotopic ossification is a common finding after the anterior approach for these injuries, it is rarely proven to be symptomatic.
Giannoudis et al. reviewed femoral head fractures focusing on management, complications and clinical results. They reported on 453 femoral head fractures in 450 patients. Regarding Pipkin Is, they noted that fragment excision gave better results compared to ORIF (p=0.07), while Pipkin IIs showed improved outcomes with ORIF. Regarding complications, they noted the following rates: wound infection (3%), sciatic nerve palsy (4%), AVN (11.9%), post-traumatic OA (20%) and HO (16.8%). They also noted the anterior approach was associated with promising long-term functional results and a lower incidence of major complication rates.
Figure A is an AP pelvis radiograph revealing a left hip dislocation with a large femoral head fracture extending into the weight-bearing zone of hip joint
(Pipkin II). Figures B and C are CT scan images revealing an anteriorly dislocated hip with a large femoral head fracture without associated acetabulum fractures. Illustration A is the post-op fluoroscopy showing ORIF of femoral head with multiple 2.7 cortical screws. Illustration B demonstrates the Pipkin classification for femoral head fractures.
Incorrect Answers:
Which of the following describes the most common organism cultured from septic olecranon bursitis?
Gram positive cocci in chains
Gram positive bacilli in branches
Gram positive cocci in pairs and clusters
Gram negative diplococci
Gram negative bacilli with thin rods
Correct answer: 3
The most common cultured organism in the setting of septic olecranon bursitis is Staphylococcus aureus (S. aureus), appearing as gram positive cocci in pairs and clusters.
S. aureus is responsible organism in approximately 80% of cases of septic olecranon and prepatellar bursitis. Mixed flora is also common. Patient demographics in both conditions are similar, more commonly involving middle-aged males. Direct inoculation is presumed to be the primary culprit as opposed to hematogenous seeding, as blood supply to the bursal tissue is poor. Differentiating infectious from non-infectious bursitis can be challenging.
Aaron et al. provide a review article on the four most common types of bursitis: olecranon, prepatellar, trochanteric, and retrocalcaneal. They note that olecranon bursitis is the most common superficial bursitis, and that a careful history and physical exam can help differentiate infectious from noninfectious olecranon bursitis. The authors discuss one series of 46 patients demonstrating that a skin temperature overlying the affected bursa ≥2.2°C than the contralateral, unaffected bursa had a 100% sensitivity and 94% specificity in diagnosing a septic process.
Illustration A shows a patient with olecranon bursitis. Illustration B shows the classic gram stain for S. aureus (gram positive cocci in pairs and clusters).
Incorrect Answers:
During a trauma conference, a hand surgeon presents a case of a 25-year-old male who injured his elbow while roller skating. While describing the patient's radiographs, he reports that this injury is associated with valgus posterolateral rotatory instability. Which of the following images is most likely the patient's radiograph?
Posterolateral rotatory instability (PLRI) can result from a "terrible triad" fracture-dislocation pattern (seen in Figure E), classically involving a radial head fracture, coronoid tip or base fracture, and an elbow dislocation.
Terrible triad injuries typically occur with axial loading, supination, and a valgus directed force through the elbow. In comparison to PLRI which results from a terrible triad injury, posteromedial rotatory instability (PMRI) commonly results from an anteromedial coronoid facet fracture following a varus-directed force. These injuries also very frequently also have a lateral collateral ligament complex injury but often have no radial head fracture. PLRI is far more common than PMRI. Generally with a PLRI pattern, the lateral collateral ligament complex fails first, followed by injury to the anterior capsule or coronoid, and lastly the medial collateral ligament complex is affected. Nonoperative management is possible, but only indicated in small, non-displaced radial head fractures with small coronoid tip fractures. Typically, terrible triad injuries are addressed surgically with radial head fixation or arthroplasty, lateral collateral ligament repair, and, less commonly, coronoid fracture fixation or anterior capsule repair.
Ring et al. reviewed 56 patients who had been treated with an ORIF of the radial head at 48 months after injury. They found unsatisfactory outcomes for patients who had an ORIF of radial head fractures with greater than 3 articular fragments. The authors recommended ORIF of radial head fractures with 3 or few fragments.
Steinmann performed a review of coronoid process fractures. The author reports that with an anteromedial coronoid fracture, the anteroposterior (AP) radiograph of the elbow will demonstrate progressive narrowing of the joint space from lateral to medial. Dr. Steinmann concludes that an important determinant of stability is the involvement of the sublime tubercle (insertion point of the MCL), and that medial instability is likely with involvement of the sublime tubercle.
Mathew et al. review the anatomic, biomechanical, and operative principles of terrible triad injuries. The authors discuss that the primary goal of fixation is to stabilize the elbow and allow early range of motion. They underscore technical improvements and implant developments which have improved outcomes.
Figure A demonstrates a capitellum fracture. Figure B demonstrates an olecranon fracture.
Figure C demonstrates a displaced radial head fracture.
Figure D demonstrates an anteromedial facet coronoid fracture.
Figure E demonstrates a terrible triad injury with a radial head fracture,
coronoid tip fracture, and elbow subluxation.
Incorrect Answers:
A 32-year-old soccer player presents with severe right ankle pain and inability to bear weight after sustaining a slide-tackle injury during a game. Radiographs are shown in Figures A and B. Given the nature of his injury, he is taken for surgical reduction and fixation. Following medial malleolar fixation, the syndesmosis is addressed. All of the following are true regarding the most appropriate intraoperative technique for anatomic syndesmotic reduction EXCEPT:
The axis of the reduction clamp should parallel the anatomic trans-syndesmotic angle
The lateral tine of the clamp should be seated just posterior to the lateral malleolar ridge
The medial tine should be placed on the anterior third of the tibia on a true lateral fluoroscopic view of the ankle
The reduction clamp should be placed 1-2cm proximal to the tibial plafond
The surgeon should apply judicious compression under fluoroscopic visualization to avoid over-compression of the syndesmosis
When placing a clamp across the syndesmosis to facilitate reduction, the lateral tine should be placed directly on the lateral malleolar ridge. Placing the lateral tine either more anteriorly or posteriorly has been shown to result in sagittal malreduction from fibular translation.
Syndesmotic reduction has proven to be technically challenging, with reportedly greater than 50% of cases resulting in malreduction. Provisional reduction is most often attained via a pointed reduction clamp. Placement of the lateral tine is outlined above. The medial tine should be placed at the anatomic midportion of the medial tibia, which can be confirmed
fluoroscopically as the anterior third of the tibia on a true lateral view of the ankle. It is important to maintain the axis of the clamp parallel to the joint line and to the anatomic syndesmotic angle. The clamp should furthermore be maintained 1-2cm proximal to the mortise, at the level of the incisura, to avoid deformation or undue translation of the fibula. Lastly, over-compression of the syndesmosis has been demonstrated, though the clinical implications remain controversial.
Putnam et al. performed a radiographic analysis of the ideal orientation for placement of a syndesmotic reduction clamp. Based on the CT scans of uninjured adult ankles, the authors showed that the trans-syndesmotic axis could be most reliably paralleled by a reduction clamp by placing the lateral tine on the lateral malleolar ridge and the medial tine radiographically within the anterior third of the tibia, anatomically half-way between the anterior and posterior cortices. They further specified that the ideal location was within the central one-third of the distance from the anterior tibial cortex to the anterior fibular cortex.
Cosgrove et al. prospectively evaluated the effect of medial clamp tine positioning on the incidence of syndesmotic malreduction. The authors found that malreduction most often resulted from deviation of the clamp axis from the syndesmotic axis. With the clamp at 1-2cm proximal to the mortise and the lateral tine on the lateral malleolar ridge, the ideal position of the medial tine was within the anterior third of the tibia. The rate of sagittal malreduction increased substantially with increasingly posterior placement of the medial tine. The medial clamp position did not affect coronal plane malreduction.
Gardner et al. review the technical considerations in reduction and fixation of syndesmotic injuries. The authors stress careful positioning of the reduction clamp, advocating that the clamp should be placed from the lateral malleolar ridge to the center of the anteroposterior width of the medial tibia.
Additionally, they note that placement too proximal or distal results in coronal plane deformity of the fibula, and that over-compression of the syndesmosis is certainly possible.
Figure A is the AP radiograph of the left ankle demonstrating a displaced medial malleolar fracture and syndesmotic widening. Figure B is the lateral radiograph of the ipsilateral knee showing an associated proximal fibular fracture.
Illustration A shows the syndesmotic angle and anatomic trans-syndesmotic axis as compared to the AP and lateral fluoroscopic axes. Illustration B shows the ideal positioning of the medial tine within the anterior third of the tibia on a true lateral view of the ankle.
Incorrect answers:
A 45-year-old male injures his wrist during Live Action Role Play in Chicago two weeks ago. He underwent operative fixation by and presents to your clinic for his 2 week follow-up visit. You review his operative note in which the surgeon reports having to apply a volar
locking plate in a distal position to secure the difficult intra-articular fracture. The patient shows you the lateral film in Figure A. You remove his splint, he has no difficulty moving any fingers, very minimal pain, and is not taking any narcotic medication. How do you counsel him about his post-operative period?
The plate may need to removed once the fracture is healed to reduce the chance of flexor pollicis longus injury
The plate may need to removed once the fracture is healed to reduce the chance of flexor carpi radialis injury
The plate may need to removed once the fracture is healed to reduce the chance of flexor digitorum superficialis – index finger injury
The patient should undergo revision fixation as soon as possible
The plate is in appropriate position and will likely never need to be removed
Correct answer: 1
This patient’s volar locking plate (VLP) is distal to the "watershed line", extending volarly beyond the most volar aspect of the distal radius. He is at greatest risk for an attritional rupture of the FPL.
A VLP placed this distal and volar is more likely to cause flexor tendon injury.
Up to 12% of all patients undergoing volar plate fixation will experience flexor tendon injury, and the FPL is the most common tendon associated with the VLP (57% of total flexor tendon ruptures). The average time from fixation to flexor tendon rupture has been cited at 9 months. To judge if a plate is volar to the watershed line, a plum line can be made in the proximal direction from the most volar edge of the distal radius. If a plate is volar to this (Soong) line, the patient is thought to be at a higher risk for flexor tendon injury. As a result, this patient should be followed closely and if pain with thumb flexion is present after 3 months, the surgeon should consider plate removal so long as the fracture is healed to reduce the chance of FPL rupture. Ruptured tendons require repair, grafting, or transfer with hardware removal.
Griffin and Chhabra comprehensively reviewed the risk factors and adverse events following VLP fixation of distal radius fractures, including flexor tendonitis and rupture. They found that risk factors for flexor tendon rupture following VLP fixation included plate placement distal to the watershed line and that PQ repair does not seem to affect flexor tendonitis.
Agnew et al. analyzed wrist MRIs to determine the relationship between the flexor tendons and the watershed line. They found that at 3mm proximal to the watershed line, the FPL and FDP to the index finger were 2.6 and 2.2mm anterior to the volar rim of the distal radius. The authors suggested that distally placed plates are incredibly close to the flexor tendons.
Chilelli et al. described 24 of 48 wrists which had VLP following distal radius fracture and went on to experiences loss of FPL flexion post-operatively. They found that FPL ROM generally returned after 52 days, however with an associated average loss of 11° in thumb IPJ ROM. The authors attribute this to stripping of FPL from the bone during the volar approach.
Soong et al. divided patients who underwent VLP fixation for distal radius fractures into three groups according to position of plate relative to a plum line extending proximally from the most volar and distal aspect of the distal radius: those with a VLP dorsal to the Soong line (grade 0), those with the VLP volar to the Soong line but proximal to the rim (grade 1), and those with a VLP volar to the Soong line and at or distal to rim (grade 2). Of the 73 cases reviewed, the authors reported three flexor tendon ruptures, two of which were grade 2 position. The authors concluded that both position of plate and type of plate were contributors to flexor tendon injury following VLP fixation.
Figure A is a lateral radiograph of the wrist demonstrating appropriate reduction and fixation but with the VLP volar to the "watershed" or Soong line.
Illustration A is a lateral radiograph with Soong's line drawn to show that this plate is too volar.
Incorrect Answers:
A 42-year-old construction worker sustains a crush injury to the hand at a job site. He has immediate pain and significant swelling, and is taken to the local emergency department for evaluation. Radiographs do not demonstrate any fracture or dislocation. On exam,
he experiences severe pain with passive motion at the metacarpal phalangeal joints and when the wrist is flexed and extended.
Otherwise he has intact sensation and appropriate capillary refill. What is the next best step in diagnosis or treatment?
Advanced imaging
Arterial Doppler
Admission for overnight observation
Surgical intervention
Pain control
This patient presents with compartment syndrome of the hand. A history and clinical exam are the best tools to identify the diagnosis, and the treatment consists of emergent fasciotomies.
Compartment syndrome of the hand may be secondary to trauma, burn, IV drug use, extravasation of IV fluids, or major limb revascularization. The diagnosis is usually made with pain out of proportion to exam, particularly with passive stretch of the digits. It is possible to have compartment syndrome without neurovascular changes (paresthesia, pallor, pulselessness), particularly earlier in the presentation. Compartment measurements may be obtained and are considered diagnostic with an absolute value greater than 30mmHg or when the compartment pressure is within 30mmHg of the patient's diastolic blood pressure. However pressure testing is not necessary in most cases, but may be particularly important in the patient who is obtunded, intubated, or who had a block, as the physical exam will be confounded. There are ten hand compartments: hypothenar, thenar, adductor pollicis, four dorsal interosseous, and three palmar interosseous; and emergent surgical release of all ten compartments is indicated.
Codding et al. comprehensively reviewed hand compartment syndrome. The authors identify the history and physical exam as the most critical aspect of the diagnosis. More specifically, they noted that pain with passive stretch of the MCPJ is the most sensitive clinical sign on physical exam. The authors conclude the short comings of the research on hand compartment syndrome, but note the potential morbidity of a missed diagnosis is so great that the threshold for surgical intervention should be very low.
Lipschitz et al. reviewed the measurement of compartment pressures in the hand. The authors discussed technical pearls including leveling the monitor at the level of the heart, using local analgesia on the skin only, inserting the needle perpendicular to the skin, and measuring all 10 hand compartments.
They noted that any measurement greater than 30mmHg or within 30mmHg of the diastolic blood pressure may be considered diagnostic.
Illustration A shows the standard incisions utilized to release all ten hand compartments. Incisions are generally placed directly overlaying the thenar musculature, hypothenar musculature, the carpal tunnel, and dorsally over the metacarpals. The radial and ulnar border of each metacarpal are incised through the dorsal incisions to release the interossei compartments.
Incorrect Answers:
A 60-year-old woman with a history of well-controlled diabetes and hypertension sustained a fall into a ditch yesterday and presents with persistent left ankle pain and deformity. The injury is closed, and the patient is neurovascularly intact. Injury films are shown in Figures A and B. An unsuccessful attempt at reduction in the emergency department with sedation was made. What is the cause of failure of closed reduction?
Subacute nature of fracture
Incarceration of the deltoid ligament
Incarceration of the fibula behind the posterolateral ridge of tibia
Entrapment of the flexor hallucis longus (FHL) tendon
Entrapment of the extensor digitorum brevis (EDB)
Correct answer: 3
The patient has sustained a Bosworth fracture-dislocation, which is a fixed dislocation of the fractured fibula behind the posterolateral tibial ridge. These fractures are generally irreducible via a closed means and require open reduction.
The initial radiographs in this vignette reveal posterior subluxation of the talus and fibula without significant coronal plane deformity. This deformity should raise the suspicion of a Bosworth fracture-dislocation, especially if closed reduction is unsuccessful. Bosworth fracture-dislocations can often be associated with posterior malleolar fractures, specifically of the posterolateral rim of the distal tibia. These injuries often fail closed reduction, given the engagement of the fibula behind the posterolateral tibial ridge, and frequently require open reduction. In this situation, the most effective method to reduce the fracture is through a posterolateral approach. This is the same approach that can then be utilized for the fixation of the posterolateral fragment and fibula.
Delasotta et al. discussed a case presentation of a 24-year-old male with a Bosworth fracture-dislocation in which the anterior compartment musculature was interposed within the fracture site, impairing both closed and eventual open reduction of the injury. The authors go on to discuss how 3D CT reconstruction of the bone and soft tissues can aid in both the diagnosis and preoperative planning of such injuries. They also note that these injuries should be admitted for compartment and neurovascular checks and undergo urgent surgical treatment.
Gardner et al. performed a cadaveric study directly comparing fixation of posterior malleolar fractures to syndesmotic stabilization in a simulated stage IV pronation-external rotation injury. Compared with the intact specimens, the authors found that fixation of the posterior malleolus restored 70% of the native stiffness, but syndesmosis stabilization only restored 40%. The authors concluded that given the likely integrity of the posterior inferior tibiofibular ligament in the setting of posterior malleolar fractures, anatomic reduction and fixation may be more appropriate than syndesmotic stabilization and better suited to restore stability.
Switaj et al. retrospectively evaluated the incidence of posterior malleolar fractures and posterior pilon variants in a 270 patients with operatively treated ankle fractures. The authors noted a relative frequency of posterior malleolar fractures of 50% and that of the posterior pilon variants of 20% within the entire cohort. While they found no significant difference in frequency of posterior malleolar or posterior pilon variants with regard to either AO/OTA or Lauge-Hansen classification, patients with posterior pilon variants were significantly older.
Figure A and B show the AP and lateral views of an ankle revealing a lateral malleolar fracture with tibiotalar subluxation and posterior dislocation of the fibula with respect to the posterolateral ridge of the tibia, consistent with a
Bosworth fracture-dislocation.
Incorrect answers:
A 42-year-old male who works as a professional clown presents with severe ankle pain and gross deformity after tripping and falling over his props at a children’s birthday party. His radiograph is shown in Figure A. Following fixation of the medial and lateral malleolar fractures, the syndesmosis is assessed and is found to be persistently unstable. All of the following are true regarding posterior malleolar fixation EXCEPT:
Fixation of the posterior malleolus obviates the need for syndesmotic fixation in most cases
Fixation of the posterior malleolus remains biomechanically inferior to trans-articular syndesmotic fixation
Functional and radiographic outcomes following posterior malleolar fixation are at least equivalent if not superior to those following syndesmotic fixation
Non-anatomic fixation of the posterior malleolus will compromise syndesmotic fixation
The syndesmosis is often incompletely injured in the setting of a posterior malleolar fracture
Fixation of the posterior malleolus has been shown to be biomechanically superior to single-screw trans-articular syndesmotic fixation. Anatomic reduction and fixation will most often obviate the need for syndesmotic fixation, as the posterior inferior tibiofibular ligament (PITFL) is typically intact and attached to the fragment.
Posterior malleolar integrity is essential to ankle function and stability. The posterior malleolus not only contains the talus posteriorly but adds to articular congruity for tibiotalar load transfer and contributes to rotatory ankle stability through the PITFL. As a result, posterior malleolar fractures compromise these critical functions. Operative management is therefore aimed at containment of
the talus, restoration of articular congruity, reduction of the incisura, and restoring integrity to the syndesmosis. Functional and radiographic outcomes following posterior malleolar fixation have been shown to be at least equivalent to those following syndesmotic fixation.
Miller et al. compared the need for syndesmotic fixation in bi- and tri-malleolar ankle fractures following anatomic reduction and fixation in the prone position versus initial conservative management in the supine position. The authors found that fixation of the posterior malleolus obviated the need for syndesmotic fixation in 97.9% of cases, while nearly 25% of patients with no initial fixation required stabilization. They concluded that prone positioning and anatomic fixation of the posterior malleolus should be performed as this adequately restored syndesmotic stability in almost all cases.
Gardner et al. performed a radiographic evaluation of syndesmotic integrity in the setting of pronation-external rotation stage 4 ankle fractures with associated posterior malleolar fractures. Based on radiographs and MRI, no complete tears of the posterior-inferior tibiofibular ligament were evident. The fracture pattern was then simulated in cadavers, and posterior malleolar fixation restored 70% of the native stability while syndesmotic fixation alone restored only 40% of the native stability. The authors advocated for posterior malleolar fixation over syndesmotic stabilization.
Miller et al. prospectively compared the outcomes following posterior malleolar and syndesmotic fixation for unstable ankle fractures with partial syndesmotic injury. At a minimum one-year follow-up, the authors found that patients who had undergone open reduction with fixation of posterior malleolar fractures had no difference in outcomes as compared to those who underwent syndesmotic fixation. They concluded that not only was syndesmotic reduction maintained at final follow-up following posterior malleolar fixation, but that functional outcomes were at least equivalent to syndesmotic fixation.
Fitzpatrick et al. evaluated the impact of posterior malleolar fixation toward restoring syndesmotic stability in a cadaveric supination-external rotation stage 4 fracture model. The authors found that failure to fix or anatomically reduce posterior malleolar fragments resulted in non-anatomic translation of the fibula and ultimately in syndesmotic malreduction. They advocated for anatomic reduction and fixation of larger posterior malleolar fractures.
Figure A is an AP radiograph of the right ankle demonstrating a displaced trimalleolar ankle fracture with maintained relationship between the distal fibula and posterior malleolar fragment.
Incorrect Answers:
A 35-year-old morbidly obese female presents with global right ankle pain and significant swelling after a misstep over one of her cats on the stairs. She is unable to bear weight, but the skin is intact. Injury films are shown in Figures A through D. What is the internervous plane through which direct anatomic reduction and fixation of both fractures could best be achieved?

Question 56:

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 57:

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 58:

Options:

lack of extension of the thumb.
lack of abduction of the little finger.
decreased sensation on the volar surface of the index finger.
decreased sensation on the volar surface of the little finger.
inability to extend the metacarpophalangeal joints of the fingers.

Correct Answer: decreased sensation on the volar surface of the index finger.

Explanation:

Question 59:

Options:

resection of the fragment through a microdiskectomy approach.
epidural steroid injections until symptoms improve.
laminectomy with surgical excision of the limbus fragment.
activity restrictions until the symptoms improve.
chiropractic manipulation.

Correct Answer: laminectomy with surgical excision of the limbus fragment.

Explanation:

DISCUSSION: A limbus or apophyseal fracture caused by heavy lifting or twisting is commonly seen in older children and adolescents. Patients describe feeling a popping sensation and report radicular symptoms. Radiographs usually are not sufficient to diagnose the injury. MRI or CT should be used to determine the exact location of the fracture. Nonsurgical management is rarely successful. A wide laminectomy with surgical excision of the limbus fragment is recommended if neurologic symptoms are present.
REFERENCE: Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, p 694.
2010 Pediatric Orthopaedic Examination Answer Book • 13

Question 60:

The radiographs and CT scan seen in Figures 28a through 28d reveal what type of acetabular fracture pattern?

Options:

Transverse
Transverse with posterior wall
Both column
Posterior wall anterior hemitransverse
T-type

Correct Answer: Transverse with posterior wall

Explanation:

Question 61:

Turf toe typically involves injury to which of the following structures of the great toe?

Options:

Nail bed
Extensor tendon
Flexor tendon
Capsule of the first metatarsophalangeal joint
Distal phalanx of the first toe

Correct Answer: Capsule of the first metatarsophalangeal joint

Explanation:

Question 62:

A 42-year-old man sustained the periprosthetic fracture shown in Figures 19a and 19b. The femoral component is well fixed. What is the next most appropriate step in management?

Options:

Closed reduction and bracing
Retrograde femoral intramedullary nailing
Open reduction and internal fixation of the fracture, leaving the femoral stem in place
Open reduction and internal fixation of the fracture and insertion of a proximally porous-coated stem
Open reduction and internal fixation of fracture fragments and insertion of a fully porous-coated femoral stem with diaphyseal fixation distal to the fracture

Correct Answer: Open reduction and internal fixation of the fracture, leaving the femoral stem in place

Explanation:

Question 63:

Figures 4a and 4b are the radiographs of an isolated injury. What is the next most appropriate step in management?

Options:

CT
MRI
Closed reduction and casting
Application of a spanning external fixator
Immediate open reduction and internal fixation (ORIF)

Correct Answer: Application of a spanning external fixator

Explanation:

Question 64:

In addition to lengthening the achilles, transfer of which tendon is important for functional ambulation after performing a Chopart amputation of the foot?

Options:

peroneus brevis
peroneus longus
tibialis anterior
tibialis posterior
flexor hallucis longus

Correct Answer: peroneus brevis

Explanation:

Question 65:

Options:

Eccentric
Concentric
Isometric
Isokinetic

Correct Answer: Eccentric

Explanation:

Question 66:

The structure that runs just beneath the peroneal tubercle of the calcaneus is the

Options:

flexor hallucis longus tendon.
peroneus brevis tendon.
peroneus longus tendon.
calcaneal fibular ligament.

Correct Answer: peroneus longus tendon.

Explanation:

DISCUSSION
The peroneal tubercle is often a good landmark at which to identify the peroneus longus tendon surgically, and a hypertrophic tubercle has been associated with peroneus longus tendinopathy. Both peroneal tendons curve anteriorly around the tip of the fibula, with the peroneal tubercle separating the 2 tendons at the level of the calcaneus. The peroneus brevis runs in front of the tubercle and the longus behind. The flexor hallucis longus runs through a fibro-osseus tunnel posterior to the hindfoot formed by the posterolateral (os trigonum) and posteromedial tubercle of the talus. The calcaneal fibular ligament attaches to the calcaneus below the posterior facet of the subtalar joint and deep to the peroneal tendons.
RECOMMENDED READINGS
Hyer CF, Dawson JM, Philbin TM, Berlet GC, Lee TH. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005 Nov;26(11):947-50. Pub PMID: 16309609.
View Abstract at PubMed
Bruce WD, Christofersen MR, Phillips DL. Stenosing tenosynovitis and impingement
of the peroneal tendons associated with hypertrophy of the peroneal tubercle. Foot Ankle Int. 1999 Jul;20(7):464-7. PubMed PMID: 10437932.
View Abstract at PubMed

Question 67:

Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral

Options:

abduction and external rotation.
abduction and internal rotation.
adduction and external rotation.
adduction and internal rotation.
external rotation and forward flexion.

Correct Answer: adduction and internal rotation.

Explanation:

Question 68:

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

Options:

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

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

Explanation:

Question 69:

-What is the mechanism of action of tranexamic acid in controlling traumatic hemorrhage?

Options:

Inhibition of vitamin K reductase
Inhibition of topoisomerase II and IV
Antithrombin-III selective inhibition of Factor Xa
Competitive inhibition of plasminogen activation
Stimulation of integrin-mediated platelet adhesion and activation

Correct Answer: Competitive inhibition of plasminogen activation

Question 70:

Options:

Spiral groove of the humerus
Midshaft of the radius
Radial neck
Anatomic neck of the humerus
Surgical neck of the humerus

Correct Answer: Radial neck

Explanation:

DISCUSSION: In this patient, the radial nerve is most likely injured at the level of the radial neck. The radial nerve emerges from the posterior cord of the brachial plexus and travels along the spiral groove of the humerus. At the level of the lateral humeral condyle, the radial nerve branches into the posterior interosseous nerve after giving off two cutaneous branches, the superficial radial and the posterior cutaneous. The posterior interosseous nerve travels through the supinator muscle and winds around the radial neck. At this level, the posterior interosseous nerve is vulnerable to injury, particularly following fracture or penetrating trauma.
REFERENCES: Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System, Part 1: Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy Corporation, 1987, vol 8, p 53.
Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 428-429.

Question 71:

Options:

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

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

Explanation:

Question 72:

Options:

Resect more distal femur.
Resect more anterior tibia.
Use a larger femoral component.
Use a smaller polyethylene insert.
Recess the posterior cruciate ligament.

Correct Answer: Recess the posterior cruciate ligament.

Explanation:

Question 73:

Options:

Above-knee amputation
En bloc resection of the lesion and reconstruction with a bone graft
Closed reduction and immobilization in a cast
Open reduction and internal fixation, followed by radiation therapy
Open reduction, curettage, and cementing of the lesion

Correct Answer: Closed reduction and immobilization in a cast

Explanation:

Question 74:

Options:

Spiral fracture pattern
Low-energy mechanism
Amount of shortening
Fracture of the fibula at a different level
Ipsilateral femoral fracture

Correct Answer: Ipsilateral femoral fracture

Explanation:

DISCUSSION: All the factors listed, with the exception of an ipsilateral femoral fracture, are representative of a low-energy stable tibial shaft fracture that will do well with closed reduction and immobilization in a long leg cast, followed by weight bearing as tolerated and then a functional brace or patellar tendon bearing cast until union is achieved. Shortening will not increase from that seen on these initial radiographs. The spiral fracture provides a broad surface for healing, and the fibular fracture at another level indicates a stable soft-tissue envelope which, with the immobilization device, will stabilize the fracture reduction. An ipsilateral femoral fracture is a strong indication to surgically stabilize both fractures.
REFERENCES: Trafton PG: Tibial shaft fractures, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 2153-2169.
Martinez
A, Sarmiento A, Latta LL: Closed fractures of the proximal tibia treated with a functional brace. Clin Orthop 2003;417:293-302.

Question 75:

Options:

C2-3
C3-4
C4-5
C5-6
C6-7

Correct Answer: C5-6

Explanation:

Question 76:

Which of the following methods of treating a vertically oriented (eg, Pauwels III) femoral neck fracture is mechanically optimal?

Options:

Two parallel fully threaded screws
Three parallel partially threaded screws
Three parallel fully threaded screws
Four parallel partially threaded screws
Sliding hip screw and side plate

Correct Answer: Two parallel fully threaded screws

Explanation:

Vertical fractures have a higher rate of displacement and nonunion because of shearing forces across the fracture. Biomechanical and clinical studies indicate that for the vertically oriented fracture of the femoral neck, the most stable fixation construct is a sliding hip screw and side plate. Antirotation screws may be used as well. Nonsurgical management carries a high risk of early displacement because of shear forces. Three screws are loaded as a cantilever and have less resistance to displacement compared with a fixed-angle device with a side plate. Fully threaded screws will not allow any compression and have the same drawbacks as partially threaded screws. The addition of a fourth screw has not been shown to be of benefit.
(SBQ12TR.68) 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 non-operatively 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 nonoperative 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 nonsmokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:

Question 77:

Options:

Bone scan
MRI
Flexion-extension radiographs
Physical therapy
Lumbosacral corset

Correct Answer: MRI

Explanation:

Question 78:

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

Options:

Bracing
Physiotherapy
Cortisone injection
Conversion to total elbow arthroplasty
Revision interposition arthroplasty

Correct Answer: Conversion to total elbow arthroplasty

Explanation:

In a series reported by Blaine and associates, 12 patients were converted from interposition to total elbow arthroplasty. This procedure was successful in 10 out of 12 patients.

Question 79:

What preoperative factor correlates best with the outcome of rotator cuff repair?

Options:

Size of the tear
Age of the patient
Arm dominance
Rupture of the long head of the biceps
Preoperative pain score

Correct Answer: Size of the tear

Explanation:

Question 80:

Which of the following amputations will lead to the greatest oxygen requirement per meter walked following prosthesis fitting?

Options:

Above-knee-amputation (transfemoral)
Below-knee-amputation (transtibial)
Through Knee
Syme
Midfoot

Correct Answer: Above-knee-amputation (transfemoral)

Explanation:

Question 81:

Options:

Posterolateral herniated nucleus pulposus at L3-4
Posterolateral herniated nucleus pulposus at L4-5
Degenerative disk disease at L3-4 and L4-5 with no significant facet hypertrophy
Degenerative spondylolisthesis at L3-4 with central and foramenal stenosis
Degenerative spondylolisthesis at L4-5 with central stenosis

Correct Answer: Degenerative spondylolisthesis at L3-4 with central and foramenal stenosis

Explanation:

Question 82:

Options:

a base plate with an offset tibial stem attachment.
a bone ingrowth surface on the augment.
a nonstemmed tibial base plate.
allograft bone instead of metal augments.
bone cement to smooth the outline of the proximal medial tibia.

Correct Answer: a base plate with an offset tibial stem attachment.

Explanation:

DISCUSSION: The problem with this reconstruction is the medial protrusion of the base plate. The use of a base plate with an offset stem can prevent the protrusion and thus the impingement and pain. Allograft bone or smoothing the outline with cement would be just as prominent and likely to cause pain. An ingrowth surface may improve soft-tissue attachment but would still leave the implant protruding medially and likely to cause pain. A nonstemmed tibial base plate would lead to less medial protrusion but at the expense of a smaller area for load carriage on the proximal tibia.
REFERENCE: Gustke K: Cemented tibial stems are not requisite in revision. Orthopedics 2004;27:991-992.

Question 83:

Options:

open excision of the radial head.
a cortisone injection into the extensor muscle origin.
a tennis elbow release.
arthroscopic removal of loose bodies and microfracture of the crater.
rest, physical therapy, pulsed electromagnetic therapy, and no further gymnastic activities.

Correct Answer: arthroscopic removal of loose bodies and microfracture of the crater.

Explanation:

DISCUSSION: The radiograph and MRI scan show osteochondritis dissecans of the capitellum, and the patient’s history suggests a loose body. The treatment of choice is arthroscopic removal of the loose body and microfracture of the crater. Excision of the radial head, a cortisone injection, or tennis elbow release does not treat the pathology in the capitellum. Nonsurgical treatment would not relieve the mechanical symptoms of the loose body or promote healing in the crater.
REFERENCES: Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med
1998;26:520-530.
Jackson DW, Silvino N, Reiman P: Osteochondritis in the female gymnast’s elbow. Arthroscopy 1989;5:129-136.
Ruch DS, Cory JW, Poehling GG: The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 1998;14:797-803.

Question 84:

Options:

Trochanteric bursitis
Femoral component loosening
Iliopsoas tendonitis
Acetabular component loosening

Correct Answer: Iliopsoas tendonitis

Explanation:

Question 85:

-Radiographs are shown in Figures 89a through 89c. What is the most likely diagnosis?

Options:

Medial tibial plateau fracture
Chronic medial collateral ligament injury
Anterior cruciate ligament (ACL) rupture
Acute lateral collateral ligament rupture

Correct Answer: Anterior cruciate ligament (ACL) rupture

Question 86:

Figure 35 is the MR image of an 18-year-old man who has had knee pain with running for 5 months. What is the most appropriate treatment?

Options:

Arthroscopic or open reduction and internal fixation with possible bone grafting
Arthroscopic chondroplasty
No weight-bearing activity for 6 weeks and then re-evaluate
Retrograde subchondral drilling without fixation

Correct Answer: Arthroscopic or open reduction and internal fixation with possible bone grafting

Explanation:

Question 87:

Options:

injection directly into the tendon with triamcinolone or methylprednisolone.
shock wave treatment to the posterior heel to break up calcific deposits.
brisement.
a simple lateral surgical approach to the posterior heel, with resection of the Haglund’s exostosis.
a central-splitting surgical approach through the tendon, excision of the Haglund’s exostosis and the insertional calcifications, bursectomy, flexor hallucis longus tendon transfer to the posterior tuberosity, and attachment of the tendon to the calcaneus.

Correct Answer: a central-splitting surgical approach through the tendon, excision of the Haglund’s exostosis and the insertional calcifications, bursectomy, flexor hallucis longus tendon transfer to the posterior tuberosity, and attachment of the tendon to the calcaneus.

Explanation:

Question 88:

03 A 26-year-old woman has chronic toe pain after hitting a bedpost 3 months ago. A radiograph is shown in Figure 27. Her injury represents an avulsion of the

Options:

lumbrical insertion.
extensor digitorum brevis.
extensor digitorum longus.
extensor hallucis longus.
flexor digitorum longus.
back answer Question 105.03

Correct Answer: extensor digitorum longus.

Explanation:

Question 89:

Iliosacral screws placed for stabilization of posterior pelvic ring injuries (eg, sacroiliac dislocation) that exit the sacrum anteriorly are most likely to injure which of the following structures?

Options:

L4 nerve root
L5 nerve root
S1 nerve root
Internal iliac artery
External iliac artery

Correct Answer: L5 nerve root

Explanation:

Question 90:

Options:

Left L4
Right L4
Left L5
Right L5
Left S1

Correct Answer: Left L5

Explanation:

Question 91:

In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures?

Options:

Interosseous ligament
Anterior inferior tibiofibular ligament
Posterior inferior tibiofibular ligament
Deltoid ligament
Tibiotalar ligament

Correct Answer: Interosseous ligament

Explanation:

Question 92:

A 13-year-old girl presents with back pain for 6 months. Figures A and B are SPECT scan and CT images taken at the time of presentation. What is the most likely diagnosis? Review Topic

Options:

Osteoid osteoma
Bone island
Spondylolysis
Osteoblastic metastases
Aneurysmal bone cyst

Correct Answer: Osteoid osteoma

Explanation:

Question 93:

Pelvic packing for a hemodynamically unstable patient with a pelvic ring fracture is best described by which of the following techniques?

Options:

Placing a pelvic external fixator followed by packing the pelvis with lap pads via a subumbilical incision
Placing lap pads for packing via a subumbilical incision in the angiography suite
Placing lap pads for packing using the lateral window of the ilioinguinal approach (anterior approach to the internal iliac fossa)
Packing the retroperitoneum with lap pads after exploration of the abdomen by the general surgeons
Direct exploration of the pelvic vasculature via a midline incision followed by packing with lap pads

Correct Answer: Placing a pelvic external fixator followed by packing the pelvis with lap pads via a subumbilical incision

Explanation:

Question 94:

The peroneus tertius is a commonly used landmark for arthroscopic portal placement. What is the function of this tendon?

Options:

Dorsiflexion
Eversion
Dorsiflexion and eversion
Fifth toe extension
Lesser toe extension

Correct Answer: Dorsiflexion and eversion

Explanation:

DISCUSSION: The peroneus tertius, although absent in 10% of the population, originates on the distal third of the extensor surface of the fibula and inserts onto the base of the fifth metatarsal, possibly extending to the fascia over the fourth interosseous space. The muscle is located in the anterior compartment of the leg and is innervated by the deep peroneal nerve. The tendon produces dorsiflexion and eversion when walking and can be used as an insertion point during tendon transfers to assist dorsiflexion. This tendon is peculiar to humans and is a proximally migrated deep extensor of the fifth toe.
REFERENCES: Joshi SD, Joshi SS, Athavale SA: Morphology of the peroneus tertius muscle.
Clin Anat 2006;19:611-614.
Williams PL, Bannister LH, Berry MM, et al (eds): Gray’s Anatomy, ed 38. London, Churchill Livingston, 1995, p 883.
Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, p 21.

Question 95:

Options:

Symmetric knee pathology
Excessive joint laxity
Recurrent patella instability
Extra-articular manifestations

Correct Answer: Symmetric knee pathology

Explanation:

Question 96:

Options:

Observation for a month
Plate the tibia after removing the nail
Autogenous bone graft to the tibia
Exchange nailing of the tibia

Correct Answer: Exchange nailing of the tibia

Explanation:

Question 97:

Options:

Referral to the pain clinic to consider insertion of a morphine pump
L1-2 laminectomy
L1-2 anterior lumbar interbody fusion via a minimally invasive technique
Posterior laminectomy and uninstrumented fusion
Posterior decompression and instrumented fusion

Correct Answer: Posterior decompression and instrumented fusion

Explanation:

DISCUSSION: The patient has degeneration of an adjacent segment with resultant
kyphosis and stenosis. Because he is healthy, has responded well to previous surgery,
|and has a potentially correctable lesion, he is not a good candidate for an end-stage failed
back procedure such as a morphine pump. The stenosis is exacerbated by the deformity; therefore, a simple decompression will contribute to instability. Because of the kyphosis and the patient’s relatively young age, the treatment of choice is restoration of sagittal alignment and posterior decompression.
REFERENCE: Eck JC, Humphreys SC, Hodges SD: Adjacent-segment degeneration after lumbar fusion: A review of clinical, biomechanical, and radiographic studies. Am J Orthop 1999;28:336-340.

Question 98:

Options:

Microdiskectomy
Posterior decompression
Posterior decompression and fusion
Anterior lumbar interbody fusion

Correct Answer: Posterior decompression and fusion

Explanation:

DISCUSSION
This patient radiographically has L4-5 degenerative stenosis and a low-grade spondylolisthesis. The axial images demonstrate a gap in the facet joint, more on the left than the right, which is highly suggestive of dynamic instability. Thus, this patient would most benefit from a laminectomy and fusion of L4-5. A microdiskectomy would not be helpful as this patient does not have a disk herniation. Patients undergoing posterior decompression alone experience an unacceptably high rate of recurrent stenosis and/or progression of spondylolisthesis. Early studies demonstrated that adding an intertransverse process fusion to posterior decompression significantly improved clinical outcomes. Anterior interbody fusion likely will not decompress the spinal canal sufficiently, though there is some thought that indirect decompression can be effective in some cases.
RECOMMENDED READINGS
Frymoyer JW. Degenerative Spondylolisthesis: Diagnosis and Treatment. J Am Acad Orthop Surg. 1994 Jan;2(1):9-15. PubMed PMID: 10708989. Majid K, Fischgrund JS. Degenerative lumbar spondylolisthesis: trends in management. J Am Acad Orthop Surg. 2008 Apr;16(4):208-15. Review. PubMed PMID: 18390483.
View
Abstract at PubMed
Carlisle E, Fischgrund JS. Lumbar spinal stenosis and degenerative spondylolisthesis. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006: 299-317.
Puschak TJ, Sasso RC. Spondylolysis-spondylolisthesis. In: Vaccaro AR, ed. Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:553-563.

Question 99:

- Which of the following conditions associated with a closed fracture of the clavicle indicates the need for open reduction and internal fixation?

Options:

Injury to the subclavian artery
Injury to the brachial plexus
Segmental fracture
100% displacement
Associated displaced surgical neck fracture of the humerus

Correct Answer: Injury to the subclavian artery

Explanation:

Question 100:

Options:

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

Correct Answer: Valgus extension overload

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

OITE & ABOS Orthopedic Board Exam MCQs: Fracture, Infection, Trauma | Part 236

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 236

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index