Arthroplasty, Fracture, Hip & Ankle MCQs - Part 238

About This Board Review Set

This is Part 238 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 238

This module focuses heavily on: Ankle, Arthroplasty, Fracture, Hip.

Sample Questions from This Set

Sample Question 1: Treatment of an atrophic nonunion of the radial diaphysis should include which of the following?...

Sample Question 2: Figure 52 shows the MRI scan of a 28-year-old baseball pitcher. Examination will most likely reveal which of the following findings?...

Sample Question 3: A 22-year-old woman injured her ankle when she fell off a ladder. Radiographs reveal a displaced large posterior malleolus fracture of about 45% of the joint. What is the best definitive treatment?...

Sample Question 4: The need for postoperative allogeneic blood transfusions after total hip arthroplasty has been shown to be reduced when using...

Sample Question 5: Receptor activator of nuclear factor kappa b (RANKL) and macrophage colony stimulating factor (MCSF) signaling pathways are necessary for the formation of multinucleated osteoclasts that resorb bone. Which of the following cells are known t...

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

Treatment of an atrophic nonunion of the radial diaphysis should include which of the following?

Explanation

DISCUSSION: Atrophic nonunions of the radius and ulna are fairly rare with modern techniques of fixation; the few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions. The referenced study by Ring et al noted a 100% healing rate and improved patient reported outcomes with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting for atrophic forearm nonunions.

Question 2

Figure 52 shows the MRI scan of a 28-year-old baseball pitcher. Examination will most likely reveal which of the following findings?

Explanation

DISCUSSION: A ganglion cyst compressing the suprascapular nerve results in poorly localized pain in the shoulder girdle. Sensation is intact, with weakness of external rotation and abduction. Supraspinatus and infraspinatus atrophy is often noted when viewed from behind. These cysts are typically associated with labral tears. Deltoid weakness is associated with an axillary nerve injury, and scapular winging results from injury to the long thoracic nerve.
REFERENCES: Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg 2002;11:600-604.
Inokuchi W, Ogawa K, Horiuchi V: Magnetic resonance imaging of suprascapular nerve palsy.

J Shoulder Elbow Surg 1998;7:223-227.

Question 3

A 22-year-old woman injured her ankle when she fell off a ladder. Radiographs reveal a displaced large posterior malleolus fracture of about 45% of the joint. What is the best definitive treatment?

Explanation

Basic understanding of fracture care requires a fundamental knowledge of the principles regarding absolute and relative stability. Compression plating and anatomic reduction of articular fractures are examples of absolute stability. Bridge plating, external fixation, casting, and intramedullary nailing are all examples of relative stability. Both bone forearm fractures have long been treated with open reduction and internal fixation even in the light of open wounds. Results have been excellent with plate fixation. Recently, intramedullary nails that are contoured and locked have been used in the treatment of both bone forearm fractures, but they are not reamed. It is well established that with restoring the proper radial bow, length, and alignment,
optimal function can be achieved. Open reduction and internal fixation allows this achievement. In cases where comminution exists, absolute stability may have to be sacrificed so as to not strip small comminuted bone fragments. Therefore, a bridging technique is worthwhile. External fixation can be used as a temporary technique until the soft tissues are more amenable to definitive fixation. Cast treatment is not indicated in adult forearm fractures. Locking nails for forearm use are not reamed. With regards to articular fractures, anatomic reduction and rigid stabilization are required to achieve the best results and allow for fracture healing. This environment also allows for the best chance of the cartilage repair process to form "hyaline-like" cartilage. Open reduction and internal fixation with absolute stability is the mainstay of treatment for partial articular fractures such as split depression tibial plateau fractures and posterior malleolus fractures involving greater than about 25% to 30% of the joint. The gold standard for the treatment of a closed femur fracture is a reamed intramedullary locked nail. Results are uniformly excellent. This can be done without stripping of the soft tissues such as in open reduction and internal fixation. External fixation can be used as a temporary device in patients in extremis for damage control reasons.Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am. 1986 Sep;68(7):1008-17. http://www.ncbi.nlm.nih.gov/pubmed/3745238')">View Abstract at PubMedJones DB Jr, Kakar S. Adult diaphyseal forearm fractures: intramedullary nail versus plate fixation. J Hand Surg Am. 2011 Jul;36(7):1216-9. Epub 2011 May

Question 4

The need for postoperative allogeneic blood transfusions after total hip arthroplasty has been shown to be reduced when using

Explanation

DISCUSSION: In a prospective study, 216 patients were randomized into three groups consisting of low-dose preoperative erythropoietin, high-dose preoperative erythropoietin, and placebo control. All patients were treated for 4 weeks prior to total hip arthroplasty. Both the low- and high-dose erythropoietin groups had a significantly lower rate of blood transfusions

(p < 0.001) after surgery.
REFERENCES: Waddell JP: Evidence-based orthopedics. J Bone Joint Surg Am 2001;83:788.
Feagan BG, Wang CJ, Kirkley A, et al: Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty: A randomized, controlled, trial. Ann Intern Med 2000;133:845-854.

Question 5

Receptor activator of nuclear factor kappa b (RANKL) and macrophage colony stimulating factor (MCSF) signaling pathways are necessary for the formation of multinucleated osteoclasts that resorb bone. Which of the following cells are known to produce RANKL?

Explanation

Osteoclast differentiation and function depend on the establishment of specific patterns of gene expression achieved through networks of transcription factors activated by osteoclastogenic cytokines such as RANKL and MCSF. RANKL and MCSF are produced by osteoblasts and T cells. Key transcriptional factors responsible for osteoclatogenesis require activation of transcriptional factors such as PU.1, NF-kappaB, AP-1, NFATc1, Mitf, Myc, and Src in osteoclast precursors that are of monocyte/macrophage origin.

Question 6

Which of the following nerves is most commonly injured during ankle arthroscopy?

Explanation

DISCUSSION: The superficial peroneal nerve, which is adjacent to the location of the lateral arthroscopic portal is most commonly injured.
REFERENCES: Ferkel RD, Heath DD, Guhl JF: Neurological complications of ankle arthroscopy. Arthroscopy 1996;12:200-208.
Barber CL, Click J, Britt BT: Complications of ankle arthroscopy. Foot Ankle 1990;10:263-266.

Question 7

A 70-year-old woman with a body mass index (BMI) of 34 and a history of hypercholesterolemia has elected to undergo total hip arthroplasty. Her son recently learned he has factor V Leiden following an episode of pulmonary embolism. What are this patient's risk factors for thromboembolic disease?

Explanation

DISCUSSION:
Risk stratification is one of the most critical clinical evaluations to undertake before performing total joint arthroplasty. Many factors have been identified that increase the risk for venous thromboembolism (VTE) The major factors include previous VTE, obesity, type of surgery (such as total joint arthroplasty), hypercoagulable states, myocardial infarction, congestive heart failure, family history of VTE, and
hormone replacement therapy. Hypercholesterolemia is not a risk factor for thromboembolic disease.

Question 8

Which of the following conditions is associated with palmoplantar pustulosis?

Explanation

DISCUSSION: Sternoclavicular hyperotosis is a seronegative and HLA-B27 negative rheumatic disease. In this condition, hyperostosis may appear in the spine, long bones, sacroiliac joints, and the sternoclavicular region. This entity is also associated with palmoplantar pustulosis.
REFERENCES: Wirth MA, Rockwood CA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,

WB Saunders, 2004, vol 2, pp 608-609.
Sonozaki H, Azuma A, Okai K, et al: Clinical features of 22 cases with inter-sterno-costo-clavicular ossification: A new rheumatic syndrome. Arch Orthop Trauma Surg 1979;95:13-22.

Question 9

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

Explanation

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

Question 10

What vessel is marked with an asterisk in Figure 44?

Explanation

DISCUSSION: The superior gluteal artery is a branch of the posterior division of the internal iliac artery and exits the pelvis through the greater sciatic notch. It can be injured as a result of a pelvic ring fracture or acetabular fracture that has a fracture of the posterior column.
REFERENCES: Agur AM, Dalley AF (eds): Grant’s Atlas of Anatomy, ed 12. Philadelphia, PA, Lippincott Williams and Wilkins, 2008.
Uflacker R: Atlas of Vascular Anatomy: An Angiographic Approach, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2006.

Question 11

A 78-year-old man has a history of worsening bilateral calf pain with activity. MRI scans are shown in Figures 31a through 31d. His symptoms are not improved with forward flexion of the lumbar spine. His lower extremity pain is relieved when he sits or ceases activity. Which of the following tests would be most helpful in establishing a diagnosis? Review Topic

Explanation

The differential diagnosis of degenerative lumbar stenosis is extensive. Vascular and neurogenic claudication frequently coexist in the older population. Therefore, it is important to determine the specific etiology of a patient's lower extremity claudication prior to any surgical intervention. Vascular claudication is relieved with cessation of activity, whereas neurogenic claudication requires that the patient sit down or flex the lumbar spine forward to increase the canal diameter. Because this patient does not experience improvement in his symptoms with sitting or forward flexion, it is likely that he is experiencing vascular claudication. The ankle-brachial index (ABI) is the ratio of the blood pressure in the lower legs to the blood pressure in the arms. Compared with the arm, lower blood pressure in the leg is a sign of peripheral vascular disease. The ABI is calculated by dividing the systolic blood pressure in the arteries at the ankle and foot by the higher of the two systolic blood pressures in the arms. An ABI value between 0.40 to 0.80 is moderately decreased and such patients often experience symptoms such as intermittent claudication. Selective nerve root blocks prove to be more useful in identifying specific level(s) of involvement in patients experiencing radicular pain and paresthesias. Their utility is less helpful in lower extremity claudication. Electrophysiologic studies are rarely useful, except in identifying the presence and source of a peripheral neuropathy. About 80% of patients with symptomatic lumbar stenosis will demonstrate electromyographic changes. Osteoarthritis of the hip may be associated with buttock, groin, hip, and thigh pain.
Decreased range of motion and hip joint pain, especially in internal rotation and abduction, are common findings in patients with degenerative arthritis of the hip. While post-myelography CT has been found superior to MRI as a single study for the preoperative planning of decompression for lumbar spinal stenosis, it will not assist in differentiating vascular from neurogenic claudication.

Question 12

A right-handed 24-year-old woman underwent an arthroscopic Bankart repair for recurrent anterior dislocations 9 months ago. Despite extensive physical therapy for 8 months, the patient has very limited range of motion (elevation to 130 degrees and external rotation to 10 degrees with the arm at the side). Shoulder radiographs are normal. The next step in management should consist of

Explanation

DISCUSSION: Arthroscopic capsular release is an effective means of treating stiffness that is the result of capsular contractures, such as in the case of a tight Bankart repair. Open release allows lengthening of a surgically shortened subscapularis, such as after a tight Putti-Platt repair. Additional physical therapy is unlikely to be effective because 8 months of treatment has failed to result in improvement. Accepting this degree of asymptomatic limited motion is not advisable because of the functional limitations for the patient and the increased risk of postoperative degenerative arthritis.
REFERENCES: Warner JJ, Allen AA, Marks PH, Wong P: Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 1997;79:1151-1158.
Harryman DT II, Matsen FA III, Sidles JA: Arthroscopic management of refractory shoulder stiffness. Arthroscopy 1997;13:133-147.

Question 13

Figure 50 shows the radiograph of a 26-year-old man who sustained an isolated open injury to his foot. Examination reveals no gross contamination in the wound. There is a palpable dorsalis pedis pulse and sensation is present on the dorsal and plantar aspects of the foot. Initial treatment should consist of wound debridement, antibiotics, and

Explanation

DISCUSSION: The radiograph shows a complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful, and provides for flexibility with any future reconstructive procedures.
REFERENCES: Smith CS, Nork SE, Sangeorzan BJ: The extruded talus: Results of reimplantation. J Bone Joint Surg Am 2006;88:2418-2424.
Brewster NT, Maffulli N: Reimplantation of the totally extruded talus. J Orthop Trauma 1997;11:42-45.

Question 14

An 18-year-old gymnast has had a 1-year history of foot pain. Examination reveals medial midfoot tenderness without swelling. Non-weight-bearing in a cast for 6 weeks has failed to provide relief. An axial CT scan of the midfoot is shown in Figure 20. What is the optimal treatment for this condition?

Explanation

DISCUSSION: Stress fractures of the navicular are often seen in running and jumping sports. Whereas most individuals heal with nonsurgical management consisting of 6 weeks of casting, this gymnast has had pain for 1 year and nonsurgical management has failed. Open reduction with bone grafting is the preferred treatment.
REFERENCES: Quirk RM: Stress fractures of the navicular. Foot Ankle Int 1998;19:494-496.
Saxena A, Fullem B, Hannaford D: Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. J Foot Ankle Surg 2000;39:96-103.

Question 15

Bleeding is encountered while developing the internervous plane between the tensor fascia lata and the sartorius during the anterior approach to the hip. The most likely cause is injury to what artery?

Explanation

DISCUSSION: The ascending branch of the lateral femoral circumflex artery crosses the gap between the tensor fascia lata and the sartorious and must be identified and ligated or coagulated. The other vessels are out of the field of dissection.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 312.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 304.

Question 16

In an effort to reduce costs, a limited MRI sequence is planned to detect a possible occult hip fracture. What is the anticipated fracture signal?

Explanation

DISCUSSION: At present, radiologists perform multiple MRI images to rule out all possible diagnoses. The ability to specify the anticipated changes on MRI should become more important as a means of reducing costs. MRI is sensitive to changes in free water (or hemorrhage) and thus this will appear dark on T₁ and bright on T₂.
REFERENCES: Miller MD: Review of Orthopaedics, ed 3. Philadelphia PA, WB Saunders, 2000, p 116.
Guanche CA, Kozin SH, Levy AS, et al: The use of MRI in the diagnosis of occult hip fractures in the elderly: A preliminary review. Orthopedics 1994;17:327-330.

Question 17

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

Explanation

DISCUSSION: The MRI scan shows detachment of the subscapularis from its insertion on the lesser tuberosity. The examination finding is consistent with a positive lift-off test, also indicating a tear of the subscapularis.
REFERENCES: Lyons RP, Green A: Subscapularis tendon tears. J Am Acad Orthop Surg 2005;13:353-363.
Warner JJ, Higgins L, Parsons IM, et al: Diagnosis and treatment of anterosuperior rotator cuff tears. J Shoulder Elbow Surg 2001;10:37-46.

Question 18

When do most symptomatic thromboembolic events occur after total joint arthroplasty?

Explanation

DISCUSSION:
Most clinical venous thromboembolism events occur between the second and sixth weeks after surgery. It is estimated that 10% of patients are readmitted to the hospital within the first 3 months after total hip or knee arthroplasties. Most pulmonary events on the day of surgery are related to fat embolism or cardiac events.

Question 19

..Staging studies show no other lesions and surgical treatment is planned; when should a biopsy be performed?

Explanation

CLINICAL SITUATION FOR QUESTIONS 117 THROUGH 120
Figures 117a through 117c are the radiographs and MRI scan of a 16-year-old boy who has had a persistent fullness in his thigh since being kicked while playing soccer 4 weeks ago. He states that initially the area was painful, but now all symptoms other than the mass have resolved.

Question 20

What are the optimal conditions for leaving the acetabular shell in place, replacing the acetabular liner, and grafting the osteolytic defect shown in Figure 39?

Explanation

DISCUSSION: Dense pods of ingrowth into the porous coating of cementless ingrowth sockets are seen. Channels through the non-ingrown portion allow access to the trabecular bone of the ilium. Polyethylene wear debris can enter these areas through screw holes. Expansile, lytic lesions can result, which can become large without compromising implant fixation. Loosening is late and results from catastrophic loss of bone. A well-fixed acetabular component with a modular design, a well-designed locking mechanism, and a good survivorship history is a candidate for exchange of the liner and grafting of the osteolytic lesion.
REFERENCES: Ries MD: Complications in primary total hip arthroplasty: Avoidance and management. Wear. Instr Course Lect 2003;52:257-265.
Dumbleton JH, Manley MT, Edidin AA: A literature review of the association between wear rate and osteolysis in total hip arthroplasty. J Arthroplasty 2002;17:649-661.
Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 175-180.

Question 21

Figures 1 and 2 show the radiograph and CT obtained from a 78-year-old woman who underwent right total hip replacement in 1995. She initially did well with no pain. She was last seen 7 years ago and was having mild hip pain at that time. She was found to have a supra-acetabular cyst on radiographs. She has had severe right hip pain for the past 9 months while using a walker for ambulation. The initial blood work reveals an estimated erythrocyte sedimentation rate of 32 mm/hr, a C-reactive protein level of 0.5 mg/L, a serum cobalt level of 0.4 µg/L, and a serum chromium level of 0.6 µg/L. Right hip aspiration is performed, revealing a white blood cell count of 139, 52% neutrophils, and a negative leukocyte esterase test. What is the best next step?

Explanation

DISCUSSION:
The hip replacement was performed in 1995, during the period when the previous generation of polyethylene was utilized. This polyethylene was subjected to irradiation in air, with subsequent oxidation and consequent osteolysis after implantation. The mechanism of osteolysis begins with the uptake of polyethylene particles by macrophages, which then initiate an inflammatory cascade and the release of osteolytic factors. This cycle continues, with eventual implant loosening and failure. The imaging shows significant osteolysis and raises concern for pelvic discontinuity and acetabular implant failure. The surgical treatment consists of acetabular reconstruction. In this patient, concern exists for discontinuity based on the substantial amount of bone loss and nonsupportive anterior and posterior columns. This scenario requires complex acetabular revision using a custom triflange device, distraction with a jumbo acetabular component, or placement of a porous metal cup/cage construct with augmentation. The laboratory values are not consistent with infection or failure due to metal debris.

Question 22

At which joint do degenerative changes occur first in a patient with chronic, untreated scapholunate dissociation?

Explanation

EXPLANATION:
Stage I of scapholunate advanced collapse (SLAC) is characterized by the presence of radioscaphoid arthritis. A predictable pattern exists of the progression of degenerative changes for SLAC wrist, including stage I (radial styloid involvement at the scaphoid fossa), stage II (scaphoid and entire scaphoid facet involvement), stage III (degeneration between the capitate and lunate), and stage IV (pancarpal involvement). The radiolunate joint is often spared.

Question 23

What approach should be chosen for the injury seen in Figure 67? Review Topic

Explanation

(SBQ12TR.4) Which of the following statements about the lateral femoral cutaneous nerve is true?
Innervates the medial aspect of the proximal thigh
Originates from the dorsal roots of L4-L5
Course runs medial to the femoral artery
Courses along the medial border of the psoas muscle
Courses under the inguinal ligament PREFERRED RESPONSE 5

Question 24

Which of the following procedures is considered most appropriate in patients with rheumatoid arthritis?

Explanation

DISCUSSION: Synovectomy of the knee prior to loss of articular cartilage has been shown to consistently relieve pain in patients with rheumatoid arthritis. Partial knee replacement will not arrest the process of joint destruction. Osteotomy of the hip has not been found to be a successful procedure in patients with rheumatoid arthritis. Hip arthrodesis should not be considered because of the multiarticular involvement in patients with rheumatoid arthritis. Core decompression of the hip has not been shown to save the femoral head because the necrosis appears to occur simultaneously with the inflammatory joint process.
REFERENCES: Granberry WM, Brewer EJ Jr: Early surgery in juvenile rheumatoid arthritis, in Calundruccio RA (ed): Instructional Course Lectures XXIII. St Louis, MO, CV Mosby, 1974, pp 32-37.
Stuchin SA, Johanson NA, Lachiewicz PF, Mont MA: Surgical management of inflammatory arthritis of the adult hip and knee, in Zuckerman JD (ed): Instructional Course Lectures 48. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 93-109.

Question 25

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

Explanation

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

Question 26

Figure 8a shows the clinical photograph of an 83-year-old woman who has an enlarging left forearm mass. MRI scans are shown in Figures 8b and 8c. What is the next most appropriate step in management?

Explanation

DISCUSSION: Any large (greater than 5 cm), deep, heterogeneous mass in the extremities should be considered a sarcoma until proven otherwise. Sarcomas are rare, and without a high index of suspicion, the lesions may be misdiagnosed or there may be a delay in diagnosis. Needle biopsies can obtain sufficient tissue for diagnosis and are associated with less morbidity than open biopsy. Marginal resections or excisional biopsies should be reserved for a few select benign lesions and locations.
REFERENCES: Damron TA, Beauchamp CP, Rougraff BT, et al: Soft-tissue lumps and bumps. Instr Course Lect 2004;53:625-637.
Sim FH, Frassica FJ, Frassica DA: Soft-tissue tumors: Diagnosis, evaluation, and management. J Am Acad Orthop Surg 1994;2:202-211.

Question 27

Which of following is pathognomonic of intervertebral disk degeneration? Review Topic

Explanation

Degradation of
large proteoglycan molecules in
the nucleus pulposus is
pathognomonic
of intervertebral disk
(IVD) degeneration.
Degeneration of the intervertebral disk (IVD) is a major pathological process implicated in low back pain and is often considered a prerequisite for intervertebral disc herniation. While the pathophysiologic causes of IVD degeneration at the molecular level are not fully known, there are many physical and molecular changes that are known to contribute to the disease process. The most significant is loss of large proteoglycan molecules and decreased water content.
An et al. showed that large proteoglycans (PGs), such as aggrecan and versican, decrease in patients with intervertebral disk (IVD) degeneration.
Kepler et al. reviewed IVD degeneration. They report that degeneration leads to changes in the expression of matrix proteins, cytokines, and proteinases. They suggest treatment with gene therapy, such as Growth and Differentiation Factor-5 (GDF-5), may help to promote the healing of degenerated intervertebral disks.
Illustration A shows a cadaveric image of normal disk anatomy (left) and IVD degeneration (right)
Incorrect Answers:

Question 28

A 44-year-old man was involved in a low speed rear-end motor vehicle accident 4 weeks ago. He predominantly reports pain in the back of the neck, with occasional radiation into the trapezius region bilaterally. He denies any extremity pain. The pain has not changed in intensity, but is worse with neck range of motion. Cervical spine radiographs were negative for acute osseous trauma or instability. What is the next most appropriate step in management? Review Topic

Explanation

The patient was involved in a low speed rear-end collision and sustained a whiplash-type injury, with management most often being nonsurgical. After 4 weeks of persistent pain, continued observation is not reasonable. Studies have shown that treatment including NSAIDs, activity modification and a brief duration of physical therapy allows for improved outcomes after whiplash-type injuries when compared with observation alone. An MRI scan of the cervical spine is not indicated at this time and represents an unnecessary expense. Cervical epidural and facet injections are not indicated in the treatment of patients with whiplash injuries.

Question 29

A 35-year-old woman with type 1 diabetes mellitus has been treated for the past 2 years at a wound care center for persistent bilateral fifth metatarsal head ulcers. Management has consisted of shoe wear modifications, treatment with multiple enzymatic ointments, and a fifth metatarsal head resection on the left side. Physical examination reveals intact pulses, minimal ankle dorsiflexion, neutral hindfoot, and a persistent ulcer under the fifth metatarsal heads. What treatment will best help heal the ulcers?

Explanation

DISCUSSION: The patient likely has a significant Achilles contracture that causes her to always bear more weight on her forefoot. A gastrocnemius recession takes the ankle out of plantar flexion and she will be able to return to a normal gait and reduce the pressures on her forefoot. A forefoot amputation is a salvage option. The other choices are appropriate; however, the patient has had this problem for 2 years and she has already had multiple attempts at shoe wear modification.
REFERENCES: Laughlin RT, Calhoun JH, Mader JT: The diabetic foot. J Am Acad Orthop Surg 1995;3:218-225.
Aronow MS, Diaz-Doran V, Sullivan RJ, et al: The effect of triceps surae contracture force on plantar foot pressure distribution. Foot Ankle Int 2006;27:43-52.

Question 30

Which of the following factors is associated with the highest rate of nonunion of a midshaft clavicle fracture?

Explanation

The risk of nonunion in patients sustaining middle 1/3 clavicle fractures is increased in female patients.
Clavicle fractures are often secondary to direct blows to the lateral aspect of the shoulder. Physical examination is important to ascertain the status of the
skin and neurovascular structures to help guide treatment management. Although most non-displaced middle 1/3 clavicle fractures may be treated successfully with conservative measures, the risk for non-union (1-5%) increases with increasing comminution, female gender, shortening greater than 2 cm and an advanced age of the patient.
Robinson et al. reviewed 581 patients treated non-operatively for midshaft clavicle fractures. A nonunion rate of 4.5 % was identified at 24 weeks after the injury. They identified four factors that contributed to non-union, including: female gender, lack of cortical apposition, comminution of the fracture fragments and advancing age.
Zlowdzki et al. reviewed 2144 clavicle fracture cases in a comprehensive meta-analysis. They report displacement as the highest risk factor for nonunion (15.1%) in nonoperatively treated clavicle fractures, and simple slings were favored over figure of 8 braces. They also report an 86% reduction in the nonunion rate when operative fixation is chosen over nonoperative treatment for displaced clavicle fractures.
Illustration A shows the presence of a non-union of a midshaft clavicle fracture. A video is provided that reviews management of clavicle injuries.
Incorrect Answers

OrthoCash 2020

Question 31

A football lineman who sustained a traumatic injury while blocking during a game now reports that his shoulder is slipping while pass blocking. Examination reveals no apprehension in abduction and external rotation; however, he reports pain with posterior translation of the shoulder. He has full strength in external rotation, internal rotation, and supraspinatus testing. What is the pathology most likely responsible for his symptoms?

Explanation

DISCUSSION: Traumatic posterior instability is a common finding in football players, especially in the blocking positions as well as in the defensive linemen and linebackers.

A traumatic blow to the outstretched arm results in posterior glenohumeral forces. Labral detachment at the glenoid rim is common. Patients report slipping or pain with posteriorly directed pressure. Rarely do these patients have true dislocations that require reduction; however, recurrent episodes of subluxation or pain are not uncommon. Posterior repair has

been shown to be successful in the treatment of traumatic instability.
REFERENCES: Bottoni CR, Franks BR, Moore JH, et al: Operative stabilization of posterior shoulder instability. Am J Sports Med 2005;33:996-1002.
Williams RJ III, Strickland S, Cohen M, et al: Arthroscopic repair for traumatic posterior shoulder instability. Am J Sports Med 2003;31:203-209.
Kim SH, Ha KI, Park JH, et al: Arthroscopic posterior labral repair and capsular shift for traumatic unidirectional recurrent posterior subluxation of the shoulder. J Bone Joint Surg Am 2003;85:1479-1487.

Question 32

A 32-year-old male presents with left leg pain and weakness. An axial image from his MRI is shown in Figure A. Which of the following physical exam findings would be most consistent with this MRI finding. Review Topic

Explanation

A positive flexion, adduction, internal rotation (FADDIR) test
A history of untreated slipped capital femoral epiphysis (SCFE)
A thrombophilia
Normal serum ESR and CRP
Positive Human Leukocyte Antigen B27 (HLA-B27)
The patient has large joint arthralgia and sacroiliac joint sclerosis on AP pelvis radiograph, which is consistent with ankylosing spondylitis. Patients with ankylosing spondylitis have positive Human Leukocyte Antigen B27 (HLA-B27).
Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy that affects the axial skeleton as well as large joints including the hips and knees. The most common initial site of pain is the sacroiliac (SI) joint, and is demonstrated as sacroiliitis on pelvic radiograph. Hip involvement is common, and typically manifests as hip pain and flexion contracture. Serologic studies will be typically be negative for rheumatoid factor, but positive for HLA-B27 in 90% of patients.
Kubiak et. al. review orthopaedic management of AS. Common orthopaedic manifestations include SI joint pain, hip flexion contractures, and stiffness of the cervical and lumbar spine. They report that laboratory analysis of patients with active disease will typically demonstrate mild elevation of ESR, CRP, and WBC. Patients with chronic AS may demonstrate a normocytic anemia. If HLA-B27 is negative, a high clinical suspicion should still be maintained.
Gensler et al. review the different clinical conditions that compose of juvenile-onset spondyloarthritis. They report on the different spondyloarthritides includes ankylosing spondylitis, reactive arthritis, arthropathy associated with inflammatory bowel disease, and that associated with psoriasis. They emphasize that the appearance of sacroiliac joint and spinal disease in the form of ankylosing spondylitis usually takes 5–10 years after initial symptom presentation, and therefore, a definite diagnosis can take several years leading to a delay in diagnosis.
Figure A is an AP pelvis radiograph of a skeletally mature individual demonstrating sclerosis of the SI joint indicative of sacroiliitis. Illustration A shows a axial CT image of the patient in the stem. Sclerosis and bone erosion can be seen in the sacroiliac joint.
Incorrect Answers:
osteonecrosis Answer 3: A infarctions,
of
the
femoral
epiphysis.
thrombophilia may have
osseous manifestations such as bone
which
are
not
evident
on
this
image.

Question 33

Figures 71a and 71b/ are the MR images of a 65-year-old man who dislocated his shoulder. What is his most likely chief symptom?

Explanation

CLINICAL SITUATION FOR QUESTIONS 72 THROUGH 75
Figures 72a through 72e 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 degrees
to 90 degrees and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted.

Question 34

A 14-year-old boy has a midshaft fibular lesion. Biopsy results are consistent with Ewing’s sarcoma. Following induction chemotherapy, local control typically consists of

Explanation

DISCUSSION: Current treatment regimens for Ewing’s sarcoma typically involve induction chemotherapy followed by local control and further chemotherapy. Local control consists of surgery alone, radiation therapy alone, or a combination of the two. In bones that are easily resectable (or expendable) with wide margins, surgery alone is usually recommended. For areas that are unresectable (ie, large, bulky pelvic tumors), radiation therapy alone is sometimes the preferred method of local control. If surgery is chosen and margins are close, radiation therapy can be used as an adjuvant. Amputation rarely is required for an isolated fibular lesion. Observation without adequate local therapy results in local recurrence.
REFERENCES: Nesbit ME Jr, Gehan EA, Burgert EO Jr, et al: Multimodal therapy for the management of primary, nonmetastatic Ewing’s sarcoma of bone: A long-term follow-up of the First Intergroup study. J Clin Oncol 1990;8:1664-1674.
Simon MA, Springfield DS, et al: Ewing’s Sarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 287-297.

Question 35

The condition shown in Figures 9a and 9b is most likely the result of

Explanation

The clinical photograph and radiograph show gout, which is the result of urate deposition in the joint and soft tissues. Radiographs frequently reveal periarticular erosions. The crystals are intracellular and negatively birefringent under the polarized microscope. Treatment for acute flares include colchicines, indomethacin, and corticosteroids (including injections). Medications such as allopurinol help prevent recurrent flares. Tophi such as that seen in this patient are often confused with and associated with infection.

Question 36

A healthy 2-year-old boy falls from a swing and sustains a displaced midshaft femoral fracture with 1 cm of shortening. What is the most appropriate treatment?

Explanation

AL-Madena Copy
DISCUSSION: For children between the ages of 1 and 6 years, closed reduction and early spica casting is recommended. In some instances, associated injuries or body habitus may preclude cast treatment. Pavlik harness treatment of femoral fractures is for infants younger than 1 year of age. Rarely is there an indication for traction. Internal fixation is reserved in general for children older than age 6 years or with confounding factors.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 271-280.
Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359.

Figure 29a Figure 29b

Question 37

A 47-year-old woman with no history of trauma has had a painful, stiff shoulder for the past 3 months. Treatment consisting of subacromial injection and nonsteroidal anti-inflammatory drugs has been ineffective. Her active range of motion is painful and is limited to 90 degrees of abduction, 60 degrees of elevation, 30 degrees of external rotation, and internal rotation to the posterior superior iliac spine. Plain radiographs of the cervical spine and shoulder are normal. Management at this time should consist of

Explanation

Idiopathic adhesive capsulitis usually responds to nonoperative therapy or closed manipulation, but shoulder stiffness due to trauma or surgery may necessitate an arthroscopic or an open-release procedure. For most patients, a supervised physical therapy program will be successful in treating adhesive capsulitis.

Question 38

A 15-year-old boy reports a 2-day history of progressive left buttock pain and severe limping. He denies any history of trauma or radiation of the pain. He has an oral temperature of 100.4 degrees F (38 degrees C). Examination reveals that the lumbar spine and left hip have unguarded motion. The abdomen is nontender. There is moderate tenderness of the left sacroiliac region with no palpable swelling. Pain is elicited when the left lower extremity is placed in the figure-4 position (FABER test). Laboratory studies show a peripheral WBC count of 11,500/mmP3P (normal to 10,500/mmP3P) and an erythrocyte sedimentation rate of 38 mm/h (normal up to 20 mm/h). Radiographs of the pelvis, hips, and lumbar spine are normal. A nucleotide bone scan (posterior view) is shown in Figure 44. Initial management should consist of Review Topic

Explanation

The symptoms, physical findings, and laboratory studies are most consistent with a diagnosis of infectious sacroiliitis, usually caused by Staphylococcus aureus. Initial radiographs will be normal, and the diagnosis of sacroiliitis is often delayed. A technetium Tc 99m bone scan will localize the problem in 90% of patients but may occasionally give a false-negative result in early cases. If suspicion is high, a gallium scan or MRI scan may help confirm the diagnosis of sacroiliitis. Needle aspiration of the sacroiliac joint is difficult; therefore, antibiotic selection is usually empiric or based on blood cultures. Sacroiliitis that is the result of connective tissue inflammatory disease is usually bilateral and without fever or leukocytosis. The lack of hip irritability, spinal rigidity, and abdominal tenderness helps to rule out other causes of limping with fever, such as psoas abscess, diskitis, and septic hip.

Question 39

Figure 6 shows a sagittal oblique MRI scan. The arrow is pointing to what structure?

Explanation

DISCUSSION: The meniscofemoral ligaments connect the posterior horn of the lateral meniscus to the intercondylar wall of the medial femoral condyle. The ligament of Humphrey (arrow) passes anterior to the posterior cruciate ligament, whereas the ligament of Wrisberg passes posterior to the posterior cruciate ligament. One or the other has been identified in 71% to 100% of cadaver knees, with the ligament of Wrisberg being more common.
REFERENCES: Clarke HD, Scott WN, Insall JN, et al: Anatomy, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 3-66.
Miller TT: Magnetic resonance imaging of the knee, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 201-224.

Question 40

Epithelioid sarcoma most commonly occurs in which of the following anatomic locations?

Explanation

DISCUSSION: Epithelioid sarcoma is a rare soft-tissue sarcoma that most commonly arises in the hand or upper extremity, and it is frequently misdiagnosed as an infection or granuloma. It tends to have a higher incidence of lymph node metastasis than other soft-tissue sarcomas. The mainstay of treatment is wide surgical excision, even if amputation is necessary.
REFERENCES: Gupta TD, Chaudhuri P (eds): Tumors of the Soft Tissues, ed 2. Stamford, CT, Appleton and Lange, 1998, p 475.
Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St. Louis, MO, Mosby-Year Book, 1995, p 1074.

Question 41

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

Explanation

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

Question 42

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

Explanation

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

Question 43

A 57-year-old man involved in a motor vehicle accident sustains an injury to his right shoulder. A spot AP radiograph is shown in Figure 34. What is the next most appropriate step in the orthopaedic management of this patient? Review Topic

Explanation

The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a “Velpeau” axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.

Question 44

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 45

The spinal cord terminates as the conus medullaris at what vertebral level in adults? Review Topic 1 T12

Explanation

The spinal cord anatomy changes at the thoracolumbar junction. The spinal cord terminates as the conus medullaris at the lower portion of L1 in women and the pedicle of L1 in men.

Question 46

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 47

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 48

What is the goal of surgical treatment in this scenario?

Explanation

DISCUSSION
This patient has a metastatic neuroendocrine tumor. Surgical treatment should prioritize palliation of her symptoms. She has high-grade spinal cord compression without neurologic signs or symptoms. Steroids are beneficial for patients with high-grade spinal cord compression caused by tumors, and these drugs should be administered in the acute setting. This patient was appropriately initially treated with conventional radiation. However, she is not a candidate for further radiation because of spinal cord tolerance limits and insufficient clearance between the tumor and spinal cord. Consequently, stereotactic radiation is not an option.
The goal of surgical treatment of this tumor should be palliation of her symptoms rather than cure. A costotransversectomy approach offers the advantage of ventral and dorsal spinal cord access, which is necessary in this case. A sternotomy or transthoracic approach would offer ventral access, but dorsal access would be less than optimal.
RECOMMENDED READINGS
Rose PS, Buchowski JM. Metastatic disease in the thoracic and lumbar spine: evaluation and management. J Am Acad Orthop Surg. 2011 Jan;19(1):37-48. Review. PubMed PMID: 21205766.View Abstract at PubMed
Rades D, Abrahm JL. The role of radiotherapy for metastatic epidural spinal cord compression. Nat Rev Clin Oncol. 2010 Oct;7(10):590-8. doi: 10.1038/nrclinonc.2010.137. Epub 2010 Aug

Question 49

The use of bisphosphonates in children with osteogenesis imperfecta is becoming more widely accepted as treatment to improve quality of life and to decrease the risks of fracture. What is the mechanism by which bisphosphonates work?

Explanation

The mechanism by which bisphosphonates act is by inhibiting osteoclasts. One mechanism of bisphosphonates is to cause osteoclast apoptosis. Another mechanism of bisphosphonates is to disrupt the cytoskeleton of osteoclasts, resulting in loss of the ruffled border. The uncoupling of bone resorption and bone formation with decreased bone resorption results in increased bone mineralization. This translates into fewer fractures in patients with osteogenesis imperfecta and improved quality of life.

Question 50

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

Explanation

Capsular exposure for an inside-out lateral meniscal repair is performed by developing the interval between the iliotibial band and biceps tendon. Posterior retraction of the biceps tendon exposes the lateral head of the gastrocnemius. Posterior retraction of the gastrocnemius provides access to the posterolateral capsule.

Question 51

What is the heaviest weight that can be safely applied to the adult cervical spine via Gardner-Wells tong traction?

Explanation

DISCUSSION: Cotler and associates reported on the use of awake skeletal traction to reduce facet fracture-dislocations in 24 patients. Seventeen patients required more than 50 pounds of traction (the “traditional” limit) to achieve reduction. More than 100 pounds of traction was safely used in one-third of the patients in this study. A cadaver study has supported the safe use of traction with weights in excess of 100 pounds.
REFERENCES: Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.
Anderson DG, Vacccaro AR, Gavin K: Cervical orthoses and cranioskeletal traction, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,

pp 110-121.

Question 52

A young gymnast fell awkwardly onto an outstretched hand during a competition. At the time of impact, his forearm was positioned in supination. Axial and posterolateral forces were loaded along the forearm into the elbow and the elbow underwent a significant valgus thrust. What injury pattern is most likely to result from the combination of these forces at the elbow?

Explanation

The combination of valgus, axial, and posterolateral rotatory forces (forearm supination) can result in a "terrible triad" injury of the elbow.
The key features of a terrible triad injury include a radial head fracture, coronoid fracture, and dislocation of the elbow. Disruption of the lateral collateral ligament complex often concomitantly occurs. While restoration of the bony anatomy is important for static stability, the key primary stabilizer that needs to be addressed is the lateral collateral ligament complex. In acute injuries LCL repair may be possible. In chronic injury, LCL reconstruction would need to be considered.
O'Driscoll et al. 1991, examined 5 patients with recurrent posterolateral rotatory instability of the elbow. They showed that by applying supination of the forearm with a valgus moment and an axial compression force to the elbow while it is flexed from full extension, this can demonstrate posterolateral rotatory instability of the elbow. The elbow is reduced in full extension and must be subluxated as it is flexed in order to obtain a positive test result (a sudden reduction of the subluxation).
O'Driscoll et al. 1992 looked at a cadaveric study of the elbow. They showed that external rotation and valgus moments with axial forces resulted in posterior dislocations in 12 of the 13 specimens when the anterior medial collateral ligament (AMCL) remained intact. Clinically, it valgus stability in pronation is demonstrated, the AMCL can be assumed to be intact.
Illustration A and B shows radiographs of a terrible triad injury. There is posterolateral dislocation of the elbow with associated radial head fracture, coronoid fracture.
Incorrect Answers:

Question 53

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

Explanation

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

Question 54

Figure 7 shows the MRI scan of a 23-year-old competitive rugby player who has anterior ankle pain and swelling. He states that he has been playing for many years and has sprained his ankle several times. Examination will reveal what specific hallmark feature?

Explanation

DISCUSSION: The history and MRI findings indicate the presence of anterior tibiotalar osteophytes. This is frequently observed in soccer, rugby, and football athletes who play on grass or turf surfaces and repetitively push off and change directions. Examination may reveal an effusion but no loss of subtalar motion. A positive external rotation (Klieger) test is described as pain at the distal ankle with external rotation of the foot and is observed in patients with syndesmosis sprains. This patient may have an increased anterior drawer because of a history of sprains; however, this finding is not specific for anterior impingement of tibiotalar osteophytes. The most specific finding on physical examination is pain with forced dorsiflexion.
REFERENCES: Ogilvie-Harris DJ, Mahomed N, Demaziere A: Anterior impingement of the ankle of the ankle treated by arthroscopic removal of bony spurs. J Bone Joint Surg Br 1993;75:437-440.
Cannon LB, Hackney RG: Anterior tibiotalar impingement associated with chronic ankle instability. J Foot Ankle Surg 2000;39:383-386.

Question 55

1 and 2 show the radiograph and CT obtained from a year-old woman who underwent right total hip replacement in She initially did well with no pain. She was last seen 7 years ago and was having mild hip pain at that time. She was found to have a supra-acetabular cyst on radiographs. She has had severe right hip pain for the past 9 months while using a walker for ambulation. The initial blood work reveals an estimated erythrocyte sedimentation rate of 32 mm/hr, a C-reactive protein level of 5 mg/L, a serum cobalt level of 4 µg/L, and a serum chromium level of 6 µg/L. Right hip aspiration is performed, revealing a white blood cell count of 139, 52% neutrophils, and a negative leukocyte esterase test. What is the best next step?

Explanation

Question 56

A 20-year-old man with fascioscapulohumeral dystrophy has severe scapular winging of both shoulders. He can no longer abduct above 80 degrees, and it affects his activities of daily living. A clinical photograph is shown in Figure 26. Definitive management should consist of

Explanation

DISCUSSION: The patient’s history is typical of patients with severe fascioscapulohumeral dystrophy. The scapular winging can be so pronounced that there is significant loss of function of the upper extremity. The surgical options include transfer of the pectoralis major muscle with a tendon graft or scapulothoracic fusion. The latter is a technically demanding procedure but can provide a very stable platform for the upper extremity. Most patients will see increased elevation of the extremity once the scapula is stabilized. Pectoralis minor transfer has not been described and would not be effective.
REFERENCES: Shapiro F, Specht L: The diagnosis and orthopaedic treatment of inherited muscular diseases of childhood. J Bone Joint Surg Am 1993;75:439-454.
Bunch WH, Siegel IM: Scapulothoracic arthrodesis in fascioscapulohumeral muscular dystrophy: Review of seventeen procedures with three to twenty-one-year follow-up. J Bone Joint Surg Am 1993;75:372-376.

Question 57

A 30-year-old woman sustained a nondisplaced unilateral facet fracture of C5 in a motor vehicle accident. She is neurologically intact and has no other injuries. Management should consist of

Explanation

DISCUSSION: The patient has a stable bony fracture that will heal with immobilization in a rigid collar. Flexion-extension radiographs may be obtained at 6 weeks to verify that there is no instability; mobilization may then be begun.
REFERENCE: Clarke CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 457-464.

Question 58

A 55-year-old man reports increasing weakness in his arms that has progressed to his lower limbs, resulting in frequent tripping and falling. Examination reveals weakness in shoulder abduction and external and internal rotation bilaterally. Fasciculation is noted. He also has weakness in elbow flexion and extension bilaterally, and his grip strength is diminished. An electromyogram and nerve conduction velocity studies show decreased amplitude of compound motor action potential, slightly slowed motor conduction velocity, and denervation signs with decreased recruitment in all extremities. The sensory study is normal. Based on these findings, what is the most likely diagnosis?

Explanation

DISCUSSION: The major determinant of ALS (Lou Gehrig disease) is progressive loss of motor neurons. The loss usually begins in one area, is asymmetrical, and later becomes evident in other areas. The first signs of ALS may include either upper or lower motor neuron loss. Recognition of upper motor neuron involvement depends on clinical signs, but electromyography and nerve conduction velocity studies can help identify lower motor neuron involvement. Electrodiagnostic abnormalities in three or more areas are required to make a definitive diagnosis. The motor unit potentials (MUPs) changes in ALS include impaired MUPs recruitment, unstable MUPs, and abnormal MUPs size and configuration. A number of abnormal spontaneous discharges can occur with ALS, especially fibrillation potentials and fasciculation potentials. In ALS, the motor nerve conduction study will be abnormal, but a co-existing normal sensory study is definitive for this disease.
REFERENCES: de Carvalho M, Johnsen B, Fuglsang-Frederiksen A: Medical technology assessment: Electrodiagnosis in motor neuron diseases and amyotrophic lateral sclerosis. Neurophysiol Clin 2001;31:341-348.
Daube JR: Electrodiagnostic studies in amyotrophic lateral sclerosis and other motor neuron disorders. Muscle Nerve 2000;23:1488-1502.
Troger M, Dengler R: The role of electromyography (EMG) in the diagnosis of ALS. Amyotroph Lateral Scler Other Motor Neuron Disord 2000;1:S33-S40.

Question 59

The essential lesion responsible for posterolateral rotatory instability of the elbow is disruption of the

Explanation

DISCUSSION: Posterolateral rotatory instability (PLRI) of the elbow represents a three-dimensional injury pattern of rotational displacement of the ulna from the trochlea and the radius from the capitellum. The ulna supinates (externally rotates) past its normal limit and the radiocapitellar joint subluxates posterolaterally, permitting the coronoid process to slide beneath the trochlea. In cadaver studies, the lateral ulnar collateral ligament has been shown to be the essential lesion responsible for PLRI. The medial collateral ligament (of which the anterior bundle is the most important) is the primary restraint to valgus instability. The posterolateral capsule and radial collateral ligament may be disrupted in a complete posterolateral dislocation but are not essential injuries for PLRI. The primary function of the annular ligament is to stabilize the proximal radioulnar joint.
REFERENCES: O’Driscoll SW, Jupiter JB, King GJW, Hotchkiss RN, Morrey BF: The unstable elbow. J Bone Joint Surg Am 2000;82:724-738.
Olsen BS, Sojbjerg JO, Dalstra M, Sneppen O: Kinematics of the lateral constraints of the elbow. J Shoulder Elbow Surg 1996;5:333-341.
O’Driscoll SW, Morrey BF, Korinek S, An KN: Elbow subluxations and dislocation: A spectrum of instability. Clin Orthop 1992;280:186-197.

Question 60

A 39-year-old male with chronic renal disease and type 2 diabetes mellitus fell 1 week ago after slipping on ice. He is unable to bear weight on the right lower extremity or perform active knee extension. He reports no prior history of knee pain or instability. Lachman, posterior drawer, posterolateral recurvatum testing are deferred secondary to patient's pain. He has a palpable dorsalis pedis pulse but does have neuropathy as determined by Semmes-Weinstein filament testing. His radiograph is shown in Figure A and MR images in Figures B and C. What is the most appropriate initial plan for management? Review Topic

Explanation

The clinical presentation, exam, and images are consistent with an acute patellar tendon rupture.
Primary surgical repair within 2 weeks of injury is recommended to prevent extensor mechanism contracture. Patellar tendon ruptures typically occur in patients younger than 40 years old. Most ruptures occur at the junction of the tendon and distal pole of the patella.
Matava et al. presents a level 5 review on patellar tendon ruptures and states that active knee extension is permitted at 3 weeks postoperatively. Non-weightbearing movement exercises like heel slides are encouraged. This can incorporate active knee flexion with passive extension. Alternatively, active knee flexion in the prone position with passive knee extension can be performed. Open chain strengthening exercises such as leg extensions are started later, as are weight bearing resistance exercises like squats, lunges and leg presses.
Volk et al. discuss potential complications and pitfalls of patients with the management of extensor mechanism injuries. They warn that complications can consist of misdiagnosis, delayed surgery, failed repair due to poor surgical planning of injury site, or wound infection.
Figure A demonstrates patella alta which in this case is indicative of complete patellar tendon rupture. Patella alta can be quantified by using the Insall-Salvati ratio (patellar tendon length / patellar bone length): PTL/PBL normal =1, >1.2 is patella alta, <0.8 is patella baja) with the knee flexed to 30 degrees. Figure B and C are sagittal T1 and T2 images showing complete patellar tendon rupture.
Incorrect answers:

Question 61

Examination of a 6-year-old boy who sustained a displaced Salter-Harris type II fracture of the distal radius reveals 35 degrees of volar angulation. A satisfactory reduction is obtained with the aid of a hematoma block. At the 10-day follow-up examination, radiographs show loss of reduction and 35 degrees of volar angulation. Management should now consist of

Explanation

DISCUSSION: In a 6-year-old child with a physeal fracture, the healing response 10 days after injury is so advanced that manipulation would have to be very forceful to be successful. A forceful manipulation in a patient this age increases the risk of early growth arrest and a significant disability because 80% of the growth of the radius comes from the distal physis. Because of the large contribution of growth from the distal radial physis and the angulation being in the plane of wrist motion, the potential for remodeling of this fracture is great. It is highly probable that this fracture will completely remodel in 1 to 2 years of growth. In this patient, even a “gentle” open reduction would probably require enough force that the physis would

be damaged.
REFERENCES: Dimeglio A: Growth in pediatric orthopaedics, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 33-62.
Waters PM: Forearm and wrist fractures, in Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 251-258.

Question 62

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

Explanation

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

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

Acta Chir Scand 1941;84:1.

Question 63

Explanation

Question 64

A young man sustains a lumbar strain in an on-the-job motor vehicle accident. Both he and his treating physician feel that he is capable of limited duty with appropriate restrictions shortly after the injury. What term best describes his work status?

Explanation

DISCUSSION: Because the man is only recently removed from his injury and is judged capable of returning to work with some restrictions, the term that best describes his work status is temporary partial disability.
REFERENCE: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 131-137.

Question 65

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

Explanation

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

Question 66

Because of the ongoing pain and instability and the demonstration of radiographic instability when the ankle is stressed, what surgical procedure should be performed to restore stability to the ankle joint based on the CT findings?

Explanation

DISCUSSION FOR QUESTIONS 107 AND 108:
The fracture at the insertion of the AITFL into the fibula represents a syndesmosis injury. In some cases, a direct repair of the fracture will stabilize the syndesmosis, but in most cases this injury should most likely be reinforced by placing a screw or suture tensioning device across the syndesmosis for additional support.A Brostrom or allograft reconstruction is indicated for an ankle sprain involving the ATFL or CFL.Simply excising the fragment will leave the patient with an incompetent syndesmosis. Repairing the SPR with or without a groove deepening procedure is indicated if there is evidence of subluxated or dislocated peroneal tendons, which is not demonstrated on the CT scans. The bone has been avulsed off the fibula by the portion of the AITFL that attaches to the fibula, therefore indicating that there is a syndesmosis injury. Allograft lateral ligament reconstruction and excision of loose body/fracture fragment are incorrect procedures based on location. The deltoid is a medial structure and this fracture is lateral. The ATFL and CFL attach at the inferior margin of the fibula near the lateral process of the talus and calcaneus. A SPR avulsion would present as an avulsion off the lateral wall of the fibula, not superior and not into the syndesmotic space as shown on the CT scans.

Question 67

Figures 15a through 15c show the radiographs of a 23-year-old football player who was injured when another player fell on his flexed and planted foot. He reports severe pain in the midfoot with a feeling of numbness on the dorsum of the foot, and he is unable to bear weight on the limb. Examination reveals mild swelling. Management should consist of

Explanation

DISCUSSION: Myerson and associates studied the outcomes of 19 patients with tarsometatarsal joint injuries during athletic activity. Injuries were classified as first- or second-degree sprains of the tarsometatarsal joint or a third-degree sprain with diastasis between the metatarsals or cuneiforms. Poor functional results were seen in those with a delay in diagnosis and with inadequate treatment. For patients with third-degree sprains, poor results were obtained with nonsurgical management. These patients required open reduction and internal fixation for optimal return to function. The anatomic reduction is critical to the outcome; therefore, open reduction is preferred.
REFERENCES: Baxter DE: The Foot and Ankle in Sport, ed 1. St Louis, MO, Mosby, 1995,

pp 107-123.
Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete. Am J Sports Med 1993;21:497-502.
Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.
Thompson MC, Mormino MA: Injury to the tarsometatarsal joint complex. J Am Acad Orthop Surg 2003;11:260-267.

Question 68

Standard guidelines necessitate the use of intraoperative neurophysiological monitoring for patients undergoing surgery for which condition?

Explanation

DISCUSSION
There are currently no official guidelines on the appropriate use of neuromonitoring in spine surgery. In general, use of neuromonitoring is at surgeon discretion and often is based on the surgeon's perceived risk for neurologic injury during surgery and medicolegal concerns. In most reports,
neuromonitoring is considered useful in cases of deformity correction, spinal cord decompression, instrumentation placement, and revision surgery. However, even for some of these cases, studies have shown limited benefits of neuromonitoring and substantial associated costs.
RECOMMENDED READINGS
Lall RR, Lall RR, Hauptman JS, Munoz C, Cybulski GR, Koski T, Ganju A, Fessler RG, Smith ZA. Intraoperative neurophysiological monitoring in spine surgery: indications, efficacy, and role of the preoperative checklist. Neurosurg Focus. 2012 Nov;33(5):E10. doi: 10.3171/2012.9.FOCUS12235. Review. PubMed PMID: 23116090. View Abstract at PubMed Peeling L, Hentschel S, Fox R, Hall H, Fourney DR. Intraoperative spinal cord and nerve root monitoring: a survey of Canadian spine surgeons. Can J Surg. 2010 Oct;53(5):324-8. PubMed PMID: 20858377. View Abstract at PubMed
Garces J, Berry JF, Valle-Giler EP, Sulaiman WA. Intraoperative neurophysiological monitoring for minimally invasive 1- and 2-level transforaminal lumbar interbody fusion: does it improve patient outcome? Ochsner J. 2014 Spring;14(1):57-61. PubMed PMID: 24688334. View Abstract at PubMed

Question 69

Figures 18a through 18c show injuries sustained by a 22-year-old woman after falling 45 feet while mountain climbing. After being airlifted to the nearest trauma center, her arterial blood gas was 7.21, pO2 84, pCO2 48, and delta base -11 mmol/L. Her Hgb is 8.7 and her resuscitation is ongoing. Based on this data, what would be the best management of her orthopaedic injuries?

Explanation

The patient is under-resuscitated and would benefit from minimally invasive stabilization of the pelvic ring and long bone fractures in a "damage-control" approach. External fixation of the pelvis and femur can be performed quickly and with minimal blood loss which should limit the "second hit" associated with more
prolonged, invasive surgery. Upper extremity fractures are best managed acutely with splints in this clinical setting. Definitive fracture fixation should be delayed until the patient is adequately resuscitated.

Question 70

Figure below shows the abdominal radiograph obtained from a 70-year-old woman who experiences nausea and abdominal tightness 48 hours following left total knee arthroplasty performed under general anesthesia. She received 24 hours of cefazolin antibiotic prophylaxis and a patient-controlled analgesia narcotic pump for pain management. She has been receiving warfarin for thromboembolic prophylaxis. Her severe abdominal distension and markedly decreased bowel sounds are most likely secondary to the administration of

Explanation

DISCUSSION:
The radiograph reveals severe intestinal dilatation, which has occurred as the result of acute colonic pseudo-obstruction and is associated with excessive narcotic administration following total joint arthroplasty. Anesthetic type, antibiotic administration, and warfarin have not been associated with this obstruction. Electrolyte imbalances such as hypokalemia have been associated with postsurgical acute colonic pseudo-obstruction.

Question 71

Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios?

Explanation

DISCUSSION: Rupture of the extensor pollicis longus (EPL) tendon after non operative treatment for a distal radius fracture occurs with a 0.3-3% incidence. The causes of EPL rupture include mechanical irritation, attrition, and vascular impairment leading to delayed rupture. Synovitis of the extensor carpi radialis due to repetitive use may invade the EPL tendon and lead to rupture. Recommended treatment in the pre-rupture setting includs a third dorsal compartment release with or without an extensor retinacular patch graft. Palmaris longus graft or a transfer from the extensor indicis proprius to the EPL tendon are reasonable treatment options. Results of all treatments seem to be
clinically satisfactory.
The referenced article by Gelb is a review of the etiology and treatment of this injury. He reviews the above discussion and findings.

Question 72

The images reveal T2-weighted MRI sequences with edema isolated to the infraspinatus. In the absence of a tear in the infraspinatus tendon, the edema is most likely due to compression of the suprascapular nerve in the spinoglenoid notch. As this pathology persists, progressive muscle atrophy and fatty infiltration can result. Compression of the suprascapular nerve in the suprascapular notch would have resulted in edema and weakness in both the supra- and infraspinatus muscles. Compression is commonly caused by cysts from the joint secondary to labral tears. A rotator cuff tear of the infraspinatus is not identified on these images, and there is no history of trauma provided. There is no evidence of an anteroinferior labral tear, nor would this be expected to result in external rotation weakness or MRI abnormality of the infraspinatus. Quadrilateral space syndrome results in compression of the axillary nerve, which supplies the teres minor. Correcr answer : C

Explanation

Figure 1 is the radiograph of a 12-year-old baseball player who has posterolateral elbow pain with throwing. The area of interest is designated by the black arrow. His range of motion and strength are full. No previous treatment has been provided. What is the most appropriate initial treatment?

Elbow arthroscopy with debridement

Immobilization and rest for 6 weeks

Corticosteroid injection

Open osteochondral autograft transfer

Osteochondritis dissecans of the capitellum is a painful condition that affects immature athletes who undergo repetitive compression of the radiocapitellar joint. Management is based primarily on the integrity of the articular cartilage surface and the stability of the lesion. Nonsurgical treatment is typically selected for patients

with early-grade, stable lesions, and it involves activity modification with cessation of sports participation. The duration of activity modification is dictated by symptoms, with 3 to 6 weeks of rest followed by return to sport in 3 to 6 months commonly used as a guideline. Strengthening and stretching exercises are commonly incorporated after the pain has subsided. Surgical intervention or corticosteroid injection would not be first-line treatment.

Figures 1 and 2 are the radiographs of a 69-year-old man with a history of treated prostate cancer and hemodialysis-dependent end- stage renal disease who presents to the emergency department with progressively worsening right shoulder pain and stiffness. Laboratory tests reveal a white blood cell count of 17,000, erythrocyte sedimentation rate, 75, and CRP, 10.1. He has a draining sinus located along the anterior shoulder. What is the best next step?

Question 73

A decrease in alkaline phosphatase would most likely be manifest in which metabolic disorder?

Explanation

A decrease in tissue non-specific alkaline phosphatase (TNSALP) is found in hypophosphatasia.
TNSALP is found in osteoblasts and hydrolyzes inorganic phosphates, leading to an increase in serum phosphate levels, which helps to maintain physiologic levels. A decrease in this process impairs bone mineralization leading to rickets. In the perinatal period, hypophosphatasia and decreased mineralization leads to caput membraneceum, shortened limbs and respiratory failure. Childhood hypophosphatasia is marked by premature loss of deciduous teeth and rachitic deformities. Adult hypophosphatasia I is characterized by teeth and chest wall deformities (similar to adolescent hypophosphatasia) as well as recurrent metatarsal and femoral stress fractures.
Mornet reviewed hypophosphatasia and the alkaline phosphatase mutations. Screening for the 65 distinct mutation can aid in diagnosis and family counseling in severe forms.
Illustration A shows abnormal dentition found in hypophosphatasia. Illustration B shows widespread rachitic changes characteristic of hypophosphatasia.
Incorrect Answers:

Question 74

What is a risk factor for interdigital neuroma?

Explanation

DISCUSSION
The only proven risk factor for development of an interdigital neuroma is female gender, which likely is related to the use of fashionable shoes that force plantar flexion of the metatarsal heads and secondary hyperdorsiflexion of the metatarsophalangeal joints. The other factors listed have not been proven to cause interdigital neuroma, as well as mediolateral compression of the forefoot.
RECOMMENDED READINGS
Hill KJ. Peripheral nerve disorder. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:307-327.
Schon LC, Mann RA. Diseases of the nerves. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby-Elsevier; 2007:613-686.

Question 75

A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. What is the most common sentinel event related to spine surgery?

Explanation

DISCUSSION: Patient safety and prevention of medical errors is a major focus of recent national advocacy groups. Analysis has shown that the most common sentinel event in spine surgery is surgery on the wrong level. Therefore, it is recommended that every patient have the surgical site signed, the level of surgery marked intraoperatively, and a radiograph taken. Surgery on the wrong level is most likely to occur in single-level decompressive procedures.
REFERENCES: Wong DA, Watters WC III: To err is human: Quality and safety issues in spine care. Spine 2007;32:S2-S8.
Wong DA: Spinal surgery and patient safety: A systems approach. J Am Acad Orthop Surg 2006;14:226-232.

Question 76

A patient sustains a closed dorsal dislocation of the proximal interphalangeal joint of the middle finger without an associated fracture. Closed treatment results in a cocentric stable reduction. The finger is not immobilized. Which of the following conditions may appear 1 year later?

Explanation

Examination of a 3-year-old boy who slammed his finger in a door 3 months ago reveals 0 to 40 degrees of proximal interphalangeal joint motion. Radiographs are shown in Figures 47a and 47b. Management should consist of
Volar osteotomy
Observation only
Flexor tenolysis
Volar plate arthoplasty
A hinged distraction external fixator
Subcondylar fractures of the proximal and middle phalynx occur at the neck of the phalynx, usually as a result of a crush injury, and almost exclusively in the pediatric age group. The distal fragment rotates dorsally and the degree of displacement may be misjudged if a true lateral is not obtained. If malunion occurs there is block to flexion. Subcondylar fossa reconstruction by removal of bone through a palmar approach removes this boney block.

Question 77

Figures 76a and 76b are the sagittal T1-weighted MRI scans of an active 27-year-old man who has had left dominant extremity shoulder pain and weakness for the past 5 months. He denies any history of a precipitating event but recalls that the pain began around the time he started lifting weights after a year off from lifting. Examination reveals full range of active and passive motion, negative Hawkins and Neer impingement signs, 5/5 abduction strength, 5/5 external rotation strength with arm adducted at his side, and a negative belly press, Gerber lift-off, and O'Brien's test. He does have weakness with resisted external rotation with the arm abducted to 90 degrees. Radiographs are unremarkable. An MRI arthrogram shows no rotator cuff tear or labral tears. What is the most likely diagnosis? Review Topic

Explanation

Examination reveals weakness of the teres minor muscle, and the MRI scan shows moderate isolated atrophy of the teres minor muscle belly. This is consistent with quadrilateral space syndrome, which is compression of the axillary nerve and posterior circumflex humeral artery in the quadrilateral space (bounded by the teres minor, teres major, long head of triceps and the humerus). This syndrome has been related to compression of the neurovascular structures by muscle hypertrophy consistent with the patient's history of lifting weights near the onset of symptoms. The next step in confirming the diagnosis is a subclavian arteriogram with the arm in adduction as well as in abduction and external rotation. Suprascapular nerve compression would be manifested by atrophy and weakness of both the supraspinatus and infraspinatus (if occurring at the suprascapular notch) or just infraspinatus (if occurring at the spinoglenoid notch). The patient does not demonstrate signs or symptoms of either impingement syndrome or scapular dyskenisia.

Question 78

Figures below demonstrate the radiographs obtained from a 63-year-old man who had right total hip arthroplasty (THA) 4 months ago. Progressive stiffness began 2 months after surgery, and he now reports pain only after prolonged physical activity. His examination reveals a normal gait and painless range of motion with flexion of 70°, extension of 0°, internal rotation of 20°, external rotation of 20°, abduction of 10°, and adduction of 10°. His erythrocyte sedimentation rate and C-reactive protein level are within defined limits. Physical therapy has produced no benefit. What is the most appropriate next step?

Explanation

This patient presents with HO 4 months after undergoing THA. Symptomatic HO may complicate nearly
7% of primary THA cases. Improvement in pain is expected within 6 months, and most patients will not need surgical treatment. Surgical excision may be warranted for symptomatic patients after full maturation of the HO, usually 6 to 18 months after the surgery. Patients can be followed with repeated serum alkaline phosphatase levels, which are elevated initially and should return to normal upon maturation of the HO. Alternatively, a bone scan can show decreased activity after the HO has matured. Twenty-five milligrams of indomethacin 3 times daily for 6 weeks or 1 dose of irradiation at 700 to 800 Gy is effective in the prevention of HO but not for the treatment of established HO.

Question 79

Figure 22 shows the radiograph of a 7-year-old boy who underwent retrograde elastic nailing of a femoral shaft fracture. What is the most common problem following this procedure?

Explanation

DISCUSSION: Several large clinical studies have shown that the most common problem after elastic nailing of a femoral shaft fracture is persistent pain and irritation at the nail insertion site. Unacceptable shortening and malunion are very rare in a 7-year-old patient. Rotational malalignment also is unusual. Osteonecrosis has been reported in solid antegrade nailing but not with elastic nailing of femoral shaft fractures in skeletally immature patients.
REFERENCES: Flynn JM, Luedtke LM, Ganley TJ, et al: Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. J Bone Joint Surg Am 2004;86:770-777.
Flynn JM, Hresko T, Reynolds RA, et al: Titanium elastic nails for pediatric femur fractures: A multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4-8.
Ligier JN, Metaizeau JP, Prevot J, et al: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-77.

Question 80

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

Explanation

EXPLANATION:
Reduction, either open or closed, with internal fixation (pinning) is the recommended treatment for the majority of these injuries. Closed reduction with pinning is most often performed for acute injuries. Open reduction with pinning is performed for those injuries that cannot be reduced by closed means or those with a delayed presentation. Four cases of successful closed reduction and splinting, all performed upon presentation in the emergency department, have been described by Storken and associates, but the authors note that their review of three prior reports uncovered cases of secondary dislocation, which required surgical stabilization. One of the dislocations occurred 4 months after the reduction. They assert that an indication for primary ORIF is a CMC dislocation associated with major fractures. Primary arthrodesis can be considered in cases with severe intra-articular comminution, but this procedure substantially limits the ability of the hand to increase and decrease the transverse metacarpal arch, which is an important functional movement. It can also lead to osteoarthritis of the triquetrohamate joint. Suspension arthroplasty has been described for old fracture-dislocations of the fifth CMC joint, using a partial slip of the extensor carpi ulnaris.

Question 81

What is the most common complication associated with the treatment of the distal biceps ruptures as shown in Figures 79a and 79b? Review Topic

Explanation

The patient shown underwent distal biceps repair with a button technique. Among the reports in the literature, the most commonly noted complication associated with this technique is lateral antebrachial cutaneous nerve irritation. Re-rupture, radioulnar synostosis, and posterior interosseous nerve injury can occur, but are not as common as lateral antebrachial cutaneous nerve injury.

Question 82

A 32-year-old woman sustained an injury to her left upper extremity in a motor vehicle accident. Examination reveals a 2-cm wound in the mid portion of the dorsal surface of the upper arm and deformities at the elbow and forearm; there are no other injuries. Her vital signs are stable, and she has a base deficit of minus 1 and a lactate level of less than 2. Radiographs are shown in Figures 9a and 9b. In addition to urgent debridement of the humeral shaft fracture, management should include

Explanation

DISCUSSION: With a severe injury to the upper extremity, the best opportunity for achieving a good functional result for a floating elbow is immediate debridement of the open fracture, followed by internal fixation of the fractures. The ability to do this depends on the patient’s physiologic status. In this patient, the procedure is acceptable because she has normal vital signs and no chest or abdominal injuries, and normal physiologic parameters (base excess and lactate) show adequate peripheral perfusion. The surgical approaches will be determined by the associated injury patterns and open wounds. In this patient, the humerus was debrided and stabilized through a posterior approach as was the medial condyle fracture. The ulna was fixed through an extension of the posterior incision and the radius through a separate dorsal approach.
REFERENCES: Solomon HB, Zadnik M, Eglseder WA: A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-570.
Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopedic surgery. J Trauma 2002;53:452-461.

Question 83

A right-handed 20-year-old college baseball pitcher has had a 6-month history of vague right elbow pain while pitching. Examination reveals full flexion of the elbow and a loss of only a few degrees of full extension. The elbow is stable, but palpation reveals tenderness over the olecranon. Plain radiographs are inconclusive. MRI and CT scans are shown in Figures 20a and 20b. Management should consist of

Explanation

DISCUSSION: The patient has a stress fracture of the olecranon that occurs with repetitive throwing motions. If the fracture is not displaced, the initial treatment of choice is rest and rehabilitation to maintain elbow motion, followed by aggressive strengthening at 6 to 8 weeks. A light throwing program generally can begin at 8 to 12 weeks. Complete recovery may require 3 to 6 months. If the fracture is displaced or if nonsurgical management fails, surgery is indicated for internal fixation of the stress fracture.
REFERENCES: Azar FM, Wilk KE: Nonoperative treatment of the elbow in throwers. Oper Tech Sports Med 1996;4:91-99.
Griffin LY (ed): Orthopaedic Knowledge Uupdate: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 191-203.

Question 84

Which of the following pelvic injury types has the highest reported mortality rate?

Explanation

mechanism injuries all have lower mortality rates than APC injuries.

OrthoCash 2020

Question 85

What is the most common mechanism of injury that produces turf toe?

Explanation

DISCUSSION: The most common mechanism of injury for turf toe is a hyperextension injury to the MTP joint. The foot is typically in a dorsiflexed position with the heel raised when an external force drives the MTP joint into further dorsiflexion. The joint capsule usually tears at the metatarsal neck because its attachment is weaker there than at the proximal phalanx. Some compression injuries to the dorsal articular surface of the metatarsal head can result from extension or hyperextension.
REFERENCES: Clanton TO, Ford JJ: Turf toe injury. Clin Sports Med 1994;13:731-741.
Rodeo SA, O’Brien S, Warren RF, et al: Turf toe: An analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med 1990;18:280-285.

Question 86

A 14-year-old girl has had mild pain and nail deformity of the great toe for the past 4 months. A radiograph is shown in Figure 50. What is the most likely etiology of the lesion?

Explanation

DISCUSSION: The lesion is typical of a subungual exostosis, which is most often found on the medial aspect of the great toe in children and young adults. The diagnosis is confirmed on radiographs and usually requires excision for relief.
REFERENCES: Lokiec F, Ezra E, Krasin E, Keret D, Wientraub S: A simple and efficient surgical technique for subungual exostosis. J Pediatr Orthop 2001;21:76-79.
Letts M, Davidson D, Nizalik E: Subungual exostosis: Diagnosis and treatment in children. J Trauma 1998;44:346-349.
Davis DA, Cohen PR: Subungual exostosis: Case report and review of the literature. Pediatr Dermatol 1996;13:212-218.

Question 87

Figure 54 is the lateral radiograph of a 55-year-old man who is evaluated for a 2-year history of pain and stiffness of his right metatarsophalangeal (MTP) joint. Upon examination he has dorsal bossing, severe crepitation, and pain with passive range of motion. There is pain with the "grind" test. Dorsiflexion is limited to 0 degrees. No sesamoid tenderness is present. What is the most appropriate surgical treatment?

Explanation

DISCUSSION
The radiograph reveals end-stage degenerative changes of the first MTP joint with a dorsal loose body. MTP arthritis and decreased joint dorsiflexion is referred to as hallux rigidus. A chevron bunionectomy is used to correct hallux valgus deformity without arthritis. The cheilectomy is used in lesser degrees of joint destruction. Resection of the proximal phalanx results in a floppy toe and is generally not recommended.
RECOMMENDED READINGS
McNeil DS, Baumhauer JF, Glazebrook MA. Evidence-based analysis of the efficacy for operative treatment of hallux rigidus. Foot Ankle Int. 2013 Jan;34(1):15-32. doi: 10.1177/1071100712460220. Review. PubMed PMID: 23386758.
View Abstract at PubMed
Deland JT, Williams BR. Surgical management of hallux rigidus. J Am Acad Orthop Surg. 2012 Jun;20(6):347-58. doi: 10.5435/JAAOS-20-06-347. Review. PubMed PMID: 22661564.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 55 THROUGH 58
Figures 55a and 55b are the anteroposterior and lateral radiographs of a 57-year-old man who fell off of a ladder 10 days ago and landed on his left foot. He is now unable to weight bear on the left. He has no history of trauma to this foot, and his medical history is unremarkable. Upon examination his left foot is swollen and tender. Pulses and sensation are intact.

A B

Question 88

Immobilization with a sling

Explanation

Upon review of the radiograph in fig. 63 it has the appearance of a classic Unicameral Bone Cyst of the proximal humerus of a skeletally immature individual. Also noted is a nondisplaced fracture of proximal humerus through the cyst. The article above gives accepted treatment protocols for unicameral bone cysts:
Radiographically Active Cyst (age 4 to 8 years old with pathologic fracture)
Align and immobilize
Observe for spontaneous healing
Reassess after 2 to 4 months and if recurrent, follow procedure for pathological fracture of radiographically active cysts described in the article above.

Question 89

A previously asymptomatic 14-year-old girl sustained a twisting injury to her ankle. Radiographs are shown in Figures 2a and 2b. Management should consist of

Explanation

DISCUSSION: The radiographs show a well-defined, irregular, eccentric lesion in the distal tibia metaphysis with a thin sclerotic margin. The radiographs are diagnostic of nonossifying fibroma, a common entity in this age group and in this location. No further work-up is indicated. The patient was asymptomatic prior to the injury and the lesion is small and thus not worrisome for an impending pathologic fracture; therefore, no treatment is indicated beyond observation. The natural history of these lesions is to gradually ossify as the patient reaches skeletal maturity.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 69-75.
Biermann JS: Common benign lesions of bone in children and adolescents. J Pediatr Orthop 2002;22:268-273.

Question 90

A 70-year-old man has worn through his metal-backed patellar component and sustained damage to the femoral component. Following removal of the components and debridement of the metal-stained synovium, the surgeon finds that the thickness of the remaining patella is 10 mm. Treatment should now include

Explanation

DISCUSSION: Revision of a failed patellar component can be difficult because of bone loss and damage to the extensor mechanism. Several authors have advised against reinsertion of a patellar component if the residual patellar thickness is 10 mm or less. Leaving an unresurfaced bony remnant in place at the time of revision or reimplantation surgery has been shown to be a reasonable option; however, the results are of a lower quality when compared with revision surgery where the patellar component can be retained or revised. The other treatment options have not been shown to be effective approaches to this problem.
REFERENCES: Rand JA: The patellofemoral joint in total knee arthroplasty. J Bone Joint Surg Am 1994;76:612-620.
Pagnano MW, Scuderi GR, Insall JN: Patellar component resection in revision and reimplantation total knee arthroplasty. Clin Orthop 1998;356:134-138.
Barrack RL, Matzkin E, Ingraham R, Engh G, Rorabeck C: Revision knee arthroplasty with patella replacement versus bony shell. Clin Orthop 1998;356:139-143.

Question 91

In a postganglionic brachial plexus lesion at Erb’s point (point of formation of the upper trunk by the C5 and C6 nerve roots), which of the following nerves will still function normally?

Explanation

DISCUSSION: In a postganglionic injury to the brachial plexus, the rhomboid muscle, innervated by the dorsal scapular nerve, would still be expected to function. This is a useful clinical sign that the brachial plexus lesion is postganglionic as opposed to preganlionic. The musculocutaneous, axillary, and suprascapular nerves are all located distal to Erb’s point (the most common location of an upper nerve root brachial plexus injury), and all contain fibers from the C5 and C6 nerve roots. Therefore, these nerves are not expected to function normally following a postganglionic C5 and C6 nerve root injury.
REFERENCES: Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System: Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy, 1991, vol 8, pp 28-29.
Zimmerman NB, Weiland AJ: Assessment and monitoring of brachial plexus injury in the adult, in Gelberman RH (ed): Operative Nerve Repair and Reconstruction. Philadelphia, PA,

JB Lippincott, 1991, vol 2, pp 1273-1283.

Question 92

A prospective randomized trial is conducted to test the efficacy of Vitamin C versus placebo in treating patients who develop chronic regional pain syndrome (CRPS) after distal radius fractures. At first follow-up, the rates of CRPS are 1% and 9% in the study and placebo group, respectively. Which statistical test is most appropriate to determine significance?

Explanation

In the study provided, we need to determine whether distributions of categorical variables differ from one another. The appropriate study is the chi-square test.
Data can be classified as numerical (continuous) or categorical (proportional). Responses to such questions as "What is your major?" or Do you own a car?" are categorical because they yield data such as "biology" or "no." In contrast, responses to such questions as "How tall are you?" or "What is your G.P.A.?" are numerical. When comparing two independent means from numeric data, a t-test is performed. However, if categorical data is being compared, the chi-square test will determine if the proportions are really different.
Kocher et al. review basic clinical epidemiology and biostatistics relevant to orthopaedic surgery. Amongst other things, they describe that data can be summarized in terms of measures of central tendency, such as mean, median, and mode, and in
terms of measures of dispersion, such as range, standard deviation, and percentiles. Illustration A shows an algorithm for determining which test to use for varying data.
Incorrect Answers:

Question 93

Which of the following changes occur in the spinal cord and the spinal canal when the cervical spine moves from neutral to full flexion?

Explanation

DISCUSSION: The spinal cord and spinal canal undergo dynamic changes during neck flexion and extension. In neck flexion, the spinal cord initially unfolds and then undergoes elastic deformation with full flexion; the spinal canal lengthens. This may explain the presence of Lhermitte’s sign as the cord is pulled anteriorly over an anterior osteophyte or disk, generating a compressive force on the spinal cord. During neck extension, the spinal cord relaxes (folding like an accordion) and the spinal canal shortens.
REFERENCES: Breig A: Biomechanics of the Central Nervous System: Some Basic Normal and Pathologic Phenomena. Stockholm, Sweden, Almquist and Wiksell, 1960.
Ghanayem AJ, Zdeblick TA, Panjabi MM: Biomechanics of nonacute cervical spine trauma, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 103-105.

Question 94

Which of the following characteristics is seen in patients with osteochondritis dissecans of the elbow? Review Topic

Explanation

Osteochondritis dissecans occurs in the older child or adolescent (typically older than age 13 years). It involves the lateral compartment. The etiology is felt to be microtraumatic vascular insufficiency from repetitive rotatory and compressive forces. MRI typically shows separation of cartilage from the capitellum and chondral fissuring. Panner’s disease is usually seen in children younger than age 10 years, involves the entire capitellar ossific nucleus, and resolves typically with no residual deformity or late sequelae. There is no evidence of ligamentous injury.

Question 95

A 25-year-old man sustains a left brachial plexus injury from a fall while rock climbing. Examination reveals poor intrinsic function of the hand, ptosis, and miosis. He is able to abduct and forward flex his shoulder with full strength. This combination of physical findings is most suggestive of what pattern of nerve injury?

Explanation

EXPLANATION:
A preganglionic lesion occurs proximal to the spinal foramen, whereas a postganglionic lesion occurs distal to the spinal foramen in the root, trunk, division, cord, or branches of the brachial plexus. The Horner sign, which is characterized by miosis, ptosis, anhydrosis, and enophthalmos, results from an injury to the sympathetic ganglion, which lies in close proximity to the T1 root level. The presence of a Horner sign is highly suggestive of a T1 preganglionic injury. Other physical examination indicators of a preganglionic injury include atrophy of the parascapular muscles (injury to the dorsal rami of the cervical spinal nerve roots), winged scapula (injury to the long thoracic nerve) and hemidiaphragmatic paralysis (phrenic nerve injury). The lack of intrinsic hand function in this patient is also suggestive of an injury at the level of C8-T1. Preservation of shoulder abduction and forward flexion would not typically be seen with an injury to the C5-C6 roots or the upper trunk.

Question 96

important in patients with renal impairment, which is not typically seen in SCT.

Explanation

This is prospective cohort study with Level-II evidence.
Level of evidence provides guidance to the study quality. It is used to assess therapeutic studies (as with this question), prognostic studies, diagnostic studies and economic or decision models. When determining the level of evidence, readers must critically appraise the study question, treatment, intervention and outcomes of the study design. Level-II therapeutic studies consist of well-designed prospective cohort studies, poor-quality randomized controlled trials (follow-up less than 80%) and systematic review of Level-II studies or non-homogenous Level-I studies.
Wright et al. provided an excellent summary of clinical research study level of evidence. This has been provided as Illustration A.
Illustration A shows a chart of level of evidence. There is a column for each type of study which corresponds to a row that outlines the level of evidence based on study
design.
Incorrect Answers:
Low serum phosphate and normal calcium levels are found in what common etiology of hereditary rickets?
X-linked hypophosphatemic
Vitamin D-dependent, type I
Vitamin D-dependent, type II
Autosomal dominant hypophosphatemic
Jansen's metaphyseal chondrodysplasia
Low serum phosphate and normal calcium levels are found in X-linked hypophosphatemic rickets.
X-linked hypophosphatemic rickets is the most common form of hereditary rickets. It is an X-linked dominant disorder which has been linked to the PHEX gene. Laboratory findings
of this disorder include low serum phosphate, normal serum calcium and 25 hydroxycholecalciferol levels, and inappropriately low 1,25-dihydroxyvitamin D3.
Carpenter et al. showed hypophosphatemic rickets was initially referred to as “vitamin D resistant rickets” due to its lack of response to therapeutic vitamin D. Current treatment with activated vitamin D metabolites (calcitriol or
alfacalcidol) and phosphate salts have been shown to help with this condition.
Illustration A shows an insufficiency fracture of the proximal tibia in an adult patient with X-linked hypophosphatemic rickets. A stress fracture on the medial tibia may be a presenting feature of untreated disease.
Incorrect Answers:
receptor (PTHR1).
A healthy patient undergoes routine pre-operative laboratory testing and is found to have a leukocyte count of 1.5 × 10(9) cells/L. When the historical records are examined, this is found to be the patients base-line level over a period of years. Which of the following statements is most likely to be true:
The patient is at a significantly higher risk of surgical infection
The patient is more likely to be of African than of European descent
The patient is more likely to be of European than of Middle Eastern descent
The patient is more likely to be a non-athlete than an athlete
The patient is more likely to be female than male
The clinical presentation is consistent with Benign Ethnic Neutropenia, a condition in which a patient has chronic, benign, inborn and lifelong absolute neutrophl count below population mean. This condition is found in the U.S. to be most common in African- Americans, some groups of Middle Eastern patients, males, children under 5 years old, and athletes compared to non- athletes.
A standardized level at present for abnormally low absolute neutrophil count (ANC) is below 1.5 x 10(9) cells/L, however this may not have clinical or scientific relevance as a cutoff point, particularly in the affected Ethnic groups. Fewer than 1% of all populations have absolute neutrophil count < 1.0 X 10(9) cells/L. Most patients in the affected ethnic groups with low ANC and no associated history or symptoms are not expected to have any increased risk of infection or adverse effect. Smoking was also associated with higher leukocyte and neutrophil counts but proportionately lower increase in African-American patients. One hypothesis for the increased prevalence of B.E.N. in patients of African descent is a theorized evolutionary protection against malaria, though
it remains unclear if this is causal or just correlative.
Haddy et al. provide an excellent scientific review of B.E.N. and emphasize the importance of recognizing this most common form of neutropenia.
Eichner et al. review B.E.N. in the setting of sports medicine and state the relative increase of these lab findings in athletes vs non-athletes.
Hsieh et al. provide an extensive cross-sectional population study focused on the prevalence of Benign Ethnic Neutropenia in the U.S. They reviewed 25,222 participants in the National Health and Nutrition Examination Survey 1yr of
age or older from 1999-2004, and detail the association of this condition with age, sex, ethnicity, and smoking status.
Denic et al. analyzed neutrophil count in a healthy Arab population in the U.A.E. and found low neutrophil counts in this population with a distribution suggestive, but not definitively, of an autosomal dominant inheritance. They also discuss the hypothesized association of B.E.N. and malaria infection.
Incorrect answers:

Question 97

The arrow in Figure 11 points toward a finding consistent with which of the following?

Explanation

DISCUSSION: The finding of a unilateral absent pedicle is often referred to as a winking owl sign and is a manifestation of pedicle destruction from metastatic disease. As the vertebral body is destroyed from the neoplastic process, it extends into the pedicle and destroys the cortical rim that normally creates the oval ring of the pedicle on an AP image.
REFERENCES: McLain R, Weinstein J (eds): Rothman-Simeone: The Spine, ed 4. Philadelphia, PA, WB Saunders, 1999, p 1173.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 674.

Question 98

What molecules have been shown to promote fibrosis during muscle injury?

Explanation

A muscle's response to injury can be divided into 4 phases: necrosis, inflammation, repair, and fibrosis. Necrosis involves the degeneration of the muscle fibrils and death. The inflammatory cells then phagocytose the debris and secrete cytokines that promote vascularity. Muscle regeneration does not occur until phagocytic cells remove the debris. Consequently, anti-inflammatory drugs may have negative effects on muscle healing by inhibiting macrophage-induced phagocytosis. Muscle fibrosis occurs at the same time as muscle regeneration and has been shown to involve TGF-ß1. IGF-1 and bFGF are important trophic factors in muscle regeneration. Bone morphogenetic protein has several functions including bone and cartilage regeneration.

Question 99

A 78-year-old woman undergoes an uneventful semiconstrained total elbow arthroplasty through a Bryan-Morrey approach. Her immediate postoperative management should include which of the following? Review Topic

Explanation

Postoperative management of total elbow arthroplasty patients is directed to avoidance of complications commonly associated with this procedure. Following total elbow arthroplasty, 24 hours of perioperative antibiotics should be given, consistent with other arthroplasty procedures. Because of the relatively thin soft-tissue envelope surrounding the elbow, particularly in patients with rheumatoid arthritis, consideration must be given to the surrounding soft tissues postoperatively. The surgical wound should be given several days of quiescence prior to initiation of motion to minimize wound healing complications. Splinting at 60 to 90 degrees allows tension to be removed from the soft tissues. Immediate motion places these tissues under immediate stress; immobilization of the elbow for 6 to 8 weeks until the triceps has healed would result in significant stiffness. Splinting should not be used more than 10 days to avoid stiffness of the elbow.

Question 100

A 13-year-old gymnast has had recurrent right elbow pain for the past year. She denies any history of trauma. Rest and anti-inflammatory drugs have failed to provide relief. Examination reveals no localized tenderness and only slight loss of both flexion and extension (10 degrees). What is the most likely diagnosis?

Explanation

DISCUSSION: Osteochondritis of the capitellum is characterized by pain, swelling, and limited motion. Catching, clicking, and giving way also can occur. It commonly affects athletes who participate in competitive sports with high stresses, such as pitching or gymnastics.
REFERENCES: Krijnen MR, Lim L, Willems WJ: Arthoscopic treatment of osteochondritis dissecans of the capitellum: Report of 5 female athletes. Arthroscopy 2003;19:210-214.
Schenck RC, Goodnight JM: Osteochondritis dissecans. J Bone Joint Surg Am 1996;3:439-456.

Full Question & Answer Text (for Search Engines)

Question 1:

Treatment of an atrophic nonunion of the radial diaphysis should include which of the following?

Options:

Ilizarov fixation
Electrical stimulation
Ultrasound bone stimulator
Plate exchange with autogenous cancellous grafting
Plate exchange with ulnar shortening osteotomy

Correct Answer: Ilizarov fixation

Explanation:

Question 2:

Figure 52 shows the MRI scan of a 28-year-old baseball pitcher. Examination will most likely reveal which of the following findings?

Options:

Weakness of the deltoid
Numbness in the C7 dermatomal distribution
Winging of the scapula
A positive lift-off test
Clinical findings similar to a large rotator cuff tear

Correct Answer: Clinical findings similar to a large rotator cuff tear

Explanation:

Question 3:

A 22-year-old woman injured her ankle when she fell off a ladder. Radiographs reveal a displaced large posterior malleolus fracture of about 45% of the joint. What is the best definitive treatment?

Options:

Open reduction and internal fixation with absolute stability
Open reduction and internal fixation with relative stability
Closed reduction with casting
Reamed locked intramedullary nailing
External fixation

Correct Answer: Open reduction and internal fixation with absolute stability

Explanation:

Basic understanding of fracture care requires a fundamental knowledge of the principles regarding absolute and relative stability. Compression plating and anatomic reduction of articular fractures are examples of absolute stability. Bridge plating, external fixation, casting, and intramedullary nailing are all examples of relative stability. Both bone forearm fractures have long been treated with open reduction and internal fixation even in the light of open wounds. Results have been excellent with plate fixation. Recently, intramedullary nails that are contoured and locked have been used in the treatment of both bone forearm fractures, but they are not reamed. It is well established that with restoring the proper radial bow, length, and alignment,
optimal function can be achieved. Open reduction and internal fixation allows this achievement. In cases where comminution exists, absolute stability may have to be sacrificed so as to not strip small comminuted bone fragments. Therefore, a bridging technique is worthwhile. External fixation can be used as a temporary technique until the soft tissues are more amenable to definitive fixation. Cast treatment is not indicated in adult forearm fractures. Locking nails for forearm use are not reamed. With regards to articular fractures, anatomic reduction and rigid stabilization are required to achieve the best results and allow for fracture healing. This environment also allows for the best chance of the cartilage repair process to form "hyaline-like" cartilage. Open reduction and internal fixation with absolute stability is the mainstay of treatment for partial articular fractures such as split depression tibial plateau fractures and posterior malleolus fractures involving greater than about 25% to 30% of the joint. The gold standard for the treatment of a closed femur fracture is a reamed intramedullary locked nail. Results are uniformly excellent. This can be done without stripping of the soft tissues such as in open reduction and internal fixation. External fixation can be used as a temporary device in patients in extremis for damage control reasons.Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am. 1986 Sep;68(7):1008-17.
http://www.ncbi.nlm.nih.gov/pubmed/3745238')">View Abstract at PubMedJones DB Jr, Kakar S. Adult diaphyseal forearm fractures: intramedullary nail versus plate fixation. J Hand Surg Am. 2011 Jul;36(7):1216-9. Epub 2011 May

Question 4:

The need for postoperative allogeneic blood transfusions after total hip arthroplasty has been shown to be reduced when using

Options:

cementless fixation.
suction drains.
general anesthesia.
preoperative erythropoietin injections.
low-molecular-weight heparin.

Correct Answer: preoperative erythropoietin injections.

Explanation:

DISCUSSION: In a prospective study, 216 patients were randomized into three groups consisting of low-dose preoperative erythropoietin, high-dose preoperative erythropoietin, and placebo control. All patients were treated for 4 weeks prior to total hip arthroplasty. Both the low- and high-dose erythropoietin groups had a significantly lower rate of blood transfusions
(p < 0.001) after surgery.
REFERENCES: Waddell JP: Evidence-based orthopedics. J Bone Joint Surg Am 2001;83:788.
Feagan BG, Wang CJ, Kirkley A, et al: Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty: A randomized, controlled, trial. Ann Intern Med 2000;133:845-854.

Question 5:

Options:

Macrophages
Osteoclasts
Osteoblasts
Monocytes
Histiocytes

Correct Answer: Osteoblasts

Explanation:

Question 6:

Which of the following nerves is most commonly injured during ankle arthroscopy?

Options:

Sural
Deep peroneal
Saphenous
Superficial peroneal
Posterior tibial

Correct Answer: Superficial peroneal

Explanation:

Question 7:

Options:

Type of surgery, age, and BMI
Type of surgery, hypercholesterolemia, and age
Age, BMI, and hypercholesterolemia
BMI, type of surgery, and hypercholesterolemia

Correct Answer: Type of surgery, age, and BMI

Explanation:

Question 8:

Which of the following conditions is associated with palmoplantar pustulosis?

Options:

Condensing osteitis
Sternoclavicular hyperostosis
Friedreich’s disease
Scleroderma
Reiter syndrome

Correct Answer: Sternoclavicular hyperostosis

Explanation:

DISCUSSION: Sternoclavicular hyperotosis is a seronegative and HLA-B27 negative rheumatic disease. In this condition, hyperostosis may appear in the spine, long bones, sacroiliac joints, and the sternoclavicular region. This entity is also associated with palmoplantar pustulosis.
REFERENCES: Wirth MA, Rockwood CA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,
WB Saunders, 2004, vol 2, pp 608-609.
Sonozaki H, Azuma A, Okai K, et al: Clinical features of 22 cases with inter-sterno-costo-clavicular ossification: A new rheumatic syndrome. Arch Orthop Trauma Surg 1979;95:13-22.

Question 9:

Options:

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

Correct Answer: Amoxicillin will allow faster return to play

Explanation:

Question 10:

What vessel is marked with an asterisk in Figure 44?

Options:

Obturator artery
Inferior epigastric artery
Superior gluteal artery
Internal pudendal artery
Lateral sacral artery

Correct Answer: Superior gluteal artery

Explanation:

DISCUSSION: The superior gluteal artery is a branch of the posterior division of the internal iliac artery and exits the pelvis through the greater sciatic notch. It can be injured as a result of a pelvic ring fracture or acetabular fracture that has a fracture of the posterior column.
REFERENCES: Agur AM, Dalley AF (eds): Grant’s Atlas of Anatomy, ed 12. Philadelphia, PA, Lippincott Williams and Wilkins, 2008.
Uflacker R: Atlas of Vascular Anatomy: An Angiographic Approach, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2006.

Question 11:

Options:

Selective nerve root blocks
Electromyography and a nerve conduction velocity study of the lower extremities
Ankle-brachial index (ABI)
Bilateral hip radiographs
Post-myelography CT scan

Correct Answer: Ankle-brachial index (ABI)

Explanation:

Question 12:

Options:

cessation of physical therapy and acceptance of the limited range of motion.
additional physical therapy for 3 to 4 months.
arthroscopic capsular release.
open release with Z-plasty lengthening of the subscapularis tendon.
closed manipulation under anesthesia.

Correct Answer: arthroscopic capsular release.

Explanation:

Question 13:

Options:

talectomy.
reimplantation of the talus.
reimplantation of the talus with acute triple arthrodesis.
Syme amputation.
transtibial amputation.

Correct Answer: reimplantation of the talus.

Explanation:

DISCUSSION: The radiograph shows a complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful, and provides for flexibility with any future reconstructive procedures.
REFERENCES: Smith CS, Nork SE, Sangeorzan BJ: The extruded talus: Results of reimplantation. J Bone Joint Surg Am 2006;88:2418-2424.
Brewster NT, Maffulli N: Reimplantation of the totally extruded talus. J Orthop Trauma 1997;11:42-45.

Question 14:

Options:

Partial weight bearing in a walking cast for an additional 6 weeks
Open reduction and internal fixation
Open reduction and internal fixation with autologous bone grafting
No treatment
Non-weight-bearing in a cast for an additional 6 weeks

Correct Answer: Open reduction and internal fixation with autologous bone grafting

Explanation:

Question 15:

Options:

Ascending branch of the lateral femoral circumflex
Superior gluteal
Femoral
Profunda femoris
Medial femoral circumflex

Correct Answer: Ascending branch of the lateral femoral circumflex

Explanation:

DISCUSSION: The ascending branch of the lateral femoral circumflex artery crosses the gap between the tensor fascia lata and the sartorious and must be identified and ligated or coagulated. The other vessels are out of the field of dissection.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 312.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 304.

Question 16:

In an effort to reduce costs, a limited MRI sequence is planned to detect a possible occult hip fracture. What is the anticipated fracture signal?

Options:

Bright on T 1 and T 2
Dark on T 1 and T 2
Dark on T 1 , bright on T 2
Bright on T 1 , dark on T 2
Enhancement by gadolinium

Correct Answer: Dark on T 1 , bright on T 2

Explanation:

DISCUSSION: At present, radiologists perform multiple MRI images to rule out all possible diagnoses. The ability to specify the anticipated changes on MRI should become more important as a means of reducing costs. MRI is sensitive to changes in free water (or hemorrhage) and thus this will appear dark on T
1
and bright on T
2
.
REFERENCES: Miller MD: Review of Orthopaedics, ed 3. Philadelphia PA, WB Saunders, 2000, p 116.
Guanche CA, Kozin SH, Levy AS, et al: The use of MRI in the diagnosis of occult hip fractures in the elderly: A preliminary review. Orthopedics 1994;17:327-330.

Question 17:

Options:

Pectoralis major tendon rupture
Supraspinatus rupture
Subscapularis rupture
Bankart tear
Humeral avulsion of the inferior glenohumeral ligament

Correct Answer: Subscapularis rupture

Explanation:

DISCUSSION: The MRI scan shows detachment of the subscapularis from its insertion on the lesser tuberosity. The examination finding is consistent with a positive lift-off test, also indicating a tear of the subscapularis.
REFERENCES: Lyons RP, Green A: Subscapularis tendon tears. J Am Acad Orthop Surg 2005;13:353-363.
Warner JJ, Higgins L, Parsons IM, et al: Diagnosis and treatment of anterosuperior rotator cuff tears. J Shoulder Elbow Surg 2001;10:37-46.

Question 18:

When do most symptomatic thromboembolic events occur after total joint arthroplasty?

Options:

On the day of surgery
Within the first week after surgery
Between 1 week and 6 weeks after surgery
More than 3 months after surgery

Correct Answer: Between 1 week and 6 weeks after surgery

Explanation:

Question 19:

..Staging studies show no other lesions and surgical treatment is planned; when should a biopsy be performed?

Options:

Before surgery
Intraoperatively after instrumentation
After surgery (reamings/curettings sent)
No biopsy is needed DISCUSSION… Patients with a metastatic lung carcinoma are best staged and imaged with a PET scan. Although many tumors are clinically evaluated with PET scans, metastatic lung cancer is one of the few “approved” indications for PET imaging. This imaging modality is sensitive for delineating the extent of disease and helpful for identifying areas that may also be at risk for pathologic fracture. Stabilization of painful, lytic lesions in weight-bearing bones is recommended to prevent pathologic fracture. Stabilization of an impending pathologic fracture is generally easier than stabilization of a pathologic fracture; once the patient in this vignette sustains a fracture, resection and reconstruction is indicated because stabilization alone is unlikely to heal and poses high risk for failure. In cases of extreme bone loss, especially in the epiphyseal region, reconstruction with tumor megaprostheses is desirable to avoid mechanical failure of additional internal fixation. Patients with widely metastatic disease may not be able to use ambulatory assistance aids effectively, placing traditional internal fixation at risk for failure. Use of megaprostheses obviates the need for adjuvant therapies to correct the loss of bone stock. Radiation therapy alone to lesions that are radiosensitive is effective but does not alleviate the risk for pathologic fracture. Chemotherapy alone is insufficient treatment for bone metastases. Hormonal therapy is acceptable for treatment of hormone-sensitive tumors; however, is not sufficient treatment for an impending pathologic fracture. For patients with remote diagnoses of carcinoma, biopsy of new-onset presumed metastases is mandatory to avoid an incorrect treatment regimen being employed. Patients can develop a secondary malignancy or infection, both of which will require a different treatment regimen. Biopsy should be done and diagnosis established either preoperatively or intraoperatively prior to instrumentation (with frozen section analysis) to avoid contamination of the femoral canal and soft-tissue envelope. Sending a specimen after instrumenting the femur or after surgery contaminates the femur if a sarcoma is diagnosed and lessens the likelihood of limb salvage.

Correct Answer: Before surgery

Explanation:

Question 20:

What are the optimal conditions for leaving the acetabular shell in place, replacing the acetabular liner, and grafting the osteolytic defect shown in Figure 39?

Options:

Nonmodular implant
Instability
Well-designed, well-fixed modular implant
Complete radiolucency of the acetabular component
Migration of the acetabular component

Correct Answer: Well-designed, well-fixed modular implant

Explanation:

DISCUSSION: Dense pods of ingrowth into the porous coating of cementless ingrowth sockets are seen. Channels through the non-ingrown portion allow access to the trabecular bone of the ilium. Polyethylene wear debris can enter these areas through screw holes. Expansile, lytic lesions can result, which can become large without compromising implant fixation. Loosening is late and results from catastrophic loss of bone. A well-fixed acetabular component with a modular design, a well-designed locking mechanism, and a good survivorship history is a candidate for exchange of the liner and grafting of the osteolytic lesion.
REFERENCES: Ries MD: Complications in primary total hip arthroplasty: Avoidance and management. Wear. Instr Course Lect 2003;52:257-265.
Dumbleton JH, Manley MT, Edidin AA: A literature review of the association between wear rate and osteolysis in total hip arthroplasty. J Arthroplasty 2002;17:649-661.
Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 175-180.

Question 21:

Options:

Acetabular revision, with placement of a custom triflange acetabular component and femoral head exchange
Removal of the femoral and acetabular components and placement of an antibiotic spacer, with 6 weeks of intravenous antibiotics
Head and liner exchange and retention of the femoral and acetabular implants with acetabular bone grafting
Nonsurgical management with the initiation of bisphosphonates and referral to pain management

Correct Answer: Acetabular revision, with placement of a custom triflange acetabular component and femoral head exchange

Explanation:

Question 22:

At which joint do degenerative changes occur first in a patient with chronic, untreated scapholunate dissociation?

Options:

Radioscaphoid
Radiolunate
Scapholunate
Capitolunate

Correct Answer: Radioscaphoid

Explanation:

EXPLANATION:
Stage I of scapholunate advanced collapse (SLAC) is characterized by the presence of radioscaphoid arthritis. A predictable pattern exists of the progression of degenerative changes for SLAC wrist, including stage I (radial styloid involvement at the scaphoid fossa), stage II (scaphoid and entire scaphoid facet involvement), stage III (degeneration between the capitate and lunate), and stage IV (pancarpal
involvement). The radiolunate joint is often spared.

Question 23:

What approach should be chosen for the injury seen in Figure 67? Review Topic

Options:

Stoppa
Hardinge
Ilioinguinal
Watson Jones
Kocher-Langenbeck

Correct Answer: Kocher-Langenbeck

Explanation:

Question 24:

Which of the following procedures is considered most appropriate in patients with rheumatoid arthritis?

Options:

Hip arthrodesis
Osteotomy of the hip
Core decompression of the hip
Synovectomy of the knee
Unicondylar knee arthroplasty

Correct Answer: Synovectomy of the knee

Explanation:

Question 25:

Options:

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

Correct Answer: Revision of the acetabular and femoral implants

Explanation:

Question 26:

Figure 8a shows the clinical photograph of an 83-year-old woman who has an enlarging left forearm mass. MRI scans are shown in Figures 8b and 8c. What is the next most appropriate step in management?

Options:

Radiation therapy
Needle biopsy
Marginal resection
Chemotherapy
Amputation

Correct Answer: Needle biopsy

Explanation:

DISCUSSION: Any large (greater than 5 cm), deep, heterogeneous mass in the extremities should be considered a sarcoma until proven otherwise. Sarcomas are rare, and without a high index of suspicion, the lesions may be misdiagnosed or there may be a delay in diagnosis. Needle biopsies can obtain sufficient tissue for diagnosis and are associated with less morbidity than open biopsy. Marginal resections or excisional biopsies should be reserved for a few select benign lesions and locations.
REFERENCES: Damron TA, Beauchamp CP, Rougraff BT, et al: Soft-tissue lumps and bumps. Instr Course Lect 2004;53:625-637.
Sim FH, Frassica FJ, Frassica DA: Soft-tissue tumors: Diagnosis, evaluation, and management. J Am Acad Orthop Surg 1994;2:202-211.

Question 27:

Which of following is pathognomonic of intervertebral disk degeneration? Review Topic

Options:

Increased water content in the nucleus pulposus
Loss of Type X collagen in the nucleus pulposus
Decreased thickness of the inner annulus fibers
Degradation of large proteoglycans molecules in the nucleus pulposus
Annular tears and fissuring occurring most frequently in the central disc

Correct Answer: Loss of Type X collagen in the nucleus pulposus

Explanation:

Question 28:

Options:

Continued observation
Cervical epidural injections
Nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, and physical therapy
Cervical facet blocks
Cervical MRI

Correct Answer: Nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, and physical therapy

Explanation:

Question 29:

Options:

Plastizote orthotics with a metatarsal pad and a cutout under the fifth metatarsal head
Hyperbaric oxygen and prolonged non-weight-bearing
A healing shoe that completely alleviates any weight bearing on the forefoot
A gastrocnemius release and supportive wound care
A transmetatarsal amputation

Correct Answer: A gastrocnemius release and supportive wound care

Explanation:

DISCUSSION: The patient likely has a significant Achilles contracture that causes her to always bear more weight on her forefoot. A gastrocnemius recession takes the ankle out of plantar flexion and she will be able to return to a normal gait and reduce the pressures on her forefoot. A forefoot amputation is a salvage option. The other choices are appropriate; however, the patient has had this problem for 2 years and she has already had multiple attempts at shoe wear modification.
REFERENCES: Laughlin RT, Calhoun JH, Mader JT: The diabetic foot. J Am Acad Orthop Surg 1995;3:218-225.
Aronow MS, Diaz-Doran V, Sullivan RJ, et al: The effect of triceps surae contracture force on plantar foot pressure distribution. Foot Ankle Int 2006;27:43-52.

Question 30:

Which of the following factors is associated with the highest rate of nonunion of a midshaft clavicle fracture?

Options:

younger patients
female gender
simple fracture pattern
sling immobilization
early range-of-motion

Correct Answer: younger patients

Explanation:

Question 31:

Options:

Anterior glenoid rim fracture tear
Anterior inferior labral tear
Posterior labral tear
Total capsular laxity
Osteochondral defect of the humeral head

Correct Answer: Posterior labral tear

Explanation:

DISCUSSION: Traumatic posterior instability is a common finding in football players, especially in the blocking positions as well as in the defensive linemen and linebackers.
A traumatic blow to the outstretched arm results in posterior glenohumeral forces. Labral detachment at the glenoid rim is common. Patients report slipping or pain with posteriorly directed pressure. Rarely do these patients have true dislocations that require reduction; however, recurrent episodes of subluxation or pain are not uncommon. Posterior repair has
been shown to be successful in the treatment of traumatic instability.
REFERENCES: Bottoni CR, Franks BR, Moore JH, et al: Operative stabilization of posterior shoulder instability. Am J Sports Med 2005;33:996-1002.
Williams RJ III, Strickland S, Cohen M, et al: Arthroscopic repair for traumatic posterior shoulder instability. Am J Sports Med 2003;31:203-209.
Kim SH, Ha KI, Park JH, et al: Arthroscopic posterior labral repair and capsular shift for traumatic unidirectional recurrent posterior subluxation of the shoulder. J Bone Joint Surg Am 2003;85:1479-1487.

Question 32:

Options:

Numbness over dorsal aspect of the foot, weakness to gluteus medius
Numbness over plantar foot, weakness to his gastrocsoleus complex
Numbness over medial malleolus, and weakness to quadriceps
Numbness over medial calf, weakness in his EHL
Numbness over lateral malleolus, weakness to hip adduction

Correct Answer: Numbness over medial calf, weakness in his EHL

Explanation:

The MRI demonstrates a left paracentral L4/5 disc protrusion which leads to compression of the traversing (descending) left L5 nerve root. Numbness over the dorsal aspect of the foot and weakness to gluteus medius is consistent with a L5
radiculopathy.
While nerve root innervation shows some variability by patient, L5 is "characteristically" responsible for the sensation to the dorsal aspect of the foot, ankle dorsiflexion (tibialis anterior - along with L4), great toe extension (EHL), and hip abduction (gluteus medius).
Suri et al. reported on specific physical exam findings that significantly increased the likelihood of nerve root impingement at specific lumbar levels. They found: L2 was associated with decreased anterior thigh sensation. L3 was associated with a positive femoral stretch test. L4 was associated with a blunted patellar reflex, decreased medial ankle sensation or a positive crossed femoral stretch test. L5 was associated with was associated with decreased hip abductor strength.
Luri et al. reported 8-year follow up on the patients in the spine patient outcomes research trial who underwent surgical vs. conservative care for treatment of lumbar herniated disc. They found that patients who underwent surgical treatment had superior results that were maintained at 8 years compared to patients who underwent conservative management.
Figure A is an axial MRI at the L4/5 disc space that shows a left paracentral disc herniation compressing the descending L5 nerve root. Illustration A identifies the structures in the MRI image. Illustration B demonstrates the dermatome, reflex and motor function associated with the L4, L5 and S1 nerve root.
Incorrect Answers:
(SBQ13PE.102) An 26-year-old male presents to your office complaining of bilateral hip and low back pain. On physical examination, he has 10 degree bilateral hip flexion contractures. An AP pelvis radiograph is demonstrated in figure A. Which of the following findings is consistent with this patient's presentation?
Review Topic
A positive flexion, adduction, internal rotation (FADDIR) test
A history of untreated slipped capital femoral epiphysis (SCFE)
A thrombophilia
Normal serum ESR and CRP
Positive Human Leukocyte Antigen B27 (HLA-B27)
The patient has large joint arthralgia and sacroiliac joint sclerosis on AP pelvis radiograph, which is consistent with ankylosing spondylitis. Patients with ankylosing spondylitis have positive Human Leukocyte Antigen B27 (HLA-B27).
Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy that affects the axial skeleton as well as large joints including the hips and knees. The most common initial site of pain is the sacroiliac (SI) joint, and is demonstrated as sacroiliitis on pelvic radiograph. Hip involvement is common, and typically manifests as hip pain and flexion contracture. Serologic studies will be typically be negative for rheumatoid factor, but positive for HLA-B27 in 90% of patients.
Kubiak et. al. review orthopaedic management of AS. Common orthopaedic manifestations include SI joint pain, hip flexion contractures, and stiffness of the cervical and lumbar spine. They report that laboratory analysis of patients with active disease will typically demonstrate mild elevation of ESR, CRP, and WBC. Patients with chronic AS may demonstrate a normocytic anemia. If HLA-B27 is negative, a high clinical suspicion should still be maintained.
Gensler et al. review the different clinical conditions that compose of juvenile-onset spondyloarthritis. They report on the different spondyloarthritides includes ankylosing spondylitis, reactive arthritis, arthropathy associated with inflammatory bowel disease, and that associated with psoriasis. They emphasize that the appearance of sacroiliac joint and spinal disease in the form of ankylosing spondylitis usually takes 5–10 years after initial symptom presentation, and therefore, a definite diagnosis can take several years leading to a delay in diagnosis.
Figure A is an AP pelvis radiograph of a skeletally mature individual demonstrating sclerosis of the SI joint indicative of sacroiliitis. Illustration A shows a axial CT image of the patient in the stem. Sclerosis and bone erosion can be seen in the sacroiliac joint.
Incorrect Answers:
osteonecrosis Answer 3: A infarctions,
of
the
femoral
epiphysis.
thrombophilia may have
osseous manifestations such as bone
which
are
not
evident
on
this
image.

Question 33:

Figures 71a and 71b/ are the MR images of a 65-year-old man who dislocated his shoulder. What is his most likely chief symptom?

Options:

Numbness in the anterior aspect of his shoulder
Recurrent instability
Difficulty raising his arm
Biceps muscle deformity

Correct Answer: Difficulty raising his arm

Explanation:

DISCUSSION
This patient has a massive rotator cuff tear resulting in disruption of the transverse force couple between the subscapularis anteriorly and the infraspinatus and teres minor posteriorly. These muscles provide dynamic shoulder stability throughout active elevation. Loss of the force couple produces a pathologic increase in translation of the humeral head and decreased active abduction and external rotation, which results in difficulty raising an arm. The most common neurologic deficit after shoulder dislocation is isolated injury to the axillary nerve that supplies sensation to the lateral aspect of the shoulder, not the anterior aspect. Recurrent instability is uncommon unless there is a labral tear or massive subscapularis tear. The biceps muscle is not viewed in the MR images, and a complete proximal biceps tendon rupture would be uncommon in the setting of an anterior shoulder dislocation.
CLINICAL SITUATION FOR QUESTIONS 72 THROUGH 75
Figures 72a through 72e 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 degrees
to 90 degrees and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted.

Question 34:

A 14-year-old boy has a midshaft fibular lesion. Biopsy results are consistent with Ewing’s sarcoma. Following induction chemotherapy, local control typically consists of

Options:

radiation therapy only.
curettage and bone grafting.
wide excision.
below-knee amputation.
observation.

Correct Answer: wide excision.

Explanation:

Question 35:

The condition shown in Figures 9a and 9b is most likely the result of

Options:

infection.
uric acid deposition.
trauma.
a virus.
severe cold exposure.

Correct Answer: uric acid deposition.

Explanation:

Question 36:

A healthy 2-year-old boy falls from a swing and sustains a displaced midshaft femoral fracture with 1 cm of shortening. What is the most appropriate treatment?

Options:

Pavlik harness
Skeletal traction for 3 weeks followed by a spica cast
Skin traction for 3 weeks followed by a spica cast
Closed reduction and spica casting
Closed reduction and an intramedullary pin

Correct Answer: Closed reduction and spica casting

Explanation:

AL-Madena Copy
DISCUSSION: For children between the ages of 1 and 6 years, closed reduction and early spica casting is recommended. In some instances, associated injuries or body habitus may preclude cast treatment. Pavlik harness treatment of femoral fractures is for infants younger than 1 year of age. Rarely is there an indication for traction. Internal fixation is reserved in general for children older than age 6 years or with confounding factors.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 271-280.
Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359.
Figure 29a Figure 29b

Question 37:

Options:

arthroscopic capsular release
manipulation under anesthesia
a physical therapy program
an intra-articular corticosteroid injection
administration of high-dose oral corticosteroids

Correct Answer: a physical therapy program

Explanation:

Question 38:

Options:

oral nonsteroidal anti-inflammatory drugs.
intravenous antistaphylococcal antibiotics.
incision and debridement of the retroperitoneal abscess.
incision and debridement of the left sacroiliac joint.
arthrotomy and irrigation of the left hip joint.

Correct Answer: intravenous antistaphylococcal antibiotics.

Explanation:

Question 39:

Figure 6 shows a sagittal oblique MRI scan. The arrow is pointing to what structure?

Options:

Bucket-handle tear of the medial meniscus
Ligament of Humphrey
Ligament of Wrisberg
Posterior intermeniscal ligament
Partial tear of the posterior cruciate ligament

Correct Answer: Ligament of Humphrey

Explanation:

DISCUSSION: The meniscofemoral ligaments connect the posterior horn of the lateral meniscus to the intercondylar wall of the medial femoral condyle. The ligament of Humphrey (arrow) passes anterior to the posterior cruciate ligament, whereas the ligament of Wrisberg passes posterior to the posterior cruciate ligament. One or the other has been identified in 71% to 100% of cadaver knees, with the ligament of Wrisberg being more common.
REFERENCES: Clarke HD, Scott WN, Insall JN, et al: Anatomy, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 3-66.
Miller TT: Magnetic resonance imaging of the knee, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 201-224.

Question 40:

Epithelioid sarcoma most commonly occurs in which of the following anatomic locations?

Options:

Upper extremity
Lower extremity
Pelvis and buttock
Retroperitoneum
Spine

Correct Answer: Upper extremity

Explanation:

Question 41:

Options:

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

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

Explanation:

Question 42:

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

Options:

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

Correct Answer: greater direct costs.

Explanation:

Question 43:

Options:

Axillary view
CT of the shoulder
Closed reduction
Sling and close follow-up
Functional brace

Correct Answer: Axillary view

Explanation:

Question 44:

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 45:

The spinal cord terminates as the conus medullaris at what vertebral level in adults? Review Topic 1 T12

Options:

Correct Answer: L2

Explanation:

The spinal cord anatomy changes at the thoracolumbar junction. The spinal cord terminates as the conus medullaris at the lower portion of L1 in women and the pedicle of L1 in men.

Question 46:

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 47:

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 48:

What is the goal of surgical treatment in this scenario?

Options:

To cure cancer
To prolong life
To relieve pain
To reverse neurologic symptoms

Correct Answer: To relieve pain

Explanation:

DISCUSSION
This patient has a metastatic neuroendocrine tumor. Surgical treatment should prioritize palliation of her symptoms. She has high-grade spinal cord compression without neurologic signs or symptoms. Steroids are beneficial for patients with high-grade spinal cord compression caused by tumors, and these drugs should be administered in the acute setting. This patient was appropriately initially treated with conventional radiation. However, she is not a candidate for further radiation because of spinal cord tolerance limits and insufficient clearance between the tumor and spinal cord. Consequently, stereotactic radiation is not an option.
The goal of surgical treatment of this tumor should be palliation of her symptoms rather than cure. A costotransversectomy approach offers the advantage of ventral and dorsal spinal cord access, which is necessary in this case. A sternotomy or transthoracic approach would offer ventral access, but dorsal access would be less than optimal.
RECOMMENDED READINGS
Rose PS, Buchowski JM. Metastatic disease in the thoracic and lumbar spine: evaluation and management. J Am Acad Orthop Surg. 2011 Jan;19(1):37-48. Review. PubMed PMID: 21205766.
View Abstract at PubMed
Rades D, Abrahm JL. The role of radiotherapy for metastatic epidural spinal cord compression. Nat Rev Clin Oncol. 2010 Oct;7(10):590-8. doi: 10.1038/nrclinonc.2010.137. Epub 2010 Aug

Question 49:

Options:

Inhibits osteoclasts
Stimulates osteoblasts
Increases gastrointestinal absorption of calcium
Decreases renal excretion of calcium
Acts as a transcription factor to increase production of type I collagen

Correct Answer: Inhibits osteoclasts

Explanation:

Question 50:

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

Options:

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

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

Explanation:

Question 51:

What is the heaviest weight that can be safely applied to the adult cervical spine via Gardner-Wells tong traction?

Options:

40 pounds
50 pounds
75 pounds
100 pounds
Greater than 100 pounds

Correct Answer: Greater than 100 pounds

Explanation:

DISCUSSION: Cotler and associates reported on the use of awake skeletal traction to reduce facet fracture-dislocations in 24 patients. Seventeen patients required more than 50 pounds of traction (the “traditional” limit) to achieve reduction. More than 100 pounds of traction was safely used in one-third of the patients in this study. A cadaver study has supported the safe use of traction with weights in excess of 100 pounds.
REFERENCES: Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.
Anderson DG, Vacccaro AR, Gavin K: Cervical orthoses and cranioskeletal traction, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,
pp 110-121.

Question 52:

Options:

Extension-type supracondylar fracture
Flexion-type supracondylar fracture
Anterior olecranon fracture dislocation
Coronoid fracture, olecranon fracture and elbow dislocation
Coronoid fracture, radial head fracture and elbow dislocation

Correct Answer: Coronoid fracture, olecranon fracture and elbow dislocation

Explanation:

Question 53:

Options:

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

Correct Answer: Bone graft interposition arthrodesis

Explanation:

Question 54:

Options:

A palpable effusion
Positive anterior drawer test
Positive external rotation test
Pain with forced dorsiflexion
Loss of subtalar motion

Correct Answer: Pain with forced dorsiflexion

Explanation:

Question 55:

Options:

Acetabular revision, with placement of a custom triflange acetabular component and femoral head exchange
Removal of the femoral and acetabular components and placement of an antibiotic spacer, with 6 weeks of intravenous antibiotics
Head and liner exchange and retention of the femoral and acetabular implants with acetabular bone grafting
Nonsurgical management with the initiation of bisphosphonates and referral to pain management

Correct Answer: Acetabular revision, with placement of a custom triflange acetabular component and femoral head exchange

Explanation:

Question 56:

Options:

a rehabilitation program to strengthen his remaining scapular muscles.
a scapular brace to keep his scapula reduced.
scapulothoracic fusion.
pectoralis minor muscle transfer.
latissimus dorsi muscle transfer.

Correct Answer: scapulothoracic fusion.

Explanation:

Question 57:

A 30-year-old woman sustained a nondisplaced unilateral facet fracture of C5 in a motor vehicle accident. She is neurologically intact and has no other injuries. Management should consist of

Options:

skeletal tong traction for 6 weeks.
halo application.
immobilization in a rigid collar for 6 weeks.
open reduction posteriorly with interspinous wiring and bone grafting.
open reduction anteriorly with diskectomy, interbody grafting, and plating.

Correct Answer: immobilization in a rigid collar for 6 weeks.

Explanation:

Question 58:

Options:

Syrinx of the cervical spine
Intracranial mass
Myasthenia gravis
Amyotrophic lateral sclerosis (ALS)
Fascioscapulohumeral dystrophy

Correct Answer: Amyotrophic lateral sclerosis (ALS)

Explanation:

Question 59:

The essential lesion responsible for posterolateral rotatory instability of the elbow is disruption of the

Options:

lateral ulnar collateral ligament.
medial collateral ligament.
radial collateral ligament.
annular ligament.
posterolateral capsule.

Correct Answer: lateral ulnar collateral ligament.

Explanation:

Question 60:

Options:

Primary repair of injured structure
Primary repair of injured structure combined with anterior and medial tibial tubercle transfer
Immobilization of knee in full extension with a progressive weight-bearing exercise program
Semitendinosus or gracilis tendon autograft reconstruction of the injured structure
CT angiography followed by primary repair of injured structure if the limb has vascular stability

Correct Answer: CT angiography followed by primary repair of injured structure if the limb has vascular stability

Explanation:

Question 61:

Options:

acceptance of the malalignment and continued cast immobilization.
repeat closed reduction with the aid of IV morphine and midazolam.
repeat closed reduction with the aid of IV ketamine.
repeat closed reduction with the patient under general anesthesia.
gentle open reduction with smooth cross-pin fixation.

Correct Answer: acceptance of the malalignment and continued cast immobilization.

Explanation:

DISCUSSION: In a 6-year-old child with a physeal fracture, the healing response 10 days after injury is so advanced that manipulation would have to be very forceful to be successful. A forceful manipulation in a patient this age increases the risk of early growth arrest and a significant disability because 80% of the growth of the radius comes from the distal physis. Because of the large contribution of growth from the distal radial physis and the angulation being in the plane of wrist motion, the potential for remodeling of this fracture is great. It is highly probable that this fracture will completely remodel in 1 to 2 years of growth. In this patient, even a “gentle” open reduction would probably require enough force that the physis would
be damaged.
REFERENCES: Dimeglio A: Growth in pediatric orthopaedics, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 33-62.
Waters PM: Forearm and wrist fractures, in Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 251-258.

Question 62:

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

Options:

Limbus
Pulvinar
Ligamentum teres
Transverse acetabular ligament
Acetabular labrum

Correct Answer: Acetabular labrum

Explanation:

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

Question 63:

Options:

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

Correct Answer: Revision of the acetabular and femoral implants

Explanation:

Question 64:

Options:

Temporary total disability
Temporary partial disability
Temporary partial illness
Permanent total disability
Permanent partial disability

Correct Answer: Temporary partial disability

Explanation:

Question 65:

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

Options:

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

Correct Answer: Pivot shift

Explanation:

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

Question 66:

Options:

Brostrom procedure
Syndesmosis repair or stabilization
Allograft lateral ligament reconstruction
Excision of loose body/fracture fragment
Repair of the SPR with possible fibular groove deepening

Correct Answer: Syndesmosis repair or stabilization

Explanation:

DISCUSSION FOR QUESTIONS 107 AND 108:
The fracture at the insertion of the AITFL into the fibula represents a syndesmosis injury. In some cases, a direct repair of the fracture will stabilize the syndesmosis, but in most cases this injury should most likely be reinforced by placing a screw or suture tensioning device across the syndesmosis for additional support.A Brostrom or allograft reconstruction is indicated for an ankle sprain involving the ATFL or CFL.Simply excising the fragment will leave the patient with an incompetent syndesmosis. Repairing the SPR with or without a groove deepening procedure is indicated if there is evidence of subluxated or dislocated peroneal tendons, which is not demonstrated on the CT scans. The bone has been avulsed off the fibula by the portion of the AITFL that attaches to the fibula, therefore indicating that there is a syndesmosis injury. Allograft lateral ligament reconstruction and excision of loose body/fracture fragment are incorrect procedures based on location. The deltoid is a medial structure and this fracture is lateral. The ATFL and CFL attach at the inferior margin of the fibula near the lateral process of the talus and calcaneus. A SPR avulsion would present as an avulsion off the lateral wall of the fibula, not superior and not into the syndesmotic space as shown on the CT scans.

Question 67:

Options:

casting.
closed reduction, casting, and no weight bearing for 6 weeks.
open reduction and internal fixation.
closed reduction and percutaneous Kirschner wire fixation.
closed reduction and percutaneous screw fixation.

Correct Answer: open reduction and internal fixation.

Explanation:

DISCUSSION: Myerson and associates studied the outcomes of 19 patients with tarsometatarsal joint injuries during athletic activity. Injuries were classified as first- or second-degree sprains of the tarsometatarsal joint or a third-degree sprain with diastasis between the metatarsals or cuneiforms. Poor functional results were seen in those with a delay in diagnosis and with inadequate treatment. For patients with third-degree sprains, poor results were obtained with nonsurgical management. These patients required open reduction and internal fixation for optimal return to function. The anatomic reduction is critical to the outcome; therefore, open reduction is preferred.
REFERENCES: Baxter DE: The Foot and Ankle in Sport, ed 1. St Louis, MO, Mosby, 1995,
pp 107-123.
Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete. Am J Sports Med 1993;21:497-502.
Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.
Thompson MC, Mormino MA: Injury to the tarsometatarsal joint complex. J Am Acad Orthop Surg 2003;11:260-267.

Question 68:

Standard guidelines necessitate the use of intraoperative neurophysiological monitoring for patients undergoing surgery for which condition?

Options:

Primary lumbar disk herniation
Adolescent idiopathic scoliosis
Cervical spondylotic myelopathy
No conditions; there are no official guidelines

Correct Answer: No conditions; there are no official guidelines

Explanation:

DISCUSSION
There are currently no official guidelines on the appropriate use of neuromonitoring in spine surgery. In general, use of neuromonitoring is at surgeon discretion and often is based on the surgeon's perceived risk for neurologic injury during surgery and medicolegal concerns. In most reports,
neuromonitoring is considered useful in cases of deformity correction, spinal cord decompression, instrumentation placement, and revision surgery. However, even for some of these cases, studies have shown limited benefits of neuromonitoring and substantial associated costs.
RECOMMENDED READINGS
Lall RR, Lall RR, Hauptman JS, Munoz C, Cybulski GR, Koski T, Ganju A, Fessler RG, Smith ZA. Intraoperative neurophysiological monitoring in spine surgery: indications, efficacy, and role of the preoperative checklist. Neurosurg Focus. 2012 Nov;33(5):E10. doi: 10.3171/2012.9.FOCUS12235. Review. PubMed PMID: 23116090.
View Abstract at PubMed
Peeling L, Hentschel S, Fox R, Hall H, Fourney DR. Intraoperative spinal cord and nerve root monitoring: a survey of Canadian spine surgeons. Can J Surg. 2010 Oct;53(5):324-8. PubMed PMID: 20858377.
View
Abstract at PubMed
Garces J, Berry JF, Valle-Giler EP, Sulaiman WA. Intraoperative neurophysiological monitoring for minimally invasive 1- and 2-level transforaminal lumbar interbody fusion: does it improve patient outcome? Ochsner J. 2014 Spring;14(1):57-61. PubMed PMID: 24688334.
View
Abstract at PubMed

Question 69:

Options:

External fixation of the pelvis, external fixation of the distal femur, and splinting of the humerus
External fixation of the pelvis, external fixation of the distal femur, and intramedullary nailing of the humerus
External fixation of the pelvis, open reduction and internal fixation of the distal femur, and splinting of the humerus
Open reduction and internal fixation of the pelvis, open reduction and internal fixation of the distal femur, and intramedullary nailing of the humerus
Open reduction and internal fixation of the pelvis, open reduction and internal fixation of the distal femur, and open reduction and internal fixation of the humerus

Correct Answer: External fixation of the pelvis, external fixation of the distal femur, and splinting of the humerus

Explanation:

Question 70:

Options:

general anesthesia.
antibiotics.
warfarin.
narcotics.

Correct Answer: narcotics.

Explanation:

Question 71:

Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios?

Options:

Nondisplaced distal radius fracture
Nondisplaced Rolando fracture
Second metacarpal base fracture
Boxer's fracture
Nondisplaced radial styloid fracture

Correct Answer: Nondisplaced distal radius fracture

Explanation:

Question 72:

Options:

A 41-year-old right-hand-dominant man has been treated nonsurgically for right elbow arthritis. His radiographs reveal end-stage ulnohumeral arthritis with complete loss of the joint space. He reports pain during the mid-arc of elbow flexion and extension. During the last 8 years, he has attempted activity modification, medication, physical therapy, and multiple cortisone injections. His symptoms have progressed, resulting in constant pain, loss of a functional range of motion, and an inability to perform many activities of daily living. Secondary to his age and activity demands, he undergoes a soft-tissue interposition arthroplasty of his elbow with an Achilles allograft. Which presurgical finding correlates with elevated risk for postsurgical complications?
Inflammatory elbow arthritis
A presurgical flexion-extension elbow arc of approximately 50°
Retained distal humerus hardware on presurgical radiographs
Evidence of presurgical elbow instability End-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to concerns about implant longevity. Soft-tissue interposition arthroplasty does not necessitate the same activity and weight restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey published their findings on 38 patients with a mean age of 39 years following soft-tissue interposition arthroplasty for posttraumatic and inflammatory end-stage elbow arthritis. These investigators reported a significant improvement in Mayo Elbow Performance Score in addition to improvement in the flexion-extension arc from 51° to 97° after surgery. They reported worse results and elevated incidence of complications for patients with presurgical elbow instability. Retained hardware from prior surgery was not deemed a contraindication.

Correct Answer: Inflammatory elbow arthritis

Explanation:

Figure 1 is the radiograph of a 12-year-old baseball player who has posterolateral elbow pain with throwing. The area of interest is designated by the black arrow. His range of motion and strength are full. No previous treatment has been provided. What is the most appropriate initial treatment?
Elbow arthroscopy with debridement
Immobilization and rest for 6 weeks
Corticosteroid injection
Open osteochondral autograft transfer
Osteochondritis dissecans of the capitellum is a painful condition that affects immature athletes who undergo repetitive compression of the radiocapitellar joint. Management is based primarily on the integrity of the articular cartilage surface and the stability of the lesion. Nonsurgical treatment is typically selected for patients
with early-grade, stable lesions, and it involves activity modification with cessation of sports participation. The duration of activity modification is dictated by symptoms, with 3 to 6 weeks of rest followed by return to sport in 3 to 6 months commonly used as a guideline. Strengthening and stretching exercises are commonly incorporated after the pain has subsided. Surgical intervention or corticosteroid injection would not be first-line treatment.
Figures 1 and 2 are the radiographs of a 69-year-old man with a history of treated prostate cancer and hemodialysis-dependent end- stage renal disease who presents to the emergency department with progressively worsening right shoulder pain and stiffness. Laboratory tests reveal a white blood cell count of 17,000, erythrocyte sedimentation rate, 75, and CRP, 10.1. He has a draining sinus located along the anterior shoulder. What is the best next step?

Question 73:

A decrease in alkaline phosphatase would most likely be manifest in which metabolic disorder?

Options:

Familial hypocalciuric hypercalcemia
Hypophosphatasia
X-linked hypophosphatemia
Secondary hyperparathyroidism
Tertiary hyperparathyroidism

Correct Answer: Familial hypocalciuric hypercalcemia

Explanation:

Question 74:

What is a risk factor for interdigital neuroma?

Options:

Female gender
Increased mobility between the third and fourth rays
Achilles tendon contracture
Prolonged standing at work

Correct Answer: Female gender

Explanation:

Question 75:

Options:

Surgery on the wrong patient
Surgery on the wrong side
Incorrect procedure performed
Intraoperative death
Surgery on the wrong level

Correct Answer: Surgery on the wrong level

Explanation:

DISCUSSION: Patient safety and prevention of medical errors is a major focus of recent national advocacy groups. Analysis has shown that the most common sentinel event in spine surgery is surgery on the wrong level. Therefore, it is recommended that every patient have the surgical site signed, the level of surgery marked intraoperatively, and a radiograph taken. Surgery on the wrong level is most likely to occur in single-level decompressive procedures.
REFERENCES: Wong DA, Watters WC III: To err is human: Quality and safety issues in spine care. Spine 2007;32:S2-S8.
Wong DA: Spinal surgery and patient safety: A systems approach. J Am Acad Orthop Surg 2006;14:226-232.

Question 76:

- A patient sustains a closed dorsal dislocation of the proximal interphalangeal joint of the middle finger without an associated fracture. Closed treatment results in a cocentric stable reduction. The finger is not immobilized. Which of the following conditions may appear 1 year later?

Options:

Triggering
Lateral instability
Swan-neck deformity
Boutonniere deformity
Loss of distal interphalangeal joint flexion

Correct Answer: Triggering

Explanation:

Swan neck deformity describes a posture of the finger in which the PIP joint is hyperextended and the DIP joint is flexed. Initially this is a dynamic imbalance that occurs when a patient attempts maximal digital extension. This dynamic finger imbalance can progress to a static deformity. There are many etiologies for SND and include injuries resulting in volar plate laxity (e.g. dorsal dislocation of the PIP.), spastic conditions such as stroke & CP, RA, fractures of the middle and proximal phx healed in extension.
Question 199 -
Examination of a 3-year-old boy who slammed his finger in a door 3 months ago reveals 0 to 40 degrees of proximal interphalangeal joint motion. Radiographs are shown in Figures 47a and 47b. Management should consist of
Volar osteotomy
Observation only
Flexor tenolysis
Volar plate arthoplasty
A hinged distraction external fixator
Subcondylar fractures of the proximal and middle phalynx occur at the neck of the phalynx, usually as a result of a crush injury, and almost exclusively in the pediatric age group. The distal fragment rotates dorsally and the degree of displacement may be misjudged if a true lateral is not obtained. If malunion occurs there is block to flexion. Subcondylar fossa reconstruction by removal of bone through a palmar approach removes this boney block.

Question 77:

Options:

Scapular dyskenisia
Quadrilateral space syndrome
Subacromial impingement syndrome
Suprascapular nerve compression by a spinoglenoid notch
Suprascapular nerve compression at the suprascapular notch

Correct Answer: Quadrilateral space syndrome

Explanation:

Question 78:

Options:

25 mg of indomethacin 3 times daily for 6 weeks
1 dose of irradiation at 800 Gy
Surgical excision of heterotopic ossification (HO)
Reevaluation in 6 months

Correct Answer: Reevaluation in 6 months

Explanation:

Question 79:

Figure 22 shows the radiograph of a 7-year-old boy who underwent retrograde elastic nailing of a femoral shaft fracture. What is the most common problem following this procedure?

Options:

Unacceptable shortening
Osteonecrosis of the femoral head
Malunion
Persistent pain and irritation at the nail insertion site
Rotational malalignment

Correct Answer: Persistent pain and irritation at the nail insertion site

Explanation:

DISCUSSION: Several large clinical studies have shown that the most common problem after elastic nailing of a femoral shaft fracture is persistent pain and irritation at the nail insertion site. Unacceptable shortening and malunion are very rare in a 7-year-old patient. Rotational malalignment also is unusual. Osteonecrosis has been reported in solid antegrade nailing but not with elastic nailing of femoral shaft fractures in skeletally immature patients.
REFERENCES: Flynn JM, Luedtke LM, Ganley TJ, et al: Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. J Bone Joint Surg Am 2004;86:770-777.
Flynn JM, Hresko T, Reynolds RA, et al: Titanium elastic nails for pediatric femur fractures: A multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4-8.
Ligier JN, Metaizeau JP, Prevot J, et al: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-77.

Question 80:

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

Options:

Reduction and internal fixation
Closed reduction and splinting alone
Carpometacarpal arthrodesis
Carpometacarpal (CMC) joint suspension arthroplasty

Correct Answer: Reduction and internal fixation

Explanation:

Question 81:

What is the most common complication associated with the treatment of the distal biceps ruptures as shown in Figures 79a and 79b? Review Topic

Options:

Re-rupture
Radioulnar synostosis
Posterior interosseous nerve injury
Lateral antebrachial cutaneous nerve irritation
Radial fracture

Correct Answer: Lateral antebrachial cutaneous nerve irritation

Explanation:

Question 82:

Options:

closed management of the medial condyle and humeral shaft fractures and open reduction and internal fixation of the both bones forearm fracture.
closed management of the humeral shaft fracture and open reduction and internal fixation of the medial condyle and the both bones forearm fractures.
open reduction and internal fixation of the humeral shaft, medial condyle, and the both bones forearm fractures.
open reduction and internal fixation of the medial condyle and both bones forearm fractures, and external fixation of the humeral shaft fracture.
delayed stabilization of all fractures after the open wound has healed.

Correct Answer: open reduction and internal fixation of the humeral shaft, medial condyle, and the both bones forearm fractures.

Explanation:

Question 83:

Options:

repair of a triceps tendon avulsion.
arthroscopy of the elbow for removal of loose bodies.
arthroscopic removal of a posteromedial olecranon osteophyte.
internal fixation of an olecranon stress fracture.
rest, rehabilitation, and resumption of pitching when the fracture is healed.

Correct Answer: rest, rehabilitation, and resumption of pitching when the fracture is healed.

Explanation:

Question 84:

Which of the following pelvic injury types has the highest reported mortality rate?

Options:

Anterior posterior compression (APC) III injury
Lateral compression (LC) III injury
Transverse-posterior wall acetabular fracture
Vertical Shear
Combined mechanical injury (CMI) Corrent answer: 1 Anterior posterior compression (APC) injuries have the highest mortality rates of the fracture patterns listed. APC injuries have high rates of concomitant thoracic and abdominal visceral injuries leading to the highest rates of mortality among pelvic fractures. Lateral compression (LC) fractures have particularly high incidences of associated brain and head injury with lower mortality than APC injuries. Overall, as the grade of pelvic ring injury increases the rates of associated injuries increases, regardless of exact mechanism of injury. The overall mortality rate for any pelvic trauma is roughly 15%, with APC III mortality around 37%, and overall APC mortality rates around 26%. LC of any grade has an estimated mortality around 13%. Vertical shear and CMI have estimated mortality of 25% and 17.1%, respectively. The lowest mortality rates are following acetabular fractures with estimates around 1.5%. Dalal et al retrospectively reviewed 340 trauma patients with pelvic injuries to analyze organ injury, resuscitative requirements, and outcomes. They found the highest mortality rates were in APC III and that more severe APC injuries had greater organ damage and mortality. They conclude that the mechanical force type and classification of injury are predictors of organ injury pattern, resuscitation needs, and mortality. Eastridge et al reviewed 1,014 injured pedestrians for pelvic injuries, associated injuries, and relationship of treatments to outcomes. They found the highest mortality rates were associated with APC III and LC III injuries patterns at 50%. They conclude that pelvic fractures are a sign of significant energy imparted on the body and severity of associated injuries lead to the high rates of morbidity and mortality. Illustration A and B show an APC III and LC III injury, respectively. Incorrect Answers:

Correct Answer: Lateral compression (LC) III injury

Explanation:

mechanism injuries all have lower mortality rates than APC injuries.
OrthoCash 2020

Question 85:

What is the most common mechanism of injury that produces turf toe?

Options:

Valgus stress at the first metatarsophalangeal (MTP) joint
Hyperflexion stress
Hyperextension stress
Varus stress
Axial load

Correct Answer: Hyperextension stress

Explanation:

Question 86:

A 14-year-old girl has had mild pain and nail deformity of the great toe for the past 4 months. A radiograph is shown in Figure 50. What is the most likely etiology of the lesion?

Options:

Fungal infection
Ingrowth of the medial nail
Benign exostosis
Malignant neoplasm
Reactive pyogenic granuloma

Correct Answer: Benign exostosis

Explanation:

Question 87:

Options:

Chevron bunionectomy
Cheilectomy and removal of loose body
MTP arthrodesis
Resection of proximal phalanx

Correct Answer: MTP arthrodesis

Explanation:

Question 88:

Immobilization with a sling

Options:

Aspiration and steroid injection
Biopsy, curettage, and allograft bone grafting
Percutaneous Kirschner wire fixation
Percutaneous injection of autogenous bone marrow

Correct Answer: Aspiration and steroid injection

Explanation:

Question 89:

A previously asymptomatic 14-year-old girl sustained a twisting injury to her ankle. Radiographs are shown in Figures 2a and 2b. Management should consist of

Options:

observation.
MRI.
bone scan.
biopsy.
curettage and bone grafting.

Correct Answer: observation.

Explanation:

DISCUSSION: The radiographs show a well-defined, irregular, eccentric lesion in the distal tibia metaphysis with a thin sclerotic margin. The radiographs are diagnostic of nonossifying fibroma, a common entity in this age group and in this location. No further work-up is indicated. The patient was asymptomatic prior to the injury and the lesion is small and thus not worrisome for an impending pathologic fracture; therefore, no treatment is indicated beyond observation. The natural history of these lesions is to gradually ossify as the patient reaches skeletal maturity.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 69-75.
Biermann JS: Common benign lesions of bone in children and adolescents. J Pediatr Orthop 2002;22:268-273.

Question 90:

Options:

insertion of a thicker cement mantle and a thicker patellar insert to achieve a total patellar thickness of 24 mm.
a lateral release after inserting a standard patella.
a distal femoral augmentation to maximize the moment-arm on a standard patellar insert.
leaving the patella alone and performing a lateral release, if necessary, for proper patellar tracking.
an oversized femoral component to improve the moment-arm on a standard patellar insert.

Correct Answer: leaving the patella alone and performing a lateral release, if necessary, for proper patellar tracking.

Explanation:

Question 91:

In a postganglionic brachial plexus lesion at Erb’s point (point of formation of the upper trunk by the C5 and C6 nerve roots), which of the following nerves will still function normally?

Options:

Suprascapular
Musculocutaneous
Axillary
Lateral pectoral
Dorsal scapular

Correct Answer: Dorsal scapular

Explanation:

Question 92:

Options:

Single factor analysis of variance
Chi-square test
Student t-test
Mann-Whitney rank sum test
Wilcoxon rank sum test

Correct Answer: Mann-Whitney rank sum test

Explanation:

Question 93:

Which of the following changes occur in the spinal cord and the spinal canal when the cervical spine moves from neutral to full flexion?

Options:

The spinal cord relaxes and the spinal canal shortens.
The spinal cord undergoes elastic deformation and the spinal canal lengthens.
The spinal cord remains unchanged and the spinal canal lengthens.
The spinal cord remains unchanged and the spinal canal shortens.
Neither structure shows any predictable pattern of changes.

Correct Answer: The spinal cord undergoes elastic deformation and the spinal canal lengthens.

Explanation:

Question 94:

Which of the following characteristics is seen in patients with osteochondritis dissecans of the elbow? Review Topic

Options:

MRI reveals separation of cartilage from the capitellum and chondral fissuring
Fragmentation of the entire capitellar ossific nucleus
Normal capitellar regrowth with no late sequelae
Age younger than 10 years
Medial ulnar collateral ligament laxity

Correct Answer: MRI reveals separation of cartilage from the capitellum and chondral fissuring

Explanation:

Question 95:

Options:

C5-C6 postganglionic injury
C8-T1 preganglionic injury
C5 through C7 preganglionic injury
C8-T1 postganglionic injury

Correct Answer: C8-T1 preganglionic injury

Explanation:

Question 96:

important in patients with renal impairment, which is not typically seen in SCT.

Options:

A physician is interested in using platelet-rich plasma (PRP) for treatment of osteochondral lesions of the talus. He is reviewing a prospective cohort study that compares 40 patients treated with PRP and cast immobilization for 6 weeks vs. 36 patients treated conservatively with cast immobilization for 6 weeks. All patients were treated at the same time and institution. The study was not randomized although treatment and control groups were matched appropriately to reduce selection bias. Follow-up in each group was >80% over 1 year. The paper reported significant improvement with use of PRP based on three standard foot and ankle outcome scores (AOFAS, SF-36, FOAS). What is the level of evidence for this study?
Level I
Level II
Level III
Level IV
Level V

Correct Answer: Level III

Explanation:

This is prospective cohort study with Level-II evidence.
Level of evidence provides guidance to the study quality. It is used to assess therapeutic studies (as with this question), prognostic studies, diagnostic studies and economic or decision models. When determining the level of evidence, readers must critically appraise the study question, treatment, intervention and outcomes of the study design. Level-II therapeutic studies consist of well-designed prospective cohort studies, poor-quality randomized controlled trials (follow-up less than 80%) and systematic review of Level-II studies or non-homogenous Level-I studies.
Wright et al. provided an excellent summary of clinical research study level of evidence. This has been provided as Illustration A.
Illustration A shows a chart of level of evidence. There is a column for each type of study which corresponds to a row that outlines the level of evidence based on study
design.
Incorrect Answers:
Low serum phosphate and normal calcium levels are found in what common etiology of hereditary rickets?
X-linked hypophosphatemic
Vitamin D-dependent, type I
Vitamin D-dependent, type II
Autosomal dominant hypophosphatemic
Jansen's metaphyseal chondrodysplasia
Low serum phosphate and normal calcium levels are found in X-linked hypophosphatemic rickets.
X-linked hypophosphatemic rickets is the most common form of hereditary rickets. It is an X-linked dominant disorder which has been linked to the PHEX gene. Laboratory findings
of this disorder include low serum phosphate, normal serum calcium and 25 hydroxycholecalciferol levels, and inappropriately low 1,25-dihydroxyvitamin D3.
Carpenter et al. showed hypophosphatemic rickets was initially referred to as “vitamin D resistant rickets” due to its lack of response to therapeutic vitamin D. Current treatment with activated vitamin D metabolites (calcitriol or
alfacalcidol) and phosphate salts have been shown to help with this condition.
Illustration A shows an insufficiency fracture of the proximal tibia in an adult patient with X-linked hypophosphatemic rickets. A stress fracture on the medial tibia may be a presenting feature of untreated disease.
Incorrect Answers:
receptor (PTHR1).
A healthy patient undergoes routine pre-operative laboratory testing and is found to have a leukocyte count of 1.5 × 10(9) cells/L. When the historical records are examined, this is found to be the patients base-line level over a period of years. Which of the following statements is most likely to be true:
The patient is at a significantly higher risk of surgical infection
The patient is more likely to be of African than of European descent
The patient is more likely to be of European than of Middle Eastern descent
The patient is more likely to be a non-athlete than an athlete
The patient is more likely to be female than male
The clinical presentation is consistent with Benign Ethnic Neutropenia, a condition in which a patient has chronic, benign, inborn and lifelong absolute neutrophl count below population mean. This condition is found in the U.S. to be most common in African- Americans, some groups of Middle Eastern patients, males, children under 5 years old, and athletes compared to non- athletes.
A standardized level at present for abnormally low absolute neutrophil count (ANC) is below 1.5 x 10(9) cells/L, however this may not have clinical or scientific relevance as a cutoff point, particularly in the affected Ethnic groups. Fewer than 1% of all populations have absolute neutrophil count < 1.0 X 10(9) cells/L. Most patients in the affected ethnic groups with low ANC and no associated history or symptoms are not expected to have any increased risk of infection or adverse effect. Smoking was also associated with higher leukocyte and neutrophil counts but proportionately lower increase in African-American patients. One hypothesis for the increased prevalence of B.E.N. in patients of African descent is a theorized evolutionary protection against malaria, though
it remains unclear if this is causal or just correlative.
Haddy et al. provide an excellent scientific review of B.E.N. and emphasize the importance of recognizing this most common form of neutropenia.
Eichner et al. review B.E.N. in the setting of sports medicine and state the relative increase of these lab findings in athletes vs non-athletes.
Hsieh et al. provide an extensive cross-sectional population study focused on the prevalence of Benign Ethnic Neutropenia in the U.S. They reviewed 25,222 participants in the National Health and Nutrition Examination Survey 1yr of
age or older from 1999-2004, and detail the association of this condition with age, sex, ethnicity, and smoking status.
Denic et al. analyzed neutrophil count in a healthy Arab population in the U.A.E. and found low neutrophil counts in this population with a distribution suggestive, but not definitively, of an autosomal dominant inheritance. They also discuss the hypothesized association of B.E.N. and malaria infection.
Incorrect answers:

Question 97:

The arrow in Figure 11 points toward a finding consistent with which of the following?

Options:

Metastatic disease
Hemangioma
Flexion-compression fracture
Infection
Diastomatomyelia

Correct Answer: Metastatic disease

Explanation:

DISCUSSION: The finding of a unilateral absent pedicle is often referred to as a winking owl sign and is a manifestation of pedicle destruction from metastatic disease. As the vertebral body is destroyed from the neoplastic process, it extends into the pedicle and destroys the cortical rim that normally creates the oval ring of the pedicle on an AP image.
REFERENCES: McLain R, Weinstein J (eds): Rothman-Simeone: The Spine, ed 4. Philadelphia, PA, WB Saunders, 1999, p 1173.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 674.

Question 98:

What molecules have been shown to promote fibrosis during muscle injury?

Options:

Insulin growth factor 1 (IGF-1)
Basic fibroblast growth factor (bFGF)
Transforming growth factor beta 1 (TGF-ß1)
Bone morphogenetic protein

Correct Answer: Transforming growth factor beta 1 (TGF-ß1)

Explanation:

Question 99:

Options:

Five days of intravenous antibiotics for perioperative prophylaxis
Use of continuous passive motion beginning on postoperative day one
Immediate initiation of active flexion and gravity-assisted passive extension
Splinting at 60 to 90 degrees of flexion for 5 to 10 days, followed by initiation of active flexion and gravity-assisted passive extension
Splinting at 60 to 90 degrees of flexion until the triceps has healed, followed by initiation of active flexion and extension

Correct Answer: Splinting at 60 to 90 degrees of flexion for 5 to 10 days, followed by initiation of active flexion and gravity-assisted passive extension

Explanation:

Question 100:

Options:

Recurrent valgus overload (medial collateral ligament sprain)
Posterior lateral rotatory instability
Biceps tendinitis
Medial epicondylitis
Osteochondritis of the capitellum

Correct Answer: Osteochondritis of the capitellum

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

Orthopedic Board Review MCQs: Arthroplasty, Fracture, Hip & Ankle | Part 238

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 238

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index