OITE & ABOS Orthopedic Prep: Trauma, Lower & Upper Extremity | Part 246

Figure 1 is the MR image of a high school soccer player who sustained a right knee injury during a game while making a cut toward the ball. He felt a pop and his leg gave way. During physical examination, as the knee is moved from full extension into flexion with an internal rotation and valgus force, you notice a "clunk" within the knee. What is the most likely biomechanical basis for the "clunk"?

A 32-year-old man who sustained a tarsometatarsal (Lisfranc) injury 3 years ago now reports increasing pain in the left foot. Orthotics, nonsteroidal anti-inflammatory drugs, and injections have provided only temporary relief. Examination reveals swelling and tenderness over the tarsometatarsal joints. Radiographs show advanced arthrosis of the first and second tarsometatarsal joints. Management should now include

A 48-year-old woman has knee pain that is worse with weight bearing. She reports no night pain or pain at rest. History reveals that she underwent total knee arthroplasty with cementless components 2 years ago. Examination reveals tenderness along the medial joint line. Figures 12a through 12c show radiographs and a bone scan. What is the most likely cause of the patient’s pain?

A 19-year-old wrestler has numbness along the radial aspect of the forearm after undergoing an open Bankart repair through an anterior deltopectoral approach. Motor weakness would be expected along with what other finding?

A patient with a displaced and comminuted fracture of the radial head and neck also has pain and swelling about the ipsilateral distal radioulnar joint. Which treatment option may exacerbate the wrist disorder?

• Figures 38a & 38b show radiographs of a 40 year old man who underwent a Putti-Platt repair for recurrent dislocations at age 22. He reports increasing pain in the shoulder and limited motion for five years. Examination reveals 130 degrees of elevation and 15 degrees of external rotation. Non-surgical treatment has failed. Treatment should now consist of what?

What type of cementless femoral fixation results in the highest rate of distal femoral osteolysis?

A 7-year-old boy has a limp with pain and tenderness over the distal right femur. Radiographs are shown in Figures 5a and 5b. Based on these findings, what is the best course of action?

A 56-year-old man who tripped and fell out of his golf cart onto his right shoulder 4 days ago now reports mild pain while chipping. Examination reveals mild bruising over the lateral clavicle but good shoulder range of motion and strength. A radiograph is shown in Figure 9. Appropriate treatment at this time should include which of the following?

A 28-year-old woman has a moderate hallux valgus deformity and a prominence of the medial eminence. She can participate in all activities and reports that she could wear 3-inch heels in the past, but she now notes medial eminence pain even while wearing a soft leather flat shoe with a cushioned sole. She requests recommendations regarding surgical correction. Examination reveals a 1-2 intermetatarsal angle of 10 degrees. A clinical photograph and radiograph are shown in Figures 13a and 13b. What is the best course of action?

Myodesis of which muscle group is most important for optimal outcome after transfemoral amputation?

A 7-year-old girl has pain and a mass in the left scapula. A MRI scan and biopsy specimen are shown in Figures 30a and 30b. After staging studies, initial management should consist of

A 22-year-old man who sustained a Gustilo-Anderson grade IIIC open fracture of the right tibia and fibula was treated with an immediate open transtibial amputation. After two serial debridements, he underwent wound closure with a posterior myocutaneous soft-tissue flap. What is the preferred method of early rehabilitation?

Which wear mechanism is most likely responsible for the wear damage on the modular tibial insert retrieval shown in Figure 82?

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

What spinal nerves in the cauda equina are primarily responsible for innervation of the bladder?

A 21-year-old football player reports increasing pain and a deformity involving his chest after colliding with another player during a scrimmage. Imaging studies confirm an anterior sternoclavicular dislocation. Management should consist of

Which of the following is a contraindication to laminoplasty in a patient with cervical spondylotic myelopathy? Review Topic

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

Figures 27a through 27c show the AP radiograph, MRI scan, and biopsy specimen of an otherwise healthy man who has a painful wrist. Serum chemistry studies are normal. What is the most likely diagnosis?

Which laboratory findings would most support a diagnosis of prosthetic joint infection (PJI) in a hip or knee arthroplasty performed 3 weeks ago?

A 29-year-old obese patient is transferred from an outside facility for the management of a closed-head injury and the fracture shown in Figure A. He presents to the trauma bay as a transient responder to blood products, and undergoes urgent pre-surgical angiography embolization. Surgery is performed within 8 hours from the time of injury. The patient develops a deep wound infection 1 week post-operatively. Which of the following factors would be considered the MOST statistically significant predictor for post-operative infection in this patient.

The anterior portal of a hip arthroscopy places what structure at greatest risk for injury?

03 Figure 9 shows the radiograph of a patient who has anterior knee pain and range of motion from 0-of the tibial tubercle. Treatment should consist of

Figures 122a and 122b are the radiographs of a 79-year-old woman with a 2-year history of progressively worsening right hip pain. She had a right total hip arthroplasty 7 years prior. An infection workup is negative. She opts for revision surgery; the most appropriate surgical plan to address her femoral component is

A 45-year-old man is seen in the emergency department after returning from a 2-hour airplane flight. He is reporting severe pain in his right leg but has no trouble moving his ankle, leg, or knee. Venous doppler testing reveals no evidence of deep venous thrombosis. He is placed on IV cephazolin but continues to worsen. On the third day in the hospital he has increased pain, some respiratory distress, and trouble maintaining his blood pressure. His leg takes on the appearance seen in Figure 15. An urgent MRI scan shows thickening of the subcutaneous tissues and superficial swelling in the leg but no evidence of an abscess. What is the next most appropriate step in management?

A 3-year-old boy has hip pain and refuses to walk. His right hip is tender with any range of motion. His temperature is 102.2 degrees F (39.0 degrees C). Laboratory studies reveal the following values: C-reactive protein level of 6.0, WBC count of 19,000/mm3 (normal 3,500 to 10,500/mm3), and an erythrocyte sedimentation rate of 45 mm/h (normal up to 20 mm/h). A hip sonogram demonstrates a large effusion in the right hip. What is the best treatment plan? Review Topic

A 40-year-old woman has had sciatic pain on the left side for the past 8 weeks. She reports that the pain radiates to her posterior thigh, lateral calf, and into the dorsum of her left foot. Neurologic examination shows weakness of the left extensor hallucis longus. Axial T 2 -weighted MRI scans through L4-L5 are shown in Figure 14. Management should consist of

Which of the following studies is considered most sensitive in monitoring a therapeutic response in acute hematogenous osteomyelitis?

3 degrees Celsius and heart rate of 105 bpm. A clinical photograph, results of synovial fluid analysis, and a polarizing microscopy image are seen in Figures A through C. Synovial fluid gram stain and cultures are pending. What is the most appropriate next step in management?

Radiographs of a 12-year-old boy who has knee pain show a 2-cm osteochondral lesion of the lateral aspect of the medial femoral condyle. The fragments are not detached from the femur. Initial management should consist of

A 40 year-old-man was involved in a motor vehicle accident and sustained the pelvic injury seen in Figures 24a and 24b. Definitive management of the injury should consist of reduction by

A B

What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered?

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

A patient presenting with scapulothoracic dissocation and ipsilateral extremity neurologic injury is most likely to have which of the following outcomes?

Radial nerve palsy is most commonly associated with which of the following types of humeral fractures?

A 43-year-old man sustained a closed, intra-articular pilon fracture. It has now been 1 year since he underwent open reduction and internal fixation. Which of the following statements most accurately describes his perceived outcome?

A 35-year-old woman undergoes an L4-5 anterior fusion via a left retroperitoneal approach. Postoperative examination reveals that her right foot is cool and pale. Her neurologic examination is normal, and her pedal pulses are asymmetric. What is the most likely reason for the right foot finding?

A 70-year-old man reports symptomatic medial knee pain that has become progressively worse during the past year. MRI reveals a complex, posterior horn medial meniscus tear with associated medial lateral and patellofemoral cartilage defects. Radiographs reveal medial joint space narrowing and osteophytes in the other compartments. What treatment is most likely to provide long-term, durable relief of symptoms?

A 48-year-old man has had pain and swelling of the hallux metatarsophalangeal joint for the past 9 months. A rocker bottom stiff-soled shoe has failed to provide relief; however, two cortisone injections have temporarily alleviated his symptoms. The radiographs shown in Figures 20a and 20b reveal diffuse arthritis of the entire hallux metatarsophalangeal joint. What is the most definitive surgical treatment?

-Postsurgically, the patient recovers well and is fully rehabilitated. He demonstrates full motion with no instability or pain and is cleared to return to play 12 months after the surgery. He asks for your advice regarding use of a functional brace for playing basketball following his reconstruction. What is the most appropriate recommendation?

A 35-year-old man sustained a 10% compression fracture of the C5 vertebra in a diving accident. Radiographs show good alignment, and examination reveals no neurologic compromise. An MRI scan reveals no significant soft-tissue disruption posteriorly. Management should consist of

When performing a posterior cruciate-substituting total knee revision, trial components are inserted. The knee comes to full extension but is tight in flexion. The surgeon should consider

Figures below show the radiographs, and the CT obtained from a 58-year-old woman who underwent cementless left total hip arthroplasty. Nine months after surgery, she continued to have groin pain when actively flexing her hip. She has trouble walking up stairs and getting out of her car. What is the most likely diagnosis?

A 24-year-old former high school wrestler had anterior cruciate ligament (ACL) reconstruction with hamstring autograft 6 years ago. He now experiences daily instability of his knee with routine activities including walking. Examination reveals a grade 3+ Lachman test with a soft endpoint, varus laxity at 30°, and a positive dial test at 30° that dissipates at 90° of knee flexion. He has mild medial joint line tenderness. When walking, there is a slight varus thrust. What treatment is most likely to lead to a successful outcome?

The flexor hallucis longus tendon is at greatest risk of injury with a lateral-to-medial drill or screw during fixation of what structure?

intermittent PTH injections increase bone mass, 2) continous infusion lead to bone resorption, and 3) dosing should not continue past 2 yrs. Thus, intermittent parathyroid hormone is anabolic to bone and is used as a treatment of osteoporosis (forteo).

Rupture of the structure shown in the axial cross and the sagittal sections in Figures 100a and 100b causes weakness in

Figures below depict the radiographs obtained from a 76-year-old woman with a painful total knee arthroplasty. She describes an uneventful recovery with no wound-healing issues and was pain free for the first 10 years. Although reporting no trauma or inciting event, she now describes pain in the entire knee that is most severe with her first few steps. She has begun to notice night pain and, more recently, constant swelling. What is the most appropriate work-up at this time?

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

A 69-year-old patient with diabetes has had acute-onset back pain and difficulty with ambulation for several hours. Evaluation reveals a temperature of 38.3°C, a white blood cell (WBC) count of 14000/µL (reference range [rr], 4500-11000/µL), C-reactive protein (CRP) level of 120 mg/L (rr, 0.08-3.1 mg/L), erythrocyte sedimentation rate of 130 mm/h (rr, 0-20 mm/h), normal rectal examination findings, and normal sensation to light touch. Motor function testing of the lower extremities reveals 3/5 ankle dorsiflexion and 4/5 plantar flexion strength bilaterally. An MR image reveals a large epidural abscess from L1-5. What is the most appropriate treatment at this time?

A 34-year-old male arrives intubated with a closed head injury to the trauma bay after a motor vehicle accident. After initial hospital workup and resuscitation, he is transferred to the intensive care unit. In addition to multiple systemic injuries, he sustained the closed injury shown in Figure A. Intracompartmental pressure monitoring of the limb measure in a range from 28-30 mm Hg. Which of the following sustained blood pressure measurements would support the treatment of limb fasciotomy? Review Topic 1 110/60 mmHg 2 115/55 mmHg 3 92/64 mmHg

A 25-year-old athletic woman has a 16-week history of left lower-extremity radiating pain in an S1 distribution. MR images obtained by her family physician reveal a large L5-S1 paracentral disk herniation impinging on the left S1 nerve root. You suggest a left-sided L5-S1 microdiskectomy and tell her that when comparing tubular diskectomy and open procedures

Figure below depicts the radiograph obtained from a 30-year-old woman who began having more right than left hip pain during a recent pregnancy. Physical examination reveals increased range of motion with positive flexion abduction and external rotation and flexion adduction and internal rotation as well as pain with external logroll. Assessment of Figure below reveals

An olecranon fracture-dislocation of the elbow in which the fracture line exits distal to the coronoid process is best managed by open reduction and

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

A 22-year-old man sustained a shoulder dislocation while playing collegiate football at age 18. Since that time, he has dislocated the shoulder three more times despite physical therapy. His last dislocation occurred 4 weeks ago while sleeping. What is the most appropriate management for this patient? Review Topic

Which of the following is an FDA approved adjunctive treatment for an acute open tibia fracture being treated with an intramedullary nail?

-What leads to muscle hypertrophy?

A 45-year-old man is seen in the emergency department after returning from a 2-hour airplane flight. He is reporting severe pain in his right leg but has no trouble moving his ankle, leg, or knee. Venous doppler testing reveals no evidence of deep venous thrombosis. He is placed on IV cephazolin but continues to worsen. On the third day in the hospital he has increased pain, some respiratory distress, and trouble maintaining his blood pressure. His leg takes on the appearance seen in Figure 15. An urgent MRI scan shows thickening of the subcutaneous tissues and superficial swelling in the leg but no evidence of an abscess. What is the next most appropriate step in management? Review Topic

A 14-year-old boy is involved in a motor vehicle accident and sustains the injury shown in Figures 18a and 18b. What is the most likely diagnosis? Review Topic

Figures 47a and 47b show the CT scans of a patient who reports persistent pain in the sinus tarsi following a fall. The avulsion fracture fragment remains attached to what ligament?

Which of the following studies has the highest sensitivity and specificity in diagnosis of osteonecrosis of the femoral head?

Which of the following is considered the best measure of the adequacy of resuscitation in the first 6 hours after injury?

A 17-year-old girl who initially presented as a child with multiple skeletal lesions, café-au-lait spots, and precocious puberty now has bone pain. A recent bone scan reveals multiple areas of increased scintigraphic uptake, including bilateral proximal femurs. A radiograph is shown in Figure 19. Besides activity modification, what is the next best line of treatment for decreasing her pain? Review Topic

A 30-year-old man landed on his shoulder in a fall off his mountain bike. An AP radiograph and CT scan are shown in Figures 34a and 34b. Management should consist of

A high school athlete reports the sudden onset of low back pain while performing a dead lift. Examination reveals a lumbar paraspinal spasm and a positive straight leg raising test. The deep tendon reflexes, motor strength, and sensation in the lower extremeties are normal. The radiographs are normal. If symptoms persist for more than a few weeks, management should consist of

-A 75-year-old woman fell at home and sustained the injury seen in Figures 249a through 249c. What is the most appropriate treatment option?

A 37-year-old man pulled his hamstring playing softball 3 weeks ago. The patient had not noted any mass prior to his injury. MRI scans of the posterior thigh are shown in Figures 4a and 4b. Figure 4c shows the biopsy specimen from a needle biopsy. What is the most likely diagnosis?

A morbidly obese 80-year-old woman presents with back pain for 2 months. Sagittal T2-weighted, sagittal T1-weighted, coronal short tau inversion recovery (STIR) images are shown in Figures A through C, respectively. Which of the following statements is true of her diagnosis? Review Topic

Figure 3a is the initial radiograph of a 19-year-old man who sustained a closed clavicle fracture. Figures 3b and 3c show postoperative radiographs. If the patient had been treated nonsurgically, which of the following would most likely occur?

A 20-year-old elite college football player has ecchymosis, swelling, and pain on the lateral side of his foot after a game. Radiographs are shown in Figures 31a through 31c. Management should consist of

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

Which of the following best characterizes the injury shown in Figure 53? Review Topic

Figure 48 shows a current lateral radiograph of a 23-year-old man who sustained a closed femoral diaphyseal fracture 5 months ago. Treatment consisted of placement of a retrograde femoral nail for the femoral fracture. The patient now reports a sudden onset of pain in the midthigh and cannot bear weight on his leg. Management should consist of

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

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

Figures A through C are the radiograph and CT scans of a 42-year-old man who sustained an injury to both of his ankles and underwent surgical repair 2 weeks prior to presentation to your office. One ankle is healing well. On the contralateral side, he reports pain and restricted ankle range of motion. Management should consist of

Figure 22 reveals what anatomic variant of the lumbar spine?

The newborn foot deformity seen in Figures 64a and 64b should initially treated with Review Topic

Figures 1 and 2 are the MRI scans of a 57-year-old man who dislocated his left shoulder after a fall while playing tennis. On examination, he had full passive shoulder range of motion, but he was unable to actively elevate his injured shoulder. Sensation was intact to light touch over the lateral shoulder. What is the most likely etiology of his shoulder weakness?

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?

What neurovascular structure is in closest proximity to the probe in the arthroscopic view of the elbow shown in Figure 50? Review Topic

A 26-year-old man was thrown from a car and sustained the injury seen in Figures 44a and 44b. Nonsurgical management of this injury is recommended. Which of the following factors increases the risk of nonunion?

Figure 20 shows the clinical photograph of a man who has had diabetes mellitus controlled with oral medication for the past 10 years. He wears soft-soled shoes and only uses leather-soled shoes for important business meetings. Examination reveals palpable dorsalis pedis and posterior tibial pulses, although they are somewhat diminished. He is insensate to pressure with the Semmes-Weinstein 5.07 monofilament. The ulcer heals after treatment with a full contact cast. What is the best course of action at this time?

A 45-year-old man underwent unipolar hemiarthroplasty reconstruction using cementless fixation for nontraumatic osteonecrosis of the femoral head 5 years ago. He now reports buttock and groin pain that is associated with loading activities. What is the most likely cause of his pain?

Oxidation of polyethylene after sterilization occurs most rapidly when the implant undergoes

Which of the following best describes the relationship of the anterior tibial artery and dorsalis pedis artery to the extensor hallucis longus (EHL) tendon as they progress from the level of the ankle to the dorsum of the foot?

Varus malalignment after a talar neck fracture with medial comminution causes a decrease in what motion?

A 23-year-old woman falls from a bicycle and sustains a right knee injury. Figures 12a through 12d show radiographs and MRI scans of the knee. What is the most likely diagnosis?

A 27-year-old woman reports the acute atraumatic onset of burning pain in her right shoulder followed a week later by significant weakness and the inability to abduct her shoulder. One week prior to this incident she had recovered from a flu-like syndrome. Examination reveals full passive motion of the shoulder and the inability to actively raise the arm. Sensation in the right upper extremity is normal. Cervical spine examination is normal. Radiographs of the shoulder and cervical spine are normal. What is the most likely diagnosis?

An otherwise healthy 30-year-old man undergoes right shoulder arthroscopic Bankart repair under regional anesthesia using an interscalene brachial plexus block. In the recovery room, he reports mild difficulty breathing and his chest radiograph shows a high riding diaphragm on the right side. His peripheral oxygenation is 97% on 2 liters of oxygen by nasal cannula. What is the most appropriate management?

Nonossifying fibroma

Osteoarthritic cartilage is characterized by decreased

Figure 47 shows the radiograph of a 2-day-old girl who has been referred for swelling and limited use of the right upper extremity. The second of twins, the infant was breech and delivered with forceps at age 38 weeks, weighing 5.37 lb. Difficulty in moving the arm was noted shortly after birth. Examination shows no active motion of the shoulder, elbow, or wrist. Active finger flexion and extension are present. The elbow is mildly swollen, and passive motion shows lack of full extension of 20°, lack of full flexion of 15°, and no restriction of pronation or supination. What is the most likely diagnosis?

A 46-year-old male construction worker has right hip pain that has failed to respond to nonsurgical management. His body mass index (BMI) is 32, he is 6’2” tall, and he has no other medical comorbidities. AP and lateral radiographs of the right hip are shown in Figures 23a and 23b. The patient inquires about his suitability for metal-on-metal hip resurfacing. The patient should be educated that he is at higher risk for failure secondary to which of the following?

Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive quadriceps active test, and normal Lachman test finding. The injured structure is composed of an

Which clinical signs are consistent with the diagnosis of cauda equina syndrome?

Figures 129a through 129b are the radiographs and MRI and CT scans of the lumbar spine of a 10-yearold premenarchal girl who has back pain and scoliosis. What is the most likely etiology of her scoliosis?