Orthopedic Board Prep MCQs: Knee Arthroplasty & Revision Surgery | Part 254

What arterial vessel is most prone to injury during posterior iliac crest bone graft harvest?

An orthopaedic surgeon makes an incision on a right knee and realizes that the patient was supposed to have a left total knee arthroplasty. The surgeon should do which of the following?

The incidence of osteosarcoma is highest in what age group?

An active 48-year-old woman has had progressive retrocalcaneal pain for the past 2 years. She reports that an injection into the retrocalcaneal bursa 3 weeks ago provided relief, but she now has swelling and weakness after tripping on the stairs 3 days ago. The Thompson test is positive. A radiograph is shown in Figure 36. What is the next most appropriate step in management?

Which of the following is considered the most common complication of the impaction grafting technique for femoral revision surgery?

Following surgery for an ankle fracture, which of the following is considered the most important factor in achieving a satisfactory outcome? Review Topic

A 14-year-old boy sustains a right leg injury after being thrown from his motorcycle while racing. He reports diffuse right leg pain starting at his knee and proceeding distally to include his foot. After the injury the patient’s mother reports the tibia moving posteriorly then anteriorly while she was supporting the leg. In the emergency department 4 hours after injury, examination reveals a large knee effusion, firm compartments of the leg, a palpable posterior tibialis pulse with a warm, pink foot, and capillary refill of 2 seconds at the toes. His blood pressure is 100/50 mm Hg. Motor examination is intact, but there is decreased sensation in the dorsal first interspace and plantar aspect of the foot. Compartment pressure measurement reveals all four compartments with pressures of 33, 36, 33, and 38 mm Hg respectively. Radiographs are shown in Figure 59a and 59b. The remainder of the skeletal examination is normal. What is the optimal management for this injury?

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

A 26-year-old ballet dancer reports posterolateral ankle pain, especially with maximal plantar flexion. Examination reveals maximal tenderness just posterior to the lateral malleolus, and symptoms are heightened with forced passive plantar flexion. Radiographs are shown in Figures 42a and 42b. What is the most likely cause of the patient’s symptoms?

After humeral head replacement for four-part fractures, what is the most commonly reported difficulty?

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

In providing culturally competent care to a Muslim woman with a cervical spine injury, which of the following most accurately describes the steps a male orthopaedist should take to respect her religious beliefs during his examination?

A 9-year-old child has right groin pain after falling from a tree. Examination reveals that the right leg is held in external rotation, and there is significant pain with attempts at passive range of motion. Radiographs are shown in Figures 43a and 43b. Management should consist of

..The best initial treatment would entail

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

Figure 54 shows the preoperative radiograph of a 45-year-old woman who is considering total hip arthroplasty with her orthopaedic surgeon. What femoral characteristic is a typical concern in this patient?

The most appropriate treatment for this fracture is

A 40-year-old unrestrained passenger reports chest wall pain after a motor vehicle accident. Which of the following structures is most important in preventing the injury shown in Figure 33?

In Dupuytren’s disease, the retrovascular cord typically displaces the radial proper digital nerve of the ring finger in what direction?

• A 25-year-old patient who was wearing a seat belt in the back chair of a car involved in a head-on collision undergoes a laparotomy. During surgery, an injury to the sigmoid colon is identified and treated. Two days later the patient has back pain when sitting in a chair. What is the most likely diagnosis?

Which one of the following lower extremity amputations requires a soft-tissue balancing procedure to prevent deformity following amputation? Review Topic

A 53-year-old man with insulin-dependent diabetes has the ulcer on his heel shown in Figure 9. Radiographs and an MRI scan are consistent with osteomyelitis of the calcaeus, contiguous with the ulcer itself. Arterial flow to the foot is adequate. Management should consist of

What is the most common complication associated with open reduction and internal fixation using a 90/90 plate configuration and olecranon osteotomy for an OTA type C2 distal humerus fracture?

A healthy, active collegiate soccer player returns to your office approximately 10 months after returning to full play and 18 months after undergoing ACL reconstruction with bone-patellar tendon-bone (BTB) autograft. The patient reports landing awkwardly after a jumping for a ball and felt his knee give way. He presents with pain, worse with weight bearing. On physical exam, there is a mild effusion and a grade 2B Lachman. Radiographs are shown in Figure A. What is the likely underlying cause of his current diagnosis? Review Topic

A 24-year-old man who was involved in a high speed motor vehicle accident is transferred for definitive care after having been diagnosed with an acute spinal cord injury from a fracture-dislocation at C6-7. He has a complete C6 neurologic level and it is now approximately 10 hours from his injury. What is the most appropriate pharmacologic treatment at this time?

Figure 51 shows an arthroscopic view of the patellofemoral joint from an inferolateral portal. The arrow points to which of the following structures?

One year after undergoing anterior cervical decompression and fusion, what percentage of patients still have dysphagia?

Figures 5a and 5b show the radiograph and MRI scan of a patient who has severe mechanical neck pain but no neurologic problems. Biopsy and work-up show the lesion to be a solitary plasmacytoma. Treatment should consist of

A child presents with the radiograph shown in Figure A. Which of the following conditions is LEAST likely to be associated with this disorder? Review Topic

A 31-year-old man sustained a closed injury to his arm in a motor vehicle accident 16 months ago. Treatment of the fracture consisted of intramedullary nailing of the humerus. He now reports pain with minimal activities. Clinical examination and laboratory studies suggest no signs of infection. Radiographs are seen in Figures 12a through 12c. Treatment should now consist of

A 19-year-old female field hockey player sustains a right ankle injury last night during a game. The patient is on crutches and reports that she has not been able to put any weight on her right ankle since the injury. She was running alongside with another player when her right ankle “gave out” and she twisted it, falling to the ground. Physical examination reveals discoloration similar to a hematoma and significant swelling around the lateral ankle area. Pain is elicited during palpation of the anterior talofibular ligament. What is the most appropriate course of action for this patient’s condition?

What structure is most at risk with anterior penetration of C1 lateral mass screws?

What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture?

The risk of progression with congenital kyphosis is greatest with which of the following?

What is the most common contracture deformity of the spastic shoulder secondary to a cerebrovascular accident?

Figure 11 shows the radiograph of an 18-year-old soccer player who reports recurrent lateral foot pain after sustaining an inversion injury. History reveals that 6 months ago he had been treated in a non-weight-bearing cast for a fifth metatarsal fracture. Management should consist of

-In zone II flexor tendon lacerations, repairing only 1 slip compared to repairing both slips of the flexor digitorum sublimis results in

• Which of the following rehabilitation methods should be used for the first 24 hours following a blunt injury to the quadriceps musculature to avoid short-term stiffness?

A 25-year-old man has chronic back pain that has been slowly worsening. He has no constitutional symptoms, and he denies any previous medical problems. Examination shows a tall lean build with no objective neurologic findings or skin lesions. Figure 32 shows a T2-weighted sagittal MRI scan. What is the most likely diagnosis?

A 10-year-old girl was thrown over the handlebars of her bicycle and landed directly on her left shoulder. She was treated with a figure-of-8 strap and analgesics. Follow-up examination 2 weeks later reveals that the lateral end of the clavicle is superiorly dislocated relative to the acromion. A radiograph of the shoulder shows calcification lateral to the coracoid process at the level of the acromion, and the clavicle is superiorly displaced. Management should consist of

A 27-year-old professional football player complains of acute onset neck and radiating left arm pain after making a tackle. For approximately 1 week after injury his left deltoid strength was 4/5. An MRI is performed, which demonstrates a C4-5 disc herniation without evidence of cord compression. He was treated with a brief course of oral steroids followed by aggressive physical therapy. At this time he is asymptomatic and his neurologic exam is normal. If the patient returns to professional football play, what is his increased risk of sustaining a catastrophic spinal cord injury? Review Topic

Figure 1 shows the radiograph of a patient who underwent a total knee revision with a posterior stabilized mobile-bearing prosthesis and now has recurrent knee dislocations. What is the most likely cause?

A 15-year-old boy has had pain in the right knee for the past 3 months. He denies any history of trauma. Examination reveals a firm mass in the distal thigh; the remainder of the examination is unremarkable. A radiograph is shown in Figure 24. What further work-up should be completed prior to biopsy?

An otherwise healthy 65-year-old man reports thigh pain of insidious onset. He states that the pain is increased with weight bearing and also occurs at night. He denies any history of cancer. Radiographs are shown in Figures 22a and 22b. A bone scan shows an isolated lesion. CT scans of the chest and abdominal are negative for any other lesions. Initial management should consist of

A 44-year-old man reports persistent left leg pain following a L5-S1 hemilaminotomy and partial diskectomy. Examination shows a grade 4 weakness of the left extensor hallucis longus and a positive left straight leg raise. A radiograph is shown in Figure 1a, and sagittal and axial MRI scans are shown in Figures 1b and 1c. Nonsurgical management consisting of medication, physical therapy, and injections has failed to provide relief. Surgical management should consist of

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

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?

Well-differentiated liposarcomas never have chromosomal abnormalities. Liposarcomas account for approximately 10% to 15% of sarcomas. Some general statements about liposarcomas are listed below:

What is the most common malignant tumor of the foot?

CLINICAL SITUATION Figures 1 through 3 are the radiographs of a 25-year-old man who is brought to the emergency department after a motorcycle collision. He is complaining of isolated knee pain. Examination reveals swelling, popliteal ecchymosis, joint line pain, and limited knee joint motion. His pulses and sensation are normal. Initial surgical management should consist of

A patient with diabetic peripheral neuropathy undergoes a partial first ray amputation for a chronic ulcer beneath the first metatarsal head. The insertion of the anterior tibialis is preserved. The patient has 10 degrees of passive dorsiflexion at the ankle and no other foot deformities or ulcers. Which of the following is considered appropriate shoe wear for this patient?

Porous hydroxyapatite is placed into a bone defect. Incorporation of this bone graft substitute is expected to follow which of the following patterns?

Based on the injury shown on the axial MRI scan of the shoulder in Figure 1, what other pathology should be closely examined for during surgery?

When performing the exposure for an anterior approach to the cervical spine, the surgical dissection should not enter the plane between the trachea and the esophagus and excessive retraction should be avoided to prevent injury to the

A 52-year-old man has had right shoulder pain in the deltoid region that increases at night for the past 2 months. He denies any history of trauma. Examination reveals mild tenderness over the greater tuberosity, and the Neer and Hawkins impingement signs are positive. AP and outlet lateral radiographs are shown in Figures 24a and 24b. Initial management should consist of

-Figures 3a and 3b are the clinical photographs of a 35-year-old man seen 3 months after repair of an acute Achilles tendon rupture. He has no constitutional symptoms and is unable to perform a single heelrise test. The most appropriate treatment is

When performing surgical excision of the lesion shown in the MRI scan in Figure 3, what nerve is most likely at risk?

Alpha fetoprotein (AFP) can be seen in many cancers, but is most commonly seen in hepatocellular carcinomas.

Which of the following clinical findings is most often seen with the MRI scan findings shown in Figures 19a through 19c? Review Topic

Which of the following agents have been shown to reduce the incidence of skeletal events in patients with multiple myeloma?

In the nonsurgical management of posterior tibial tendon dysfunction with flexible deformity, a common strategy is to prescribe an ankle-foot orthosis or a University of California Biomechanics Laboratory (UCBL) orthosis with medial posting. A high patient satisfaction rating and favorable outcome with this nonsurgical management is most likely in which of the following situations?

Passive glycation of articular cartilage results in

A 16-year-old football player is participating in the second session of two-a-day preseason practices. He complains of dizziness and fatigue. He is brought to the sideline by the athletic trainer where examination demonstrates confusion and disorientation. Ambient temperature is 82°F. What would be the next most appropriate step in his treatment?

A 30-year-old woman injured her ankle playing soccer 3 months ago. She now reports popping and pain over the lateral side of her ankle. An MRI scan is shown in Figure 33. What structure needs to be repaired to alleviate the popping?

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?

Dorsal intercalated segment instability (DISI) describes which carpal deformity?

Figure 74 shows the radiograph of an 84-year-old woman who reports severe right knee pain. At the time of total knee arthroplasty, she is found to have gross insufficiency and attenuation of the medial collateral ligament (MCL) complex. Optimal management should consist of

• Following closed reduction for the injury shown in Figures 69a and 69b, treatment should consist of

Which of the following patients has the highest risk of developing recurrent instability after an arthroscopic Bankart procedure for anterior shoulder instability? Review Topic

A 21-year-old college student fell from a balcony and landed on his outstretched right hand. He is seen in the emergency department 4 hours later and reports wrist pain and diffuse hand numbness. The volar forearm compartment is soft and there is no pain with passive finger extension. Radiographs are shown in Figures 25a and 25b. Definitive treatment should consist of

An 18-year-old high school football player exits the field after making a tackle on the opening kickoff. He reports “feeling out of it” and states that he has a headache. He does not recall any loss of consciousness and has no amnesia. He is unable to list the months of the year in reverse order on questioning. He does not return to the game and feels normal at the completion of the game. What is the most sensitive test in assessing deficits after mild traumatic brain injury?

-What leads to muscle hypertrophy?

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

What is the most common problem seen following epiphysiodesis for limb-length discrepancy?

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

Which of the following drawbacks is associated with the Ganz periacetabular osteotomy?

A 70-year-old golfer has pain in her dominant shoulder. She reports that initially the pain was at night but now she is unable to play. Examination reveals weakness in external rotation and shoulder abduction. Radiographs reveal the humeral head articulating with a thin acromion. Management should consist of

Figures  below  demonstrate  the  radiographs  obtained  from  a  35-year-old  woman  with  end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, nonsurgical treatment,  including  weight  loss,  activity  modifications,  and  intra-articular  injections,  has  failed.  Her infection work-up reveals laboratory findings within defined limits. A further work-up reveals elevations in serum cobalt and chromium levels and fluid collections surrounding the hip on MRI  with MARS. Revision THA is recommended. The most common complication following revision of a failed metal-on- metal hip arthroplasty is

A 68-year-old woman with serologically proven rheumatoid arthritis underwent an open synovectomy and radial head resection 10 years ago. She now has severe pain that has failed to respond to nonsurgical management. Examination reveals a flexion arc of greater than 90 degrees. Radiographs are shown in Figures 15a and 15b. What is the most appropriate management?

The anterolateral (Watson-Jones) approach to the hip exploits the intermuscular interval between the

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

• A 15-year-old girl has a thoracic kyphosis that causes mild pain. Examination reveals a sagittal curve measuring 55 degrees and wedging of the eighth through tenth vertebrae. The iliac apophyses are Risser 4. Management should include

A 55-year-old man presents with low back pain that has progressed over the last year. He reports the pain is worse with activity, especially when bending forward and lifting objects. He denies any pain in the buttocks or lower extremities. On physical he has age-appropriate motion in the lumbar spine. He is neurologically intact in the lower extremities. Figure A shows his axial and sagittal T2-weighted MRI scans. A histological sample of this lesion would most likely show Review Topic

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

A 59-year-old man reports moderate shoulder pain and very restricted range of motion after undergoing humeral arthroplasty for osteoarthritis 1 year ago. An AP radiograph is shown in Figure 32. Management should now consist of

Surgical treatment for symptomatic disk herniations is associated with which of the following? Review Topic

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

5 mm of change in the atlanto-dens interval (ADI) between flexion and extension views

positive skin-test response to CSD skin-test antigen; 3) characteristic lymph node lesions; and 4) negative laboratory investigation for unexplained lymphadenopathy. Treatment consists of azithromycin, ciprofloxacin, doxycycline, or multiple other antibiotics, all of which have been used successfully. Radiation therapy and chemotherapy would be reserved for malignant diseases and would not be appropriate in this setting. Treatment is necessary for this infectious entity; therefore, observation or physical therapy is not indicated.