Orthopedic Board Review MCQs: Knee, Shoulder & Foot/Ankle Arthroplasty | Part 256

A 79-year-old woman reports a history of left leg pain with walking. Her pain is exacerbated with walking and stair climbing, and her symptoms are improved by standing after she stops walking. Lumbar flexion does not provide any significant improvement of the symptoms and sitting does not significantly change symptoms. Her leg pain is worse at night and she obtains relief by hanging her leg over the side of the bed. The neurologic examination is essentially normal.

A patient underwent anterior stabilization of the shoulder 6 months ago, and examination now reveals lack of external rotation beyond 0°. The patient has a normal apprehension sign and normal strength, and the radiographs are normal. Based on these findings, the patient is at greater risk for the development of

A 63-year-old man with type I diabetes mellitus who underwent open forefoot amputation now has a high fever, and an elevated WBC count and blood glucose levels. Repeat laboratory studies the day after surgery show a WBC count of 9,500/mm 3 , a serum albumin level of 1.9 g/dL, and a total lymphocyte count of 1,900/mm 3 . Examination reveals that he is afebrile, and his blood glucose level is now normal. An ultrasound Doppler of the dorsalis pedis artery shows an ankle-brachial index of 0.6. A transcutaneous partial pressure measurement of oxygen at the ankle joint shows a level of 38 mm Hg. What is the best course of action?

Which of the following surgical devices employed for stabilization of the sternoclavicular joint is associated with the highest incidence of life-threatening complications?

A 73-year-old man has stiffness after undergoing primary posterior cruciate ligament-retaining total knee arthroplasty 18 months ago. Extensive physiotherapy, dynamic splinting, and manipulations under anesthesia have failed to result in improvement. Examination reveals range of motion from 30 degrees to 60 degrees of flexion. The components are well fixed, and the evaluation for infection is negative. In discussing the possibility of revision arthroplasty, the patient should be advised that

What is the structure indicated by the letter “A” in Figure A? Review Topic

A 27-year-old woman with Down syndrome has a severe bunion with pain and deformity in the left forefoot. Nonsurgical management has failed to provide relief. She does not use any assistive ambulatory devices. A radiograph is shown in Figure 21. Treatment should now consist of

An otherwise healthy 45-year-old man has a 3-cm subcutaneous mass on his anterior thigh that is presumed to be a lipoma. Removal of the mass is performed in the office of his primary care physician. Pathologic evaluation shows a high-grade malignant fibrous histiocytoma. Staging reveals no evidence of metastatic disease. Management at this time should consist of

Figure 31 is the abdominal radiograph of 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

A 13-year-old girl has had pain in her ankle and difficulty with sporting activities for the past 6 months. Nonsteroidal anti-inflammatory drugs and use of a short leg cast have provided minimal relief. A radiograph and MRI scan are shown in Figures 43a and 43b. What is the next most appropriate step in treatment?

The specificity of intraoperative frozen sections obtained for the evaluation of infected total hip arthroplasty may be improved by

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?

Mirror therapy is indicated for which of the following clinical conditions?

-Figure is the radiograph of a 55-year-old veteran who developed avascular necrosis after a traumatic hip dislocation. He was treated with hemiarthroplasty 10 years ago and also has posttraumatic stress disorder and chronic pain. He has had multiple spinal surgeries and takes 30 mg of methadone daily. He now has severe groin pain and is unable to ambulate. Laboratory studies showed a C-reactive protein level of 0.2 mg/L (reference range, 0-3 mg/L), erythrocyte sedimentation rate of 50 mm/h (reference range, 0-20 mm/h), hip aspiration of 500/mm3 white blood cell count, 50% polynucleated cells, 30%monocytes, and 20% lymphocytes What is the most likely cause of his hip pain?

A 10-year-old boy reports a gradual onset of weakness; however, he is fully ambulatory. History reveals that he has a 17-year-old brother who has just stopped walking because of a similar condition. Laboratory studies show a creatine kinase level of 5,480 IU/L (normal 25 to 232 IU/L), and examination shows a slightly positive Gower sign. What is the most likely diagnosis?

A football player sustains a traumatic anterior inferior dislocation of the shoulder in the last game of the season. It is reduced 20 minutes later in the locker room. The patient is neurologically intact and has regained motion. If the patient undergoes arthroscopic evaluation, what finding is seen most consistently?

A 22-year-old volleyball player has atrophy of the infraspinatus muscle. This deficit is the result of entrapment of what nerve?

A 47-year-old man sustained a degloving injury over the pretibial surface and anterior ankle region in a motor vehicle accident. After debridement and irrigation, there is inadequate tissue for closure of the exposed anterior tibial tendon and tibia. Prior to definitive soft-tissue coverage, management should consist of

Figures 1 and 2 are the radiographs of a 35-year-old right-hand-dominant man who has had progressive right wrist pain for 1 year. There is no history of trauma, and he has had no treatment to date. He reports some pain at rest with limited motion and substantial pain with use. He is currently out of work on short-term disability because of this wrist problem. An examination reveals mild dorsal wrist swelling, decrease wrist range of motion, and decreased grip strength. Contralateral wrist examination findings are normal. What is the most appropriate course of treatment?

A 30-year-old patient underwent open reduction internal fixation of a talar neck fracture 8 weeks ago. His current radiographs demonstrate a subchondral radiolucency of the dome of the talus. What is the next most appropriate course of action?

The condition seen in Figure 60 is attributable to

A 52-year-old man has shoulder pain and stiffness after undergoing a “mini-lateral” rotator cuff repair 6 months ago. Examination reveals that he is afebrile with normal vital signs. There is slight erythema but no drainage from the incision. Range of motion is limited in all planes, and there is weakness with resisted external rotation and abduction. Radiographs show a well-positioned metal implant within the greater tuberosity. Laboratory studies reveal a WBC count of 8,400/ mm 3 (normal 3,500 to 10,500/ mm 3 ) and an erythrocyte sedimentation rate of 63 mm/h (normal up to 20 mm/h). What is the next most appropriate step in management?

What is the most common complication following total disk arthroplasty in the lumbar spine?

Citrate dextrose - anticoagulant used with whole blood during the process of preparation of the PRP before centrifugation. 3,4,5) TGF-beta, IL-8, and PDGF are all proteins released by the platelets upon activation.

Figure 17 shows the radiograph of an 82-year-old right-hand dominant woman who fell while weeding her garden. She has severe right shoulder pain. She is neurovascularly intact. What is the most appropriate treatment? Review Topic

A 42-year-old woman has cervical stenosis and radicular deficits at the C5-6 and C6-7 levels. History reveals that she has smoked one pack of cigarettes a day for 25 years. Because nonsurgical management has failed to provide relief, she is now seeking surgical treatment. After preoperative counseling, it becomes clear that she is not likely to stop smoking. Which of the following surgical procedures should be used?

Figures 9a and 9b show the radiographs of a 28-year-old woman who sustained a head injury and a closed injury, without soft-tissue compromise, to her right lower extremity in a motor vehicle accident. Appropriate management of the foot injury should include

What structure (arrow) is shown in Figure 24?

What is the preferred treatment of displaced distal clavicle fractures in children less than eight years old?

What is the most significant benefit of percutaneous transforaminal lumbar interbody fusion (TLIF) vs open posterior lumbar interbody fusion (PLIF)?

A patient who underwent a high tibial osteotomy (HTO) is now scheduled to undergo total knee arthroplasty (TKA). When compared with a patient undergoing primary TKA without a prior HTO, the patient should be advised to expect a higher incidence of

What is the most common diagnosis in a patient older than age 40 years with a destructive bony lesion?

Suprapatellar intramedullary nailing for tibia fractures when compared to infrapatellar nailing is associated with

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

What is the most likely diagnosis based on the MRI findings shown in Figures 87a and 87b? Review Topic

A B Figures 19a and 19b are the CT scans of an 18-year-old man who was a restrained driver in a rollover motor vehicle collision. What was the primary mechanism of injury?

• The familial occurrence of Legg-Calve-Perthes disease may, in some cases, be attributed to

A 74-year-old man with ankylosing spondylitis falls off a step stool and now has a minimally displaced T10-T11 extension-type fracture. He is initially treated with percutaneous pedicle screw fixation from T8-L1 and has good pain relief. The next day, however, he experiences increased back pain and loss of strength in his lower extremities.

When performing elbow arthroscopy, it is often necessary to evaluate the posterior compartment. When entering the posterior compartment of the elbow, what are the two safest and most commonly used portals? Review Topic

A patient with a cobalt-chromium alloy (Co-Cr) femoral stem has a periprosthetic fracture that is to be fixed with a cable-plate device. The surgeon should make sure that the plate, screws, and cable, respectively, are made of

What is the optimum position of immobilization of the foot and ankle immediately after Achilles tendon repair to maximize skin perfusion?

The parents of a 10-year-old boy with Down syndrome are seeking sports clearance for participation in the high jump at the Special Olympics. He is asymptomatic, and the neurologic examination is normal. The hips and patellae are clinically stable. Radiographs of the cervical spine in flexion and extension show a maximum atlanto-dens interval (ADI) of 6 mm. Based on these findings, what recommendation should be made?

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

Which patient would expect to have the longest implant survivorship after undergoing total elbow arthroplasty (TEA)? Review Topic

An 18-year-old man sustains an injury to his lateral ankle after being kicked while playing soccer. He reports persistent pain on the lateral ankle as well as a popping sensation with attempted ankle dorsiflexion and eversion. Which of the following structures anatomically restrains the retracted structure shown in Figure 12?

The decision to perform fasciotomy of the fingers for a hand compartment syndrome is most appropriately made using

What structure is the primary restraint to inferior translation of the shoulder?

Primary arthrodesis is associated with which outcome when compared to outcomes associated with open reduction and internal fixation (ORIF) without arthrodesis?

A 35-year-old woman who is a recreational runner reports posterior knee pain and tightness in the knee with flexion during running. She denies any history of trauma. Examination reveals normal patellar glide and tilt and no patellar apprehension. Range of motion is 5 degrees to 120 degrees, and quadriceps function and knee ligamentous examination are normal. Radiographs are normal. An MRI scan is shown Figure 18. What is the most likely diagnosis?

below demonstrate the radiographs obtained from a 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 10-year-old girl with a history of an obstetrical brachial plexus palsy has been referred for evaluation. Examination reveals a severe adduction internal rotation contracture of the shoulder and a mild flexion contracture of the elbow. Hand function is normal. Radiographs show mild glenohumeral joint incongruity. To achieve the best functional outcome, management should consist of

Use of long-term (at least 5 years) bisphosphonate medications for osteoporosis is associated with

A 46-year-old man has acute tenderness along the ulnar aspect of the wrist after falling on his outstretched hand while playing basketball. Examination reveals tenderness and mild swelling along the volar ulnar aspect of the wrist. Radiogaphs are shown in Figures 14a through 14c. Management should consist of

Figures 124a and 124b are the radiographs of a 30-year-old man who sustained an ankle injury and has swelling with lateral tenderness. The patient denies any previous ankle injuries. After 6 weeks of rest and use of a removable ankle brace, he continues to have swelling, lateral pain, and popping. An anterior drawer test reveals a solid end point. Recommended treatment should include which of the following?

• The Magnetic resonance imaging signal characteristics of a high-grade soft-tissue sarcoma are best described as

Figure 28 shows an AP radiograph of a 54-year-old woman who underwent lumbar laminectomy and fusion at the L4 and L5 levels with placement of a bone stimulator 8 years ago. She also underwent a left total hip arthroplasty 2 years ago; aspiration of that joint now reveals that it is infected with a gram-positive cocci organism. History is also significant for IV drug use and human immunodeficiency virus (HIV). The patient reports fever, chills, and left flank and abdominal pain. Examination reveals significant pain with resisted left hip flexion and passive hip extension. She also has lumbar hyperlordosis. Which of the following studies would best identify the underlying cause of her infection?

A collegiate football player who sustained an injury to his neck has significant neck pain and weakness in his extremities. Following immobilization, which of the following steps should be taken prior to transport?

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared with a standard parapatellar approach, what is the expected outcome?

..Oncologic outcome for this patient

.A patient is unable to actively externally rotate the shoulder when the arm is placed into 90 degrees of abduction and neutral rotation. This finding is most consistent with a tear of the

What factor is associated with a higher risk of dislocation after total hip arthroplasty?

A 17-year-old javelin thrower reports medial-sided elbow pain and diminished grip strength while throwing. He has decreased sensation in the little and ring fingers of his throwing hand only while throwing. The sensory deficits resolve at rest. Examination of the elbow reveals no instability and full motion. He has a positive Tinel’s sign over the cubital tunnel and a positive elbow flexion test. Radiographs are normal. What is the next most appropriate step in management?

Deep anterior compartment

In patients with displaced radial neck fractures treated with open reduction and internal fixation with a plate and screws, the plate must be limited to what surface of the radius to avoid impingement on the proximal ulna?

Which of the following studies best increases the ability to diagnose femoral neck fractures in patients with femoral shaft fractures?

Risks associated with vertebral compression fractures in the elderly population can be defined by which of the following? Review Topic

A 38-year-old man has an enlarging left paraspinal soft-tissue mass. Based on the MRI scans and biopsy specimens shown in Figures 32a through 32e, what is the most likely diagnosis?

A 28-year-old woman undergoes a closing-wedge high tibial osteotomy (HTO) for medial compartment overload after medial meniscectomy. Postsurgically, she reports improvement in her medial pain and resumes normal activities. About 9 months after her surgery, however, she reports burning pain in the front of her knee with running. Her examination reveals no joint line tenderness, mild pain with patellar compression, and limited patellar glides. What is the most likely cause of her symptoms?

A patient who underwent a total knee arthroplasty for osteoarthritis 18 months ago now reports the sudden development of pain in the ipsilateral knee. Radiographs and examination of the knee are unremarkable. Aspiration of the synovial fluid 3 days later reveals a WBC count of 1,500/mm 3 . The cells consist of 30% neutrophils and 70% monocytes. Culture results will not be available for several days. The patient has not been on antibiotics prior to this point. Based on these findings, what is the most appropriate management?

A 12-year-old boy has had progressive pain and flatfeet for the past year. Pain is increased with weight-bearing activities. Examination reveals that subtalar motion is absent. On standing, the patient has obvious hindfoot valgus and loss of the normal arch bilaterally. Plain radiographs are shown in Figures 43a through 43c, and a CT scan is shown in Figure 43d. What is the most likely diagnosis?

Figures 36a and 36b show the MRI scans of a 15-year-old girl who has had pain and recurrent hemarthrosis in the knee for the past year. Plain radiographs are normal. What is the most likely diagnosis?

The parents of a 13-year-old boy with Down syndrome report that he has an increasing limp and decreased endurance with activities. Lateral flexion-extension radiographs of the cervical spine show no evidence of instability. Examination reveals a right Trendelenburg limp and an obvious limb-length discrepancy. Hip motion is symmetric except for some decreased abduction on the right side. A standing AP radiograph is shown in Figure 20. Management should consist of

A 14-year-old boy is seen for back pain. Radiographic evaluation reveals a grade III isthmic spondylolisthesis. What measurement is most useful in predicting the likelihood of progression?

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? Review Topic

You are asked to evaluate the patient whose current clinical photographs are shown in Figures 46a and 46b following aortic valve replacement 9 days ago. He is currently taking anticoagulation medication. He has no systemic signs of sepsis. What is the best management?

A 49-year-old woman noted pain in her right axilla 1 day after moving heavy furniture. Two weeks later, she now reports persistent numbness and paresthesias along the inner aspect of her upper arm radiating into the ulnar digits. Examination reveals full shoulder motion, tenderness over the first rib, and a decreased radial pulse with the shoulder placed overhead. What is the most likely diagnosis?

A child born with myelomeningocele is expected to be an ambulator with bracing. Examination by the consulting orthopaedic surgeon reveals rigid clubfeet in addition to the neurologic issues. Management should consist of

The parents of a 14-year-old female soccer player are concerned about any future injury. They have been advised that she has the potential to play for the US Olympic team. They are especially concerned about the anterior cruciate ligament (ACL). What should you advise them?

Which of the following is associated with the use of large femoral heads in total hip arthroplasty?

A 17-year-old male soccer player sustains repeated lateral patellar dislocations refractory to physical therapy, bracing, and taping. After a workup including radiographs and MRI, the orthopaedic surgeon considers an isolated tibial tubercle osteotomy (TTO). He plans a 60-degree anteromedialization to address instability and to unload the patellofemoral joint. What is a relative contraindication to this procedure?

A 23-year-old woman has had a 3-year history of snapping and pain in her left hip. She notes that the snapping started while marathon training and is only problematic about 15 minutes into a run. Examination is consistent with a negative Stinchfield, negative logroll, negative flexion abduction/external rotation test (FABER) of the hip; however, she has a positive Ober test as she has difficulty adducting her hip across the midline in the lateral decubitus position. Management consisting of nonsteroidal anti-inflammatory drugs and stretching has failed to improve her snapping. What is the most reliable surgical treatment? Review Topic

A 32-year-old man sustained a closed injury after falling 25 feet from a roof. His ankle and foot are severely swollen. Radiographs and CT scans are shown in Figures 29a through 29d. Initial management should consist of

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

Figure 1 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain?

A 12-year-old girl has had right knee pain for the past 3 months. Radiographs and a coronal T 2 -weighted MRI scan are shown in Figures 10a through 10c. A biopsy specimen is shown in Figure 10d. What is the most appropriate treatment for this lesion?

A 23-year-old woman has had a 14-month history of ankle pain after surgical treatment of multiple injuries resulting from a motor vehicle accident. Weight bearing began 4 months after surgery. The pain occurs with weight bearing and motion, but there is very little pain at rest. She has no pertinent medical history and does not smoke. Figures 23a and 23b show current radiographs. What is the most appropriate surgical option?

A B Figures 18a and 18b are the lumbar spine radiographs of a 72-year-old man with no significant medical history who has had severe back pain for 3 weeks. He denies radiating symptoms, weakness, or numbness when he is seen in the emergency department. He is sent home with a soft corset. At his followup visit he continues to describe significant back pain with activity that is not relieved with oral narcotic mediations. A follow-up CT scan shows a nondisplaced fracture through all 3 columns of the spine. What is the most appropriate treatment?

Figures 45a and 45b show the CT scans of a 41-year-old man who was ejected from a vehicle after a high-speed collision. Examination reveals weak (2/5) toe flexion on the right side, but otherwise he has no voluntary motor function in his lower extremities and no sensation. He has some perianal sensation. He has no other associated injuries and his upper extremities are neurologically intact. Which of the following represents the best treatment option? Review Topic

Following application of a short leg cast, a patient reports a complete foot drop. A compression injury of the peroneal nerve at the fibular neck is confirmed by electrical studies. Which of the following muscles is expected to be the last to recover function during the ensuing months?

A 30 year-old male is involved in a motor vehicle collision and sustains a scapular fracture. In patients with scapular fractures, what other fracture is MOST commonly observed?

What is the main benefit of using metal-backed tibial components in total knee arthroplasty?

Accurate evaluation of the upper portion of the subscapularis muscle is best accomplished with active internal rotation

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

A 27-year-old professional baseball pitcher who underwent arthroscopic olecranon debridement continues to have medial-sided elbow pain during late cocking. Physical examination reveals laxity and pain with valgus stress testing. What is the most likely cause of his pain?

What is the most common neurologic complication following an anterior cervical diskectomy and fusion?

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

An 8-year-old boy reports ankle pain after striking the ground with the medial aspect of his foot while attempting to kick a soccer ball. Radiographs reveal slight distal tibial physeal widening but no other abnormalities. In treating this injury, which of the following associated conditions is most likely present but may be missed without careful evaluation?

A 6-year-old girl sustains an ankle injury after falling on roller blades. An AP radiograph is shown in Figure 68. Treatment should consist of which of the following?

A 54-year-old woman sustains the injury seen in Figures 71a and 71b. The injury involves her nondominant extremity. What should the patient be told regarding her expected outcome?

Figure 6a shows the radiograph of a 50-year-old man who sustained an anterior dislocation of the shoulder. He undergoes closed reduction, and the postreduction radiograph is shown in Figure 6b. Management should now consist of