Trauma, Hand, Foot & Ankle Orthopedic MCQs - Part 258

About This Board Review Set

This is Part 258 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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Two distinct learning modes are available:

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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 258

This module focuses heavily on: Ankle, Fracture, Wrist.

Sample Questions from This Set

Sample Question 1: A 25-year-old farm worker sustained a grade III open fracture of the midshaft of the left tibia after falling from a ladder. Which of the following antibiotic regimens is best for this patient?...

Sample Question 2: Figure 24 shows an axial MRI scan of the ankle. The arrowhead is pointing to what structure?...

Sample Question 3: -A 50-year-old alcoholic man has erythema and swelling in his entire dominant upper extremity. He has a WBC of 15,000/mm3, a temp of 101 oF (38.3 oC), and a blood pressure of 90/60 mm Hg. After hemodynamic stabilization, the cellulitic fore...

Sample Question 4: An 11-year-old female gymnast has had gradually increasing right wrist pain for the past 6 months. Examination reveals normal range of motion and strength. Moderate tenderness is present over the distal radius. AP radiographs will most like...

Sample Question 5: Which of the following nonunions is appropriately treated with exchange reamed nailing without bone graft augmentation?...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

A 25-year-old farm worker sustained a grade III open fracture of the midshaft of the left tibia after falling from a ladder. Which of the following antibiotic regimens is best for this patient?

Explanation

DISCUSSION: Patients who sustain grade III open fractures that are related to a farm environment require ampicillin or penicillin for Clostridium coverage.
REFERENCES: Holton PD, Mader J, Nelson CL, Osmon DR, Patzakis MJ: Antibiotics for the practicing orthopaedic surgeon. Instr Course Lect 2000;341:36-42.
Wilkins J, Patzakis M: Choice and duration of antibiotics in open fractures. Orthop Clin North Am 1991;22:433-437.

Question 2

Figure 24 shows an axial MRI scan of the ankle. The arrowhead is pointing to what structure?

Explanation

DISCUSSION: The peroneus brevis is easily identified by its location behind the fibula and its distal muscle belly. Axial MRI images provide a reliable guide even when one of the peroneals is completely ruptured, subluxated out of the peroneal groove, or absent.
REFERENCES: Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. New York, NY, Lippincott, 1993, pp 234-235.
Sammarco GJ: Peroneus longus tendon tears: Acute and chronic. Foot Ankle Int

1995;16:245-253.

Question 3

A 50-year-old alcoholic man has erythema and swelling in his entire dominant upper extremity. He has a WBC of 15,000/mm3, a temp of 101 oF (38.3 oC), and a blood pressure of 90/60 mm Hg. After hemodynamic stabilization, the cellulitic forearm is longitudinally incised dorsally and volarly. The forearm muscles are normal in appearance; however, the subcutaneous fat is necrotic. A culture will most likely reveal

Explanation

Necrotizing fasciitis is frequently caused by strep infections. Cellulitis, which is an inflammatory infection of the subcutaneous tissues, is usually due to Staph or Strep infections (Haemophilus is also seen in children). Significant Streptococcal infections include erysipelas, which produces a progressively enlarging red, raised painful plaque, severe toxicity, fever, leukocytosis and bacteremia; Necrotizing fasciitis produces XXXXX. Clostridium perforingens typically causes gas gangrene (which can also develop from gram neg. and strep infections), presenting as progressive pain, distal edema, and a malodorous serosanguinous discharge.

Question 4

An 11-year-old female gymnast has had gradually increasing right wrist pain for the past 6 months. Examination reveals normal range of motion and strength. Moderate tenderness is present over the distal radius. AP radiographs will most likely show

Explanation

DISCUSSION: Distal radial physeal stress syndrome has been reported in up to 25% of nonelite gymnasts showing premature closure of the distal radial physis and distal ulnar overgrowth, producing positive ulnar variance. The diagnosis should be suspected when there is tenderness at the distal radial physis in a young gymnast. The pathology is thought to be the result of repetitive compressive stresses caused by upper extremity weight-bearing forces. The recommended treatment is 3 to 6 months of rest. Salter-Harris fractures with a distal radial epiphyseal slip are unlikely, especially in the absence of a specific traumatic event.
REFERENCES: Mandelbaum BR, Bartolozzi AR, Davis CA, Teurlings L, Bragonier B: Wrist pain syndrome in the gymnast: Pathogenetic, diagnostic, and therapeutic consideration. Am J Sports Med 1989;17:305-317.
Roy S, Caine D, Singer KM: Stress changes of the distal radial epiphysis in young gymnasts: A report of twenty-one cases and a review of the literature. Am J Sports Med 1985;13:301-308.

Question 5

Which of the following nonunions is appropriately treated with exchange reamed nailing without bone graft augmentation?

Explanation

DISCUSSION: Exchange nailing is indicated for nonunions of diaphyseal femoral and tibia fractures in the absence of infection, comminution, or segmental bone loss. Hypertrophic nonunions need better stability (increased nail diameter) to acheive union. Where as atrophic nonunions often need better biology (bone graft, flap coverage, etc.) The referenced article by Brinker et al reviews the indications for exchange nailing. They argue, on the basis of the available literature, that exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral and tibia fractures. Zelle et al. demonstrated 95% success with reamed exchange nailing for the treatment of aseptic tibial shaft nonunions that were initially treated with nonreamed intramedullary nailing.

Question 6

Figure 46 shows the MRI scan of a patient who has a mass in the calf that has been fluctuating in size. Radiographs are negative. Which of the following procedures will most quickly aid in confirming the diagnosis?

Explanation

DISCUSSION: The bright signal on the T2-weighted MRI scan suggests fluid. The multiloculated appearance in proximity to the proximal tibiofibular joint suggests that the most likely diagnosis is a ganglion. They typically increase and decrease in size and can be diagnosed by the classic gelatinous fluid obtained through needle aspiration.
REFERENCES: Bianchi S, Abdelwahab IF, Kenan S, Zwass A, Ricci G, Palomba G: Intramuscular ganglia arising from the superior tibiofibular joint: CT and MR evaluation. Skeletal Radiol 1995;24:253-256.
Feldman F, Singson RD, Staron RB: Magnetic resonance imaging of para-articular and ectopic ganglia. Skeletal Radiol 1989;18:353-358.

Question 7

The MRI scans reveal a root tear of the medial meniscus. Studies demonstrate that this tear pattern greatly increases the tibiofemoral contact forces. These forces, and meniscal extrusion, worsen with increasing flexion. Correct answer : B 69- A 45-year-old postmenopausal smoker with a body mass index (BMI) of 22 has had severe knee pain for the past year. The pain has been progressing and the patient is now only able to perform activities of daily living. Knee radiographs reveal medial compartment osteoarthritis without any involvement of the patellofemoral joint or the lateral compartment. What is the contraindication for a high tibial osteotomy (HTO) in this patient?

Explanation

In an asymptomatic athlete, what condition represents an absolute contraindication to returning to contact or collision sports?
A. Healed one-level anterior cervical fusion
B. Congenital atlanto-occipital fusion
C. Cervical disk herniation previously treated nonoperatively
D. Spina bifida occulta
The one overriding principle regarding the return to any collision sport, as Torg and associates has described, is that the athlete be "neurologically intact, asymptomatic, and pain-free and have full strength and full cervical range of motion". Forces exerted on the cervical spine can be absorbed by the "elasticity of the intervertebral disk, the mobility of the spine itself, and the impact of absorbing capabilities of the cervical paravertebral musculature". The C1 and C2 levels (atlanto-occipital level) control movement of the skull and articulate the large motion movements. Specifically, partial or complete 56
congenital fusion of the atlas to the base of the occiput results in progressive cord compression by the posterior lip of the foramen magnum. It can result in sudden death.
A cervical disk herniation that was previously treated nonsurgically and is not causing cord compression in the currently asymptomatic patient is not a contraindication to return to collision sports. Spina bifida occulta is common (10-20% of healthy individuals). It is typically an incidental finding and does not result in neurologic problems. If individuals have a healed anterior, lateral or posterior disk herniation that is treated nonsurgically and they are currently asymptomatic, then there is no contraindication to participation in contact sports. If they require a diskectomy and fusion and they have a solid/healed fusion, are asymptomatic and neurologically intact with full and pain-free range of motion, then there is no contraindication to return to collision sports. An acute disk herniation, a disk herniation with associated pain or neurologic symptoms, or the presence of cord compression or loss of normal lordosis are all contraindications.
71- 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?
A. Subscapularis tear
B. Supraspinatus tear
C. Superior labral anterior- posterior (SLAP) tear
D. Bankart tear
The axial MRI scan reveals a subluxated biceps tendon. In the study by Koh and associates, 85% of patients with a biceps subluxation on MRI were found to have a subscapularis tear at the time of arthroscopy. These are not always obvious on the MRI, and close inspection of the leading edge/upper border of the subscapularis tendon at the time of arthroscopy is necessary. Although supraspinatus tears, SLAP tears, and Bankart tears can all occur in conjunction with a biceps subluxation, none have been shown to be strongly correlated with this pathology, nor as specific to this pathology.
73- Figures 1 through 4 are the MRI scans of a 24-year-old former collegiate basketball player who injured his left knee while playing recreational basketball 10 days prior to presentation. He landed from a jump awkwardly and reported that his knee gave out. He heard a pop at the time of injury and was unable to continue playing. He complains of medial and lateral knee pain and difficulty with weight bearing. On physical examination, he has a moderate effusion and his range of motion is from 10° to 80°. Ligament examination reveals a 2B Lachman, negative posterior drawer as well as negative varus and valgus stress testing. What is the diagnosis?
A. Meniscus tear
B. Anterior cruciate ligament (ACL) tear
C. ACL tear and posterior cruciate ligament (PCL) tear
D. ACL tear and medial meniscus tear

Question 8

When compared to patients with osteoarthritis, patients with ankylosing spondylitis undergoing total hip arthroplasty can expect a

Explanation

DISCUSSION: Joshi and associates reported a 96% incidence of pain relief in 181 total hip arthroplasties in patients with ankylosing spondylitis. Only 65% of patients had good to excellent functional results, primarily the result of associated systemic diseases and spinal deformity. The incidence of infection was slightly higher, and the incidence of heterotopic ossification was higher in this group of patients.
REFERENCE: Joshi A, Markovic L, Hardinge K, Murphy J: Total hip arthroplasty in ankylosing spondylitis: An analysis of 181 hips. J Arthroplasty 2002;17:427-433.

Question 9

An obese (BMI = 35) 72-year-old woman with diabetes mellitus, hyptertension and a 22-pack-year smoking history is scheduled to undergo posterior spinal fusion from T10 to S1 with a pedicle subtraction osteotomy at L3 for the spinal deformity seen in Figure 1. Which of the following risk factors is most predictive of major complication following surgery Review Topic

Explanation

The patients age (> 60 years) is the most significant risk factor for a major perioperative complication during posterior spinal fusion for adult spinal deformity correction.
The surgical treatment of adult spinal deformity often requires multilevel arthrodesis with complex osteotomies including three column osteotomies such as pedicle
subtraction (PSO) and vertebral column resection (VCR). They can involve both anterior and posterior surgical approaches. Surgical time, blood loss, length of hospital stay, and length of recovery can be greater than it is for the more common degenerative conditions.
Auerbach et al. characterized the risk factors for the development of major complications in patients undergoing 3-column osteotomies for adult spinal deformity correction. They also aimed to determine whether the presence of complications affected the ultimate clinical outcome. They found age > 60 years, > or = 3 comorbid conditions and preoperative sagittal imbalance of = 40mm was associated with a major complication. However, the presence of a major complication did not affect the ultimate clinical outcomes at 2 years or more.
Daubs et al. conducted a retrospective analysis of forty-six patients = 60 years of age who underwent major spinal deformity surgery requiring a minimum 5-level arthrodesis procedure to determine the rate of complication and outcomes. The overall complication rate was 37% and the major complication rate was 20%. Increasing age was a significant factor (p<0.05) in predicting the presence of a complication, while presence of comorbidities was found to have no association.
Figure A is a standing preoperative lateral radiograph of the spine demonstrating a thoracic kyphosis of ~25° and thoracolumbar kyphosis of ~25°. Illustration A demonstrates proper sagittal balance after spinal fusion from T10 to S1 and L3 PSO.
Incorrect Answers:

Question 10

A 17-year-old boy has had elbow pain for the past 6 weeks. A radiograph, MRI scans, and biopsy specimens are shown in Figures 65a through 65e. What is the most likely diagnosis?

Explanation

DISCUSSION: The findings are consistent with an osteoblastoma. The radiographs show a bone-forming lesion of the distal humerus. The lesion has an osseous component extending out of the native cortex with a thin sclerotic border. The T₂-weighted MRI scan shows the lesion extending anteriorly beyond the native cortex. No fluid-fluid levels are seen. Histology shows large osteoblasts producing osteoid and woven bone. The tissue between the spicules of bone and osteoid contains thin fibrous tissue and capillaries. Osteoid osteoma is a smaller lesion usually with sclerotic reactive bone around a small nidus. The histology differentiates osteoblastoma from osteosarcoma because no malignant cells are seen. There is no cartilage production or chondroblasts in the histologic specimen, eliminating chondroblastoma. Giant cell tumors of bone typically occur in a epiphyseal metaphyseal location, most commonly after skeletal maturity, and contain numerus giant cells.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 87-102.
Campanacci M: Bone and Soft Tissue Tumors, ed 2. New York, NY, Springer-Verlag, 1999,

pp 415-433.

Question 11

A 15-year-old boy with a type I hereditary sensory motor neuropathy (Charcot-Marie-Tooth disease) reports recurrent ankle sprains and significant pain in the hindfoot and midfoot despite orthotic management. Examination reveals that he walks with a drop foot and has dynamic clawing of the toes. Clinical photographs of the left foot are shown in Figure 7. Management should consist of

Explanation

DISCUSSION: The clinical photographs show a patient with a type I hereditary sensory motor neuropathy who has cavus feet with a flexible hindfoot. The Coleman block test shows that the hindfoot corrects into valgus. To prevent progressive cavus, patients with this condition may benefit from soft-tissue releases at a younger age while the foot is flexible. Once there is fixed deformity, combined soft-tissue and bone procedures usually are necessary. Metatarsal osteotomies will correct the cavus, but will do nothing for the drop foot. Transfer of the extensor hallucis longus to the neck of the first metatarsal and modified transfer of the extensor digitorum longus to the dorsum of the foot will prevent further claw toes and improve foot dorsiflexion. Anterior transfer of the posterior tibialis tendon will also aid in dorsiflexion. Calcaneal osteotomy should be reserved for fixed hindfoot varus that does not correct with block testing, and triple arthrodesis should be avoided as long as possible because the long-term outcome is poor.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1999, pp 235-245.
Coleman SS: Complex Foot Deformities in Children. Philadelphia, Pa, Lea & Febiger, 1983, pp 147-165.
Thometz JG, Gould JS: Cavus deformity, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992, pp 343-353.

Question 12

Excision of heterotopic bone about the forearm or elbow can be done with limited recurrence rates as early as which of the following after initial injury?

Explanation

DISCUSSION: Excision of heterotopic bone about the elbow and forearm was classically treated once the bone was mature and no further bone development was occuring (bone scan became negative). However, several studies have shown that earlier removal before this point in time is safe, when done in conjunction with radiation therapy (XRT).
The referenced study by McAuliffe et al is a retrospective review of heterotopic ossification (HO) about the elbow followed by 100 cGY (5 fractions over 1 week) of XRT as early as 3 months post-injury. They were able to achieve an average arc of motion > 100 degrees.
The other referenced study by Beingessner et al is a review of HO excision of the forearm. They found that excision and XRT, followed by 6 weeks of indomethacin, led to an increase of forearm motion from an average of 17 degrees to 136 degrees when the excision was done at 4 months post-injury.

Question 13

Figure 10 is an anteroposterior pelvis radiograph of an 82-year-old man who had right hip pain that began 2 weeks ago but has since resolved with use of over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs). Currently he has no pain. Examination of his hip shows decreased internal rotation and minimal pain at the extremes of motion. What is the most appropriate treatment at this point?

Explanation

DISCUSSION
The radiograph shown is consistent with Paget disease of the bone. It demonstrates classic findings of widened lamellae and disorganized sclerotic and lytic areas. The cause is not clearly defined, but may be linked to a viral infection and subsequent alterations of osteoblastic and osteoclastic activity. Most patients are asymptomatic, and Paget disease is often found incidentally on radiographs. In this case, the patient’s symptoms likely were caused by hip arthritis, but Paget disease can cause diffuse bone pain in some cases. Considering the patient’s mild and short-term symptoms, observation and NSAID use is most appropriate. An MRI scan or biopsy is indicated if sarcomatous transformation is suspected, but this condition is rare and is associated with a substantial, unrelenting increase in pain. SPEP and UPEP are tests for multiple myeloma, of which the radiographs show no signs.
RECOMMENDED READINGS
Ralston SH. Pathogenesis of Paget's disease of bone. Bone. 2008 Nov;43(5):819-25. doi: 10.1016/j.bone.2008.06.015. Epub 2008 Jul 11. Review. PubMed PMID: 18672105.View Abstract at PubMed
Bonenberger E, Einhorn T. Metabolic bone diseases. In: Callaghan JJ, Rosenberg
AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams 14
& Wilkins; 2007:514-533.

Question 14

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

Explanation

DISCUSSION: The recurrent laryngeal nerve provides innervation to the vocal cords and was the most common neurologic injury reported in a series of 36,000 patients. The nerve is felt to be more vulnerable during a right-sided approach because of its anatomic course. A recent study has also suggested a role for increased endotracheal cuff pressures in this nerve injury.
REFERENCES: Flynn TB: Neurologic complications of anterior cervical interbody fusion. Spine 1982;7:536-539.
Apfelbaum RI, Kriskovich MD, Haller JR: On the incidence, cause, and prevention of recurrent laryngeal nerve palsies during anterior cervical spine surgery. Spine 2000;25:2906-2912.

Question 15

What patient factor is predictive of better outcomes for surgical management of a displaced calcaneal fracture compared to nonsurgical management?

Explanation

DISCUSSION: A recent randomized trial of surgical versus nonsurgical management of calcaneal fractures showed that patients who were on workers’ compensation did poorly with surgical care. These patients had less favorable outcomes regardless of their initial management. Factors such as age, smoking, and vasculopathies compromise skin healing, leading to greater surgical risks. The best results were obtained in patients who are younger than age 40 years, have unilateral injuries and are injured during noncompensable activities. Women tend to do better with surgery than men.
REFERENCES: Howard JL, Buckley R, McCormack R, et al: Complications following management of displaced intra-articular calcaneal fractures: A prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 2003;17:241-249.
Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.

Question 16

Figures 20a through 20c show the radiographs of a 69-year-old woman who has severe pain in her dominant right arm after falling on the ice. History includes arthritis, hypertension, and heart disease. She is neurovascularly intact. Management should consist of

Explanation

DISCUSSION: The radiographs reveal a severely comminuted distal humerus fracture. A long arm cast, functional bracing, and closed reduction and percutaneous pin fixation all have a poor outcome and could result in a nonunion that will be very difficult to treat. Open reduction and internal fixation is indicated in most supracondylar humerus fractures, but total elbow arthroplasty is a good alternative in elderly patients who have multiple medical problems and when the fracture pattern may preclude stable enough internal fixation to allow postoperative motion.
REFERENCES: Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am 1997;79:826-832.
Morrey BF: Fractures of the distal humerus: Role of elbow replacement. Orthop Clin North Am 2001;31:145-155.

Question 17

The therapeutic effect of etanercept in the treatment of rheumatoid arthritis is primarily mediated through

Explanation

DISCUSSION: Etanercept is a fusion protein that combines the ligand-binding domain of the TNF-α receptor to the Fc portion of human immunoglobulin G (IgG). Protein serves as a competitive inhibitor of TNF-α signaling. COX2 is the target of NSAIDs, including newer formulations that are more COX2-specific. The remaining responses are not direct targets of etanercept.
REFERENCES: Weinblatt ME, Kremer JM, Bankhurst AD, et al: A trial of etanercept, a recombinant tumor necrosis factor receptor: Fc fusion protein, in patients with rheumatoid arthritis receiving methotrexate. N Engl J Med 1999;340:253-259.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 489-530.

Question 18

When placing a percutaneous retrograde pubic rami screw for fixation of an acetabular fracture, which of the following radiographic views can best ensure that the screw does not exit the posterior aspect of the superior pubic ramus?

Explanation

DISCUSSION: As reviewed in the referenced article by Starr et al, when placing a retrograde pubic rami screw, the pelvic inlet iliac oblique view will best determine the anteroposterior placement of the screw in the pubic ramus. To ensure placement outside of the joint, the outlet obturator oblique is best, but all other views should be incorporated into determination of the position of fixation, as the corridor for this screw placement is quite narrow.

Question 19

Figure below shows the radiograph obtained from a 68-year-old man who fell 3 weeks after undergoing a successful left primary total hip arthroplasty. He is experiencing a substantial increase in pain and an inability to bear weight. What is an appropriate treatment plan?

Explanation

DISCUSSION:
The fracture has occurred around the stem, representing a Vancouver type B fracture, and the stem is clearly loose, making it a type B2 fracture. The appropriate treatment is removal of the loose in situ stem; ORIF of the femur using cerclage wires, cables, or a plate; and insertion of a longer revision stem such as a tapered fluted modular titanium or fully porous coated cylindrical stem to bypass the fracture. All of the other options are incorrect, because they represent inappropriate treatment options for a Vancouver type B2 fracture.

Question 20

Figures 1 and 2 show the radiographs obtained from a 56-year-old man who has been experiencing progressive wrist pain since he felt a pop while throwing a 25-pound bag over his shoulder 6 months ago. Failure to address the injury surgically might lead to progressive arthritic changes in what order?

Explanation

EXPLANATION:
This patient demonstrates scapholunate dissociation with an associated dorsal intercalated segment instability deformity. Chronic scapholunate ligament tears lead to scapholunate advanced collapse (SLAC) wrist. Watson and Ballet describe SLAC wrist as having a predictable progression of arthritic changes, starting at the radial styloid, progressing to the radioscaphoid joint, and advancing to the lunocapitate joint. Some authors have described the radiolunate joint as being affected in very late-stage SLAC wrist.

Question 21

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?

Explanation

Heat exhaustion and heat stroke reflect varying degrees of heat illness, with both marked by increased heat production with impaired heat dissipation. Heat exhaustion typically involves a core body temperature between 37°C (98.6°F) and 40°C (104°F) and usually presents with heavy sweating, as well as nausea; vomiting; headache; fainting; weakness; and cold or clammy skin. Fatigue, malaise, and dizziness may occur, but necessary to the diagnosis is normal mentation and stable neurologic status. Heat stroke is defined by a core body temperature >40°C (>104°F) and disturbances of the central nervous system, such as confusion, irritability, ataxia, and even coma. Heat exhaustion is a less urgent scenario and can usually be treated with rest, elevation, and rehydration. Heat stroke, confirmed here by the presence of mental status changes, is a more critical situation. The most important immediate step is rapid body cooling through whatever means are available, as this has been clearly shown to improve outcomes. Ideally, a whole body ice bath would be used, with ice towels, ice packs, cold water, and air fans all utilized if needed. Emergency department transportation and rehydration may be considered as well but are not as important as immediate lowering of body temperature. Anti-pyretics have no role in this process.

Question 22

Failure of high tibial osteotomy (HTO) is most closely associated with which of the following factors?

Explanation

DISCUSSION: Long-term survivorship studies have attempted to clarify patient factors related to good outcomes in HTO. One particular study showed that a patient age of less than 50 years was related to good outcomes in those who had good preoperative knee flexion. The same study found no relation between HTO failure and the presence of postoperative infection or deep venous thrombosis. The presence of a lateral tibial thrust is a contraindication to performing this surgery. As expected, good patient selection is critical to obtaining good long-term results

with HTO.

REFERENCES: Naudie D, Borne RB, Rorabeck CH, Bourne TJ: Survivorship of the high tibial valgus osteotomy: A 10- to 22-year followup study. Clin Orthop 1999;367:18-27.
Rinonapoli E, Mancini GB, Corvaglia A, Musiello S: Tibial osteotomy for varus gonarthrosis: A 10- to 21-year followup study. Clin Orthop 1998;353:185-193.
Coventry MB, Ilstrup DM, Wallrichs SL: Proximal tibial osteotomy: A critical long-term study of eighty-seven cases. J Bone Joint Surg Am 1993;75:196-201.

Question 23

What type of physical therapy is most effective for chronic noninsertional Achilles tendinopathy?

Explanation

DISCUSSION: Eccentric gastrocsoleus strengthening (especially with heavy loads) consistently has been shown to be superior in the management of Achilles tendinopathy. Decreases in pain and increases in strength have been demonstrated despite the frequently refractory nature of this condition.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 91-102.
Vora AM, Myerson MS, Oliva F, et al: Tendinopathy of the main body of the Achilles tendon.

Foot Ankle Clin 2005;10:293-308.

Question 24

A 75-year-old woman reports foot pain and states that her foot has become progressively “flatter” in the past 3 years. Custom inserts and physical therapy have failed to provide relief. Examination reveals a flexible hindfoot and mild heel cord contracture. The patient is able to perform a single limb heel rise. Weight-bearing radiographs are shown in Figures 21a through 21d. What is the most appropriate surgical management?

Explanation

DISCUSSION: The patient has end-stage midfoot arthritis, with a secondary flatfoot deformity through the midfoot. The ability to perform a single limb heel rise indicates that the posterior tibial tendon is functioning, and the weight-bearing radiographs show normal calcaneal pitch and talar head coverage, thus confirming that the flatfoot deformity is isolated to the midfoot. Therefore, the most appropriate treatment is medial column arthrodesis and heel cord lengthening. The other listed procedures are not indicated because they are used in the management of adult flatfoot from posterior tibial tendon insufficiency.
REFERENCES: Toolan BC: Midfoot arthrodesis: Challenges and treatment alternatives. Foot Ankle Clin 2002;7:75-93.
Horton GA, Olney BW: Deformity correction and arthrodesis of the midfoot with a medial plate. Foot Ankle 1993;14:493-499.

Question 25

When reconstructing the anterior cruciate ligament (ACL) with autograft, what is the most common source of surgical failure?

Explanation

Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause for technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. Although graft choice is an important factor when planning an ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position.

Question 26

In Charcot-Marie-Tooth disease a progressive deformity develops in the foot. Which functional muscles predominate in deformity formation?

Explanation

DISCUSSION: In Charcot-Marie-Tooth disease, the posterior tibialis and peroneus longus tendons remain strong, serving to invert the hindfoot and depress the first metatarsal head thus causing the cavovarus foot associated with this disease. In contrast, the tibialis anterior and peroneus brevis are less functional and therefore cannot dorsiflex the ankle, elevate the first metatarsal, or evert the foot, contributing to the deformity.
REFERENCE: Herring JA (ed): Tachjians Pediatric Orthopedics, ed 3. Philadelphia, PA,

WB Saunders, 2002, vol 2, p 984.

Question 27

The use of nonsteroidal anti-inflammatory drugs following femoral nailing has been associated with which of the following?

Explanation

DISCUSSION: The risk of femoral nonunion after intramedullary nailing is significantly increased when NSAIDs are administered post-operatively.
Giannoudis et al assessed factors which could affect union in 32 patients with nonunion of a fracture of the diaphysis of the femur and 67 matched patients whose fracture had united. They found that there was no relationship between the rate of union and the type of implant, mode of locking, reaming, distraction or smoking. They also concluded that there was a marked association between nonunion and the use of NSAIDs after injury and delayed healing was noted in patients who took NSAIDs and whose fractures had united.
Burd et al performed a study to determine if patients with an acetabular fracture, who received indomethacin for prophylaxis against HO, were at risk of delayed healing or nonunion of any associated fractures of long bones. The study group consisted of 112 patients who had sustained at least one concomitant fracture of a long bone; of which 36 needed no prophylaxis, 38 received focal radiation and 38 received indomethacin. When comparing patients who received indomethacin with those who did not, a significant difference was noted in the rate of long bone nonunion (26% vs 7%).

Question 28

A 68-year-old woman with metastatic breast carcinoma is seen in the emergency department. She appears lethargic, and she reports abdominal pain, nausea, and constipation. An EKG reveals a shortened QT interval. The only physical finding on examination is diffuse hyporeflexia. What is the most appropriate step in management?

Explanation

DISCUSSION: Intravenous fluid administration is the best first step to treat the hypercalcemia of malignancy. Many of these patients are dehydrated, and the increased serum calcium impairs the ability of the kidney to concentrate the urine. The decreased glomerular filtration rate secondary to the hypovolemia also leads to increased tubular resorption of calcium. The establishment of normovolemia will help promote increased urinary excretion of calcium. Lasix can also be used to help promote calciuria. Mithramycin is an antibiotic derived from Streptomyces plicatus. It is part of a group of drugs referred to as chromomycin antibiotics and is the only one of this group used clinically in the United States. It is rarely used in cancer chemotherapy because of its toxicity. A number of drug-related deaths have occurred from the use of mithramycin. Its use is now limited to the treatment of hypercalcemia associated with malignancy where it is used in lower dosage than that used for the treatment of tumors. Methotrexate has no role in the treatment of hypercalcemia of malignancy. While intravenous bisphosphonates are helpful in slowing progression of metastases and may help lower cerum calcium, they are not appropriate in the emergent treatment of hypercalcemia in the metastatic cancer patient.
REFERENCE: Stewart AF: Clinical practice: Hypercalcemia associated with cancer. N Engl J of Med 2005;352:373-379.

Question 29

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

Explanation

DISCUSSION: Chronic rotator cuff tears should be nonsurgically managed initially with a strengthening program. A cortisone injection may reduce inflammation. Surgery is reserved for patients who continue to have pain and lose sleep despite the use of physical therapy. Blood tests for infection or inflammation are nonspecific. Arthroscopy may play a role, but surgical replacement is reserved for advanced cases.
REFERENCES: Bokor DJ, Hawkins RJ, Huckell GH, et al: Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop 1993;294:103-110.
Wirth MA, Basamania C, Rockwood CA Jr: Nonoperative management of full-thickness tears of the rotator cuff. Orthop Clin North Am 1997;28:59-67.

Question 30

A 2-year-old child has marked hypotonia and depressed reflexes. History reveals that the child was normal at birth and developed normally for the first year. The child also began to ambulate, but lost this ability during the next 6 months. Laboratory studies show a creatine phosphokinase level that is within the normal range. DNA testing confirms a deletion in the survival motor neuron (SMN) gene. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has spinal muscular atrophy, type 2. This type is intermediate in severity between the Werdnig-Hoffmann type (type 1) and the Kugelberg-Welander type

(type 3). It normally manifests itself between the ages of 3 and 15 months. Survival until adolescence is common. All three types of spinal muscular atrophy have been linked to the SMN gene at the 5q12.2-13.3 locus. DNA testing is available and is preferred to muscle biopsy because it is less invasive and more definitive.
REFERENCES: Biros I, Forrest S: Spinal muscular atrophy: Untangling the knot? J Med Genet 1999;36:1-8.
Zerres K, Wirth B, Rudnik-Schoneborn S: Spinal muscular atrophy: Clinical and genetic correlations. Neuromuscul Disord 1997;7:202-207.

Question 31

A 25 year-old-male presents with the injury seen in Figure A. Which of the following would be a contraindication to closed management with a functional brace?

Explanation

Closed treatment of humeral shaft fractures with functional bracing is indicated in the vast majority of isolated injuries. An ipsilateral brachial plexus injury, however, is a contraindication to nonoperative management in a functional brace.
Indications for operative management of humeral shaft fractures are limited given the high rates of union and ability of adjacent joints to compensate for deformity. Intact muscular tone is necessary to effect bony apposition in closed treatment with a functional brace. The absence of neurologic and muscle function in patients with a flail extremity leads to increased rates of nonunion and malunion.
Rutgers and Ring conducted a retrospective review of patients managed with functional bracing of humeral shaft fractures at a single institution. The authors found a 90% overall union rate, with maintenance of shoulder and elbow motion. They caution though, that 29% of their proximal third fractures went on to nonunion.
Figure A demonstrates an AP radiograph of a comminuted humeral shaft fracture with varus alignment.
Incorrect Answers:

Question 32

The blood supply to the anterior cruciate ligament is primarily derived from what artery?

Explanation

DISCUSSION: Microvascular studies have shown that the majority of the blood supply to the cruciate ligaments comes from the middle geniculate artery, although there is collateral flow through the other geniculates and from bone.
REFERENCES: Arnoczky SP: Blood supply to the anterior cruciate ligament and supporting structures. Orthop Clin North Am 1985;16:15-28.
Arnoczky SP, Rubin RM, Marshall JL: Microvasculature of the cruciate ligaments and its response to injury. J Bone Joint Surg Am 1979;61:1221-1229.

Question 33

A patient is in respiratory distress as a result of a high-speed motor vehicle accident. After emergent intubation, the arterial blood is poorly oxygenated, and examination shows left-sided tracheal deviation, absence of breath sounds on the right side and tympany on percussion over the right side of the chest. Management should include

Explanation

This patient has a tension pneumothorax and needs immediate decompression to convert it to a simple pneumothorax until definitive treatment with a chest tube can be performed. The other choices are inappropriate.

Question 34

A 60-year-old woman reports a painful hip arthroplasty after undergoing surgery 18 months ago. Radiographs show stable cementless implants without signs of ingrowth. Laboratory studies show an erythrocyte sedimentation rate of 50 mm/h. Management should now consist of

Explanation

DISCUSSION: Significant elevation of the erythrocyte sedimentation rate in a patient with a painful hip arthroplasty mandates a complete work-up for infection prior to considering revision surgery. Reproducibility and reliability of ultrasonography as a diagnostic test still needs clarification. Aspiration is the easiest and most cost-effective test and should be performed prior to nuclear imaging. The latter is most valuable if the results are negative, strongly predicting the absence of infection.
REFERENCES: Barrack RL, Harris WH: The value of aspiration of the hip joint before revision total hip arthroplasty. J Bone Joint Surg Am 1993;75:66-76.
McAuley JP, Moreau G: Sepsis: Etiology, prophylaxis, and diagnosis, in Callaghan JJ, Rosenberg AG, Rubash HE (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, pp 1295-1306.

Question 35

What is the most significant prognostic factor in nontraumatic osteonecrosis of the humeral head?

Explanation

DISCUSSION: Use of systemic steroids has been implicated in the development of nontraumatic osteonecrosis of the humeral head. Staging of the disease is most relevant to prognosis and treatment. Cruess has described a widely accepted staging system. Several authors have shown that patients who have a lower stage of disease (ie, stage I or II) have a much less likely chance of progression compared with those who are in the later stages (IV and V).
REFERENCES: Cruess RL: Osteonecrosis of bone: Current concepts as to etiology and pathogenesis. Clin Orthop 1986;208:30-39.
Cruess RL: Steroid-induced avascular necrosis of the humeral head: Natural history and management. J Bone Joint Surg Br 1976;58:313-317.
Rutherford CS, Cofield RH: Osteonecrosis of the shoulder. Orthop Trans 1987;11:239.
Hattrup SJ, Cofield RH: Osteonecrosis of the humeral head: Relationship of disease stage, extent, and cause to natural history. J Shoulder Elbow Surg 1999;8:559-564.

Question 36

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?

Explanation

DISCUSSION: At the ankle level, the anterior tibial artery lies medial to the EHL tendon. The artery becomes the dorsalis pedis after crossing onto the dorsum of the foot. At this point, the artery lies lateral to the tendon.
REFERENCES: Resch S: Functional anatomy and topography of the foot and ankle, in Myerson M (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 1, pp 25-49.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 37

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 38

A 38-year-old woman has a lesion on her left foot that has increased in size over the past 6 months. The clinical photograph is shown in Figure 17a, and a photomicrograph of the biopsy specimen is shown in Figure 17b. What is the most likely diagnosis?

Explanation

DISCUSSION: Melanoma comprises 25% of lower extremity lesions and is the most common malignant tumor of the foot. The preferred treatment is wide resection.
REFERENCES: Hughes LE, Horgan K, Taylor BA, Laidler P: Malignant melanoma of the hand and foot: Diagnosis and management. Br J Surg 1985;72:811-815.
Fortin PT, Freiberg AA: Malignant melanoma of the foot and ankle. J Bone Joint Surg Am 1995;77:1396-1403.

Question 39

Which of the following is considered a specific advantage of using COX-2 inhibitors over COX-1 inhibitors?

Explanation

DISCUSSION: Inflammation is mediated through two isoforms of cyclooxygenase that convert arachidonic acid to prostaglandins. Selectivity, but not specificity, is one of the unique characteristics of this process that has been able to provide more protection from the effects of gastric mucosal alterations using the COX-2 selective inhibitors. The use of COX-1 selective inhibitors is associated with side effects such as ulcerative conditions and platelet interference, both of which have been difficult to control in the past until the advent of the COX-2 inhibitors. PGE₂ inhibition by COX-1 in the intestinal track can then be bypassed, thereby reducing ulceration complications associated with use of nonsteroidal anti-inflammatory drugs.
REFERENCES: Lane JM: Anti-inflammatory medications: Selective COX-2 inhibitors. J Am Acad Orthop Surg 2002;10:75-78.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000.

Question 40

When using highly cross-linked ultra-high molecular weight polyethylene as an articulating surface for total knee arthroplasty, what property of the material raises concern?

Explanation

DISCUSSION: The decreased mobility of the polymer chains from cross-linking leads to decreased volumetric wear but also to decreases in ductility and fatigue resistance. Stresses at the knee are higher and varied in the point of application, leading to the concern for fatigue resistance and fracture.
REFERENCE: Koval KJ (ed): Orthopaedic Knowlegde Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 193-199.

Question 41

A professional pitcher reports pain localized to the medial aspect of his throwing elbow. History reveals that he was pitching in a playoff game and heard and felt a pop in his elbow. MRI reveals a complete ulnar-sided avulsion of the medial collateral ligament (MCL). Examination reveals valgus instability and ulnar nerve involvement. What recommendations should be made based on the patient’s desire to return to sport? Review Topic

Explanation

Injuries to the MCL usually result from repetitive high valgus stress on the medial aspect of the elbow joint due to overhead throwing or racquet sports. Excessive
stresses during the late cocking and acceleration phase of throwing can injure the anterior band of the MCL. Clinically, the injuries may present as chronic or acute, and a pop may be noted in the latter. Associated ulnar nerve involvement is common. Valgus instability is present in about 25% of patients. Patients typically are athletes who participate in throwing and have localized medial elbow pain and tenderness along the course of a ligament that extends from the medial epicondyle of the distal humerus to the sublime tubercle of the ulna. Surgical reconstruction is the procedure of choice in an athlete desiring a return to a high level of throwing.

Question 42

Figures 23a and 23b show the radiographs of a 75-year-old woman who sustained an injury to her nondominant hand. Initial treatment should consist of

Explanation

DISCUSSION: Definitive treatment decisions for displaced distal radius fractures in the elderly are based on a number of factors related to the fracture pattern and patient demographics. The first step in any treatment algorithm is a closed reduction and splinting with reassessment of alignment parameters. This is an extra-articular fracture with dorsal angulation. Low-demand elderly patients can be treated well with accepted minor malreduction.
REFERENCES: Handoll HH, Madhok R: Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;2:CD000314.
Young CF, Nanu AM, Checketts RG: Seven-year outcome following Colles’ type distal radial fracture: A comparison of two treatment methods. J Hand Surg Br 2003;28:422-426.

Question 43

A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals no other injuries. Radiographs are shown in Figures 35a and 35b. Initial management of this fracture should consist of

Explanation

DISCUSSION: The radiographs show a minimally displaced fracture of the tibial eminence, which is classified as a McKeever type II injury. In a number of studies, it has been found that most of these fractures will reduce with extension of the knee. This is often made easier with evacuation of the hemarthrosis. The position of knee immobilization is controversial, with some authors preferring full extension and others preferring 20 degrees of flexion. Flexion to 90 degrees will further displace the fragment. If the fragment does not reduce or if the patient has a McKeever type III or IV injury, reduction and internal fixation are required. This can be done with either an open or an arthroscopic procedure. Excision of the fragment is not indicated.
REFERENCES: Meyers MH, McKeever FM: Fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.
Wiley JJ, Baxter MP: Tibial spine fractures in children. Clin Orthop 1990;255:54-60
Janarv PM, Westblad P, Johansson C, Hirsch G: Long-term follow-up of anterior tibial spine fractures in children. J Pediatr Orthop 1995;15:63-68.
Kuhn JE, Sailer MJ, Sterett WI, Hawkins RJ: Arthroscopic technique for the treatment of tibial spine fractures in the skeletally immature patient. J Ortho Tech 1995;3:7-12.

Question 44

-The center of rotation of the knee can be best described as

Explanation

Question 45

Atraumatic neuropathy of the suprascapular nerve usually occurs at what anatomic location?

Explanation

DISCUSSION: The suprascapular nerve passes through the suprascapular notch and the spinoglenoid notch before innervating the infraspinatus muscle. At both locations, the suprascapular nerve is prone to nerve compression, which often results from a ganglion cyst. The other anatomic locations are not associated with suprascapular nerve impingement.
REFERENCES: Romeo AA, Rotenberg DD, Bach BR: Suprascapular neuropathy. J Am Acad Orthop Surg 1999;7:358-367.
Post M, Mayer J: Suprascapular nerve entrapment: Diagnosis and treatment. Clin Orthop 1987;223:126-136.

Question 46

Examination of a 13-year-old boy with asymptomatic poor posture reveals increased thoracic kyphosis that is fairly rigid and accentuates during forward bending. The neurologic examination is normal. Spinal radiographs show 10 degrees of scoliosis at Risser stage 2, and there is no evidence of spondylolisthesis. A standing lateral view of the thoracic spine is shown in Figure 41. The kyphosis corrects to 50 degrees. Management should consist of Review Topic

Explanation

The radiograph shows excessive thoracic kyphosis (normal 20 degrees to 50 degrees) with multiple contiguous vertebral wedging and end plate irregularity, all consistent with the diagnosis of Scheuermann’s kyphosis. The patient is skeletally immature; therefore, there is the potential for progression of the kyphotic deformity. Extension bracing has shown efficacy in the treatment of Scheuermann’s kyphosis that measures 50 degrees to 74 degrees, and has actually reduced the curvature permanently in some patients. A thoracolumbosacral orthosis may be used if the apex of kyphosis is at T7 or lower. Indications for surgical treatment are controversial, but spinal fusion most likely should not be considered for a painless kyphosis measuring less than 75 degrees.

Question 47

A 39-year-old competitive cyclist sustains an injury to her left hip in a fall. Gadolinium arthrography, with an accompanying MRI scan, is shown in Figure 31. A cleft, or defect, identified by the arrow, indicates a detachment of the

Explanation

DISCUSSION: The area indicated by the arrow represents gadolinium contrast extending into a separation between the lateral labrum and its acetabular attachment. This can be a traumatic detachment, but occasionally a cleft may be present as a normal variant of the labral morphology. The capsular attachment of the iliofemoral ligament is peripheral to the labrum. The pulvinar is the common name applied to the fat and overlying synovium contained within the acetabular fossa above the ligamentum teres. The zona orbicularis is a circumferential thickening of the capsule around the femoral neck, and the retinacular vessels travel within the capsular synovium up the femoral neck to supply the femoral head.
REFERENCES: Petersilge CA, Haque MA, Petersilge WJ, Lewin JS, Lieberman JM, Buly R: Acetabular labral tears: Evaluation with MR arthrography. Radiology 1996;200:231-235.
Czerny C, Hofmann S, Neuhold A, et al: Lesions of the acetabular labrum: Accuracy of MR imaging and MR arthrography in detection and staging. Radiology 1996;200:225-230.
Byrd JWT: Indications and contraindications, in Byrd JWT (ed): Operative Hip Arthroscopy. New York, NY, Thieme, 1998, pp 7-24.

Question 48

Explanation

Rheumatoid synovitis in the cervical spine causes pathologic changes in the ligaments with distention and rupture, articular cartilage destruction, and, in bone osteoporosis, cyst formation, and erosion. The specific deformity caused is dependent on the structure destroyed. The inflammatory cells involved in rheumatoid inflammation have been identified in biopsy specimens at the atlantoaxial junction and reflect the same cell types as found peripherally. Atlantoaxial subluxation is ascribed to erosive synovitis in the atlantoaxial, atlantoodontoid, and atlantooccipital joints as well as the synovium-lined bursa between the odontoid and the transverse ligament. In the figure (fig 10-1) contained in the text there are flexion and extension views depicting a widening of the space between the odontoid and the posterior aspect of the anterior ring. Atlantoaxial impaction (upward translocation of the odontoid, pseudobasilar invagination, cranial settling, vertical subluxation) describes the settling of the skull on the atlas and the atlas on the axis, resulting from erosion and bone loss in the occipitoatlantal and atlantoaxial joints. In the figure (10-2) Atlantoaxial impaction is seen on a lateral x-ray. The dens is noted above the clivus and is circumferentially eroded by synovitis. The ring of the atlas lies low on the body of C2.
In the context of viewing a lateral cervical spine to evaluate cranial setting, multiple lines can be used to assess anatomic relationships (i.e. McRae’s Chamberlin’s, or McGregor’s) McRae’s and Chamberlin’s use the foramen magnum as one land mark. Commonly, however, the margins of the foramen magnum are difficult to precisely identify. McGregor’s line connects the posterior margin of the hard palate to the most caudal point of the occiput and is easier to use. The tip of the odontoid should not project more than 4.5 mm above this line.
Anterior subluxation of more than 10-12 mm implies destruction of the entire ligamentous complex.
An atlantoaxial distance greater than 3.5mm is considered abnormal in an adult. The subaxial cervical spine is affected through involvement of the facets, interspinous ligaments, and intervertebral discs (spondylodiscitis). The initial site of destruction has been postulated to be through synovitis of the neurocentral joints with erosion of the adjacent disc and bone causing subluxation, or through primary facetal arthritis and ligamentous laxity causing secondary chronic discovertebraltrauma and destructive hypermobile segmentsis associated with disc destruction and toward the C2-C3 and C3-C4 segments, typically lack osteophytes, and often are at multiple levels, giving a stepladder appearance.

Question 49

Which of the following is the primary mechanism of polyethylene wear in the hip?

Explanation

DISCUSSION: Although previous theories on acetabular wear implicated fatigue cracking and delamination as primary wear mechanisms, these have actually manifested as major modes of polyethylene wear in knees. The primary mechanism of wear in polyethylene acetabular components appears to be adhesion and abrasion. In an analysis of 128 components retrieved at autopsy or revision surgery, wear appeared to occur mostly at the surface of the components and was the result of large strain plastic deformation and orientation of the surface layers into fibrils that subsequently ruptured during multidirectional motion. It was also shown conclusively that 32-mm heads displayed significantly more wear (volumetric wear) than either 22-mm or

26-/28-mm heads (1-mm increase in size increased volumetric wear by 10%). The wear at the articulating surface was characterized by highly worn polished areas superiorly and less worn areas inferiorly separated by a ridge. Abrasion was very common, occurring after adhesion and plastic deformation of polyethylene fibrils, and abrasion secondary to third-body wear. Wear rates decreased with longer survival of components, indicating a “bedding in” phenomenon, arguing against oxidative and fatigue wear. Crevice corrosion occurs in fatigue cracks with low oxygen tension (under screw heads, etc). Oscillatory fretting consists of cyclical abrading of the outer surface from small movements. Fatigue and delamination is predominant in total knee arthroplasty where stresses are maximum just below the surface of the polyethylene component, causing fatigue over time with subsequent delamination. In contrast, hip wear occurs primarily at the surface of the polyethylene component.
REFERENCES: Jasty M, Goetz DD, Bragdon CR, et al: Wear of polyethylene acetabular components in total hip arthroplasty: An analysis of one hundred and twenty-eight components retrieved at autopsy or revision operations. J Bone Joint Surg Am 1997;79:349-358.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 47-53.
Bell CJ, Walker PS, Abeysundera MR, et al: Effect of oxidation on delamination of
ultrahigh-molecular-weight polyethylene tibial components. J Arthroplasty 1998;13:280-290.
Sutula LC, Collier JP, Saum KA, et al: The Otto Aufranc Award: Impact of gamma sterilization on clinical performance of polyethylene in the hip. Clin Orthop 1995;319:28-40.

Question 50

This image represents the end stage of an uncompensated rotator cuff tear.

Explanation

DISCUSSION
Axillary lateral and anteroposterior (AP) images of the right shoulder (Figures 59c and 59d) reveal osteoarthrosis of the glenohumeral joint, which typically is not associated with significant rotator cuff pathology. An examination often shows limitations in range of motion, crepitance, and pain with motion. An AP radiographic image of the right shoulder (Figure 59b) reveals proximal humeral migration, which normally correlates with rotator cuff tear size. Tears extending into the infraspinatus tendon are associated with more humeral migration than is seen with isolated supraspinatus tears. Presenting complaints are usually of pain and weakness. Examination findings include subacromial crepitance and weakness during rotator cuff testing. Rarely, this may be associated with pseudoparalysis in large uncompensated rotator cuff tears. The CT image of the right shoulder (Figure 59a) shows superior migration of the humerus with respect to the glenoid surface and end-stage
degenerative changes at the glenohumeral joint. These changes are classified as rotator cuff arthropathy. Pain and weakness are common, as is the presence of pseudoparalysis and limited range of motion.
RECOMMENDED READINGS
Kelly JD Jr, Norris TR. Decision making in glenohumeral arthroplasty. J Arthroplasty. 2003 Jan;18(1):75-82. Review. PubMed PMID: 12555187. View Abstract at PubMed
Keener JD, Wei AS, Kim HM, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am. 2009 Jun;91(6):1405-13. doi: 10.2106/JBJS.H.00854. PubMed PMID:

Question 51

The vessel seen in the clinical photographs shown in Figures 50a and 50b (1,2 intercompartmental supraretinacular artery) is being dissected to be used as a source of vascularized bone graft for a patient who is scheduled to undergo internal fixation of a scaphoid nonunion. This vessel is a branch of what artery?

Explanation

DISCUSSION: The 1,2 intercompartmental supraretinacular artery is a branch of the radial artery. The vessel provides a reliable source of vascularized bone graft with an adequate pedicle length for use in scaphoid nonunions.
REFERENCES: Sheetz KK, Bishop AT, Berger RA: The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts. J Hand Surg 1995;20:902-914.
Steinmann SP, Bishop AT, Berger RA: Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg

2002;27:391-401.

Question 52

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?

Explanation

DISCUSSION:
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

Question 53

When performing the exposure for an anterior approach to the cervical spine, excessive retraction of the trachea and esophagus should be avoided to prevent injury of the

Explanation

DISCUSSION: The recurrent laryngeal nerve lies between the trachea and the esophagus and is subject to stretch injury if excessive retraction is applied. The vagus nerve lies in the carotid sheath. The sympathetic trunk lies anterior to the longus colli muscles. The hypoglossal nerve and superior laryngeal nerve are both at risk during the exposure but are not located between the trachea and esophagus.
REFERENCES: An HS: Principles and Techniques of Spine Surgery. Baltimore, MD,

Williams and Wilkins, 1998, chapter 2.
Flynn TB: Neurologic complication of anterior cervical interbody fusion. Spine 1982;7:536-539.

Question 54

Figures below show the radiographs obtained from an 86-year-old-woman who has had chronic left hip pain for several years. She now uses a walker and a wheelchair for ambulation. She is medically healthy. What is the most appropriate surgical intervention?

Explanation

DISCUSSION:
This 86-year-old woman has poor bone quality and osteoarthritis of the left hip. Her lateral radiograph confirms Dorr type C bone quality. A hybrid left THA with a cemented femoral stem would be the treatment of choice.

Question 55

A 56-year-old woman presents with left hip pain and diminishing range of motion. Examination reveals pain with range of motion of the hip. Radiographs reveal multiple calcific lesions within the hip and well-preserved joint space. MRI scan shows thickened synovium nodular loose bodies with decreased signal on T1 and T2. What is the best next step?

Explanation

Figures 1 through 3 show the radiographs obtained from an 86-year-old- woman who has had chronic left hip pain for several years. She now uses a walker and a wheelchair for ambulation. She is medically healthy. What is the most appropriate surgical intervention?

Question 56

..Figures 83a and 83b are the radiographs of a 53-year-old otherwise healthy homemaker who had a syncopal episode and sustained a ground-level fall and injury to her right elbow. She presently admits to right elbow pain, swelling, and an inability to bend her elbow. What is the best initial treatment for this injury?

Explanation

He did not have an engaging Hill-Sachs lesion, the rotator cuff was unremarkable, and the capsule was not torn from the humerus. After surgery, he did well for 6 months until he jumped into a lake and again dislocated his shoulder anteriorly. He says his shoulder no longer felt stable after his reduction.

Question 57

A B Figures 45a and 45b are the CT and MR spine images of an 82-year-old man who has a history of ankylosing spondylitis falls onto his back. He has no neurologic deficits upon examination in the emergency department. What is the most appropriate next step?

Explanation

DISCUSSION
Spinal fractures in patients with ankylosing spondylitis are unstable and generally necessitate surgical intervention. In a patient with a spinal fracture in the setting of ankylosing spondylitis, posterior instrumented fusion is an appropriate surgical procedure. Treatment with a thoracolumbar orthosis is not an option for patients with extension distraction injuries in the setting of an ankylosed spine because of risk for displacement. Similarly, simply checking upright radiographs is generally not advocated. Laminectomy alone is inappropriate for this patient because there is no cord compression and neurologic symptoms are absent. Stabilization is the treatment goal.
RECOMMENDED READINGS
Braun J, Sieper J. Ankylosing spondylitis. Lancet. 2007 Apr 21;369(9570):1379-90. Review. PubMed PMID: 17448825.View Abstract at PubMed
Caron T, Bransford R, Nguyen Q, Agel J, Chapman J, Bellabarba C. Spine fractures in patients with ankylosing spinal disorders. Spine (Phila Pa 1976). 2010 May 15;35(11):E458-64. doi: 10.1097/BRS.0b013e3181cc764f. PubMed PMID: 20421858. View Abstract at PubMed Finkelstein JA, Chapman JR, Mirza S. Occult vertebral fractures in ankylosing spondylitis. Spinal Cord. 1999 Jun;37(6):444-7. PubMed PMID: 10432265. View Abstract at PubMed Hitchon PW, From AM, Brenton MD, Glaser JA, Torner JC. Fractures of the thoracolumbar spine complicating ankylosing spondylitis. J Neurosurg. 2002 Sep;97(2 Suppl):218-22. PubMed PMID: 12296682. View Abstract at PubMed

Question 58

A woman injures the metacarpophalangeal (MCP) joint of her thumb while skiing. Examination reveals tenderness along the ulnar aspect of the MCP joint. Radially directed stress of the joint in full extension produces 5° of angulation. When the MCP joint is flexed 30°, a radially directed stress produces 45° of angulation. Radiographs are otherwise normal. Management should consist of

Explanation

DISCUSSION: Injuries to the ulnar collateral ligament of the MCP joint of the thumb commonly occur in recreational skiers. Historically, this injury has been referred to as “gamekeeper’s thumb.” The ligament consists of the proper collateral ligament and the more volar accessory collateral ligament. In extension, the accessory ligament is taut, and in flexion, the proper ligament is taut. For a complete tear of the ligament complex to occur, there must be laxity in full extension. Incomplete tears respond well to thumb spica splinting or casting for 2 to 3 weeks and gradual resumption of range of motion. Prolonged immobilization of incomplete injuries leads to higher rates of MCP joint stiffness.
REFERENCES: Stener B: Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb: A clinical and anatomical study. J Bone Joint Surg Br 1971;44:869.
Heyman P: Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint.

J Am Acad Orthop Surg 1997;5:224-229.

Question 59

A 14-year-old female has anal hemorrhoids. The General Surgical team has asked for a consultation in regards to her history of hand, wrist, and ankle joint pain and swelling over the past 3 years. Her physical examination reveals a swollen left wrist, right knee and left ankle. Lab work shows low hemoglobin, low albumin, elevated erythrocyte sedimentation rate (ESR), elevated antinuclear antibody (ANA) count, and a negative rheumatoid factor. Radiography of the affected joints are normal. What additional work up is required prior to her rectal surgery? Review Topic

Explanation

This patient has a diagnosis of Juvenile Idiopathic Arthritis (JIA). Flexion-extension c-spine radiographs should be ordered to rule out atlantoaxial instability prior to surgery.
JIA is a persistent autoimmune inflammatory arthritis lasting more than 6 weeks in a patient younger than 16 years of age. Serologic testing for this condition will usually show elevated ESR/CRP, low hemoglobin, low albumin and an elevated anti-nuclear antibody (ANA) count, as well as negative rheumatoid factor and positive HLA-B27. Radiographs of the c-spine should be considered in patients undergoing intubation as cervical kyphosis, facet ankylosis, and atlantoaxial subluxation is associated with this condition.
Punaro et al. reviewed rheumatologic conditions in children. The typical patient with
oligoarticular JIA is a white female (5:1, F:M), with a peak onset between ages 1 and 3 years. Nearly half of patients have monoarticular involvement, with the knee and ankle being most commonly involved. Uveitis is typically chronic, bilateral, and asymptomatic.
Borchers et al. reviewed juvenile idiopathic arthritis (JIA). They state that no laboratory test can conclusively establish a rheumatic diagnosis. They state that laboratory tests will be negative for systemic inflammation and antinuclear antibody (ANA) test has no use in screening for JIA, as it has a high false positive rate.
Incorrect Answers:

Question 60

Figures A-C are images of a 37-year-old man who presents with isolated muscle atrophy due to a compressed nerve. Which of the following sequences correctly describes the pathway of this nerve through the brachial plexus, before it innervates the affected muscles?

Explanation

Figures A-C shows atrophy of teres minor and deltoid due to compression of the axillary nerve. The correct pathway of the axillary nerve within the brachial plexus is, C5-C6 nerve roots; upper trunk, posterior division, posterior cord.
Quadrilateral space syndrome is a condition defined by axillary nerve, +/- posterior humeral circumflex artery compression in the quadrilateral space. It most commonly affects the dominant shoulder in overhead movement athletes (e.g. basketball players) or other throwing athletes. Physical examination may reveal weakness with the arm positioned in abduction and external rotation. In situations of long-standing compression, there may also be atrophy of the teres minor and deltoid muscle.
Chafik et al. dissected thirty-one cadaveric human shoulders to describe the neuromuscular anatomy of teres minor. They showed that the primary nerve branch to teres minor travelled in a fascial sling 44 mm medial to the muscular insertion. This
area may be the potential site of greatest compression and tethering of this nerve in patients with isolated teres minor atrophy.
Friend et al. performed a cadaveric dissection of nine shoulder specimens to look at the anatomical variability in course, length and branching pattern of both the teres minor nerve and the axillary nerve. These were compared to a case-based study of these two male patients with isolated atrophy of teres minor. They concluded that there is no good anatomical predictor of nerve compression outside the quadrilateral space as there is considerable anatomical variation in its origin and course, as well as potential site of compression.
Figure A-C are MRI images that show atrophy of the teres minor muscle and possibly deltoid muscle. The rotator cuff muscles are labeled in Illustration A. The teres minor muscle is labeled in Illustration B. Illustration C shows a diagram of the brachial plexus.
Incorrect
1:
This
describes
the
musculocutaneous
nerve.
3:
This
describes
the
suprascapular
nerve.
4:
This
describes
the
long thoracic
nerve.

Question 61

What is the primary intracellular signaling mediator for bone morphogenetic protein (BMP) activity?

Explanation

DISCUSSION: BMPs signal through the activation of a transmembrane serine/threonine kinase receptor that leads to the activation of intracellular signaling molecules called SMADs. There are currently eight known SMADs, and the activation of different SMADs within a cell leads to different cellular responses. The other mediators are not believed to be directly involved with BMP signaling.
REFERENCES: Lieberman J, Daluiski A, Einhorn TA: The role of growth factors in the repair of bone: Biology and clinical applications. J Bone Joint Surg Am 2002;84:1032-1044.
Li J, Sandell LJ: Transcriptional regulation of cartilage-specific genes, in Rosier RN, Evans C (eds): Molecular Biology in Orthoapedics, Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 21-24.
Zuscik MJ, Drissi MH, Reynolds PR, et al: Molecular and cell biology in orthopaedics, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006,

in press.

Question 62

Which of the following anatomic changes is observed as part of the normal aging process of the adult spine?

Explanation

DISCUSSION: The primary change that takes place in the aging spine is degeneration of the lumbar disks and loss of the overall lumbar lordosis. This also may be associated with osteopenic-related compression fractures. With these changes, the sagittal vertical line moves anteriorly relative to the sacrum; cervical scoliosis is uncommon and not part of the normal aging process. Overall kyphosis in the thoracic spine gradually increases, but the coronal balance remains essentially the same unless scoliosis develops.
REFERENCES: Gelb DE, Lenke LG, Bridwell KH, et al: An analysis of sagittal spinal alignment in 100 asymptomatic middle and older aged volunteers. Spine 1995;20:1351-1358.
Vedantam R, Lenke LG, Keeney JA, et al: Comparison of standing sagittal spinal alignment in asymptomatic adolescents and adults. Spine 1998;23:211-215.

Question 63

In infantile idiopathic scoliosis, which of the following factors suggests progression?

Explanation

DISCUSSION: Infantile idiopathic scoliosis occurs more commonly in boys, with a 3 to 1 male to female ratio. Neural axis abnormalities, hip dysplasia, and congenital heart disease are all associated with the condition; spontaneous correction frequently occurs. Curve progression can be predicted by the rib vertebral angle difference or the phase of the rib head. Rib overlap of the apical vertebral body or a rib vertebral angle difference of greater than 20 degrees indicates that the curve is likely to progress. Gender, family history, and age at presentation have not been found to be risk factors for progression.
REFERENCES: Mehta MH: The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. J Bone Joint Surg Br 1972;54:230-243.
Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, p 697.

Question 64

Following operative repair of lower extremity long bone and periarticular fractures, what is the time frame for patients to return to normal automobile braking time?

Explanation

DISCUSSION: According to the first referenced study by Egol et al, appropriate braking time returns at a point 6 weeks after initiation of weightbearing after treatment of lower extremity long bone and periarticular fractures, as examined with a driving simulator. No differences were seen in return of braking time between periarticular fractures and long bone injuries.
The second reference by Egol studied only operatively treated ankle fractures and found that time to appropriate braking returns at 9 weeks postoperatively. Interestingly, no significant association was found between the functional scores and normalization of total braking time.

Question 65

Figure 22 reveals what anatomic variant of the lumbar spine?

Explanation

DISCUSSION: Unilateral sacralization of the fifth lumbar vertebra was first described by Bertolotti in 1917. Bertolotti’s syndrome is present in 12% to 21% of the population. The altered biomechanics have been postulated to cause low back pain by placing increased stress on the adjacent cephalad disk, thus contributing to accelerated degenerative disk disease at this level. It has also been found that the neoarticulation between the enlarged transverse process and the sacrum and/or ilium may be a source of neural impingement on the exited L5 nerve root and results in radicular pain syndrome. Brault and associates reported on a case treated surgically at the Mayo Clinic, in which the pain generator was found to be the contralateral facet joint.
REFERENCES: Brault JS, Smith J, Currier BL: Partial lumbosacral transitional vertebra resection for contralateral facetogenic pain. Spine 2001;26:226-229.
Quinlan JF, Duke D, Eustace S: Bertolotti’s syndrome: A cause of back pain in young people.

J Bone Joint Surg Br 2006;88:1183-1186.
Whelan MA, Feldman F: The variant lumbar pedicle. Neuroradiology 1982;22:235-242.

Question 66

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?

Explanation

DISCUSSION: The radiographs reveal nonunion of a talar neck fracture. There is no radiographic evidence of osteonecrosis or significant degenerative arthritis. The results of talectomy are suboptimal. Arthrodesis would be indicated for degenerative arthritis. Revision ORIF is feasible and preserves motion. A vascularized graft should be considered whenever osteonecrosis is present, but the talar body appears viable in this case.
REFERENCES: Calvert E, Younger A, Penner M: Post talus neck fracture reconstruction.

Foot Ankle Clin 2007;12:137-151.
Migues A, Solari G, Carrasco NM, et al: Repair of talar neck nonunion with indirect corticocancellous graft technique: A case report and review of the literature. Foot Ankle Int 1996;17:690-694.

Question 67

In a patient with a major head injury and a femoral shaft fracture, intraoperative hypotension during femoral fixation has been associated with which of the following?

Explanation

DISCUSSION: Hypoxia and hypotension are associated with lower GCS scores in polytrauma patients with major head injuries, but whether early fracture fixation adversely affect CNS outcomes has been controversial. New studies, however, have found no association between early surgery and decreased discharge GCS scores. The referenced study by Scalea et al reviewed 171 patients with pelvic or lower extremity fractures and head injuries; they showed no difference in CNS outcomes or mortality in patients who underwent early fixation. The second reference by Brundage et al showed improved outcomes (including high GCS scores at time of discharge) in those who had early fixation of femoral shaft fractures in the head-injured patient. The last referenced study by Jaicks et al found a lower discharge GCS in the early fracture fixation group compared with the late group. However, they also found that early fracture fixation was associated with hypoxemia and hypotension, as well as greater fluid administration.

Question 68

All of the following indicators of resuscitation may be within normal limits for a trauma patient that is in "compensated" shock EXCEPT:

Explanation

DISCUSSION: Historically, normal blood pressure, heart rate, and urine output have been endpoints to signal complete resuscitation in the polytrauma patient. The review article by Porter et al states that there is a high incidence of patients (as much as 85%) in "compensated" shock despite normal vital signs and urine output parameters. Compensated shock is secondary to a maldistribution of blood flow and tissue oxygenation as splanchnic organs have less distribution of the cardiac output compared to the heart and the brain. The article by Elliott is also a review, and it states that serum lactate is the best indicator of peripheral organ perfusion and tissue oxygenation. It also states that base deficit and gastric mucosal pH are appropriate end points to determine the complete resuscitation of trauma patients.

Question 69

The palmar cutaneous branch of the median nerve (PCBMN) originates from the

Explanation

DISCUSSION: The PCBMN originates from the median nerve proper between 3 and 21 cm proximal to the wrist with moderate variation. It virtually always originates from the radial side of the nerve and travels distally with the median nerve, radial to the palmaris longus, and ulnar to the flexor carpi radialis.
REFERENCES: Hobbs RA, Magnussen PA, Tonkin MA: Palmar cutaneous branch of the median nerve. J Hand Surg Am 1990;15:38-43.
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,

p 52.

Question 70

A 9-year-old boy is injured while playing soccer. His examination reveals painful range of motion between 5° and 75°. There is tenderness on the medial side of his knee. There is no effusion, a grade 1A Lachman test, and severe pain over the medial epicondyle of the knee. Varus stress is negative and pain is elicited with valgus stress. Initial radiographs were negative for abnormality. What is the most likely area of injury?

Explanation

This patient likely has a physeal injury to the distal femoral physis. Stress radiographs or an MRI scan will most reliably reveal this diagnosis. The growth plate, when injured, is most commonly fractured through the hypertrophic zone of cartilage, its weakest point. This patient is optimally treated in a cylindrical or long-leg cast.

Question 71

A 72-year-old woman presents for follow-up after elbow surgery. Her radiographs are shown in Figures A and B. Which of the following pre-operative diagnoses is a relative contraindication to the use of this prosthesis design? Review Topic

Explanation

This patient has had an unconstrained total elbow arthroplasty (TEA). Unconstrained TEA is least preferred for late-stage rheumatoid arthritis where there is significant capsuloligamentous instability and bony erosion.
Unconstrained (unlinked or resurfacing prosthesis) TEA depend on intact bony and ligamentous constraints for stability. These are appropriate for humeroulnar conditions with intact collateral ligaments and radiocapitellar articulation e.g. osteoarthritis, post-traumatic arthritis, intra-articular distal humerus fracture, and malunion of the distal humerus. Conditions with increased risk of instability (ligamentous injury, rheumatoid arthritis) will benefit from a linked or semiconstrained prosthesis.
Mansat et al. reviewed the Coonrad-Morrey linked (semi-constrained) TEA implant in 70 patients after 5 years. They found that patients with inflammatory arthritis had higher function than those with traumatic conditions (fractures, nonunions and posttraumatic arthritis). Survival rate was 98% and 91% at 5 and 10 years, respectively. They concluded that this implant provided satisfactory treatment for different indications although radiolucent lines and bushing wear were a concern.
Hildebrand et al. reviewed the functional outcome of the Coonrad-Moorey prosthesis in 51 elbows after 50 months. The inflammatory arthritis group had higher performance scores than the traumatic/post-traumatic conditions group. Isometric extensor torque was found to be less than the nonoperated side. Radiolucency was noted in 11 elbows.
Figures A and B show an unconstrained TEA with radial head replacement. Illustration A shows more examples of unconstrained TEA. Illustration B shows a semiconstrained TEA. The arrow points to the anterior flange. Illustration C shows radiolucent lines around the stems. Illustration D shows severe bushing wear leading to locking mechanism failure. Illustration E is a table comparing linked and unlinked implants.
Incorrect Answers:

Question 72

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

Explanation

The patient sustained a traumatic shoulder dislocation at age 18 that has subsequently failed to respond to nonsurgical management. Discussion of surgical stabilization procedures is warranted at this time. A corticosteroid injection or a trial of NSAIDs will not provide any stabilizing effect. Further immobilization in this patient population has not been shown to improve stability.

Question 73

A 79-year-old woman with a massive rotator cuff tear presents to the emergency department with pain and difficulty moving her arm 7 weeks after undergoing reverse TSA for a displaced 4-part proximal humerus fracture.

Explanation

DISCUSSION
The complication rate is high after surgical treatment of proximal humerus fractures, particularly in elderly patients with osteoporotic bone. In patients treated with ORIF, common complications include varus malunion (16%), avascular necrosis (10%), screw penetration (8%), and infection (4%). In cases involving a dislocation of the humeral head, avascular necrosis is more common. In patients treated with hemiarthroplasty or TSA, complications include component loosening, infection, and dislocation. TSA is associated with
glenoid loosening in patients with rotator cuff incompetence and should be avoided in these patients. Reverse TSA is a potential solution for this population. Dislocation and postoperative infection are potential complications after reverse TSA.
RECOMMENDED READINGS
Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS. Predicting failure after surgical fixation of proximal humerus fractures. Injury. 2011 Nov;42(11):1283-

Question 74

A 54-year-old man undergoes total shoulder arthroplasty for osteoarthritis. Despite compliance with an early passive range-of-motion exercise program, he does not regain more than 90 degrees of elevation, 10 degrees of external rotation, and has internal rotation to the fifth lumbar vertebra. At 6 months, his motion fails to improve. Radiographs are shown in Figures 18a and 18b. What is the best course of action?

Explanation

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

Question 75

A 32-year-old man presents to the emergency department with a humeral shaft fracture. He has wrist drop as well as impaired finger and thumb extension. Which motor function would be expected to recover last?

Explanation

DISCUSSION: The patient is presenting with radial nerve palsy secondary to his humerus fracture. Motor recovery proceeds in a proximal to distal direction.
Abrams et al detailed the order of innervation of the radial nerve and found the following order (proximal to distal): brachioradialis, extensor carpi radialis longus, supinator, extensor carpi radialis brevis, extensor digitorum communis, extensor carpi ulnaris, extensor digiti quinti, abductor policis longus, extensor policis longus, extensor policis brevis, and extensor indicis proprius.
Branovacki et al found a slightly different pattern: brachioradialis, extensor carpi radialis longus, superficial sensory, extensor carpi radialis brevis, supinator, extensor digitorum/extensor carpi ulnaris, extensor digiti minimi, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus and extensor indicis proprius.
While both extensor digitorum and extensor indicis proprius extend the index finger MCP joint, only extensor indicis proprius hyperextends the index finger past neutral

Question 76

What is the most likely cause of the lesion shown in Figures 35a and 35b?

Explanation

DISCUSSION: The most common cause of myositis ossificans is contusion. Certain regions, including the quadriceps and brachialis, are more commonly affected. The mechanisms of development have not been clearly established.
REFERENCES: Beiner JM, Jokl P: Muscle contusion injuries: Current treatment options. J Am Acad Orthop Surg 2001;9:227-237.
Jarvinen TA, Jarvinen TL, Kaariainen M, et al: Muscle injuries: Biology and treatment. Am J Sports Med 2005;33:745-764.

Question 77

Which nerve root contributes to both the sciatic and femoral nerves?

Explanation

DISCUSSION
The lumbosacral plexus is formed from the lumbar and sacral roots that are redistributed into the obturator, femoral, and sciatic nerves. The obturator nerve is composed of the L1, L2, and L3 roots. The femoral nerve has contributions from the L3 and L4 roots. The sciatic nerve contains the L4, L5, S1, and lower sacral roots. Therefore, only the L4 root contributes to the femoral and sciatic (via the lumbosacral trunk) nerves, which allows it to innervate the quadriceps and the anterior tibialis muscles.
RECOMMENDED READINGS

Question 78

A patient sustained a sharp laceration to the base of his left, nondominant thumb 4 months ago. Examination reveals no active flexion but full passive motion of the interphalangeal joint. What is the best treatment option?

Explanation

DISCUSSION: The patient has a chronic flexor tendon laceration. There are options to restore motion and strength; therefore, fusion is not necessary. Full range of motion is present so the soft tissues are suitable for a tendon transfer. A transfer of the flexor digitorum superficialis of the ring finger to the insertion of the flexor pollicis longus on the distal phalanx provides good results with a one-stage operation.
REFERENCES: Schneider LH, Wiltshire D: Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer. J Hand Surg Am 1983;8:98-101.
Posner MA: Flexor superficialis tendon transfers to the thumb: An alternative to the free tendon graft for treatment of chronic injuries within the digital sheath. J Hand Surg Am 1983;8:876-881.

Question 79

To preserve blood supply to the fractured bone seen in Figures 12a and 12b, care should be taken when exposing which of the following areas?

Explanation

DISCUSSION: The blood supply to the adult capitellum and lateral trochlea comes from posterior vessels arising from the radial recurrent, radial collateral, and interosseous recurrent arteries. These arteries penetrate the distal humerus posterior and superior to the capitellum.
REFERENCE: Yamaguchi K, Sweet FA, Bindra R, et al: The extraosseous and intraosseous arterial anatomy of the adult elbow. J Bone Joint Surg Am 1997;79:1653-1662.

Question 80

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

Explanation

DISCUSSION: In a midterm (7 to 11 years) follow-up study of lumbar total disk arthroplasty, 5 of 55 patients had transient radicular leg pain without evidence of nerve root compression. Implant migration is rare. Deep venous thrombosis, incisional hernia, and retrograde ejaculation are less common complications of disk arthroplasty.
REFERENCE: Tropiano P, Huang RC, Girardi FP, et al: Lumbar total disc replacement: Seven to eleven-year follow-up. J Bone Joint Surg Am 2005;87:490-496.

Question 81

A positive straight leg raising sign is when pain radiates distal to the knee when the affected leg is passively elevated. The increased tension generally occurs between Review Topic

Explanation

A positive straight leg raising sign causes pain radiating distal to the knee when the nerve is under tension. This increased tension generally occurs between 30 degrees and 70 degrees of passive elevation.

Question 82

Figure 16 shows an axial MRI scan through the knee joint. What structure is identified by the arrow?

Explanation

DISCUSSION: The anterior cruciate ligament can be visualized on an axial MRI scan as a low-signal structure lying in the lateral aspect of the intercondylar notch. Visualization in multiple planes increases the accuracy of MRI to view the anterior cruciate ligament. The posterior cruciate ligament and ligament of Wrisberg are located on the medial wall of the notch. The ligamentum mucosum is anterior to the notch, and the popliteus tendon is posterior to the lateral femoral condyle.
REFERENCES: Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 675-699.
Fitzgerald SW, Remer EM, Friedman H, Rogers LF, Hendrix RW, Schafer MF: MR evaluation of the anterior cruciate ligament: Value of supplementing sagittal images with coronal and axial images. Am J Roentgenol 1993;160:1233-1237.

Question 83

A 6-year-old girl has the bilateral foot deformity shown in Figure 1. There is no family history of disease. Examination reveals fixed hindfoot equinus, and muscle function testing shows strong posterior tibial function, fair plus anterior tibial function, poor peroneal function, and strong gastrocnemius function. A Coleman block test shows a correctable hindfoot. Nerve conduction velocity studies show diminished function in the peroneal and ulnar nerves on both sides. Pathologic changes found in a sural nerve biopsy include “onion bulb” formation, and DNA testing confirms the presence of a mutation in the MPZ gene, consistent with hereditary motor sensory neuropathy type III (HMSN-III). What is the best course of action?

Explanation

DISCUSSION: The patient has HMSN-III or Dejerine-Sottas syndrome. This form of HMSN progresses very rapidly and frequently results in severe foot deformity in early childhood. The changes are progressive and are the result of muscle imbalance during growth. Balancing of the foot musculature is essential, particularly during the phases of rapid growth of the foot. However, this cannot be accomplished using the anterior tibial muscle because it is already weak and the transfer will further weaken it. Bony procedures also may be required, and tendon transfers cannot be depended on to correct bony deformity. However, these procedures can be deferred until the foot is closer to adult size. Surgeries that lead to joint arthrodesis, such as triple arthrodesis and some midfoot osteotomies, are contraindicated because the feet may lose protective sensation as the disease progresses. Fusions in insensate feet are less successful than realignment procedures that maintain mobility.
REFERENCES: Wetmore RS, Drennan JC: Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease. J Bone Joint Surg Am 1989;71:417-422.
Roper BA, Tibrewal SB: Soft tissue surgery in Charcot-Marie-Tooth. J Bone Joint Surg Br 1989;71:17-20.
Miller GM, Hsu JD, Hoffer MM, Rentfro R: Posterior tibial tendon transfer: A review of the literature and analysis of 74 procedures. J Pediatr Orthop 1982;2:363-370.

Question 84

A 30-year-old man underwent an open Bankart repair with capsulorrhaphy for recurrent anterior instability 6 months ago. In a recent fall, he described a hyperabduction and external rotation mechanism of injury. He denies dislocating his shoulder. He now has anterior shoulder pain, weakness, and the sensation of instability. Examination reveals tenderness just lateral to the coracoid and bicipital groove. An MRI scan is shown in Figure 31. Management should now consist of

Explanation

DISCUSSION: Subscapularis tendon tears are being recognized with increasing frequency, and the mechanism of injury involves hyperabduction and external rotation. The patient will have anterior shoulder pain and may report a sensation of instability. Examination will reveal anterior shoulder tenderness over the lesser tuberosity and bicipital groove, and the Gerber lift-off test usually is positive. The MRI scan shown here reveals an intact anterior labrum. The subscapularis tendon is avulsed and retracted, with no evidence of the biceps tendon within the groove; this implies dislocation of the biceps, a common accompanying feature of a subscapularis tear. This injury is also recognized as a complication after open anterior shoulder stabilizations where the subscapularis has been incised as part of the approach. Therefore, the appropriate management involves repair of the subscapularis. The injury does not represent a recurrence so immobilization or revision stabilization, which may be reasonable treatment for recurrent instability, is not indicated. The findings are not consistent with a superior labral tear.
REFERENCES: Deutsch A, Altchek DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.
Gerber C, et al: Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am 1996;78:1015-1023.

Question 85

A 62-year-old patient with rheumatoid arthritis has had pain and instability of the elbow following total elbow replacement 2 years ago. A complete work-up, including aspiration and cultures, is negative. Figures 9a and 9b show the AP and lateral radiographs. Treatment should consist of

Explanation

DISCUSSION: The patient has aseptic loosening of the original semiconstrained prosthesis and significant proximal ulnar bone destruction; therefore, the treatment of choice is revision arthroplasty using a semiconstrained design. Although orthotic stabilization could be used, it will not provide long-term pain relief. Resection arthroplasty after removal of the components may lead to painful instability. Elbow arthrodesis would be difficult with the bone stock loss and is not considered the best option. Two main contraindications to the use of an unconstrained prosthesis are significant bone loss and previous use of a hinged or semiconstrained prosthesis. An ulnar allograft could be combined with the use of a semiconstrained long-stemmed ulnar prosthesis as a treatment modification.
REFERENCES: Ewald FC, Simmons ED Jr, Sullivan JA, et al: Capitellocondylar total elbow replacement in rheumatoid arthritis: Long-term results. J Bone Joint Surg Am 1993;75:498-507.
Morrey BF, King GJ: Revision of failed total elbow arthroplasty, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 602-610.

Question 86

Figure 30 shows the radiograph of a 38-year-old man who reports persistent pain laterally and plantarly about the fifth metatarsal head. Examination reveals calluses dorsolaterally and plantarly about the fifth metatarsal head. Nonsurgical management has failed to provide relief. Surgical treatment should include

Explanation

DISCUSSION: The patient has painful lateral and plantar keratoses with metatarsus quintus valgus deformity. This combination of problems is best addressed with an oblique mid-diaphyseal osteotomy that allows the distal metatarsal to be displaced medially and dorsally. Lateral eminence resection alone will not address the painful plantar keratosis. A distal chevron osteotomy has a more limited ability to address the plantar keratosis (if translated medially and slight dorsally). Proximal diaphyseal osteotomies of the fifth metatarsal are associated with an increased risk of delayed union or nonunion secondary to the relative hypovascularity in the proximal diaphysis. Excision of the fifth metatarsal head can result in a floppy fifth toe and transfer metatarsalgia.
REFERENCES: Coughlin MJ: Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle 1991;11:195-203.
Moran MM, Claridge RJ: Chevron osteotomy for bunionette. Foot Ankle Int 1994;15:684-688.

Question 87

Figures 1 through 3 are the MRI scans of a 26-year-old man who injured his knee wrestling one day prior. He has a moderate effusion, medial knee pain and an inability to extend his knee actively or passively. What is the most appropriate definitive treatment option?

Explanation

Figures 1 through 3 are the MRI scans of a 15-year-old boy who sustained an injury to his shoulder after a fall while playing soccer. Following completion of a month-long rehabilitation program, he is able to tolerate sports-specific drills without symptoms. The patient is eager to return to play, as it is mid-season. How should the patient be counseled?

Question 88

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

Explanation

DISCUSSION: Conversion TKA following a previous HTO can be successful; however, it is associated with poorer clinical results when compared with other primary TKAs. There is an increased likelihood of poor range of motion that is partially affected by patella infera created from the osteotomy. Patella infera also results in difficulty with surgical exposure. There has been no reported increase in the rate of infection, fracture, or loosening.
REFERENCE: Mont MA, Alexander N, Krackow KA, Hungerford DS: Total knee arthroplasty after failed high tibial osteotomy. Orthop Clin North Am 1994;25:515-525.

Question 89

A 13-year-old boy sustains a valgus stress injury to the knee while playing football, and he is unable to bear weight after the injury. Examination reveals tenderness medially superior to the joint line. The knee is held in flexion, and he has a large effusion and localized medial swelling. Plain radiographs show no obvious fracture. What is the next diagnostic step?

Explanation

DISCUSSION: In the skeletally mature individual, this mechanism of injury will often result in a sprain of the medial collateral ligament. In skeletally immature patients, the same mechanism can cause a fracture of the distal femoral physis. If the fracture is nondisplaced, the plain radiographs may show only soft-tissue swelling or effusion. While the MRI scan may show edema in the soft tissues on the medial side of the knee and even an abnormality of the physis, stress radiographs provide a quicker and less expensive means of making the diagnosis. Arthroscopy and arthrography would not be helpful in making the diagnosis. Arthroscopy may result in further displacement of the injury.
REFERENCES: Smith L: Concealed injury to the knee. J Bone Joint Surg Am 1962;44:1659-1660.
Beaty JH, Kumar A: Fractures about the knee in children. J Bone Joint Surg Am 1994;76:1870-1880.

Question 90

Which of the following best describes heat stroke?

Explanation

DISCUSSION: Heat stroke consists of hyperthermia (greater than 105.8 degrees F
[41 degrees C]), central nervous system dysfunction, and cessation of sweating with hot, dry skin. It is a medical emergency that results from failure of the thermoregulatory mechanisms of the body. It has a high death rate and requires rapid reduction in body core temperature. Heat syncope is characterized by a transient loss of consciousness with peripheral vasodilation and decreased cardiac output with normal body temperature. Heat cramps involve painful contractions of large muscle groups because of decreased hydration and a decrease of serum sodium and chloride. Heat exhaustion is distinguished by a core temperature of less than

Question 91

In patients with suspected hepatitis C, which of the following tests is commonly used to confirm the diagnosis after a positive ELISA screening test?

Explanation

DISCUSSION: The basic diagnostic test for hepatitis C (HCV) is detection of an antibody to epitopes on an enzyme-linked immunosorbent anti-HCV assay (ELISA). The currently used ELISA has high sensitivity (92%) and specificity (95%). False positives, however, still occur. The currently used supplemental test for HCV is strip immunoblot assay, which is based on detection of several HCV epitopes on nitrocellulose paper by antibody-capture techniques. Molecular amplification by PCR technology is very sensitive, but difficult to standardize and susceptible to contamination. Microarray and proteomics are relatively recent molecular techniques used for analysis of genes or proteins, respectively. A Northern blot is used to detect mRNA levels of specific genes but is not used in this situation.
REFERENCES: de Medina M, Schiff ER: Hepatitis C: Diagnostic assays. Semin Liver Dis 1995;15:33-40.
McGrory BJ, Kilby AE: Hepatitis C virus infection: Review and implications for the orthopedic surgeon. Am J Orthop 2000;29:261-266.

Question 92

Figure 8 shows the AP radiograph of a 33-year-old woman who sustained a midshaft clavicle fracture from a motorcycle accident 15 months ago. She continues to have significant pain with activities of daily living. Management should consist of

Explanation

DISCUSSION: The patient has a symptomatic painful atrophic midclavicular nonunion, and the treatment of choice is rigid internal fixation with a dynamic compression plate and autogenous bone grafting. A tension band effect is desired and achieved by placing the plate superiorly. Excellent success rates of 90% to 100% have been reported using this technique. Intramedullary screw fixation without bone grafting has a decreased success rate. Partial claviculectomy is not a preferred option.
REFERENCES: Jupiter JB, Leffert RD: Non-union of the clavicle: Associated complications and surgical management. J Bone Joint Surg Am 1987;69:753-760.
Simpson NS, Jupiter JB: Clavicular nonunion and malunion: Evaluation and surgical management. J Am Acad Orthop Surg 1996;4:1-8.

Question 93

What is the best initial screening test for a patient with a limb-length discrepancy?

Explanation

DISCUSSION: With the patient standing, add blocks under the short leg until the pelvis is level, then measure the blocks to determine the discrepancy. This method is an accurate, simple, and inexpensive way to assess limb-length discrepancy. Differences of less than 2 cm need no treatment. Increasing discrepancy in a growing child should be followed clinically. Radiographic examination can include scanography, CT scanography, or a standing pelvic radiograph with the pelvis leveled. CT scanography is the most accurate diagnostic test when hip, knee, or ankle contractures are present.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002, pp 1041-1045.
Schoenecker PL, Rich MM: The lower extremity, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 1120-1122.
Stanitski DF: Limb-length inequality: Assessment and treatment options. J Am Acad Orthop Surg 1999;7:143-153.
Aaron A, Weinstein D, Thickman D, Eilert R: Comparison of orthoroentgenography and computed tomography in the measurement of limb-length discrepancy. J Bone Joint Surg Am 1992;74:897-902.

Question 94

A 7 5-year-old man who sustained an intertrochanteric hip fracture underwent open reduction and internal fixation with a sliding hip screw. Six months after the procedure, the patient has shortening and external rotation of the extremity and progressively severe groin pain with ambulation. Radiographs are shown in Figures 5a and 5b. What is the most appropriate management?

Explanation

DISCUSSION: The patient has an intertrochanteric fracture malunion with protrusion of the hardware and penetration into the acetabulum. To restore leg length and relieve pain, total hip arthroplasty is necessary. Valgus osteotomy is appropriate for fracture nonunion with an intact femoral head with no signs of osteonecrosis. Bipolar hemiarthroplasty with acetabular erosion will most likely lead to pain as will removal of the hardware with or without physical therapy.
REFERENCE: Said GZ, Farouk O, El-Sayed A, et al: Salvage of failed dynamic hip screw fixation of intertrochanteric fractures. Injury 2006;37:194-202.

Question 95

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

Explanation

DISCUSSION:
Studies have demonstrated that pelvic inclination can dramatically affect the interpretation of radiographs in the dysplastic hip, with 9° of increased pelvic inclination leading to the presence of crossover signs and posterior wall signs. A distance of 30 mm to 50 mm from the sacrococcygeal junction to the pubis is often used to assess the adequacy of pelvic inclination on radiographs, although Siebenrock and associates determined the mean difference to be 32 mm in men and 47 mm in women. In this patient, the pelvic inclination is dramatically increased, leading to overestimation of acetabular retroversion.

Question 96

A complication associated with using the Morrey approach (triceps reflecting) to implant a semiconstrained total elbow arthroplasty is

Explanation

Numerous approaches can be used to implant a total elbow arthroplasty. The Morrey approach identifies, transposes, and protects the ulnar nerve, and then subperiosteally reflects the triceps off the ulna. The sleeve of tissue is very thin distally, and the triceps need to be meticulously repaired at the time of closure. Implant dislocation and malposition are less likely with an extensile approach, and dislocation is unlikely with a semiconstrained implant. The development of heterotopic ossification is unrelated to the surgical approach
used for elbow arthroplasty.

Question 97

A 5-year-old boy reports intermittent left elbow pain. History reveals that he injured his elbow 4 months ago, but had no treatment. He is now using his arm normally but reports pain almost daily. Examination reveals tenderness over the lateral epicondyle and a prominence is evident. Range of motion is from -5 degrees to

Explanation

The patient has a nonunion of the lateral condyle of the left humerus. Observation or cast treatment at this stage is not likely to lead to healing of the fracture. MRI will not add any additional information. Open reduction, with minimal posterior soft-tissue stripping, is recommended to establish union of the fracture. Local or other bone graft may also be required. There are no studies that indicate that the displaced fracture will heal with late percutaneous fixation.
(SBQ13PE.40) Immediate spica casting is most appropriate for which of the following?: Review Topic
2-month-old girl with a displaced spiral mid-diaphyseal femur fracture
A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with <2 centimeters of shortening
3-day-old with teratologic right hip dislocation
9-year-old boy with a displaced spiral mid-diaphyseal femur fracture
12-year-old girl weighing 90 pounds with a displaced spiral mid-diaphyseal femur fracture
Children older than 6 months and up to 6 years with diaphyseal femur fractures may be treated with spica casting.
Children younger than 6 months may only require a Pavlik harness. Immediate spica casting is indicated in children 6 months to 6 years with less than 2 cm of shortening. Each additional cm of shortening at presentation doubles the risk of loss of reduction (1 cm: 12%, 2 cm: 24%, 3 cm; 50%).
Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. Their recommendation for diaphyseal femur fractures with <2 cm shortening in children 6 months to 5 years is Grade B, based on Level II evidence (two level II and one level I study). They recommend early spica or traction with delayed spica. They suggest early spica, as this is more convenient than traction.
In an earlier article, Flynn et al. review the management of pediatric femoral shaft fractures. They recommend early spica casting for the child between 1 and 6 years in
low-energy femoral fractures with up to 2 cm shortening. Illustration A shows several styles of lower extremity spica casts.
Incorrect answers:

Question 98

A high school football player asks you about an oral supplement that increases body mass and improves sprint times. He would like to use it to improve performance. What is the most likely agent?

Explanation

DISCUSSION: The supplement is creatine. Approximately 17% of high school athletes and about 30% of high school football players use creatine. Creatine is a protein synthesized in the liver and the kidney, circulates in the bloodstream, and is incorporated into muscle. Its use is associated with increased muscle mass, short-term improvement in sprinting, and may allow for increased anaerobic resistance performance. Caffeine and ephedrine are taken orally but do not increase muscle mass. Testosterone and human growth hormone are both associated with increased body mass but must be injected.
REFERENCES: McGuine TA, Sullivan JC, Bernhardt DT: Creatine supplementation in high school football players. Clin J Sports Med 2001 ;11:247-253.
Rawson ES, Gunn B, Clarkson PM: The effects of creatine supplementation on exercise-induced muscle damage. J Strength Cond Res 2001; 15:178-184.
Branch JD: Effect of creatine supplementation on body composition and performance: A meta-analysis.
Int J Sport Nutr Exerc Metab 2003;13:198-226.

Question 99

A year-old man with insulin-dependent diabetes mellitus underwent primary total knee arthroplasty (TKA). A full-thickness skin slough measuring 3 cm by 4 cm developed, with postsurgical exposure of the patellar tendon. No change is observed in the appearance of the wound after 2 weeks of wet-to-dry dressing changes. What is the best next treatment step for the soft-tissue defect?

Explanation

DISCUSSION:
If wound healing does not occur and deep soft tissues such as the patellar tendon are exposed following TKA, local rotational flap is the procedure of choice. The procedure should be performed relatively early after the recognition of a soft-tissue wound-healing problem. In the setting of TKA, the gastrocnemius muscle is an excellent source of flaps for wound coverage of the proximal tibia.

Question 100

An 18-year-old boy has had pain in the right knee for the past 6 months. Examination reveals some fullness behind the knee but no significant palpable soft-tissue mass. There is no effusion, and he has full knee range of motion. The remainder of the examination is unremarkable. A radiograph and MRI scans are shown in Figures 33a through 33c, and biopsy specimens are shown in Figures 33d and 33e. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has parosteal osteosarcoma. The posterior aspect of the distal femur is the typical location for this variant of osteogenic sarcoma. The imaging studies indicate a surface lesion with no involvement of the adjacent intramedullary canal. The histologic appearance is that of a low-grade fibroblastic osteosarcoma, consisting of relatively mature bone and a bland fibroblastic stroma lacking cytologic atypia and mitotic activity. A cartilaginous component is also frequently seen. Classic osteosarcoma typically has a more aggressive radiologic and histologic appearance. Sessile osteochondromas, while common behind the knee, have a presence of hematopoietic marrow and fat. The cartilage found in the associated cartilaginous cap is oriented. Chondrosarcomas are more typical in an older age group and have a histologic pattern consisting of malignant chondroid.
REFERENCES: Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 20-21.
Unni KK, Dahlin DC, Beabout JW, Ivins JC: Parosteal osteogenic sarcoma. Cancer 1976;37:2466-2475.

Full Question & Answer Text (for Search Engines)

Question 1:

A 25-year-old farm worker sustained a grade III open fracture of the midshaft of the left tibia after falling from a ladder. Which of the following antibiotic regimens is best for this patient?

Options:

First-generation cephalosporin
Cephalosporin, penicillin, and quinolone
Cephalosporin and aminoglycoside
Quinolones
Synthetic penicillin and aminoglycoside

Correct Answer: Synthetic penicillin and aminoglycoside

Explanation:

Question 2:

Figure 24 shows an axial MRI scan of the ankle. The arrowhead is pointing to what structure?

Options:

Tibial nerve
Flexor hallucis longus
Tibialis posterior
Peroneus longus
Peroneus brevis

Correct Answer: Peroneus brevis

Explanation:

Question 3:

- A 50-year-old alcoholic man has erythema and swelling in his entire dominant upper extremity. He has a WBC of 15,000/mm3, a temp of 101 oF (38.3 oC), and a blood pressure of 90/60 mm Hg. After hemodynamic stabilization, the cellulitic forearm is longitudinally incised dorsally and volarly. The forearm muscles are normal in appearance; however, the subcutaneous fat is necrotic. A culture will most likely reveal

Options:

Bacteroides
coli
Staph. aureus
group A streptococcus
Clostridium perforingens

Correct Answer: group A streptococcus

Explanation:

Question 4:

Options:

overgrowth of the distal radial epiphysis.
premature closure of the distal radial physis.
premature closure of the distal ulnar physis.
a Salter-Harris type I fracture of the distal radius with a volar slip of the epiphysis.
a Salter-Harris type I fracture of the distal radius with a dorsal slip of the epiphysis.

Correct Answer: premature closure of the distal radial physis.

Explanation:

Question 5:

Which of the following nonunions is appropriately treated with exchange reamed nailing without bone graft augmentation?

Options:

Infected tibial shaft nonunion 6 months status post intramedullary nail fixation
Oligotrophic humeral shaft nonunion 7 months status post non-operative management
Hypertrophic tibial shaft nonunion 7 months status post intramedullary nail fixation
Comminuted open tibial shaft nonunion with segmental bone loss 8 months status post intramedullary nail fixation
Supracondylar femoral shaft nonunion 6 months status post intramedullary nail fixation with 4 distal locking screws

Correct Answer: Infected tibial shaft nonunion 6 months status post intramedullary nail fixation

Explanation:

Question 6:

Options:

Open biopsy
Needle aspiration
Arthroscopy
CT
Arthrography

Correct Answer: Needle aspiration

Explanation:

Question 7:

Options:

Smoking status
Postmenopausal status
BMI
Radiographic findings The principal contraindications to valgus-producing HTO include (1) lateral compartment degenerative joint disease, (2) loss of a significant portion of the lateral meniscus, (3) symptomatic patellofemoral degenerative joint disease, (4) nonconcordant pain (ie, patellofemoral pain with medial compartment osteoarthritis), (5) smoking, (6) patient unwillingness to accept the anticipated cosmetic appearance of the desired amount of angular correction, and (7) inflammatory arthritis.

Correct Answer: Smoking status

Explanation:

Question 8:

When compared to patients with osteoarthritis, patients with ankylosing spondylitis undergoing total hip arthroplasty can expect a

Options:

decreased risk of heterotopic ossification.
higher hip pain score.
lower level of functional return.
comparable infection rate.
comparable level of blood loss.

Correct Answer: lower level of functional return.

Explanation:

Question 9:

Options:

Age > 60 years
> or = 2 comorbid conditions
History of tobacco use
BMI > 30 kg/m²
Using a pedicle subtraction osteotomy

Correct Answer: > or = 2 comorbid conditions

Explanation:

Question 10:

A 17-year-old boy has had elbow pain for the past 6 weeks. A radiograph, MRI scans, and biopsy specimens are shown in Figures 65a through 65e. What is the most likely diagnosis?

Options:

Osteoid osteoma
Osteoblastoma
Osteosarcoma
Chondroblastoma
Giant cell tumor

Correct Answer: Osteoblastoma

Explanation:

DISCUSSION: The findings are consistent with an osteoblastoma. The radiographs show a bone-forming lesion of the distal humerus. The lesion has an osseous component extending out of the native cortex with a thin sclerotic border. The T
2
-weighted MRI scan shows the lesion extending anteriorly beyond the native cortex. No fluid-fluid levels are seen. Histology shows large osteoblasts producing osteoid and woven bone. The tissue between the spicules of bone and osteoid contains thin fibrous tissue and capillaries. Osteoid osteoma is a smaller lesion usually with sclerotic reactive bone around a small nidus. The histology differentiates osteoblastoma from osteosarcoma because no malignant cells are seen. There is no cartilage production or chondroblasts in the histologic specimen, eliminating chondroblastoma. Giant cell tumors of bone typically occur in a epiphyseal metaphyseal location, most commonly after skeletal maturity, and contain numerus giant cells.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 87-102.
Campanacci M: Bone and Soft Tissue Tumors, ed 2.
New York, NY, Springer-Verlag, 1999,
pp 415-433.

Question 11:

Options:

revision of the current orthotics.
metatarsal osteotomies to correct cavus.
a sliding calcaneal osteotomy to correct hindfoot varus.
triple arthrodesis, with anterior transfer of the posterior tibialis.
extensor transfer to the metatarsal necks, soft-tissue releases, and anterior transfer of the posterior tibialis tendon.

Correct Answer: extensor transfer to the metatarsal necks, soft-tissue releases, and anterior transfer of the posterior tibialis tendon.

Explanation:

Question 12:

Excision of heterotopic bone about the forearm or elbow can be done with limited recurrence rates as early as which of the following after initial injury?

Options:

Once ankylosis of the forearm or elbow occurs
6 weeks
6 months
12 months
18 months

Correct Answer: Once ankylosis of the forearm or elbow occurs

Explanation:

Question 13:

Options:

Observation and NSAID use as needed
MRI scan
Bone biopsy
Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP).

Correct Answer: Observation and NSAID use as needed

Explanation:

DISCUSSION
The radiograph shown is consistent with Paget disease of the bone. It demonstrates classic findings of widened lamellae and disorganized sclerotic and lytic areas. The cause is not clearly defined, but may be linked to a viral infection and subsequent alterations of osteoblastic and osteoclastic activity. Most patients are asymptomatic, and Paget disease is often found incidentally on radiographs. In this case, the patient’s symptoms likely were caused by hip arthritis, but Paget disease can cause diffuse bone pain in some cases. Considering the patient’s mild and short-term symptoms, observation and NSAID use is most appropriate. An MRI scan or biopsy is indicated if sarcomatous transformation is suspected, but this condition is rare and is associated with a substantial, unrelenting increase in pain. SPEP and UPEP are tests for multiple myeloma, of which the radiographs show no signs.
RECOMMENDED READINGS
Ralston SH. Pathogenesis of Paget's disease of bone. Bone. 2008 Nov;43(5):819-25. doi: 10.1016/j.bone.2008.06.015. Epub 2008 Jul 11. Review. PubMed PMID: 18672105.
View Abstract at PubMed
Bonenberger E, Einhorn T. Metabolic bone diseases. In: Callaghan JJ, Rosenberg
AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams
14
& Wilkins; 2007:514-533.

Question 14:

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

Options:

Spinal cord injury
Nerve root injury
Vagus nerve injury
Recurrent laryngeal nerve injury
Horner’s syndrome

Correct Answer: Recurrent laryngeal nerve injury

Explanation:

Question 15:

What patient factor is predictive of better outcomes for surgical management of a displaced calcaneal fracture compared to nonsurgical management?

Options:

Young man injured at the work site
Young woman injured during recreational activities
Heavy smoker
Patient older than age 50 years
Patient with bilateral fractures

Correct Answer: Young woman injured during recreational activities

Explanation:

Question 16:

Options:

a long arm cast.
immediate functional bracing.
closed reduction and percutaneous pin fixation.
percutaneous olecranon pin traction.
total elbow arthroplasty.

Correct Answer: total elbow arthroplasty.

Explanation:

Question 17:

The therapeutic effect of etanercept in the treatment of rheumatoid arthritis is primarily mediated through

Options:

antagonism of tumor necrosis factor-alpha (TNF-α).
antagonism of matrix metalloproteinases (MMPs).
inhibition of COX2.
stimulation of interleukin-1 (IL-1).
stimulation of tissue inhibitors of metalloproteinases (TIMPs).

Correct Answer: antagonism of tumor necrosis factor-alpha (TNF-α).

Explanation:

Question 18:

Options:

AP pelvis
Outlet obturator oblique view
Inlet iliac oblique view
Iliac oblique view
Obturator oblique view

Correct Answer: AP pelvis

Explanation:

Question 19:

Options:

Open reduction and internal fixation (ORIF) of the fracture
Removal of the current stem, femur ORIF, and insertion of a longer revision stem
Femur ORIF with cables and strut graft, leaving the current stem in situ
Femur ORIF combined with reimplantation of the primary component

Correct Answer: Removal of the current stem, femur ORIF, and insertion of a longer revision stem

Explanation:

Question 20:

Options:

Lunocapitate, radioscaphoid, radial styloid, radiolunate
Radioscaphoid, radial styloid, lunocapitate, radiolunate
Radial styloid, radioscaphoid, lunocapitate, radiolunate
Radial styloid, radioscaphoid, radiolunate, lunocapitate

Correct Answer: Radial styloid, radioscaphoid, lunocapitate, radiolunate

Explanation:

Question 21:

Options:

Rapid cooling via ice bath, cold water and fans
Transportation via ambulance to a local emergency department
Rapid rehydration via oral and IV fluids
Immediate administration of acetaminophen or other anti-pyretics

Correct Answer: Rapid cooling via ice bath, cold water and fans

Explanation:

Question 22:

Failure of high tibial osteotomy (HTO) is most closely associated with which of the following factors?

Options:

Patient age of less than 50 years at the time of surgery
Stable fixaton of the osteotomy
Development of deep venous thrombosis postoperatively
Type of osteotomy performed (ie, opening wedge versus dome osteotomy)
Presence of a lateral tibial thrust preoperatively

Correct Answer: Presence of a lateral tibial thrust preoperatively

Explanation:

DISCUSSION: Long-term survivorship studies have attempted to clarify patient factors related to good outcomes in HTO. One particular study showed that a patient age of less than 50 years was related to good outcomes in those who had good preoperative knee flexion. The same study found no relation between HTO failure and the presence of postoperative infection or deep venous thrombosis. The presence of a lateral tibial thrust is a contraindication to performing this surgery. As expected, good patient selection is critical to obtaining good long-term results
with HTO.
REFERENCES: Naudie D, Borne RB, Rorabeck CH, Bourne TJ: Survivorship of the high tibial valgus osteotomy: A 10- to 22-year followup study. Clin Orthop 1999;367:18-27.
Rinonapoli E, Mancini GB, Corvaglia A, Musiello S: Tibial osteotomy for varus gonarthrosis: A 10- to 21-year followup study. Clin Orthop 1998;353:185-193.
Coventry MB, Ilstrup DM, Wallrichs SL: Proximal tibial osteotomy: A critical long-term study of eighty-seven cases. J Bone Joint Surg Am 1993;75:196-201.

Question 23:

What type of physical therapy is most effective for chronic noninsertional Achilles tendinopathy?

Options:

Stair climbing
Eccentric strengthening
Concentric strengthening
Isometric strengthening
Rope jumping

Correct Answer: Eccentric strengthening

Explanation:

DISCUSSION: Eccentric gastrocsoleus strengthening (especially with heavy loads) consistently has been shown to be superior in the management of Achilles tendinopathy. Decreases in pain and increases in strength have been demonstrated despite the frequently refractory nature of this condition.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 91-102.
Vora AM, Myerson MS, Oliva F, et al: Tendinopathy of the main body of the Achilles tendon.
Foot Ankle Clin 2005;10:293-308.

Question 24:

Options:

Posterior tibial tendon debridement and synovectomy
Tendon transfer, spring ligament repair, and heel cord lengthening
Tendon transfer, lateral column lengthening, and heel cord lengthening
Realignment triple arthrodesis and heel cord lengthening
Medial column arthrodesis and heel cord lengthening

Correct Answer: Medial column arthrodesis and heel cord lengthening

Explanation:

DISCUSSION: The patient has end-stage midfoot arthritis, with a secondary flatfoot deformity through the midfoot. The ability to perform a single limb heel rise indicates that the posterior tibial tendon is functioning, and the weight-bearing radiographs show normal calcaneal pitch and talar head coverage, thus confirming that the flatfoot deformity is isolated to the midfoot. Therefore, the most appropriate treatment is medial column arthrodesis and heel cord lengthening. The other listed procedures are not indicated because they are used in the management of adult flatfoot from posterior tibial tendon insufficiency.
REFERENCES: Toolan BC: Midfoot arthrodesis: Challenges and treatment alternatives. Foot Ankle Clin 2002;7:75-93.
Horton GA, Olney BW: Deformity correction and arthrodesis of the midfoot with a medial plate. Foot Ankle 1993;14:493-499.

Question 25:

When reconstructing the anterior cruciate ligament (ACL) with autograft, what is the most common source of surgical failure?

Options:

Graft choice
Tunnel position
Tibial fixation
Femoral fixation

Correct Answer: Tunnel position

Explanation:

Question 26:

In Charcot-Marie-Tooth disease a progressive deformity develops in the foot. Which functional muscles predominate in deformity formation?

Options:

Posterior tibialis and peroneus longus
Posterior tibialis and peroneus brevis
Anterior tibialis and peroneus longus
Anterior tibialis and peroneus brevis
Extensor digitorum and anterior tibialis

Correct Answer: Posterior tibialis and peroneus longus

Explanation:

Question 27:

The use of nonsteroidal anti-inflammatory drugs following femoral nailing has been associated with which of the following?

Options:

Increased rate of nonunion
Decreased narcotic requirements
Faster time to union
Increased rate of heterotopic ossification
Decreased rate of revision surgery

Correct Answer: Increased rate of nonunion

Explanation:

Question 28:

Options:

Intravenous fluid administration
Intravenous bisphosphonates
Intranasal calcitonin
Methotrexate
Mithramycin by oral administration

Correct Answer: Intravenous fluid administration

Explanation:

Question 29:

Options:

a scapular and rotator cuff strengthening program.
arthroscopy.
review of her golf technique.
humeral head replacement.
an erythrocyte sedimentation rate.

Correct Answer: a scapular and rotator cuff strengthening program.

Explanation:

Question 30:

Options:

Rett syndrome
Spinal muscular atrophy, type 2
Congenital muscular dystrophy
Duchenne muscular dystrophy
Congenital myotonic dystrophy

Correct Answer: Spinal muscular atrophy, type 2

Explanation:

DISCUSSION: The patient has spinal muscular atrophy, type 2. This type is intermediate in severity between the Werdnig-Hoffmann type (type 1) and the Kugelberg-Welander type
(type 3). It normally manifests itself between the ages of 3 and 15 months. Survival until adolescence is common. All three types of spinal muscular atrophy have been linked to the SMN gene at the 5q12.2-13.3 locus. DNA testing is available and is preferred to muscle biopsy because it is less invasive and more definitive.
REFERENCES: Biros I, Forrest S: Spinal muscular atrophy: Untangling the knot? J Med Genet 1999;36:1-8.
Zerres K, Wirth B, Rudnik-Schoneborn S: Spinal muscular atrophy: Clinical and genetic correlations. Neuromuscul Disord 1997;7:202-207.

Question 31:

A 25 year-old-male presents with the injury seen in Figure A. Which of the following would be a contraindication to closed management with a functional brace?

Options:

Radial nerve injury
1 cm shortening
20 degree varus deformity
Brachial plexus injury
Comminuted fracture pattern

Correct Answer: Radial nerve injury

Explanation:

Question 32:

The blood supply to the anterior cruciate ligament is primarily derived from what artery?

Options:

Anterior tibial artery
Superolateral geniculate
Middle geniculate
Inferolateral geniculate
Inferomedial geniculate

Correct Answer: Middle geniculate

Explanation:

Question 33:

- A patient is in respiratory distress as a result of a high-speed motor vehicle accident. After emergent intubation, the arterial blood is poorly oxygenated, and examination shows left-sided tracheal deviation, absence of breath sounds on the right side and tympany on percussion over the right side of the chest. Management should include

Options:

Positive-pressure ventilation
An immediate radiograph of the chest
Adjustment of the position of the endotrachael tube
Insertion of a large-bore needle into the pericardial space
Insertion of a large-bore needle in the right second intercostal space, midclavicular line

Correct Answer: Insertion of a large-bore needle in the right second intercostal space, midclavicular line

Explanation:

Question 34:

Options:

a technetium Tc 99m scan.
an indium scan.
an ultrasound examination.
aspiration.
revision.

Correct Answer: aspiration.

Explanation:

Question 35:

What is the most significant prognostic factor in nontraumatic osteonecrosis of the humeral head?

Options:

Duration of symptoms
Age of the patient
Total amount of steroid use
Stage of the disease
Status of the rotator cuff

Correct Answer: Stage of the disease

Explanation:

Question 36:

Options:

Artery medial, then lateral
Artery lateral, then medial
Artery always medial
Artery always lateral
Artery always deep

Correct Answer: Artery medial, then lateral

Explanation:

DISCUSSION: At the ankle level, the anterior tibial artery lies medial to the EHL tendon. The artery becomes the dorsalis pedis after crossing onto the dorsum of the foot. At this point, the artery lies lateral to the tendon.
REFERENCES: Resch S: Functional anatomy and topography of the foot and ankle, in Myerson M (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 1, pp 25-49.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 37:

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 38:

Options:

Kaposi sarcoma
Squamous cell carcinoma
Pigmented basal cell carcinoma
Melanoma
Basillary angiomatosis

Correct Answer: Melanoma

Explanation:

Question 39:

Which of the following is considered a specific advantage of using COX-2 inhibitors over COX-1 inhibitors?

Options:

Conversion of arachidonic acid to prostaglandins
Higher degree of efficacy
Does not affect platelet function and can be used during the perioperative period
Can be used in patients with congestive heart failure and renal disease
High levels of COX-2 (cyclooxygenase) found in normal tissue

Correct Answer: Does not affect platelet function and can be used during the perioperative period

Explanation:

DISCUSSION: Inflammation is mediated through two isoforms of cyclooxygenase that convert arachidonic acid to prostaglandins. Selectivity, but not specificity, is one of the unique characteristics of this process that has been able to provide more protection from the effects of gastric mucosal alterations using the COX-2 selective inhibitors. The use of COX-1 selective inhibitors is associated with side effects such as ulcerative conditions and platelet interference, both of which have been difficult to control in the past until the advent of the COX-2 inhibitors. PGE
2
inhibition by COX-1 in the intestinal track can then be bypassed, thereby reducing ulceration complications associated with use of nonsteroidal anti-inflammatory drugs.
REFERENCES: Lane JM: Anti-inflammatory medications: Selective COX-2 inhibitors. J Am Acad Orthop Surg 2002;10:75-78.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000.

Question 40:

When using highly cross-linked ultra-high molecular weight polyethylene as an articulating surface for total knee arthroplasty, what property of the material raises concern?

Options:

Decreased volumetric wear
Decreased ductility
Increased mobility of the ultra-high molecular weight polyethylene chains in the material
Increased fatigue resistance
Increased fracture toughness

Correct Answer: Decreased ductility

Explanation:

Question 41:

Options:

Surgical reconstruction
Rest, followed by physical therapy
Splinting in 15 degrees of flexion
Primary repair
Arthroscopic debridement, followed by bracing in full extension for 4 weeks

Correct Answer: Surgical reconstruction

Explanation:

Question 42:

Figures 23a and 23b show the radiographs of a 75-year-old woman who sustained an injury to her nondominant hand. Initial treatment should consist of

Options:

closed reduction and splinting.
open reduction and internal fixation through a volar approach.
external fixation and Kirschner wire fixation.
intrafocal pinning and casting.
acceptance of alignment and bracing.

Correct Answer: closed reduction and splinting.

Explanation:

DISCUSSION: Definitive treatment decisions for displaced distal radius fractures in the elderly are based on a number of factors related to the fracture pattern and patient demographics. The first step in any treatment algorithm is a closed reduction and splinting with reassessment of alignment parameters. This is an extra-articular fracture with dorsal angulation. Low-demand elderly patients can be treated well with accepted minor malreduction.
REFERENCES: Handoll HH, Madhok R: Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;2:CD000314.
Young CF, Nanu AM, Checketts RG: Seven-year outcome following Colles’ type distal radial fracture: A comparison of two treatment methods. J Hand Surg Br 2003;28:422-426.

Question 43:

Options:

open reduction and internal fixation.
arthroscopic reduction and internal fixation.
closed reduction following evacuation of the hemarthrosis and casting in extension if reduction is adequate.
closed reduction and casting in 90 degrees of flexion.
excision of the fragment.

Correct Answer: closed reduction following evacuation of the hemarthrosis and casting in extension if reduction is adequate.

Explanation:

Question 44:

-The center of rotation of the knee can be best described as

Options:

remaining fixed during flexion.
moving posterior as flexion increases.
shifting forward and then back with flexion.
shifting posterior on the lateral side with flexion.
sliding forward on the medial side with increasing flexion.

Correct Answer: shifting posterior on the lateral side with flexion.

Question 45:

Atraumatic neuropathy of the suprascapular nerve usually occurs at what anatomic location?

Options:

Suprascapular and spinoglenoid notches
Omohyoid muscle
Anterior trapezius muscle
Infraspinatus fascia
Teres minor superior border

Correct Answer: Suprascapular and spinoglenoid notches

Explanation:

Question 46:

Options:

electrical stimulation.
a Charleston bending brace at night.
an extension-type spinal orthosis.
posterior spinal fusion with instrumentation.
anterior spinal release and posterior spinal instrumentation.

Correct Answer: an extension-type spinal orthosis.

Explanation:

Question 47:

Options:

acetabular labrum.
zona orbicularis.
iliofemoral ligament.
acetabular pulvinar.
retinacular vessels.

Correct Answer: acetabular labrum.

Explanation:

Question 48:

Options:

Which of the following conditions associated with rheumatoid arthritis of the cervical spine is shown in the flexion-extension views in figures 45a and 45b?
Cranial setting
Cranial subluxation
Odontoid fracture
Lysis of the arch of the atlas
Atlantoaxial subluxation

Correct Answer: Lysis of the arch of the atlas

Explanation:

Question 49:

Which of the following is the primary mechanism of polyethylene wear in the hip?

Options:

Fatigue cracking and delamination
Oscillatory fretting
Crevice corrosion
Oxidative degradation
Adhesion and abrasion

Correct Answer: Adhesion and abrasion

Explanation:

DISCUSSION: Although previous theories on acetabular wear implicated fatigue cracking and delamination as primary wear mechanisms, these have actually manifested as major modes of polyethylene wear in knees. The primary mechanism of wear in polyethylene acetabular components appears to be adhesion and abrasion. In an analysis of 128 components retrieved at autopsy or revision surgery, wear appeared to occur mostly at the surface of the components and was the result of large strain plastic deformation and orientation of the surface layers into fibrils that subsequently ruptured during multidirectional motion. It was also shown conclusively that 32-mm heads displayed significantly more wear (volumetric wear) than either 22-mm or
26-/28-mm heads (1-mm increase in size increased volumetric wear by 10%). The wear at the articulating surface was characterized by highly worn polished areas superiorly and less worn areas inferiorly separated by a ridge. Abrasion was very common, occurring after adhesion and plastic deformation of polyethylene fibrils, and abrasion secondary to third-body wear. Wear rates decreased with longer survival of components, indicating a “bedding in” phenomenon, arguing against oxidative and fatigue wear. Crevice corrosion occurs in fatigue cracks with low oxygen tension (under screw heads, etc). Oscillatory fretting consists of cyclical abrading of the outer surface from small movements. Fatigue and delamination is predominant in total knee arthroplasty where stresses are maximum just below the surface of the polyethylene component, causing fatigue over time with subsequent delamination. In contrast, hip wear occurs primarily at the surface of the polyethylene component.
REFERENCES: Jasty M, Goetz DD, Bragdon CR, et al: Wear of polyethylene acetabular components in total hip arthroplasty: An analysis of one hundred and twenty-eight components retrieved at autopsy or revision operations. J Bone Joint Surg Am 1997;79:349-358.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 47-53.
Bell CJ, Walker PS, Abeysundera MR, et al: Effect of oxidation on delamination of
ultrahigh-molecular-weight polyethylene tibial components. J Arthroplasty 1998;13:280-290.
Sutula LC, Collier JP, Saum KA, et al: The Otto Aufranc Award: Impact of gamma sterilization on clinical performance of polyethylene in the hip. Clin Orthop 1995;319:28-40.

Question 50:

This image represents the end stage of an uncompensated rotator cuff tear.

Options:

Figure 59a is the CT image of an 86-year-old woman with acromiohumeral distance of less than 2 mm, night pain, and an inability to actively raise the affected arm above shoulder level.
Figure 59b is the radiograph of a 45-year-old man with acromiohumeral distance equal to 7 mm. He is able to actively raise his arm above shoulder level, has lateral arm pain,
and abduction and external rotation weakness. 56
Figures 59c and 59d are the radiographs of a 72-year-old man with night pain and reduced range of motion.

Correct Answer: Figure 59a is the CT image of an 86-year-old woman with acromiohumeral distance of less than 2 mm, night pain, and an inability to actively raise the affected arm above shoulder level.

Explanation:

DISCUSSION
Axillary lateral and anteroposterior (AP) images of the right shoulder (Figures 59c and 59d) reveal osteoarthrosis of the glenohumeral joint, which typically is not associated with significant rotator cuff pathology. An examination often shows limitations in range of motion, crepitance, and pain with motion. An AP radiographic image of the right shoulder (Figure 59b) reveals proximal humeral migration, which normally correlates with rotator cuff tear size. Tears extending into the infraspinatus tendon are associated with more humeral migration than is seen with isolated supraspinatus tears. Presenting complaints are usually of pain and weakness. Examination findings include subacromial crepitance and weakness during rotator cuff testing. Rarely, this may be associated with pseudoparalysis in large uncompensated rotator cuff tears. The CT image of the right shoulder (Figure 59a) shows superior migration of the humerus with respect to the glenoid surface and end-stage
degenerative changes at the glenohumeral joint. These changes are classified as rotator cuff arthropathy. Pain and weakness are common, as is the presence of pseudoparalysis and limited range of motion.
RECOMMENDED READINGS
Kelly JD Jr, Norris TR. Decision making in glenohumeral arthroplasty. J Arthroplasty. 2003 Jan;18(1):75-82. Review. PubMed PMID: 12555187.
View Abstract at PubMed
Keener JD, Wei AS, Kim HM, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am. 2009 Jun;91(6):1405-13. doi: 10.2106/JBJS.H.00854. PubMed PMID:

Question 51:

Options:

Radial
Ulnar
Median
Posterior interosseous
Anterior interosseous

Correct Answer: Radial

Explanation:

Question 52:

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?

Options:

Improvement in range of motion
Reduction in range of motion
Increase in extensor mechanism lag
No differences in motion and strength

Correct Answer: No differences in motion and strength

Explanation:

DISCUSSION:
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

Question 53:

When performing the exposure for an anterior approach to the cervical spine, excessive retraction of the trachea and esophagus should be avoided to prevent injury of the

Options:

vagus nerve.
recurrent laryngeal nerve.
superior laryngeal nerve.
hypoglossal nerve.
sympathetic trunk.

Correct Answer: recurrent laryngeal nerve.

Explanation:

DISCUSSION: The recurrent laryngeal nerve lies between the trachea and the esophagus and is subject to stretch injury if excessive retraction is applied. The vagus nerve lies in the carotid sheath. The sympathetic trunk lies anterior to the longus colli muscles. The hypoglossal nerve and superior laryngeal nerve are both at risk during the exposure but are not located between the trachea and esophagus.
REFERENCES: An HS: Principles and Techniques of Spine Surgery. Baltimore, MD,
Williams and Wilkins, 1998, chapter 2.
Flynn TB: Neurologic complication of anterior cervical interbody fusion. Spine 1982;7:536-539.

Question 54:

Options:

Cemented left total hip arthroplasty (THA)
Cementless left THA with a proximally porous coated femoral stem
Hybrid left THA
Cementless left THA with a diaphyseal engaging conical femoral stem

Correct Answer: Hybrid left THA

Explanation:

Question 55:

Options:

Hip arthroscopy versus open debridement with synovectomy
CT of the chest, abdomen and pelvis as part of a staging protocol
Total hip arthroplasty (THA)
Nonoperative treatment with routine follow-up The patient has synovial chondromatosis, a benign metaplastic disorder of cartilagenous synovial nodules, often intra-articular. This condition is usually monoarticular, most commonly affecting the knee, followed by hip, elbow and shoulder. It occurs preferentially in men between the ages of 20 to 40. It may cause pain, mechanical or impingement symptoms and loss of motion, and may cause degenerative changes due to impingement. Synovectomy with excision of the cartilaginous nodules is the treatment of choice, and equally good results may be achieved with arthroscopic debridement and open debridement. Recurrence rates vary, reported from 0% to 22%. THA would not be indicated without the presence of arthritis.

Correct Answer: Hip arthroscopy versus open debridement with synovectomy

Explanation:

Question 56:

Options:

Closed reduction with immobilization
Closed reduction with percutaneous pinning
Open reduction, bicolumnar fixation with plate and screws
Open reduction, bicolumnar fixation with Kirschner wires DISCUSSION.. The radiographs and CT scans indicate a comminuted and displaced intra-articular fracture of the distal humerus. Rigid internal fixation with bicolumnar orthogonal or parallel plating is the treatment of choice for most fractures of the distal humerus that involve the joint surface. Closed reduction and variations thereof will not yield a stable environment for healing. To achieve adequate exposure for fixation, a chevron olecranon osteotomy is the preferred approach. Disadvantages associated with this approach include complications such as nonunion of the osteotomy site and intra-articular adhesions. Prominent hardware may need to be removed during a secondary procedure, and intraoperative conversion to an elbow arthroplasty may be limited. The most common complications after open reduction and internal fixation include elbow stiffness, nonunion (2%-10%), and ulnar neuropathy (0%-12%).

Correct Answer: Open reduction, bicolumnar fixation with plate and screws

Explanation:

CLINICAL SITUATION FOR QUESTIONS 84 THROUGH 87
Figure 84 is the glenoid CT scan of a 20-year-old man who dislocated his shoulder anteriorly while playing football. He had persistent instability 2 months after the injury, but he did not have a sulcus sign or posterior instability. He underwent an arthroscopic Bankart repair with 4 bioabsorbable anchors with simple sutures through the labrum and capsule.
He did not have an engaging Hill-Sachs lesion, the rotator cuff was unremarkable, and the capsule was not torn from the humerus. After surgery, he did well for 6 months until he jumped into a lake and again dislocated his shoulder anteriorly. He says his shoulder no longer felt stable after his reduction.

Question 57:

Options:

Obtain upright radiographs
Thoracolumbar orthosis
Posterior stabilization and fusion
Laminectomy

Correct Answer: Posterior stabilization and fusion

Explanation:

DISCUSSION
Spinal fractures in patients with ankylosing spondylitis are unstable and generally necessitate surgical intervention. In a patient with a spinal fracture in the setting of ankylosing spondylitis, posterior instrumented fusion is an appropriate surgical procedure. Treatment with a thoracolumbar orthosis is not an option for patients with extension distraction injuries in the setting of an ankylosed spine because of risk for displacement. Similarly, simply checking upright radiographs is generally not advocated. Laminectomy alone is inappropriate for this patient because there is no cord compression and neurologic symptoms are absent. Stabilization is the treatment goal.
RECOMMENDED READINGS
Braun J, Sieper J. Ankylosing spondylitis. Lancet. 2007 Apr 21;369(9570):1379-90. Review. PubMed PMID: 17448825.
View Abstract at PubMed
Caron T, Bransford R, Nguyen Q, Agel J, Chapman J, Bellabarba C. Spine fractures in patients with ankylosing spinal disorders. Spine (Phila Pa 1976). 2010 May 15;35(11):E458-64. doi: 10.1097/BRS.0b013e3181cc764f. PubMed PMID: 20421858.
View Abstract at PubMed
Finkelstein JA, Chapman JR, Mirza S. Occult vertebral fractures in ankylosing spondylitis. Spinal Cord. 1999 Jun;37(6):444-7. PubMed PMID: 10432265.
View Abstract at PubMed
Hitchon PW, From AM, Brenton MD, Glaser JA, Torner JC. Fractures of the thoracolumbar spine complicating ankylosing spondylitis. J Neurosurg. 2002 Sep;97(2 Suppl):218-22. PubMed PMID: 12296682.
View Abstract at
PubMed

Question 58:

Options:

a thumb spica cast and reassessment in 3 weeks.
a thumb spica cast and reassessment in 6 weeks.
repair of the ulnar collateral ligament of the MCP joint.
adductor pollicis advancement on the proximal phalanx.
repair of the MCP joint dorsal capsule.

Correct Answer: a thumb spica cast and reassessment in 3 weeks.

Explanation:

Question 59:

Options:

C-reactive protein (CRP)
Synovial fluid analysis of affected joints
Blood cultures
Cervical radiographs
Bethesda assay

Correct Answer: Bethesda assay

Explanation:

Question 60:

Options:

C5-C7 nerve roots; upper/middle trunks; anterior division; lateral cord
C5-C6 nerve roots; upper trunk; posterior division; posterior cord
C5-C6 nerve roots; upper trunk
C5-C7 nerve roots
C8-T1 nerve root; lower trunk; anterior division; medial cord

Correct Answer: C8-T1 nerve root; lower trunk; anterior division; medial cord

Explanation:

Question 61:

What is the primary intracellular signaling mediator for bone morphogenetic protein (BMP) activity?

Options:

Interleukin-1 (IL-1)
Runx2
NFK-B
SMADS
P53

Correct Answer: SMADS

Explanation:

Question 62:

Which of the following anatomic changes is observed as part of the normal aging process of the adult spine?

Options:

Overall kyphosis gradually decreases.
Overall lumbar lordosis gradually decreases.
The sagittal vertical line dropped from C7 gradually moves posteriorly relative to the sacrum.
Cervical scoliosis develops.
Coronal balance shifts laterally from the midsacrum.

Correct Answer: Overall lumbar lordosis gradually decreases.

Explanation:

Question 63:

In infantile idiopathic scoliosis, which of the following factors suggests progression?

Options:

Age at presentation
Rib overlap of the apical vertebra
Rib vertebral angle difference of greater then 10 degrees
Male gender
Family history

Correct Answer: Rib overlap of the apical vertebra

Explanation:

Question 64:

Following operative repair of lower extremity long bone and periarticular fractures, what is the time frame for patients to return to normal automobile braking time?

Options:

6 weeks after initiation of weight bearing
4 weeks postoperatively
8 weeks from the date of injury
Once full range of motion of the ankle and knee exist
At the time of bony union

Correct Answer: 6 weeks after initiation of weight bearing

Explanation:

Question 65:

Figure 22 reveals what anatomic variant of the lumbar spine?

Options:

Spina bifida occulta
Unilateral sacralization
An aplastic or hypoplastic pedicle
Lumbarization
Facet tropism

Correct Answer: Unilateral sacralization

Explanation:

DISCUSSION: Unilateral sacralization of the fifth lumbar vertebra was first described by Bertolotti in 1917. Bertolotti’s syndrome is present in 12% to 21% of the population. The altered biomechanics have been postulated to cause low back pain by placing increased stress on the adjacent cephalad disk, thus contributing to accelerated degenerative disk disease at this level. It has also been found that the neoarticulation between the enlarged transverse process and the sacrum and/or ilium may be a source of neural impingement on the exited L5 nerve root and results in radicular pain syndrome. Brault and associates reported on a case treated surgically at the Mayo Clinic, in which the pain generator was found to be the contralateral facet joint.
REFERENCES: Brault JS, Smith J, Currier BL: Partial lumbosacral transitional vertebra resection for contralateral facetogenic pain. Spine 2001;26:226-229.
Quinlan JF, Duke D, Eustace S: Bertolotti’s syndrome: A cause of back pain in young people.
J Bone Joint Surg Br 2006;88:1183-1186.
Whelan MA, Feldman F: The variant lumbar pedicle. Neuroradiology 1982;22:235-242.

Question 66:

Options:

Talectomy
Revision open reduction and internal fixation (ORIF) with bone grafting
Ankle arthrodesis
Tibiotalocalcaneal arthrodesis
Triple arthrodesis

Correct Answer: Revision open reduction and internal fixation (ORIF) with bone grafting

Explanation:

DISCUSSION: The radiographs reveal nonunion of a talar neck fracture. There is no radiographic evidence of osteonecrosis or significant degenerative arthritis. The results of talectomy are suboptimal. Arthrodesis would be indicated for degenerative arthritis. Revision ORIF is feasible and preserves motion. A vascularized graft should be considered whenever osteonecrosis is present, but the talar body appears viable in this case.
REFERENCES: Calvert E, Younger A, Penner M: Post talus neck fracture reconstruction.
Foot Ankle Clin 2007;12:137-151.
Migues A, Solari G, Carrasco NM, et al: Repair of talar neck nonunion with indirect corticocancellous graft technique: A case report and review of the literature. Foot Ankle Int 1996;17:690-694.

Question 67:

In a patient with a major head injury and a femoral shaft fracture, intraoperative hypotension during femoral fixation has been associated with which of the following?

Options:

Increased time needed for rehabilitation
Increased pneumonia rate
Increased intensive care unit length of stay
Decreased discharge Glascow Coma Scale
Decreased hospital length of stay

Correct Answer: Increased time needed for rehabilitation

Explanation:

Question 68:

All of the following indicators of resuscitation may be within normal limits for a trauma patient that is in "compensated" shock EXCEPT:

Options:

Systolic blood pressure
Urine output
Heart rate
Serum lactate
Mean arterial pressure

Correct Answer: Systolic blood pressure

Explanation:

Question 69:

The palmar cutaneous branch of the median nerve (PCBMN) originates from the

Options:

radial side of the median nerve and travels radial to the palmaris longus and ulnar to the flexor carpi radialis.
radial side of the median nerve and travels distally radial to the palmaris longus and flexor carpi radialis.
ulnar side of the median nerve and travels radial to the palmaris longus and ulnar to the flexor carpi radialis.
ulnar side of the median nerve and travels radial to the flexor carpi radialis.
ulnar side of the median nerve and travels radial to the palmaris longus volar.

Correct Answer: radial side of the median nerve and travels radial to the palmaris longus and ulnar to the flexor carpi radialis.

Explanation:

Question 70:

Options:

Femoral attachment of the medial collateral ligament
Tibial attachment of the medial collateral ligament
Hypertrophic zone of the growth plate
Proliferative zone of the growth plate

Correct Answer: Hypertrophic zone of the growth plate

Explanation:

Question 71:

Options:

Acute intra-articular distal humerus fracture
Malunited intra-articular distal humerus fracture
Late-stage rheumatoid arthritis
Post-traumatic bony ankylosis
Osteoarthritis

Correct Answer: Acute intra-articular distal humerus fracture

Explanation:

Question 72:

Options:

Corticosteroid injection
Changing the physical therapist to an athletic trainer
A 1-month trial of nonsteroidal anti-inflammatory drugs (NSAIDs)
Shoulder immobilization for 6 weeks
A discussion regarding surgical stabilization procedures

Correct Answer: A discussion regarding surgical stabilization procedures

Explanation:

Question 73:

Options:

- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation

Correct Answer: - Avascular necrosis, head collapse, and screw penetration

Explanation:

Question 74:

Options:

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

Correct Answer: Perform an open release.

Explanation:

Question 75:

Options:

Elbow extension
Forearm supination
Wrist extension in radial deviation
Middle finger MCP extension
Index finger MCP hyperextension

Correct Answer: Elbow extension

Explanation:

Question 76:

What is the most likely cause of the lesion shown in Figures 35a and 35b?

Options:

Surgery
Contusion
Parathyroid tumor
Bisphosphonate use
Corticosteroid use

Correct Answer: Contusion

Explanation:

DISCUSSION: The most common cause of myositis ossificans is contusion. Certain regions, including the quadriceps and brachialis, are more commonly affected. The mechanisms of development have not been clearly established.
REFERENCES: Beiner JM, Jokl P: Muscle contusion injuries: Current treatment options. J Am Acad Orthop Surg 2001;9:227-237.
Jarvinen TA, Jarvinen TL, Kaariainen M, et al: Muscle injuries: Biology and treatment. Am J Sports Med 2005;33:745-764.

Question 77:

Which nerve root contributes to both the sciatic and femoral nerves?

Options:

Correct Answer: L4

Explanation:

Question 78:

Options:

Interphalangeal joint fusion
Intercalary tendon graft
Silicone rod placement
Primary flexor pollicis longus repair
Flexor digitorum superficialis transfer

Correct Answer: Flexor digitorum superficialis transfer

Explanation:

DISCUSSION: The patient has a chronic flexor tendon laceration. There are options to restore motion and strength; therefore, fusion is not necessary. Full range of motion is present so the soft tissues are suitable for a tendon transfer. A transfer of the flexor digitorum superficialis of the ring finger to the insertion of the flexor pollicis longus on the distal phalanx provides good results with a one-stage operation.
REFERENCES: Schneider LH, Wiltshire D: Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer. J Hand Surg Am 1983;8:98-101.
Posner MA: Flexor superficialis tendon transfers to the thumb: An alternative to the free tendon graft for treatment of chronic injuries within the digital sheath. J Hand Surg Am 1983;8:876-881.

Question 79:

To preserve blood supply to the fractured bone seen in Figures 12a and 12b, care should be taken when exposing which of the following areas?

Options:

Anterolateral aspect of the distal humerus
Posterolateral aspect of the distal humerus
Medial epicondyle
Lateral epicondyle
Radial neck

Correct Answer: Posterolateral aspect of the distal humerus

Explanation:

Question 80:

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

Options:

Implant migration
Deep venous thrombosis
Transient retrograde ejaculation
Transient radicular leg pain
Incisional hernia

Correct Answer: Transient radicular leg pain

Explanation:

Question 81:

A positive straight leg raising sign is when pain radiates distal to the knee when the affected leg is passively elevated. The increased tension generally occurs between Review Topic

Options:

0 degrees to 30 degrees.
30 degrees to 70 degrees.
45 degrees to 90 degrees.
60 degrees to 90 degrees.
90 degrees.

Correct Answer: 30 degrees to 70 degrees.

Explanation:

Question 82:

Figure 16 shows an axial MRI scan through the knee joint. What structure is identified by the arrow?

Options:

Anterior cruciate ligament
Posterior cruciate ligament
Ligament of Wrisberg
Ligamentum mucosum
Popliteus tendon

Correct Answer: Anterior cruciate ligament

Explanation:

Question 83:

Options:

Triple arthrodesis
Midfoot closing wedge resection osteotomy
Calcaneal and metatarsal osteotomies
Plantar release, posterior tibial tendon transfer to the dorsum, and Achilles tendon lengthening
Serial casting

Correct Answer: Plantar release, posterior tibial tendon transfer to the dorsum, and Achilles tendon lengthening

Explanation:

Question 84:

Options:

immobilization for 3 weeks, followed by rehabilitation.
open biceps tenodesis.
arthroscopy with revision stabilization.
arthroscopy with repair of the superior labrum.
subscapularis repair.

Correct Answer: subscapularis repair.

Explanation:

Question 85:

Options:

orthotic stabilization.
removal of the components with resection arthroplasty.
revision total elbow arthroplasty with an unconstrained prosthesis and ulnar allograft.
revision total elbow arthroplasty with a semiconstrained long-stemmed ulnar prosthesis.
elbow arthrodesis with bone grafting.

Correct Answer: revision total elbow arthroplasty with a semiconstrained long-stemmed ulnar prosthesis.

Explanation:

Question 86:

Options:

simple lateral eminence resection.
distal chevron osteotomy of the fifth metatarsal.
oblique mid-diaphyseal osteotomy of the fifth metatarsal.
proximal diaphyseal osteotomy of the fifth metatarsal.
excision of the fifth metatarsal head.

Correct Answer: oblique mid-diaphyseal osteotomy of the fifth metatarsal.

Explanation:

Question 87:

Options:

Physical therapy
Posterior cruciate ligament (PCL) reconstruction
Attempted meniscus repair
Knee aspiration and manipulation under anesthesia The images show a bucket handle medial meniscus tear, which is likely responsible for the block to motion. Therefore, surgery should be recommended with a meniscus repair if possible. Physical therapy or knee aspiration/manipulation under anesthesia is not the best definitive treatment.

Correct Answer: Attempted meniscus repair

Explanation:

Question 88:

Options:

limited range of motion.
patella complications.
infection.
loosening.
tibia fracture.

Correct Answer: patella complications.

Explanation:

Question 89:

Options:

Arthroscopy
MRI scan
Stress radiographs
Tomogram
Arthrogram

Correct Answer: Stress radiographs

Explanation:

Question 90:

Which of the following best describes heat stroke?

Options:

Transient loss of consciousness with peripheral vasodilation and decreased cardiac output with normal body temperature
A condition involving painful contractions of large muscle groups because of decreased hydration and a decrease of serum sodium and chloride
Hypernatremia in poorly conditioned athletes, manifested by thirst and oliguria with a core temperature of less than 102.2 degrees F (39 degrees C)
Hyperthermia, central nervous system dysfunction, and loss of thermoregulatory function
A transient condition that responds to glucose administration

Correct Answer: Hyperthermia, central nervous system dysfunction, and loss of thermoregulatory function

Explanation:

Question 91:

In patients with suspected hepatitis C, which of the following tests is commonly used to confirm the diagnosis after a positive ELISA screening test?

Options:

Polymerase chain reaction (PCR)
Northern blot
Immunoblot assay
Microarray
Proteomics

Correct Answer: Immunoblot assay

Explanation:

Question 92:

Options:

use of an electrical bone stimulation unit.
open reduction and internal fixation with a dynamic compression plate placed superiorly and autogenous bone grafting.
open reduction and internal fixation with a dynamic compression plate placed inferiorly and autogenous bone grafting.
intramedullary screw fixation.
partial claviculectomy.

Correct Answer: open reduction and internal fixation with a dynamic compression plate placed superiorly and autogenous bone grafting.

Explanation:

Question 93:

What is the best initial screening test for a patient with a limb-length discrepancy?

Options:

CT scanography
Orthoroentgenography (scanography)
Measurement from the anterior superior iliac spine to the malleolus with a tape measure
With the patient standing, placement of blocks under the short leg to level the pelvis, followed by measurement of the blocks
Galeazzi test

Correct Answer: With the patient standing, placement of blocks under the short leg to level the pelvis, followed by measurement of the blocks

Explanation:

Question 94:

Options:

Valgus/flexion osteotomy of the proximal femur with repeat open reduction and internal fixation
Conversion to bipolar hemiarthroplasty with a cementless femoral component
Conversion to total hip arthroplasty with a calcar replacement femoral component that bypasses the hardware
External bone stimulator
Removal of hardware, followed by physical therapy and use of a shoe lift

Correct Answer: Conversion to total hip arthroplasty with a calcar replacement femoral component that bypasses the hardware

Explanation:

Question 95:

Options:

classic dysplasia with volume deficient acetabula.
acetabular retroversion with positive crossover signs and ischial spine signs.
no substantial dysplasia, with normal acetabular volume and anteversion.
inadequate radiographic evidence to assess for hip dysplasia.

Correct Answer: inadequate radiographic evidence to assess for hip dysplasia.

Explanation:

Question 96:

A complication associated with using the Morrey approach (triceps reflecting) to implant a semiconstrained total elbow arthroplasty is

Options:

loss of elbow extensor power.
implant dislocation.
implant malposition.
development of heterotopic ossification.

Correct Answer: loss of elbow extensor power.

Explanation:

Question 97:

Options:

open reduction and internal fixation.
cast immobilization.
percutaneous pin fixation.
observation, with follow-up in 3 months.
an MRI scan of the elbow.

Correct Answer: percutaneous pin fixation.

Explanation:

The patient has a nonunion of the lateral condyle of the left humerus. Observation or cast treatment at this stage is not likely to lead to healing of the fracture. MRI will not add any additional information. Open reduction, with minimal posterior soft-tissue stripping, is recommended to establish union of the fracture. Local or other bone graft may also be required. There are no studies that indicate that the displaced fracture will heal with late percutaneous fixation.
(SBQ13PE.40) Immediate spica casting is most appropriate for which of the following?:
Review Topic
2-month-old girl with a displaced spiral mid-diaphyseal femur fracture
A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with <2 centimeters of shortening
3-day-old with teratologic right hip dislocation
9-year-old boy with a displaced spiral mid-diaphyseal femur fracture
12-year-old girl weighing 90 pounds with a displaced spiral mid-diaphyseal femur fracture
Children older than 6 months and up to 6 years with diaphyseal femur fractures may be treated with spica casting.
Children younger than 6 months may only require a Pavlik harness. Immediate spica casting is indicated in children 6 months to 6 years with less than 2 cm of shortening. Each additional cm of shortening at presentation doubles the risk of loss of reduction (1 cm: 12%, 2 cm: 24%, 3 cm; 50%).
Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. Their recommendation for diaphyseal femur fractures with <2 cm shortening in children 6 months to 5 years is Grade B, based on Level II evidence (two level II and one level I study). They recommend early spica or traction with delayed spica. They suggest early spica, as this is more convenient than traction.
In an earlier article, Flynn et al. review the management of pediatric femoral shaft fractures. They recommend early spica casting for the child between 1 and 6 years in
low-energy femoral fractures with up to 2 cm shortening. Illustration A shows several styles of lower extremity spica casts.
Incorrect answers:

Question 98:

A high school football player asks you about an oral supplement that increases body mass and improves sprint times. He would like to use it to improve performance. What is the most likely agent?

Options:

Creatine
Caffeine
Testosterone
Human growth hormone
Ephedrine

Correct Answer: Creatine

Explanation:

Question 99:

Options:

Continued dressing changes
Split-thickness skin graft C. Full-thickness skin graft D. Local rotational flap

Correct Answer: Continued dressing changes

Explanation:

Question 100:

Options:

Parosteal osteosarcoma
Classic osteogenic sarcoma
Ewing’s sarcoma
Osteochondroma
Chondrosarcoma

Correct Answer: Parosteal osteosarcoma

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

OITE & ABOS Orthopedic Board Prep: Trauma, Hand, Foot & Ankle MCQs | Part 258

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 258

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index