OITE & ABOS Orthopedic Exam MCQs: Upper Extremity & Trauma

About This Board Review Set

This is Part 34 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.

How to Use the Interactive Quiz

Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
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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 34

This module focuses heavily on: Elbow, Fracture, Nerve, Shoulder, Wrist.

Sample Questions from This Set

Sample Question 1: The right shoulder exercise seen in Figure A will put the LEAST amount of stretch on which structure? Review Topic...

Sample Question 2: What is the most common presenting problem in patients with cauda equina syndrome? Review Topic...

Sample Question 3: Figures 1 through 4 are the radiographs, sagittal-cut CT scan, and coronal T1 MR image of a 16-year-old boy who has wrist stiffness and pain after sustaining an injury 2 years ago. There is no bleeding from the proximal pole during surgery....

Sample Question 4: A medial plate is best used to treat tibial plateau fractures when there is...

Sample Question 5: A fracture of the radial head is surgically exposed using a posterolateral approach to the elbow. Once the radial head is exposed, how should the arm be positioned to best protect the posterior interosseous nerve from injury?...

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

The right shoulder exercise seen in Figure A will put the LEAST amount of stretch on which structure? Review Topic

Explanation

Shoulder wand exercises, as shown in Figure A, are used to increase external range of motion of the shoulder. With the arm adducted and the elbow flexed, this exercise will put the LEAST amount of stretch on the posterior capsule.
External rotation shoulder wand exercises are commonly used for the treatment of adhesive capsulitis. Adhesive capsulitis is most commonly caused by contracture of the rotator interval. The rotator interval includes the anterior-superior capsule, superior glenohumeral ligament, coracohumeral ligament and long head biceps tendon. The structure most commonly contracted is the anterior-superior capsule, which limits external rotation when the arm is adducted.
Kuhn et al. showed that in the neutral position, each ligament except the posterior capsule significantly affected the torque required for external rotation. The greatest effect on resisting external rotation at 0 degrees of abduction was the entire inferior glenohumeral ligament > coracohumeral ligament > anterior band of the inferior glenohumeral ligament > superior and middle glenohumeral ligament.
Harryman et al. looked at the role of the rotator interval capsule in passive motion and stability of the shoulder. They found operative alteration of this capsular interval was found to affect flexion, extension, external rotation, and adduction of the humerus with respect to the scapula. Limitation of external motion was increased by operative imbrication of the rotator interval and decreased by sectioning of the rotator interval capsule.
Kim et al. reviewed shoulder MRIs to determine if abnormalities of the rotator interval were correlated with chronic shoulder instability. They found a significantly larger rotator interval height, rotator interval area, and rotator interval index in patients with chronic anterior shoulder instability compared to patients without instability.
Figure A shows a patient performing an exercise to increase right shoulder external rotation with a wand/stick. The right arm is fully adducted by her side, and her elbow flexed at 90 degrees.
Incorrect Answers:

Question 2

What is the most common presenting problem in patients with cauda equina syndrome? Review Topic

Explanation

In one recent retrospective cohort study of 42 patients with cauda equina syndrome, 83% had low back pain at presentation, 90% had radicular lower extremity pain, 60% had urinary retention, and 55% had urinary incontinence. Objective findings at presentation included 55% with leg weakness, 62% with sensory deficit, 62% with absent ankle jerk reflexes, 76% with perianal sensory deficit, and 50% with decreased rectal tone.

Question 3

Figures 1 through 4 are the radiographs, sagittal-cut CT scan, and coronal T1 MR image of a 16-year-old boy who has wrist stiffness and pain after sustaining an injury 2 years ago. There is no bleeding from the proximal pole during surgery. Which procedure will most likely result in restoration of alignment and healing?

Explanation

EXPLANATION:
The imaging studies show an established scaphoid waist nonunion with a humpback deformity (significant flexion through the nonunion site) and carpal collapse. In addition, the proximal pole appears sclerotic on the plain radiographs and appears poorly perfused on the MR image. Correction of alignment of this scaphoid nonunion would require a volar approach with a structural bone graft. Additionally, the graft would need to provide a vascular supply to the bone. Both the 1,2 ICSRA (the Zaidenberg graft) and the 4+5 ECA grafts are vascularized grafts from the dorsal distal radius. Neither of these grafts would correct the humpback deformity, and the 4+5 ECA graft pedicle is not long enough to reach the scaphoid. An iliac crest bone graft could be used to correct the deformity, but would not provide an adequate blood supply. A free-vascularized medial femoral condyle graft provides both adequate bone graft to correct the deformity and revascularization of the scaphoid.

Question 4

A medial plate is best used to treat tibial plateau fractures when there is

Explanation

DISCUSSION
The patient's plain radiographs demonstrate a bicondylar tibial plateau fracture with complete separation of the diaphysis from the epiphysis, making this a Schatzker VI injury. Clinically, the patient is neurovascularly intact with symmetric palpable pulses, and ankle brachial indices are not necessary.
There is significant lateral tibial plateau displacement with the lateral femoral condyle down into the plateau defect. Considering the swelling, abrasions, and severity of the injury, a bridging external fixator is warranted followed by CT imaging.
The ligamentotaxis will provide better definition of the injury and joint fragments and allow for soft-tissue rest and subsidence of the swelling for eventual surgical intervention. Oblique views will not add as much information as CT imaging, which will show the bicondylar nature of the injury and the proximal tibia essentially split centrally with the tubercle as a separate fragment. A midline incision with medial and lateral plating has fallen out of
favor secondary to wound-healing complications. Comminution of the metaphysis or the lateral side is not an absolute indication for a medial plate. Open lateral fractures can still be managed with a laterally based plate depending on the soft-tissue injury.
RECOMMENDED READINGS
Higgins TF, Kemper D, Klatt J. Incidence and morphology of the posteromedial fragment in bicondylar tibial plateau fractures. J Orthop Trauma. 2009 Jan;23(1):45-51. doi: 10.1097/BOT.0b013e31818f8dc1. PubMed PMID: 19104303. View Abstract at PubMed Higgins TF, Klatt J, Bachus KN. Biomechanical analysis of bicondylar tibial plateau fixation: how does lateral locking plate fixation compare to dual plate fixation? J Orthop Trauma. 2007 May;21(5):301-6. PubMed PMID: 17485994. View Abstract at PubMed
Berkson EM, Virkus WW. High-energy tibial plateau fractures. J Am Acad Orthop Surg. 2006 Jan;14(1):20-31. Review. PubMed PMID: 16394164. View Abstract at PubMed
Barei DP, O'Mara TJ, Taitsman LA, Dunbar RP, Nork SE. Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns. J Orthop Trauma. 2008 Mar;22(3):176-82. doi:10.1097/BOT.0b013e318169ef08. PubMed PMID: 18317051.
View Abstract at PubMed
Barei DP, Nork SE, Mills WJ, Coles CP, Henley MB, Benirschke SK. Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg Am. 2006 Aug;88(8):1713-21. PubMed PMID: 16882892. View Abstract at PubMed
Hall JA, Beuerlein MJ, McKee MD; Canadian Orthopaedic Trauma Society. Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Surgical technique. J Bone Joint Surg Am. 2009 Mar 1;91 Suppl 2 Pt 1:74-88. doi: 10.2106/JBJS.G.01165. PubMed PMID: 19255201. View Abstract at PubMed
Lowe JA, Tejwani N, Yoo B, Wolinsky P. Surgical techniques for complex proximal tibial fractures. J Bone Joint Surg Am. 2011 Aug 17;93(16):1548-59. PubMed PMID: 22204013. View Abstract at PubMed
Weil YA, Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Posteromedial supine approach for reduction and fixation of medial and bicondylar tibial plateau fractures. J Orthop Trauma. 2008 May-Jun;22(5):357-62. doi: 10.1097/BOT.0b013e318168c72e. PubMed PMID:

Question 5

A fracture of the radial head is surgically exposed using a posterolateral approach to the elbow. Once the radial head is exposed, how should the arm be positioned to best protect the posterior interosseous nerve from injury?

Explanation

DISCUSSION: As long as the dissection stays proximal to the annular ligament, the posterior interosseous nerve is not at risk for injury. However, to ensure that the nerve is as far removed from the surgical field as possible, the forearm should be placed in pronation. Forearm supination of any degree will bring the nerve toward the surgical field. A neutral position of the forearm or elbow extension with wrist extension will not protect the posterior interosseous nerve.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, Lippincott-Raven, 1992, p 100.
Tubiana R, McCullough CJ, Masquelet AC: An Atlas of Surgical Exposures of the Upper Extremity. Philadelphia, PA, JB Lippincott, 1990, p 106.

Question 6

An otherwise healthy 76-year-old woman has pain 2 years after total hip arthroplasty. The clinical photograph in Figures below demonstrates her skin envelope, and associated radiograph. Her C-reactive protein level is normal, and her erythrocyte sedimentation rate is mildly elevated. The white blood cell count is normal. Hip aspiration attempted under fluoroscopy generates no fluid. What is the best definitive treatment?

Explanation

DISCUSSION:
This patient clearly has a chronically infected total hip arthroplasty, indicated by the open, draining sinus, as well as trochanteric bone resorption on radiographs, and two years of pain. Recently, specific guidelines have been published to better help the clinician define infection. Repeating the hip aspiration is unnecessary, because infection is already evident. Initiating a wound care consult would not address the underlying infection. The determination whether to retain the components or perform a two-stage exchange is based more on the acuity of infection. In this particular case, the patient is chronically infected. Irrigation and debridement with a liner exchange and retention of the components are reserved for the acute setting.

Question 7

Use of titanium elastic nailing for treatment of pediatric femur fractures is associated with a higher complication rate among

Explanation

DISCUSSION
Studies of titanium elastic nailing for femur fractures demonstrated a higher rate of complications, including angular deformity and construct failure, among patients weighing more than 50 kg (100 pounds). Other methods of fixation are recommended for these patients. Flexible nails are not commonly needed, but they also are not associated with a higher complication rate in children younger than age 6.5. Titanium elastic nailing works well in closed or minimally open transverse midshaft fractures, even in the setting of early or immediate weight bearing.

Video 8a
Video 8b

Question 8

A 72-year-old woman who is right hand-dominant has severe pain in the right shoulder that has failed to respond to nonsurgical management. She reports night pain and significant disability. Examination reveals 30 degrees of active forward elevation. An AP radiograph is shown in Figure 27. Which of the following treatment options will provide the best functional improvement? Review Topic

Explanation

The patient has end-stage rotator cuff tear arthropathy. The radiograph shows complete proximal humeral migration (acromiohumeral interval of 0 mm), severe glenohumeral arthritis, and acetabularization of the acromion. In addition, she has "pseudoparalysis" with active elevation of only 30 degrees. Reverse shoulder arthroplasty affords her the best opportunity for pain relief and functional improvement. The other procedures have mixed results but typically are better for pain relief than they are for functional gains.

Question 9

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 10

A 48-year-old male is involved in a motorycycle accident and arrives in the trauma bay in hypovolemic shock. He receives 6 units of packed red blood cells during his resuscitation. Which of the following viral microbes is he most at risk of exposure from the transfusions?

Explanation

DISCUSSION: According to the article by Wang et al the risk of viral transmission following a screened blood donation is: 1 in 1.9 million donations for human immunodeficiency virus (HIV), 1 in 1.8 million donations for hepatitis C virus (HCV), and 1 in 205,000 donations for hepatitis B virus (HBV). West Nile and Human T-cell leukemia viruses are even more rare in the general population, and both are screened in blood banks. Hepatitis A virus is not a blood borne viral disease. It is contracted by the fecal-oral route. Staph Aures is a bacteria, not a virus.

Question 11

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain. The patient experiences little improvement with activity modification and more physical therapy. An intra-articular corticosteroid injection provides excellent relief, but relief only lasts for 1 month. The player requests further treatment for his hip and is counseled regarding surgical intervention. Hip arthroscopy is performed. Intraoperatively, a capsulolabral separation is observed with an underlying pincer lesion. No articular cartilage injury is seen. Which treatment is most appropriate considering these findings?

Explanation

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has important functions for hip stability and maintenance of the suction seal of the joint.

Question 12

Examination of a 4-year old child with obstetrical palsy reveals weak deltoids, pectoralis major strength of 4-5, and normal hand function. External rotation of the shoulder is limited. What is the most appropriate surgical procedure to restore external rotation?

Explanation

DISCUSSION: Transfer of the latissimus dorsi and teres major to the posterior rotator cuff will restore external rotation and some abduction. The procedure should be performed in children who are approximately age 4 years, following spontaneous recovery and prior to significant stiffness. External rotation osteotomy is more appropriate for an older child. Fusion should not be performed until skeletal maturity. Distal biceps rerouting restores pronation for a supination deformity. Latissimus dorsi and teres major transfer to the subscapularis would accentuate the internal rotation. In younger patients without significant bony deformity, a subscapularis slide or lengthening can restore external rotation.
REFERENCES: Strecker WB, McAllister JW, Manske PR, Schoenecker PL, Dailey LA: Sever-L’Episcopo transfers in obstetrical palsy: A retrospective review of twenty cases. J Pediatr Orthop 1990;10:442-444.
Hoffer MM, Wickenden R, Roper S: Brachial plexus birth palsies. J Bone Joint Surgery Am 1978;60:692-695.

Question 13

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

Explanation

DISCUSSION: Fibromatosis is a benign but aggressive fibrous lesion that principally arises from the connective tissue of muscle and the overlying fascia. The peak incidence is between the ages of 25 and 35 years. Most patients have a deep-seated, firm, poorly circumscribed mass that has grown insidiously and causes little or no pain. MRI is helpful in diagnosing the lesion and in assessing the extent of disease prior to surgical intervention. Histologically, the lesion is poorly circumscribed and infiltrates the surrounding tissue. The lesion appears bland with uniform spindle cells separated by abundant collagen, with little or no cell-to-cell contact. Despite its bland microscopic appearance, the tumor frequently behaves in an aggressive manner. These lesions do not metastasize but have a high incidence of recurrence. Treatment options consist

of surgical resection, radiation therapy, chemotherapeutic protocols, hormone modulation, and/or anti-inflammatory medications.

REFERENCES: Weiss SW, Goldblum JR, Enzinger FM: Enzinger and Weiss’s Soft Tissue Tumors, ed 4. Philadelphia, PA, Elsevier, 2001, pp 309-337.
Spear MA, Jennings LC, Mankin HJ, et al: Individualizing management of aggressive fibromatoses. Int J Radiat Oncol Biol Phys 1998;40:637-645.

Question 14

Arthritic change in cartilage is characterized by which of the following findings?

Explanation

Experimental models of late-stage arthritis in animals demonstrated lower compressive modulus, higher permeability, and higher water content. There is proteoglycan loss within the matrix. A significant and progressive decrease in the tensile and shear modulus has been observed.

Question 15

For patients undergoing a surgical procedure where the risk of requiring a transfusion is less than 10%, the International Committee of Effective Blood Usage suggests

Explanation

DISCUSSION: Recent studies have shown a high rate of waste of autologous blood. Therefore, the Committee does not recommend autologous blood donation for procedures that carry a transfusion risk of 10% or less.
REFERENCES: Toy P, Beattie C, Gould S, et al: Transfusion alert: Use of autologous blood. National Heart, Lung, and Blood Institute Expert Panel on the use of autologous blood. Transfusion 1992;35:703-711.
Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB: An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 1999;81:2-10.

Question 16

Which of the following structures is most commonly involved in lateral epicondylitis?

Explanation

DISCUSSION: The most common specific site of involvement is the origin of the extensor carpi radialis brevis. It is usually caused by overuse activities, such as the eccentric overload exhibited during a backhand in tennis. In most patients, the characteristic friable, grayish tissue described as angiofibroblastic hyperplasia or hyaline degeneration is seen at the extensor carpi radialis brevis origin.
REFERENCES: Nirschl RP: Elbow tendinosis/tennis elbow. Clin Sports Med 1992;11:851-870.
Regan W, Wold LE, Coonrad R, Morrey BF: Microscopic histopathology of chronic refractory lateral epicondylitis. Am J Sports Med 1992;20:746-749.

Question 17

Figures 1 through 5 show the radiographs obtained from a 37-year-old man who has a 10-year history of right, ulnar-sided wrist pain and a volar ulnar prominence with wrist supination. Approximately 20 years ago, he had a forearm injury that was definitively treated in a long arm cast. What surgical treatment option is most likely to improve his symptoms and maintain pronosupination?

Explanation

EXPLANATION:
The patient sustained a radial shaft fracture with subsequent apex volar malunion. As a result, his distal ulna subluxates volarly with wrist supination. Radiographs of the wrist reveal minimal arthritic changes. The most appropriate treatment option is to surgically correct his radial shaft malunion, which would indirectly address his DRUJ instability. A DRUJ ligament reconstruction or triangular fibrocartilage complex repair could be used to augment DRUJ stability; however, they might be unnecessary after correction of the radial shaft malunion. A DRUJ ligament reconstruction alone would not achieve stability of the DRUJ joint and maintain full wrist pronosupination. An ulnar head implant arthroplasty would not be reliable in eliminating the instability or the pain. Similarly, a one-bone forearm procedure might
improve the patient's pain and instability but at the cost of abnormal wrist and forearm mechanics and kinematics.

Question 18

A 73-year-old man presents to your clinic many years after undergoing total shoulder arthroplasty with pain and the radiographic findings demonstrated in Figure 56. The most likely cause of this patient’s pain is

Explanation

DISCUSSION
The radiograph shows proximal humeral migration and loosening of the glenoid component. Proximal migration of the humeral head may represent rotator cuff dysfunction and can lead to progressive failure of the glenoid component. Stress shielding will not cause lysis or loosening of the glenoid component. Humeral osteolysis is an uncommon finding and is not shown. Progressive glenoid arthrosis is not possible with a resurfaced glenoid.
RECOMMENDED READINGS
Hill JM, Norris TR. Long-term results of total shoulder arthroplasty following bone-grafting of the glenoid. J Bone Joint Surg Am. 2001 Jun;83-A(6):877-83. PubMed PMID: 11407796.View Abstract at PubMed
Fox TJ, Cil A, Sperling JW, Sanchez-Sotelo J, Schleck CD, Cofield RH. Survival of the glenoid component in shoulder arthroplasty. J Shoulder Elbow Surg. 2009 Nov-Dec;18(6):859-63. doi: 10.1016/j.jse.2008.11.020. Epub 2009 Mar 17. PubMed
PMID: 19297199.View Abstract at PubMed

Question 19

A patient wakes up with a foot drop following open reduction internal fixation of a posterior wall/posterior column acetabular fracture. What position of the leg causes the highest intraneural pressure in the sciatic nerve?

Explanation

DISCUSSION: Borrelli et al examined the intraneural pressure of the sciatic nerve with the hip and knee in various different positions. They found that the "sciatic nerve appeared to exceed published critical thresholds for alterations of blood flow and neural function only when the hip was flexed to 90 degrees and the knee was fully extended." As a result, the leg is typically position with the hip in extension (or minimal flexion) and the knee in about 90 degrees of flexion when performing acetabular surgery via a posterior approach.

Question 20

Radiating pain associated with a posterolateral thoracic disk herniation typically follows what pattern? Review Topic

Explanation

Although symptomatic thoracic disk herniations can affect more caudal structures, even to the point of paralysis, the pattern of radiating pain has been described as either following the dermatomal band around the chest or feeling to the patient as if the pain passes straight anteriorly to the chest wall.

Question 21

Titanium and its alloys are unsuitable candidates for which of the following implant applications?

Explanation

DISCUSSION: Titanium alloy is highly biocompatible, has higher strength than stainless steel, and is highly resistant to corrosion. It is particularly suited for use in fracture plates, bone screws, and intramedullary nails because of its low modulus of elasticity (low stiffness), which can reduce stress shielding. It is also widely used for porous-ingrowth coatings. However, clinical experience has shown that titanium alloy bearing surfaces such as a femoral ball are highly susceptible to severe metallic wear, particularly in the presence of third-body abrasive particles (PMMA fragments, bone chips, metal debris, etc).
REFERENCES: McKellop HA, Sarmiento A, Schwinn CP, et al: In vivo wear of titanium-alloy hip prostheses. J Bone Joint Surg Am 1990;72:512-517.
Salvati EA, Betts F, Doty SB: Particulate metallic debris in cemented total hip arthroplasty. Clin Orthop 1993;293:160-173.
Evans BG, Salvati EA, Huo MH, et al: The rationale for cemented total hip arthroplasty. Orthop Clin North Am 1993;24:599-610.

Question 22

A 31-year-old woman has a history of a painful ankle that has failed to respond to conservative management. She has associated night pain that is relieved with nonsteroidal anti-inflammatory drugs. MRI and technetium Tc 99m scans are consistent with an osteoid osteoma. Management should now consist of

Explanation

DISCUSSION: Surgical curettage or en bloc resection is the treatment of choice for osteoid osteoma. Night pain and relief of symptoms with nonsteroidal anti-inflammatory drugs are classic findings for osteoid osteoma.
REFERENCES: Donley BG, Philbin T, Rosenberg GA, Schils JP, Recht M: Percutaneous CT guided resection of osteoid osteoma of the tibial plafond. Foot Ankle Int 2000;21:596-598.
Kenzora JE, Abrams RC: Problems encountered in the diagnosis and treatment of osteoid osteoma of the talus. Foot Ankle 1981;2:172-178.
Shereff MJ, Cullivan WT, Johnson KA: Osteoid-osteoma of the foot. J Bone Joint Surg Am 1983;65:638-641.

Question 23

What is the most common donor site complication following a free vascularized fibular graft for osteonecrosis of the femoral head?

Explanation

DISCUSSION: Urbaniak and Harvey reported donor site morbidity following free vascularized fibular graft in 198 consecutive patients. At a 5-year follow-up, they reported overall complications in 24% of the patients. The most common complication was a sensory deficit (11.8%), followed by motor weakness (2.7%), flexor hallucis longus contracture (2%), and deep venous thrombosis (less than 1%).
REFERENCE: Urbaniak J, Harvey E: Revascularization of the femoral head in osteonecrosis. J Am Acad Orthop Surg 1998;6:44-54.

Question 24

What is the most anatomic location for placement of the femoral tunnel in anterior cruciate ligament reconstruction?

Explanation

DISCUSSION: It is critical for graft isometry and knee stability that the femoral tunnel be placed as far posterior as possible on the lateral femoral condyle. Superiorly, the graft should be at the one o’clock position on the left knee. Resident’s ridge is a false posterior shelf that often seems like the extreme posterior cortex. Abnormal tunnel placement results in a variety of complications, including an unstable knee, early graft failure, and joint stiffness.
REFERENCES: Johnson RJ, Beynnon BD, Nichols CE, Renstrom PA: The treatment of injuries of the anterior cruciate ligament. J Bone Joint Surg Am 1992;74:140-151.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 533-557.

Question 25

The attachments of the transverse carpal ligament include which of the following structures?

Explanation

DISCUSSION: The transverse carpal ligament is the volar boundary of the carpal tunnel. It attaches to the scaphoid and trapezium radially and the pisiform and the hook of the hamate ulnarly. The ulna and trapezoid do not receive attachments of the transverse carpal ligament.
REFERENCES: Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 471-472.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 168-170.

Question 26

Which of the following is the only nonreversible effect of anabolic steroids?

Explanation

DISCUSSION: The loss of hair or alopecia, is the only nonreversible effect of anabolic steroid use.
Once anabolic steroids are stopped, muscle hypertrophy and training gains are quickly lost and the HDL/ LDL ratios return to their preexisting levels. Fortunately, the personality effects and the acute acne are reversible.
REFERENCES: Hartgens F, Kuipers H: Effects of androgenic-anabolic steroids in athletes. Sports Med 2004;34:513-554.
Evans NA: Current concepts in anabolic-androgenic steroids. Am J Sports Med 2004;32:534-542.

Question 27

Which of the following best describes heat stroke? Review Topic

Explanation

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 102.2 degrees F (39 degrees C) and an absence of central nervous system dysfunction. Hypernatremic heat exhaustion results from inadequate water replacement.

Question 28

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

Explanation

DISCUSSION: Capsular exposure for an inside-out lateral meniscal repair is performed by developing the interval between the iliotibial band and biceps tendon. Posterior retraction of the biceps tendon exposes the lateral head of the gastrocnemius. Posterior retraction of the gastrocnemius provides access to the posterolateral capsule.
REFERENCES: Miller DB Jr: Arthroscopic meniscus repair. Am J Sports Med 1988;16:315-320.
Nawab A, Hester PW, Caborn DN: Arthroscopic meniscus repair, in Miller MD, Cole BJ (eds): Textbook of Arthroscopy. Philadelphia, PA, WB Saunders, 2004, pp 517-537.

Question 29

A 19-year-old man sustains a low-velocity gunshot wound to the forearm. What factor most strongly correlates with the development of compartment syndrome after this injury?

Explanation

DISCUSSION: In a multivariate analysis, the strongest factor for the development of compartment syndrome is fracture of the proximal third of the forearm. However, compartment syndrome can still occur without a fracture. Therefore, these patients should be followed with a high level of suspicion for the development of compartment syndrome.
REFERENCES: Moed BR, Fakhouri AJ: Compartment syndrome after low-velocity gunshot wounds to the forearm. J Orthop Trauma 1991;5:134-137.
Hahn M, Strauss E, Yang EC: Gunshot wounds to the forearm. Orthop Clin North Am 1995;26:85-93.

Question 30

Talar compression syndrome in ballet dancers typically involves injury to which of the following structures?

Explanation

DISCUSSION: Talar compression syndrome is also known as os trigonum syndrome or posterior ankle impingement syndrome and occurs in activities involving extreme ankle plantar flexion. It involves pinching of the posterior talus (os trigonum or posterior process of the talus) between the calcaneus and tibia. The flexor hallucis longus also may be impinged. The other structures are not commonly injured in this syndrome.
REFERENCES: Brodsky AE, Khalil MA: Talar compression syndrome. Am J Sports Med 1986;14:472-476.
Wredmark T, Carlstedt CA, Bauer H, Saartok T: Os trigonum syndrome: A clinical entity in ballet dancers. Foot Ankle 1991;11:404-406.
Marotta JJ, Micheli LJ: Os trigonum impingement in dancers. Am J Sports Med 1992;20:533-536.

Question 31

A 33-year old man sustains a posterior elbow dislocation after a fall. Attempts at closed reduction result in recurrent instability. What is the most common ligamentous injury found at the time of surgical stabilization?

Explanation

Classic posterior elbow dislocations result from a posterolateral rotatory mechanism, whereby the hand is fixed (typically on the ground) while the weight of the body creates a valgus and external rotation moment on the elbow. This results first in tearing of the lateral collateral ligament that proceeds medially through the anterior and posterior joint capsules, ending with potential involvement of the ulnar collateral ligament (but this is not universal). McKee and associates assessed the lateral soft-tissue injury pattern of elbow dislocations
with and without associated fractures at the time of surgery. Injury to the lateral collateral ligament complex was seen in every case, with avulsion from the distal humerus as the most common finding. Midsubstance
tears, proximal avulsions, and distal bony avulsions of the ulnar collateral ligament are less common.

Question 32

Which muscles are responsible for the displacement of the proximal fragment of the fracture shown in Figure 75?

Explanation

Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the
authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:

Question 33

Os naviculare is present in which percentage of normal feet?

Explanation

DISCUSSION
Accessory navicular is found in 10% to 14% of normal feet, is generally asymptomatic, and involves 3 radiographic types. Type I represents a small ossicle embedded within the posterior tibial tendon, type II is larger with a synchondrosis, and type III is fused to the navicular tuberosity. Approximately 50% of patients with symptoms have flexible flatfoot; however, os naviculare is not directly associated with pes planovalgus deformity.
Subtalar arthroereisis describes the use of a sinus tarsi plug or implant to restrict eversion of the subtalar joint. This surgical procedure has been used in combination with tendon reconstruction for treatment of flexible flatfoot deformity. Known complications of subtalar arthroereisis include persistent sinus tarsi pain, foreign body reaction, implant failure, and osteonecrosis of the talus.
The FDL tendon travels within the same compartment adjacent to the posterior tibial tendon and is the most commonly used tendon transfer for treatment of stage II PTTD (strength characteristics are similar). The plantaris has inferior tendon strength to the FDL, and the peroneus longus travels in a different compartment than the FDL.
RECOMMENDED READINGS
Sullivan RJ. Adolescent foot and ankle conditions. In: Pinzur MD, ED. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:47-55.
Alvarez RG, Price J, Marini A, Turner NS, Kitaoka HB. Adult acquired flatfoot deformity and posterior tibial tendon dysfunction. In: Pinzur MD, ED. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:215-229.
Pinney SJ, Lin SS. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int. 2006 Jan;27(1):66-75. Review. PubMed PMID: 16442033. View Abstract at PubMed
Viladot R, Pons M, Alvarez F, Omaña J. Subtalar arthroereisis for posterior tibial tendon dysfunction: a preliminary report. Foot Ankle Int. 2003 Aug;24(8):600-6. PubMed PMID: 12956565. View Abstract at PubMed

Question 34

An otherwise healthy 32-year-old man who underwent an uneventful L5-S1 lumbar microdiskectomy 6 weeks ago now reports increasing and severe back pain that awakens him from sleep. Examination reveals a benign-appearing wound, and the neurologic examination is normal. Laboratory studies show an erythrocyte sedimentation rate (ESR) of 90 mm/h and a WBC of 9,000/mm3. Plain radiographs are normal. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient’s history and laboratory studies are very suspicious for a postoperative diskitis. The predominant symptom often is back pain. An ESR of 90 mm/h is considered significantly elevated and normally would be expected to return to near baseline by 2 weeks postoperatively. A normal WBC result is not unusual with postoperative diskitis. Management should consist of an MRI with gadolinium to confirm the diagnosis, followed by a biopsy percutaneously to obtain tissues for pathology and microbiology. Surgical debridement is reserved for patients whose percutaneous biopsy results are negative and a high index of suspicion for diskitis remains, or when management consisting of IV antibiotics, bed rest, and spinal immobilization fails to provide relief.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 257-271.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 713-721.

Question 35

The injection shown in Figures 1a and 1b would most benefit a patient who reports which of the following symptoms?

Explanation

DISCUSSION: The images demonstrate a L5 selective root block as it exits the L5-S1 foramen. This root block best helps relieve pain or paresthesias in the L5 distribution, which is the dorsal first web space and the great toe. The lateral foot is an S1 distribution and would need to be blocked through the posterior first sacral foramen. The anterior shin and thigh represent the

L4 root which exits a level above this at the L4-5 foramen. A stocking distribution is nonanatomic and not indicative of a specific root.
REFERENCES: Magee D: Principles and concepts, in Orthopaedic Physical Assessment, ed 3. Philadelphia, PA, WB Saunders, 1997, pp 1-18.
Aeschbach A, Mekhail NA: Common nerve blocks in chronic pain management. Anesthesiol Clin North Am 2000;18:429-459.

Question 36

Which of the following factors will adversely affect bone ingrowth in a revision porous-coated stem?

Explanation

DISCUSSION: The optimal conditions for bony ingrowth include a pore size of 100 to 400 mm, interface micromotion of 50 mm or less, intimate contact between the bone and the implant, circumferential porous coating of the implant, and use of a biocompatible material. Stem designs with patch coatings have a poor record of bony ingrowth, especially in the revision setting. Failure of ingrowth in the previous stem would be the result of its own mechanical milieu and would not necessarily predict results for the new stem.
REFERENCES: Berry DJ, Harmsen WS, Ilstrup D, Lewallen DG, Cabanela ME: Survivorship of uncemented proximally porous-coated femoral components. Clin Orthop 1995;319:168-177.
Cook SD, Thomas KA, Haddad RJ Jr: Histologic analysis of retrieved human porous-coated total joint components. Clin Orthop 1988;234:90-101.
Spector M: Historical review of porous-coated implants. J Arthroplasty 1987;2:163-177.

Question 37

A 28-year-old hockey player has a shoulder deformity after being checked into the boards. Examination reveals that swelling has improved, but there is tenderness along the distal clavicle. Radiographs reveal a grade II acromioclavicular joint separation. Initial management should consist of

Explanation

DISCUSSION: The most common shoulder injury in hockey players is to the acromioclavicular joint. Early rest and control of pain and inflammation is the preferred management. Surgery is reserved for patients with significant coracoclavicular disruption that has failed to respond to nonsurgical management. Cross-chest stretches and overhead exercises may increase symptoms. A cortisone injection within the glenohumeral joint will have little effect.
REFERENCES: Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:11-18.
Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU: Surgical treatment of complete acromioclavicular dislocation. Am J Sports Med 1995;23:324-331.

Question 38

Figure 14 is a sagittal-cut MR image from the hindfoot of a 54-year-old woman who has had plantar heel pain for 3 months. There is no history of trauma. Her pain is worse when she rises and at the end of the day. Upon examination she has localizable tenderness over the plantar medial tubercle of the calcaneus. The Achilles is intact and nontender, and subtalar joint motion is full and painless. A Tinel test result is negative. What is the most likely diagnosis?

Explanation

DISCUSSION
Plantar fasciitis is inflammation of the plantar fascia at its insertion onto the medial calcaneus. The T2-weighted sagittal MR image reveals thickening of the plantar fascia with no evidence of a calcaneal stress fracture, coalition, or inflammation of the insertion of the Achilles tendon.
RECOMMENDED READINGS
Lareau CR, Sawyer GA, Wang JH, DiGiovanni CW. Plantar and medial heel pain: diagnosis and management. J Am Acad Orthop Surg. 2014 Jun;22(6):372-80. doi: 10.5435/JAAOS-22-06-

Question 39

A 26-year-old man sustained an isolated injury to his left hip joint in a motor vehicle accident. Closed reduction was performed, and the postreduction radiograph is shown in Figure 29. Management should now consist of

Explanation

DISCUSSION: The patient has a posterior fracture-dislocation of the hip and following reduction, an incarcerated fragment of bone resulted in an incongruent reduction. Whereas expedient removal of the fragment is required to limit articular cartilage damage, this situation is not an emergency and the procedure may be performed when the appropriate surgical team is available and the patient is stabilized. Skeletal traction through either the femur or tibia may relieve some pressure on the joint and prevent articular damage. Nonsurgical care for incarcerated fragments is contraindicated.
REFERENCES: Tile M, Olson SA: Decision making: Non operative and operative indications for acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum. Philadelphia, PA, Lippincott Williams and Wilkins, 2003, pp 496-532.
Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993, pp 337-339, p 507.

Question 40

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

Explanation

DISCUSSION: Through cadaveric study, Spencer and associates measured anterior and posterior translation of the sternoclavicular joint. The study demonstrated that the posterior sternoclavicular joint capsule is the most important structure for preventing both anterior and posterior translation of the sternoclavicular joint.
REFERENCES: Gilot GJ, Wirth MA, Rockwood CA: Injuries to the sternoclavicular joint, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott, Williams and Wilkins, 2006, vol 2, pp 1373-1374.
Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.

Question 41

A 13-year-old girl is diagnosed with a stage IIB osteosarcoma of the proximal tibia. Following neoadjuvant chemotherapy, local control should consist of

Explanation

DISCUSSION: Local control of osteosarcoma consists of wide resection and reconstruction. Radiation therapy is not recommended except in unresectable lesions or for palliation. Curettage and bone grafting result in intralesional resection with an unacceptable high rate of local recurrence. Chemotherapy alone is not adequate for local control.
REFERENCES: Simon M, Springfield D, et al: Osteogenic Sarcoma: Surgery for Bone and Soft Tissue. Philadelphia, PA, Lippincott Raven, 1998, p 274.
Wold LA, et al: Osteogenic Sarcoma: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 14-15.

Question 42

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

Explanation

Traumatic posterior instability is a common finding in football players, especially in the blocking positions as well as in the defensive linemen and linebackers. A traumatic blow to the outstretched arm results in posterior glenohumeral forces. Labral detachment at the glenoid rim is common. Patients report slipping or pain with posteriorly directed pressure. Rarely do these patients have true dislocations that require reduction; however, recurrent episodes of subluxation or pain are not uncommon. Posterior repair has been shown to be successful in the treatment of traumatic instability.

Question 43

A 10-year-old girl has a midshaft both bone forearm fracture. After attempted closed reduction, alignment consists of bayonet apposition, 10° of malrotation, and 8° of volar angulation. Management should now consist of

Explanation

DISCUSSION: Acceptable alignment in both bone forearm fractures is related to age and location. In children younger than age 9 years, angulations of 15° and malrotation of 45° are acceptable. In children older than age 9 years, acceptable alignment is 10° of angulation and 30° of malrotation. Bayonet apposition is acceptable provided that the angular and rotational reductions are held within these guidelines. A long arm cast provides better control of deforming forces than a short arm cast.
REFERENCES: Do TT, Strub WM, Foad SL, et al: Reduction versus remodeling in pediatric distal forearm fractures: A preliminary cost analysis. J Pediatr Orthop B 2003;12:109-115.
Flynn JM: Pediatric forearm fractures: Decision making, surgical techniques, and complications. Instr Course Lect 2002;51:355-360.
Ring D, Waters PM, Hotchkiss RN, et al: Pediatric floating elbow. J Pediatr Orthop 2001;21:456-459.
Noonan KJ, Price CT: Forearm and distal radius fractures in children. J Am Acad Orthop Surg 1998;6:146-156.

Question 44

What is the best option for treatment of the fracture shown in Figure 55?

Explanation

According to Haidukewych and associates, treatment of reverse obliquity trochanteric femoral fractures with 95-degree fixed angle plates or with cephalomedullary intramedullary nails provides results superior to sliding hip screw devices. Moroni and associates demonstrated that external fixation with hydroxyapatite-coated pins provides satisfactory results for complex trochanteric fractures. Hip arthroplasty is not indicated for reverse obliquity fractures because this procedure still requires healing of the greater trochanteric fracture fragment to the shaft.

Question 45

Figures 1 and 2 are the radiographs of a 40-year-old woman who sustained a twisting injury to her lower extremity. What additional information or studies are important in determining treatment options?

Explanation

Age greater than 70 years.
Fracture pattern in Figure A
Significant medical comorbidities.
Fracture pattern in Figure B
Fracture pattern in Figure C
The patient has been treated with non-operative management for her proximal humerus fracture. Operative management should be considered in patients with head splitting proximal humerus fractures and in those with dislocations that cannot be reduced.
Head splitting proximal humerus fractures should be treated with operative management. Open reduction internal fixation versus hemiarthroplasty are used to treat this type of fracture. Surgical management is also considered in proximal humerus fractures in young patients, in fractures where the greater tuberosity is
displaced >5 mm, and in proximal humerus fractures associated with humeral shaft fractures.
Koval et al. studied 104 patients with one-part proximal humerus fractures treated non-operatively, and found 80% with good or excellent results. They also found that 90% of patients treated non-operatively had either no or mild pain about the shoulder at follow-up.
Lefevre-Colau et al. performed a randomized prospective study on 74 patients with an impacted proximal humerus fracture. One group was treated with early mobilization of the shoulder (within 3 days after the fracture) while the other group was immobilized for 3 weeks followed by physiotherapy. They concluded that early mobilization was safe and allowed for quicker return to functional use of the affected limb.
Figure A shows an AP radiograph of a right minimally displaced greater tuberosity proximal humerus fracture. Figure B shows AP and axillary radiographs of a right head split proximal humerus fracture that is posteriorly dislocated. Figure C shows an AP radiograph of a right minimally displaced Salter Harris II proximal humerus fracture. Illustration A shows an AP radiograph of a left valgus impacted proximal humerus fracture with a greater tuberosity fragment displaced >5mm treated with ORIF.
Incorrect Answers:

Question 46

Figures 1 and 2 are the radiographs of an 18-year-old man who had surgery 6 months ago at an outside institution. He is being referred now because he has persistent pain. He is tender over the scaphoid at the snuffbox. What is the most appropriate next imaging step in his pain workup?

Explanation

EXPLANATION:
Scaphoid nonunions are difficult to diagnose on plain radiographs, which offer poor reliability when attempting to determine if there is bridging trabeculae crossing the fractures site. CT scans are more useful for diagnosing scaphoid nonunion. When scanned using conventional axial cuts, the slices mayskip through the fracture nonunion site, thereby missing the defect, even with reformats. MR imaging is useful in diagnosing acute scaphoid fractures and has a high sensitivity and diagnostic value for excluding scaphoid fractures as well. Contrast does not enhance the utility of MR imaging in fracture diagnosis.

Question 47

A 3-year-old patient with L3 myelomeningocele has bilateral dislocated hips. Management should consist of

Explanation

DISCUSSION: In patients with myelomeningocele, the presence of bilateral hip dislocation does not affect ambulation, bracing requirements, sitting ability, degree of scoliosis, or level of comfort. There is little evidence to support active treatment of bilateral hip dislocations in patients with myelomeningocele proximal to L4.
REFERENCES: Fraser RK, Hoffman EB, Sparks LT, et al: The unstable hip and mid-lumbar myelomeningocele. J Bone Joint Surg Br 1992;74:143-146.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 65-76.

Question 48

A 59-year-old woman with a history of osteoporosis is involved in a high-speed motor vehicle accident, resulting in left hip pain and deformity. The initial radiograph from the trauma bay is shown in Figure 1. Postreduction CT is shown in Figures 2 through 4. What is the most appropriate definitive surgical treatment?

Explanation

DISCUSSION:
The radiograph shows a posterior wall acetabular fracture-dislocation. Post reduction CT indicates a large comminuted posterior wall fracture with marginal impaction of the articular surface. A comminuted femoral head fracture also is seen extending to the superior weight-bearing surface. Given the marginal
impaction of the acetabulum and the considerable comminution of the femoral head (which is likely unreconstructible), this injury would have a high risk of causing posttraumatic arthritis if treated with ORIF of the fractures alone. Considering this fact and the patient’s age, ORIF of the posterior wall and acute total hip arthroplasty would likely have the best functional result and the lowest risk of reoperation. Hemiarthroplasty is inappropriate for this injury considering the acetabular fracture. Skeletal traction currently plays a limited role in the definitive treatment of acetabular fractures.

Question 49

A 28-year-old man sustains the closed injury shown in Figures 3a through 3c after falling 8 feet while rock climbing. Management should consist of

Explanation

DISCUSSION: The radiographs show a comminuted talar body fracture. The goal of treatment is to minimize the risks of posttraumatic arthrosis of the ankle and subtalar joint and to maintain vascularity. Open reduction and internal fixation with an attempt at anatomic reduction will lead to improved outcomes. Attempting to repair this fracture via an arthrotomy only is extremely difficult, and the addition of a medial malleolar osteotomy is warranted. A limited anterior lateral arthrotomy with minimal soft-tissue stripping may assist with fixation of anterior-lateral and lateral fragments and allow better assessment of reduction of the major fracture line. Nonsurgical care would lead to inadequate reduction and increased risk of both ankle and hindfoot arthrosis. Talectomy and primary ankle and hindfoot arthrodesis should not be performed as primary surgical reconstructive options in this closed injury pattern.
REFERENCES: Sanders R: Fractures and fracture-dislocations of the talus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp

1465-1518.
Grob D, Simpson LA, Weber BG, Bray T: Operative treatment of displaced talus fractures. Clin Orthop 1985;199:88-96.

Question 50

A patient has a C6 spinal cord injury. Following stabilization of the spine, the patient should be advised that their expected maximum level of function

Explanation

A patient with an injury at the level of: C4 injury needs puffer control; C5 can use hand controls; C6 can use a manual wheelchair and sliding board transfers; C7 allows independent transfers; and no cervical injury routinely allows ambulation with crutches and leg braces.

Question 51

An 84-year-old female community ambulator with a history of hypertension undergoes a right hip hemiarthroplasty for a femoral neck fracture. When performed in the post-operative period, the timed up and go (TUG) test may be used to predict which patient outcome?

Explanation

The timed up and go (TUG) test may be used as a clinical indicator of function and the need for a walking aid in patients treated with hip hemiarthroplasty for femoral neck fracture at 2-year follow-up.
Hip fractures are a cause of significant functional decline for elderly patients. Many outcome tests have been developed to prediction function after hip fracture to manage patient expectations and to assist in rehabilitation planning. The TUG test objectively measures functional mobility and dynamic balance. The test is performed by timing the amount of seconds it requires for a patient to stand up from a chair, walk 10ft (3.05m), return to the chair, and sit.
Laflamme et al performed a prospective study evaluating the utility of the TUG test to predict functional outcomes in patients undergoing hip hemiarthroplasty for femoral neck fracture. The TUG scores were significantly higher at 4-days and 3-weeks postoperatively in patients requiring a walking aid compared with patients walking independently at two-years. Patients who performed the test in >58s at 4-days postoperatively had an eightfold greater risk of requiring an assistive device.
Springer et al prospectively analyzed the unipedal stance test (UPST) with eyes open and closed in healthy subjects to establish normative values for the test across age and gender groups. Performance on the test was found to be age-specific and not related to gender. The UPST is a method of quantifying static balance ability.
Kristensen et al studied the relative and absolute inter tester reliability of TUG in patients with hip fractures. The authors found that the TUG has a high interobserver reliability and an improvement by 6.2 seconds for a patient with a baseline of 20s indicates a change in functional mobility.
Video A shows the timed up and go test.
Incorrect Answers:

Question 52

In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by

Explanation

DISCUSSION: In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by the use of a direct lateral approach to the ankle. The superficial peroneal nerve and its branches exit the fascial hiatus approximately 9 cm to 10 cm proximal to the tip of the distal fibula with a range of 4 cm to 13 cm, and their course is typically anterior to the midlateral plane of the fibula. However, small branches may course across the surgical plane directly laterally. A posterior-lateral approach diminishes the risk of injury to the superficial peroneal nerve and its branches; however, by moving farther posterior, the sural nerve and its branches may be at increased risk. Cast immobilization may injure the cutaneous nerves about the ankle; however, the risks are greater with surgical intervention. A medial or anterior-medial approach to the ankle will not injure the superficial peroneal nerve at the ankle level.
REFERENCES: Redfern DJ, Sauve PS, Sakellariou A: Investigation of incidence of superficial peroneal nerve injury following ankle fracture. Foot Ankle Int 2003;24:771-774.
Miller SD: Ankle fractures, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1341-1366.

Question 53

Compact bone, titanium, stainless steel, cobalt-chrome Modulus of elasticities are as follows in Gpa (psi 3 10 6 ):

Explanation

(1790) Q1-2189:
Which of the following precautionary measures should be taken to prevent a periprosthetic fracture when removing components from a patient with a previous compression hip screw:

Question 54

A 35-year-old man reports forefoot pain with weight-bearing activities. He reports that he has had high arches since adolescence but has never been treated. Examination reveals stiff cavus feet. He has no plantar callus or hammer toe formation. The ankle can be passively dorsiflexed 10°. Initial management should consist of

Explanation

DISCUSSION: The patient has cavus feet with minimal clinical symptoms. At this stage, conservative management is preferred. The use of a molded orthosis will allow better support of the midfoot and provide cushioning of the forefoot. This will most likely result in long-term relief. In more advanced cases with forefoot callus formation, Achilles tendon lengthening or calcaneal osteotomy and Steindler stripping are effective in correcting the cavus deformity. In the presence of arthritic changes in the hindfoot, a triple arthrodesis with corrective bone resection may be necessary.
REFERENCES: Janisse DJ: Indications and prescriptions for orthoses in sports. Orthop Clin North Am 1994;25:95-107.
Franco AH: Pes cavus and pes planus: Analyses and treatment. Phys Ther 1987;67:688-694.

Question 55

A 13-year-old boy has pain and a firm mass in his left knee. A radiograph and MRI scan are shown in Figures 2a and 2b, and a biopsy specimen is shown in Figure 2c. Based on these findings, what is the most likely diagnosis?

Explanation

DISCUSSION: The most likely diagnosis is osteosarcoma. The imaging studies show an aggressive primary tumor of bone, and the histology slide shows a typical chondroblastic osteosarcoma, with osteoid deposited along the surface of bone trabeculae. Ewing’s sarcoma histologically consists of small round blue cells. Osteochondroma and periosteal chondroma can occur near the knee but have different radiographic and histologic patterns. Chondrosarcoma rarely occurs in children.
REFERENCES: Simon M, Springfield D, et al: Osteogenic sarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 267.
Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990,
pp 14-15.

Question 56

What changes in muscle physiology would be expected in an athlete who begins a rigorous aerobic program for an upcoming marathon?

Explanation

DISCUSSION: Muscle fibers can be categorized grossly into two types. Type I muscle, also known as slow-twitch muscle, is responsible for aerobic, oxidative muscle metabolism. It has a much lower strength and speed of contraction than fast-twitch type II muscle but is significantly more fatigue resistant. With training for endurance sports, the type I muscle undergoes adaptive changes to the increased stress. Increases in capillary density, oxidative capacity, mitochondrial density, and subsequent fatigue resistance are all observed changes. Hypertrophy of type IIb muscle is seen in strength training.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 89-125.
Thayer R, Collins J, Noble EG, et al: A decade of aerobic endurance training: Histological evidence for fibre type transformation. J Sports Med Phys Fitness 2000;40:284-289.

Question 57

Which of the following indicates resolution of a postoperative wound infection? Review Topic

Explanation

Khan and associates in a retrospective review found that CRP was more responsive and normalized with resolution of infection, whereas the ESR can remain elevated in the presence of a normal CRP. Since the normal range of ESR and CRP usually begins at 0, a level that is below normal is not likely to be found.

Question 58

An 18-month-old child was involved in a motor vehicle accident and sustained an isolated injury to the left upper extremity. A radiograph is shown in Figure 33. What is the most appropriate management for this injury?

Explanation

Humeral shaft fractures in infants and young children heal rapidly and have excellent remodeling potential. Appropriate treatment in this age group is immobilization with a coaptation splint and bandaging the arm to the thorax for comfort. Internal fixation is appropriate in multiple trauma, and external fixation may be useful when soft-tissue injury is extensive.

Question 59

What is the most common non-anesthetic-related reversible cause of sustained changes in intraoperative neurophysiologic monitoring signals during spinal surgery? Review Topic

Explanation

Patient positioning that results in local nerve compression, plexus traction, or improper neck alignment is the most common non-anesthetic-related cause of changes in intraoperative neurophysiologic monitoring data during spinal surgery. Pedicle screw malpositioning, spinal cord ischemia, and retractor placement are all less common causes. Hypotension, not hypertension, can be a cause of intraoperative neurophysiologic changes.

Question 60

What malignant disease most commonly develops in conjunction with chronic osteomyelitis?

Explanation

DISCUSSION: The most common malignant disease to arise in conjunction with chronic osteomyelitis is squamous cell carcinoma particularly in patients with a long-standing draining sinus tract.
REFERENCES: Dell PC: Hand, in Simon MA, Springfield D (eds): Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott-Raven, 1998, pp 405-420.
McGrory JE, Pritchard DJ, Unni KK, Ilstrup D, Rowland CM: Malignant lesion arising in chronic osteomyelitis. Clin Orthop 1998;362:181-189.

Question 61

A 46-year-old man has incomplete paraplegia after being involved in a motor vehicle accident. The CT scan shown in Figure 5 reveals marked canal compromise. What is the most appropriate management to improve neurologic status?

Explanation

DISCUSSION: According to a study by the Scoliosis Research Society, the use of anterior decompression is most predictable for improving neurologic status. This is particularly true of bowel and bladder functional loss. Laminectomy is contraindicated because it further destabilizes the spine. Posterior instrumentation and indirect reduction through distraction and ligamentotaxis only incompletely decompress the compromised canal and are successful only if performed within 48 hours of injury. While some improvement may occur with closed management, the amount of recovery is less than that achieved with surgical decompression. A posterior approach and instrumentation may be added to the anterior decompression based on the characteristics of associated injuries to the posterior element.
REFERENCES: Gertzbein SD: Scoliosis Research Society multicenter spine fracture study. Spine 1992;17:528-540.
Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-215.
Cammisa FP Jr, Eismont FJ, Green BA: Dural laceration occurring with burst fractures and associated laminar fractures. J Bone Joint Surg Am 1989;71:1044-1052.

Question 62

Figure 40 shows the MRI scan of a 23-year-old man with a history of recurrent anterior shoulder instability. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scan shows an ALPSA lesion. This is also known as a medialized Bankart with medial displacement of the torn anterior labrum. During surgical stabilization, the labrum and periosteal sleeve must be mobilized and repaired laterally to reduce recurrent instability. A Perthes lesion is a nondisplaced labral tear. A GLAD lesion represents a nondisplaced anterior labral tear with an associated articular cartilage injury.
REFERENCES: Neviaser TJ: The anterior labroligamentous periosteal sleeve avulsion lesion:

A cause of anterior instability of the shoulder. Arthroscopy 1993;9:17-21.
Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the shoulder. Am J Sports Med 2005;33:1088-1105.

Question 63

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

Explanation

DISCUSSION: The use of gamma radiation to sterilize polyethylene will result in the formation of free radicals in the material that increase the susceptibility of the material to oxidation and wear. The packaging can also have an impact. If the polyethylene is packaged in air, the oxygen in the packaging can significantly oxidize the material on the shelf prior to clinical use. Gas plasma and ethylene oxide sterilization do not appear to increase oxidation of polyethylene.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 449-486.
Wright TM: Ultra-high molecular weight polyethylene, in Morrey BF (ed): Joint Replacement Arthroplasty. New York, NY, Churchill Livingstone, 1991, pp 37-46.
Collier JP, Sutula LC, Currier BH, et al: Overview of polyethylene as a bearing material: Comparison of sterilization methods. Clin Orthop 1996;333:76-86.
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Question 64

Figures 41a and 41b show the radiographs of a 22-year-old woman who has a bunion on her left foot. She denies pain in the foot, but she reports increasing difficulty with shoe wear. Management should consist of

Explanation

DISCUSSION: Surgery is not indicated in a patient who has a mild deformity and no pain. Shoe wear modifications should be recommended.
REFERENCE: Mann RA, Coughlin MJ: Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, p 174.

Question 65

ofhat parameter is most commonly used to estimate the maximum tension a muscle can generating?

Explanation

The mass or volume of a muscle is proportional to its work capacity, and the fiber length of a muscle is proportional to its potential excursion. By dividing the fiber length into the volume of each muscle, the cross-sectional area of the muscle is determined.
The concept of physiologic cross section of a muscle from Weber and Fick, identifies the critical importance of the cross sectional area of all the fibers of a muscle as proportional to maximum tension. (Relationship between muscle size and muscle strength).

Question 66

What is the mechanism of action of bisphosphonates?

Explanation

DISCUSSION: Bisphosphonates are stable analogues of pyrophosphate that have a strong affinity for bone hydroxyapatite; these agents inhibit bone resorption by reducing the recruitment and activity of osteoclasts and increasing apoptosis. Bone formed while patients are receiving bisphosphonate treatment is histologically normal. Bisphosphonates have been shown to be effective in decreasing pathologic fractures, bone pain, and the need for radiation therapy in patients with multiple myeloma and metastatic carcinoma to bone. The most effective method of administration is via monthly intravenous infusion. Osteonecrosis of the mandible is sometimes a complication of this treatment.
REFERENCES: Gass M, Dawson-Hughes B: Preventing osteoporosis-related fractures: An overview. Am J Med 2006;119:S3-S11.
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 226-227.

Question 67

A 32-year-old motorcycle rider is involved in a motor vehicle accident and radiographs show a burst fracture at L2 with 20 degrees of kyphosis. The neurologic examination is consistent with unilateral motor and sensory involvement of the L5, S1, S2, S3, and S4 nerve roots. He has no other injuries. CT demonstrates 20% anterior canal compromise with displaced laminar fractures at the level of injury. What is the best option for management of this patient? Review Topic

Explanation

The patient has a burst fracture with probable unilateral entrapment of the cauda equina within the elements of the fractured lamina. A dural tear is likely in this scenario as well. It is recommended that this type of burst fracture be treated surgically with laminectomy, freeing of the entrapped nerve roots, and dural repair followed by stabilization of the fracture by either a posterior or combined approach. The degree of kyphosis and the extent of anterior canal compromise does not warrant corpectomy in this patient. Therefore, after completing the laminectomy and dural repair, posterior fusion and instrumentation should be sufficient to stabilize the fracture.

Question 68

A 35-year-old man sustains a closed Monteggia fracture. Examination reveals that sensation, vascular status, and finger flexion are normal. When he extends his wrist, it deviates radially, and he is unable to extend his fingers or thumb. After reduction of the fracture, what is the next step in treatment for the extensor deficits of the thumb and fingers?

Explanation

DISCUSSION: The posterior interosseous nerve is located adjacent to the radial neck, placing it at risk for a traction injury with a dislocation of the proximal radius. The typical neurapraxia that results can be expected to resolve with observation within the first 6 to 12 weeks. If recovery is not clinically evident by 3 months, neurophysiologic studies are indicated.
REFERENCES: Jessing P: Monteggia lesions and their complicating nerve damage. Acta Orthop Scand 1975;46:601-609.
Stein F, Grabias SL, Deffer PA: Nerve injuries complicating Monteggia lesions. J Bone Joint Surg Am 1971;53:1432-1436.

Question 69

A subtrochanteric femur fracture in which the lesser trochanter is intact is associated with what deformity?

Explanation

The most commonly seen deformity in subtrochanteric femur fractures is abduction and flexion of the proximal fragment. Subtrochanteric fractures can pose challenges in reduction because of the muscle attachments proximal and distal to the fragment. The gluteus medius and gluteus minimus attach to the greater trochanter and abduct the proximal fragment. The iliopsoas attaches to the lesser trochanter, flexing and externally rotating the proximal fragment. The short external rotators (piriformis, superior and inferior gamellus) and the obturator internus also cause external rotation of the proximal fragment.

Question 70

When the great toe deviates into a valgus position, the action of the abductor hallucis muscle becomes one of

Explanation

DISCUSSION: The abductor hallucis muscle inserts together with the medial tendon of the flexor hallucis brevis into the medial base of the proximal phalanx of the great toe. When the hallux assumes a valgus position, the action of the abductor becomes one of flexion and pronation of the first metatarsal.
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 71

A 10-year-old boy has activity-related knee pain that is poorly localized. He denies locking, swelling, or giving way. Examination shows mild tenderness at the medial femoral condyle and painless full range of motion without ligamentous instability. Radiographs are shown in Figures 2a through 2c. What is the best course of action?

Explanation

DISCUSSION: The radiographs show an osteochondritis dissecans (OCD) lesion in the medial femoral condyle of a skeletally immature patient. The lesion is not displaced from its bed. Nonsurgical management of a stable OCD lesion in a patient with open physes consists of a period of activity limitation and occasional immobilization. Unstable lesions, loose bodies, and patients with closed physes require more aggressive treatment. Most of the surgical procedures can be done arthroscopically. Because the radiographic appearance is typical, biopsy is unnecessary. The radiographs do not show an osteocartilaginous loose body, and the patient reports no catching or locking; therefore, removal of the loose body is not indicated.
REFERENCES: Linden B: Osteochondritis dissecans of the femoral condyles: A long term follow-up study. J Bone Joint Surg Am 1977;59:769-776.
Cahill BR: Osteochondritis dissecans of the knee: Treatment of juvenile and adult forms. J Am Acad Orthop Surg 1995;3:237-247.
Cahill BR, Navarro R: The results of conservative management of juvenile osteochondritis dissecans using joint scintigraphy: A prospective study. Am J Sports Med 1989;17:601-606.

Question 72

Figure 14 shows an intra-articular gadolinium-enhanced MRI scan of a 52-year-old woman who has stopped playing tennis because of pain in her left shoulder while serving. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scan shows increased signal intensity along the deep fibers of the supraspinatus near its insertion. This is typical of tendinosis and a probable partial-thickness rotator cuff tear.
REFERENCES: Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20.
Iannotti JP, Zlatkin MB, Esterhai JL, et al: Magnetic resonance imaging of the shoulder: Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 1991;73:17-29.

Question 73

For a patient with an unstable pelvic fracture, the amount of blood tranfusions required in the first 24 hours has shown to be most predictive for what variable?

Explanation

DISCUSSION: Unstable pelvic fractures can be devastating injuries often resulting in significant morbidity and even death.
According to the referenced study by Smith et al, fracture pattern and angiography/embolization were not predictive of mortality in patients with unstable pelvic injuries. The three factors they found to be predictive were: increased blood transfusions in the first 24 hours, age >60 years, and increased ISS or RTS scores. Deaths were most commonly from exsanguination (<24 hours) or multiorgan failure (>24 hours).
Incorrect Answers: Choices 1-4 are not as predictive of mortality as choice 5.

Question 74

Figure below shows the standing AP radiograph obtained from a 55-year-old man who has a 5-year history of daily left knee medial joint line pain with weight-bearing activities. He denies night pain or symptoms of instability. On examination, his range of motion is 0° to 140°. He has a mild, fully correctable varus deformity and a negative Lachman test result. Nonsurgical treatment has failed. Unicompartmental knee arthroplasty (UKA) is discussed with the patient. The most appropriate next radiographic evaluation should be

Explanation

DISCUSSION:
A patient with medial compartment arthritis and a correctable varus deformity with no clinical or examination findings of knee instability most likely has an intact anterior cruciate ligament (ACL). The pattern of medial compartment osteoarthritis most commonly associated with an intact ACL is that of anteromedial osteoarthritis. An incompetent ACL is commonly associated with a fixed varus deformity and radiographic signs of posteromedial wear. An incompetent ACL is a relative contraindication to a mobile-bearing UKA. When evaluating patients for a mobile-bearing UKA, a stress radiograph aids the orthopaedic surgeon in determining the correction of the varus deformity and assessing the lateral compartment. An inability to fully correct the deformity or narrowing of the lateral compartment with valgus stress should influence the surgeon against UKA. Joint registries across the world have shown decreased survivorship associated with TKA and UKA in men compared with other age groups, but survivorship is lower for UKA than for TKA. No studies to date have shown any differences in survivorship between fixed-bearing and mobile-bearing UKAs. The complication that is unique to mobile-bearing UKA is bearing spinout, which occurs in less than 1% of mobile-bearing UKA procedures. In vivo and in vitro polyethylene wear in mobile-bearing UKA are low. Arthritis may progress faster in patients with mobile-bearing UKAs than in those with fixed-bearing UKAs.

Question 75

A previously healthy 30-year-old woman has neck pain and bilateral hand and lower extremity tingling with weakness after falling down stairs. She is alert and oriented. Examination reveals incomplete quadriplegia at the C6 level that remains unchanged throughout her evaluation and initial treatment. Radiographs show a bilateral facet dislocation of C6 on C7 without fracture. Attempts at reduction with halo cervical traction up to her body weight are unsuccessful. What is the next most appropriate step?

Explanation

DISCUSSION: A facet dislocation that cannot be reduced in an alert, awake patient with some preservation of cord function requires MRI to evaluate the disk prior to a reduction under anesthesia. The presence or absence of a disk herniation must be assessed, as this factor may influence the method of reduction.
REFERENCES: Vaccaro AR, Falatyn SP, Flanders AE, et al: Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine 1999;24:1210-1217.
Fardon DF, Garfin SR, Abitbol J (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 247-262.
Eismont FJ, Arena MJ, Green BA: Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets. J Bone Joint Surg Am 1991;73:1555-1560.
Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.

Question 76

Communication breakdown is the leading cause of which of the following?

Explanation

Communication failures are the leading cause of wrong side surgeries, medication errors and diagnostic delays.
Poor communication sets up environments in which medical errors can take place. Per the Joint Commission, medical errors may be the among the top 10 causes of death in the United States. Establishing open lines of communication is critical to reduce the risk of error and enhance patient safety.
Gandhi et al. designed a framework to study missed or delayed diagnoses and their causes. The most significant factors contributing to errors were poor handoffs, failures in judgment, failures in memory and failures in knowledge.
O’Daniel et al. review the importance of professional communication and collaborative team efforts. They note that patient safety is at risk when poor communication is in place. The leading cause for medication errors, treatment delays and wrong-site surgeries is communication failure.
Illustration A shows the leading causes of death in the United States. This includes “preventable errors” as a cause.
Incorrect Answers:

Question 77

Venous thrombolembolism is a common complication following total hip and total knee arthroplasty; therefore, prophylaxis is deemed efficacious. Several studies on low-molecular-weight heparin (LMWH) have shown which of the following findings?

Explanation

DISCUSSION: Prophylactic LMWH is associated with a risk of bleeding complications, especially if administered too soon after surgery. The risk of major bleeding is 0.3% for control, 0.4% for aspirin, 1.3% for warfarin, 1.8% for LMWH, and 2.6% for unfractionated heparin. Colwell and associates conducted a prospective, randomized trial on over 1,500 total hip arthroplasty patients. Overall, the risk of clinically apparent venous thrombolembolism was 3.6% for LMWH and 3.7% for warfarin. LMWH acts in several sites of the coagulation cascade, with its principal action being inhibition of factor 10a. Thrombocytopenia is less common with LMWH than with unfractionated heparin. The use of LMWH is a relative contraindication with indwelling epidural anesthesia.
REFERENCES: Colwell CW Jr, Collis DK, Paulson R, et al: Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty:. Evaluation during hospitalization and three months after discharge. J Bone Joint Surg Am 1999;81:932-940.
Salvati EA, Pelligrini VD Jr, Sharrock NE, et al: Recent advances in venous thromboembolic prophylaxis during and after total hip replacement. J Bone Joint Surg Am 2000;82:252-270.

Question 78

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

Explanation

DISCUSSION: The axial views show fusion of the talus and calcaneus at the medial facet (talocalcaneal coalition). Peroneal spastic flatfoot is a descriptive term applying to the symptoms of painful flatfoot associated with apparent peroneal spasm and is sometimes caused by tarsal coalition; however, this is not the most appropriate diagnosis for this patient. Flexible flatfoot with a short Achilles tendon often causes symptoms similar to the ones listed above, but subtalar motion should be normal. A diagnosis of calcaneonavicular coalition can be made based on plain oblique views of the foot but is not seen in these views. Posterior tibial tendon dysfunction in the absence of other pathology is uncommon in children.
REFERENCES: Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 583-595.

Question 79

A 57-year-old woman with diabetes mellitus has purulent drainage from a lateral incision after undergoing open reduction and internal fixation of a displaced ankle fracture 10 days ago. Examination reveals moderate erythema and a foul odor coming from the wound. Cultures are obtained. What is the next most appropriate step in management?

Explanation

DISCUSSION: Early postoperative wound infections after open reduction and internal fixation should be treated with aggressive debridement and maintenance of stability of the fracture. If infection persists following healing of the fracture, the hardware should be removed.
REFERENCES: Carragee EJ, Csongradi JJ, Bleck EE: Early complications in the operative treatment of ankle fractures: Influence of delay before operation. J Bone Joint Surg Br 1991;73:79-82.
Blotter RH, Connolly E, Wasan A, Chapman MW: Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int 1999;20:687-694.

Question 80

Figure 43 shows an arthroscopic view of a right shoulder through a lateral portal in the beach chair position. The arrow is pointing to what structure?

Explanation

DISCUSSION: This view from the lateral portal shows a full-thickness rotator cuff tear. The glenohumeral joint can be visualized through this tear. The glenoid, labrum, and biceps tendon attaching to the superior aspect of the glenoid are easily viewed from this portal, and the arrow is pointing to the biceps tendon. Arthroscopic rotator cuff repair can be performed while visualizing from this portal and using anterior and posterior working portals.
REFERENCES: Mazzocca AD, Noerdlinger M, Cole B, et al: Arthroscopy of the shoulder: Indications and general principles of techniques, in McGinty JB (ed): Operative Arthroscopy,

ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 412-427.
Burkhart, SS: Arthroscopic management of rotator cuff tears, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 508-546.

Question 81

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

Explanation

Mild to moderate metatarsus adductus is best treated with observation and possible passive stretching exercises because most of these feet will self correct. Numerous types of shoes, braces, and splints have been devised but the efficacy of these have not been determined. Serial casting is reserved for severe metatarsus adductus in the infant, although a medial surgical release may be indicated if the deformity is symptomatic and persists beyond age 4 years.

Question 82

What portion of the pitching phase creates forces approaching the tensile limit of the medial collateral ligament?

Explanation

DISCUSSION: The late cocking phase of the overhand throw places a marked valgus moment across the medial elbow. This repetitive force reaches the tensile limits of the medial collateral ligament.
REFERENCES: Fleisig GS, Andrews JR, Dillman CJ, et al: Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med 1995;23:233-239.
Lynch JR, Waitayawinyu T, Hanel DP, et al: Medial collateral ligament injury in the overhand-throwing athlete. J Hand Surg 2008;33:430-437.

Figure 5a Figure 5b

Question 83

Which of the following statements is true regarding articular cartilage?

Explanation

The one role of collagen in articular cartilage is to provide the structural framework to resist swelling under high osmotic tissue pressures created by aggrecan. Type II collagen is the predominant type in articular cartilage.
Proteoglycans, the most common of which is aggrecan, are produced by chondrocytes and give articular cartilage its hydrophilic properties. Multiple glycosaminoglycans (GAGs), such as chondroitin and keratin can attach to core proteins to form aggrecans. Link proteins then help aggrecans interact with hyaluronic acid. The negative charge of this complex helps create a strong osmotic gradient, which attracts water and increases tissue pressures. Normal aging involves a decrease in the water content of the extracellular matrix while osteoarthritis is associated with increased water content, which leads to loss of strength and elasticity.
Chen et al. evaluated the strain and depth related properties of articular cartilage in bovine models. They found that the zero-strain permeability, zero-strain equilibrium confined compression modulus, and deformation dependence constant differed among the layers of cartilage. They suggest that the complex strain-dependent properties of articular cartilage of different thickness and location have clinical implications for tissue engineering.
Illustration A is a diagram depicting the extracellular matrix of articular cartilage. Incorrect Answers:

Question 84

Figure 83a shows an axillary radiograph and Figures 83b and 83c show axial MR arthrograms of a 20-year-old collegiate offensive lineman who has shoulder pain while pass-blocking. He sustained a shoulder injury 3 months earlier when he "jammed it." Prior to this injury, he denies any pain or instability in either shoulder. Despite undergoing rehabilitation with a physical therapist and trainer and abstaining from playing for 6 weeks, he is currently unable to play because of his symptoms. Examination reveals full active range of motion, a positive jerk test which reproduces his symptoms, and a grade 2 posterior translation of the humeral head with load and shift testing which also reproduces his symptoms. What is the best management option to allow him to return to his pre-injury function next season? Review Topic

Explanation

Arthroscopic posterior capsulolabral repair is most likely to return him to competitive athletics. The patient has symptomatic posterior instability that is preventing him from performing high-level athletic activities. Posterior subluxation of the humeral head is seen on the axillary radiograph and a posterior labral tear is seen on the axial MR arthrograms. Because nonsurgical management has failed to provide relief, treatment should consist of posterior capsulolabral repair. This can be performed either arthroscopically or open with similar excellent results. An intra-articular injection may help his pain but will not likely allow him to return to his pre-injury functional level. Thermal capsulorrhaphy has limited use in the shoulder because of the high rate of complications reported, and anterior capsulorrhaphy will not correct the posterior instability. Whereas a trial of immobilization in external rotation may have benefitted him with the acute injury, it is unlike to help with this recurrent instability.

Question 85

What is the peak period of onset in children with pauciarticular juvenile rheumatoid arthritis?

Explanation

DISCUSSION: Approximately one half of patients with juvenile rheumatoid arthritis (JRA) have the pauciarticular form, which by definition includes only patients with fewer than five joints involved. The peak period of onset is between the ages of 2 and 4 years, with half of the affected children coming to medical attention before age 4 years. The knee is most often affected, with the ankle-subtalar and elbow joints next in frequency. The average duration of the disease is

2 years and 9 months, with half the cases lasting less than 2 years.
REFERENCES: Arthritis, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 3.

St Louis, MO, WB Saunders, 2002, pp 1811-1839.
Griffin PP, Tachdjian MO, Green WT: Pauciarticular arthritis in children. JAMA

1963;184:23-28.

Question 86

The mother of a 5-year-old child reports that he has had a fever of 103°F (39.4°C), leg swelling, and has been unwilling to bear weight on his right lower leg for the past 7 days. Examination reveals point tenderness at the distal femur. Aspiration at the metaphysis yields 10 mL of purulent fluid, and a Gram stain reveals gram-positive cocci. In addition to hospital admission, management should include

Explanation

DISCUSSION: The patient has a subperiosteal abscess. Because aspiration revealed 10 mL of purulent fluid, the treatment of choice is surgical incision and drainage of the abscess, followed by immobilization to reduce the risk of pathologic fracture. With an adequate response to IV antibiotics and a susceptible bacteria, the patient may then be switched to oral antibiotics.
REFERENCE: Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1996, pp 149-161.

Question 87

A concern when choosing irradiated (10 Mrad) and subsequently melted highly cross-linked polyethylene rather than lower dose–irradiated (4 Mrad) polyethylene is related to its inferior resistance to

Explanation

DISCUSSION
The higher the dose of radiation to the polyethylene, the higher the amount of cross-linking. Adhesive and abrasive wear resistance increases with an increase in cross-linking. However, fatigue properties of the material are decreased when polyethylene is melted (to remove free radicals) during the cross-linking process. Creep (deformation without wear) is also slightly increased with cross-linking of polyethylene.

Question 88

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

Explanation

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

Question 89

Which of the following bones is most frequently involved in stress fractures in athletes? Review Topic

Explanation

The tibia is the most frequent stress fracture location in most series in both athletes and modern military training. The anterior midshaft region of the tibia may be at higher risk secondary to tensile forces and a relative paucity of blood supply.

Question 90

A tall, thin 17-year-old basketball player and his parents request an evaluation of his flexible (hypermobile) pes planus/planovalgus foot deformities. As part of his evaluation, the orthopaedic surgeon notes pectus excavatum, disproportionately long arms, and scoliosis. In addition to providing treatment of his feet, what test or evaluation should the patient be referred for? Review Topic

Explanation

The current diagnostic criteria for Marfan syndrome, called the Ghent criteria, are based on clinical findings and family history. The role of genetic testing in establishing the diagnosis is limited, because testing for FBN1 mutations is neither sensitive nor specific for Marfan syndrome. By making the diagnosis and arranging for cardiovascular evaluation, the orthopaedic surgeon can help prevent sudden death in these patients. The cardiovascular manifestations, including dissection and dilation of the ascending aorta and mitral valve prolapse, are responsible for nearly all of the precocious deaths of patients with Marfan syndrome. Patients with Marfan syndrome do have problems with protrusio acetabuli, scoliosis, and opthalmologic problems but the life-threatening problem that must be considered is the risk of cardiovascular sudden death.

Question 91

A clinical trial is underway for patients with wrist extensor tendinitis. One group of 100 patients are treated with short arm casting. Another group of 100 patients are treated with physical therapy. During analysis of the results, it becomes apparent that 30 patients in the physical therapy group did not complete the full course of physical therapy. Despite not completing a full course of physical therapy, these 30 patients were included in the physical therapy group for analysis. This analysis is an example of which of the following?

Explanation

The following is an example of intent-to-treat analysis.
The intent-to-treat approach aims to keep similar groups similar by not allowing for patient selection based on post-randomization outcomes (including failure to comply with the protocol). This type of analysis ensures the power of randomization so that important unknown variables that impact outcome are likely to be dispersed equally in each comparison group. Conversely, a per-protocol comparison in a clinical trial excludes patients who were not compliant with the protocol guidelines.
Berger et al., in a Level 5 review, discuss many of the principles beyond randomization that are critical for preserving the comparability of the different groups. They report that masking, allocation concealment, restrictions on the randomization, adjustment for prognostic variables, and the intent-to-treat approach to data analysis are important features of designing a good clinical trial.
Incorrect Answers:

Question 92

A 66-year-old patient with type 1 diabetes mellitus has a deep, nonhealing ulcer under the first metatarsal head and a necrotic tip of the great toe. He has been under the direction of a wound care clinic for 4 months, and has had orthotics and shoe wear changes. What objective findings are indicative of the patient’s ability to heal the wound postoperatively?

Explanation

DISCUSSION: Absolute toe pressures greater than 40 to 50 mm Hg are a good sign of healing potential. An ABI of greater than 0.45 favors healing, but indices greater than 1 are falsely positive due to calcifications in the vessels. Normal albumin is an overall indication of nutritional status.

A transcutaneous oxygen level should be greater than 40 mm Hg for healing.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 113-122.
Pinzur MS, Stuck R, Sage R: Benchmark analysis on diabetics at high risk for lower extremity amputation. Foot Ankle Int 1996;17:695-700.

Question 93

(3875) Q4-7658:

Explanation

True
False
Missile wounds can cause a blast stretch injury to peripheral nerves and may recover with observation. Correct Answer: True

Question 94

What is the most common secondary malignancy arising in pagetic bone?

Explanation

DISCUSSION: The incidence of malignant transformation or the formation of a secondary malignancy in pagetic bone is estimated to be less than 1%. Osteosarcoma is the most common secondary malignancy, followed by fibrosarcoma and chondrosarcoma. Ewing’s sarcoma arising in pagetic bone has not been reported.
REFERENCES: Grimer RJ, Carter SR, Tillman RM, et al: Osteosarcoma of the pelvis. J Bone Joint Surg Br 1999;81:796-802.
Harrington KD: Surgical management of neoplastic complications of Paget’s disease. J Bone Miner Res 1999;14:45-48.

Question 95

You perform an ACL reconstruction with bone-patella tendon-bone (BTB) autograft and are explaining the postoperative rehabilitation protocol to your patient. Which of the following is associated with increased quadriceps volume and improved quadriceps strength at 1 year without a higher risk of knee instability? Review Topic

Explanation

Early eccentric strengthening following ACL reconstruction has been associated with increased quadriceps volume and improvement in strength at 1 year without a higher risk of knee laxity.
Proper rehabilitation following ACL reconstruction is vital to a successful outcome. The cornerstone of ACL rehabilitation is range of motion, strengthening and functional exercises without risk of destabilizing the knee. There are a variety of rehabilitation protocols and recently an effort has been made to standardize the approach to postoperative ACL care. An accelerated protocol starting at 3 weeks postoperatively has been deemed safe and may enhance the speed and safety with which an athlete returns to play.
Kruse et al completed a meta-analysis of 29 Level I and II studies focused on the ACL rehabilitation process. The authors concluded that immediate postoperative weightbearing and knee range of motion 0-90 is safe. Early eccentric strengthening appears to accelerate and improve strength gains at 1 year as compared to delayed eccentric strengthening. Home-based rehabilitation programs can be as effective as formal physical therapy. Postoperative bracing and CPM use is neither necessary nor beneficial.
Van Grinsven et al conducted a systematic review of ACL rehabilitation programs and physical therapy modalities to develop an evidence-based rehabilitation protocol. The authors demonstrated that an accelerated protocol without postoperative bracing focused on reduction of pain, swelling and inflammation and regaining range of motion, strength and neuromuscular control has significant advantages and does not lead to stability problems.
Gerber et al performed a randomized trial comparing two accelerated postoperative rehabilitation protocols – early eccentric (ECC) rehabilitation versus traditional (TRAD) rehabilitation starting at 3 weeks. There were no significant differences in knee pain, effusion or stability. However, quadriceps strength, hopping distance and activity level improved by a significantly greater amount in the ECC group versus the TRAD group at 26 weeks postoperatively. In a separate analysis of these patients, quadriceps and gluteus muscle cross-sectional area and volume in ECC patients were more than twice those in the TRAD group.
Illustration A depicts two eccentric ergometers that can be used in postoperative ACL rehabilitation.
Incorrect Responses:
another Answer
type of brace,
2:
There
duration is
of
bracing or no bracing at all.
no
advantage
to
CPM
use.

Question 96

A 24-year-old baseball pitcher reports pain over the posterior aspect of his shoulder that occurs only during throwing. He notes that the discomfort is greatest during the late cocking and early acceleration phases. Examination reveals localized tenderness with palpation over the external rotators and posterior glenoid. Radiographs are shown in Figures 38a through 38c. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs show a posterior glenoid osteophyte, often termed a “thrower’s exostosis.” These exostoses are best visualized on the Stryker notch view and may be missed on other more standard radiographic views of the shoulder. CT and MRI scans may be used, but usually add little information to the radiographic findings. Arthroscopic examination of patients with this condition commonly reveals undersurface tearing of the rotator cuff and posterior labrum. Treatment of this condition remains somewhat controversial, with avocation of both nonsurgical and surgical techniques.
REFERENCES: Meister K, Andrews JR, Batts J, Wilk K, Baumgarten T, Baumgartner T: Symptomatic thrower’s exostosis: Arthroscopic evaluation and treatment. Am J Sports Med 1999;27:133-136.
Ferrari JD, Ferrari DA, Coumas J, Pappas AM: Posterior ossification of the shoulder: The Bennett lesion. Etiology, diagnosis, and treatment. Am J Sports Med 1994;22:171-176.
Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of the supraspinatus tendon on the posteriorsuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg 1992;1:238-245.

Question 97

A 62-year-old man slips on ice and sustains an elbow dislocation. Post-reduction imaging reveals a highly comminuted radial head fracture and coronoid fracture through its base. What is the most appropriate treatment?

Explanation

DISCUSSION: The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and/or stiffness from prolonged immobilization. Therefore radial head replacement and open reduction internal fixation of the coronoid is the most appropriate treatment.
Pugh et al reported their experiences with this difficult population. Their protocol consisted of ORIF or replacement of the radial head, ORIF of the coronoid fracture, repair of the LCL and capsule, and repair of the MCL and/or hinged external fixation. Of the 36 cases, the outcome was graded as 28 excellent to good, 7 fair, and 1 poor. 8 cases required re-operation. The authors concluded that their surgical protocol restored sufficient elbow stability to allow early motion post-op, thereby enhancing the functional outcome. In fracture dislocation of the elbow with radial head
and coronoid fracture, the radial head must be fixed or replaced to restore stability. The ORIF of coronoid fracture and radial head restores some valgus stability therefore MCL repair may not be needed. However, the varus stability must be restored by LCL repair.

Question 98

A 52-year-old woman has bicompartmental osteoarthritis following patellectomy. Treatment should consist of

Explanation

DISCUSSION: The patient has extensive degenerative changes in both the medial and lateral compartments within the knee; therefore, arthroscopic debridement or an osteotomy will not be helpful. A patellar arthroplasty will not address the medial and lateral compartments. Because the extensor mechanism provides a significant amount of anteroposterior stability, a posterior cruciate-substituting total knee arthroplasty is the treatment of choice for this patient.
REFERENCES: Martin SD, Haas SB, Insall JN: Primary total knee arthroplasty after patellectomy. J Bone Joint Surg Am 1995;77:1323-1330.
Pagnano MW, Cushner FD, Scott WN: Role of the posterior cruciate ligament in total knee arthroplasty. J Am Acad Orthop Surg 1998;6:176-187.

Question 99

Figures 28a and 28b show the posteroanterior and lateral radiographs of a 38-year-old woman with adult idiopathic scoliosis. She reports symptoms of long-standing lower back pain, progressive loss of height, and the inability to stand upright at the end of the day. What radiographic finding has been found to most closely correlate with symptoms of lower back pain? Review Topic

Explanation

Adult idiopathic scoliosis and adult "de-novo" scoliosis can present with a number of symptoms that relate to associated degenerative findings such as stenosis or spondylolisthesis. In the absence of these associated conditions, increased levels of pain in patients with scoliosis has been found to most closely correlate with sagittal imbalance. Thoracolumbar and lumbar curves and thoracolumbar kyphosis have both been found to closely correlate with increased symptoms and lower health-related quality of life (HRQL) outcome scores. Thoracic scoliosis, thoracic hypokyphosis, lumbar hyperlordosis, and lumbar disk degeneration have not been found to correlate with increased symptoms.

Question 100

A year-old active woman undergoes elective total hip replacement in which a posterior approach is used. She has minimal pain and is discharged to home 2 days after surgery. Four weeks later, she dislocates her hip while shaving her legs. She undergoes a closed reduction in the emergency department. Postreduction radiographs show a reduced hip with well-fixed components in satisfactory alignment. What is the most appropriate management of this condition from this point forward?

Explanation

DISCUSSION:
First-time early dislocations are often treated successfully without revision surgery, especially when no component malalignment is present. In this clinical scenario, it appears the patient would benefit from better education about dislocation precautions. Hip orthoses are of questionable benefit unless the patient is cognitively impaired. Revision surgery can be successful but is usually reserved for patients with recurrent dislocations.

Full Question & Answer Text (for Search Engines)

Question 1:

The right shoulder exercise seen in Figure A will put the LEAST amount of stretch on which structure? Review Topic

Options:

Inferior glenohumeral ligament
Coracohumeral ligament
Anterior-superior capsule
Superior glenohumeral ligament
Posterior capsule

Correct Answer: Inferior glenohumeral ligament

Explanation:

Question 2:

What is the most common presenting problem in patients with cauda equina syndrome? Review Topic

Options:

Urinary retention
Urinary incontinence
Saddle numbness
Lower extremity numbness and weakness
Back and leg pain

Correct Answer: Back and leg pain

Explanation:

Question 3:

Options:

1,2 intercompartmental supraretinacular artery (ICSRA) graft
Free-vascularized medial femoral condyle graft
Iliac crest corticocancellous graft
4+5 extensor compartmental artery (ECA) vascularized bone graft

Correct Answer: Free-vascularized medial femoral condyle graft

Explanation:

Question 4:

A medial plate is best used to treat tibial plateau fractures when there is

Options:

- comminution of the lateral side.
- posteromedial fracture fragment.
- metaphyseal comminution.
- a lateral open fracture.

Correct Answer: - posteromedial fracture fragment.

Explanation:

DISCUSSION
The patient's plain radiographs demonstrate a bicondylar tibial plateau fracture with complete separation of the diaphysis from the epiphysis, making this a Schatzker VI injury. Clinically, the patient is neurovascularly intact with symmetric palpable pulses, and ankle brachial indices are not necessary.
There is significant lateral tibial plateau displacement with the lateral femoral condyle down into the plateau defect. Considering the swelling, abrasions, and severity of the injury, a bridging external fixator is warranted followed by CT imaging.
The ligamentotaxis will provide better definition of the injury and joint fragments and allow for soft-tissue rest and subsidence of the swelling for eventual surgical intervention. Oblique views will not add as much information as CT imaging, which will show the bicondylar nature of the injury and the proximal tibia essentially split centrally with the tubercle as a separate fragment. A midline incision with medial and lateral plating has fallen out of
favor secondary to wound-healing complications. Comminution of the metaphysis or the lateral side is not an absolute indication for a medial plate. Open lateral fractures can still be managed with a laterally based plate depending on the soft-tissue injury.
RECOMMENDED READINGS
Higgins TF, Kemper D, Klatt J. Incidence and morphology of the posteromedial fragment in bicondylar tibial plateau fractures. J Orthop Trauma. 2009 Jan;23(1):45-51. doi: 10.1097/BOT.0b013e31818f8dc1. PubMed PMID: 19104303.
View Abstract at PubMed
Higgins TF, Klatt J, Bachus KN. Biomechanical analysis of bicondylar tibial plateau fixation: how does lateral locking plate fixation compare to dual plate fixation? J Orthop Trauma. 2007 May;21(5):301-6. PubMed PMID: 17485994.
View
Abstract at PubMed
Berkson EM, Virkus WW. High-energy tibial plateau fractures. J Am Acad Orthop Surg. 2006 Jan;14(1):20-31. Review. PubMed PMID: 16394164.
View Abstract at PubMed
Barei DP, O'Mara TJ, Taitsman LA, Dunbar RP, Nork SE. Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns. J Orthop Trauma. 2008 Mar;22(3):176-82. doi:10.1097/BOT.0b013e318169ef08. PubMed PMID: 18317051.
View Abstract at PubMed
Barei DP, Nork SE, Mills WJ, Coles CP, Henley MB, Benirschke SK. Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg Am. 2006 Aug;88(8):1713-21. PubMed PMID: 16882892.
View
Abstract at PubMed
Hall JA, Beuerlein MJ, McKee MD; Canadian Orthopaedic Trauma Society. Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Surgical technique. J Bone Joint Surg Am. 2009 Mar 1;91 Suppl 2 Pt 1:74-88. doi: 10.2106/JBJS.G.01165. PubMed PMID: 19255201.
View
Abstract at PubMed
Lowe JA, Tejwani N, Yoo B, Wolinsky P. Surgical techniques for complex proximal tibial fractures. J Bone Joint Surg Am. 2011 Aug 17;93(16):1548-59. PubMed PMID: 22204013.
View Abstract at PubMed
Weil YA, Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Posteromedial supine approach for reduction and fixation of medial and bicondylar tibial plateau fractures. J Orthop Trauma. 2008 May-Jun;22(5):357-62. doi: 10.1097/BOT.0b013e318168c72e. PubMed PMID:

Question 5:

Options:

Full elbow flexion and wrist extension
Full forearm supination
Full elbow extension and wrist extension
Forearm pronation
Neutral forearm rotation

Correct Answer: Forearm pronation

Explanation:

Question 6:

Options:

Repeat left hip aspiration
Initiation of a wound care consult and oral antibiotics
Irrigation and debridement with closure of the dehisced wound, performance of a liner exchange, and administration of intravenous antibiotics
Debridement of the wound, explant of the total hip, placement of a spacer, and administration of intravenous antibiotics

Correct Answer: Debridement of the wound, explant of the total hip, placement of a spacer, and administration of intravenous antibiotics

Explanation:

Question 7:

Use of titanium elastic nailing for treatment of pediatric femur fractures is associated with a higher complication rate among

Options:

patients younger than age 6.5.
patients who bear weight immediately after surgery.
patients weighing more than 50 kg (110 pounds).
patients with grade 1 open transverse midshaft fractures.

Correct Answer: patients weighing more than 50 kg (110 pounds).

Explanation:

Question 8:

Options:

Arthroscopic debridement
Arthroscopic rotator cuff repair
Hemiarthroplasty with rotator cuff repair
Total shoulder arthroplasty
Reverse shoulder arthroplasty

Correct Answer: Reverse shoulder arthroplasty

Explanation:

Question 9:

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 10:

Options:

HIV
Staph Aureus
Hepatitis A
Hepatitis B
Hepatitis C

Correct Answer: HIV

Explanation:

Question 11:

Options:

Debridement of the labral tear plus bony resection of the pincer lesion
Debridement of the labral tear and no bony resection of the pincer lesion
Femoral neck osteoplasty plus labral repair using suture anchor
Resection of the bony pincer lesion plus labral repair using suture anchor

Correct Answer: Resection of the bony pincer lesion plus labral repair using suture anchor

Explanation:

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has
important functions for hip stability and maintenance of the suction seal of the joint.

Question 12:

Options:

Distal rerouting of the biceps tendon
Glenohumeral fusion with external rotation
External rotation osteotomy of the proximal humerus
Latissimus dorsi and teres major transfer to the posterior rotator cuff
Latissimus dorsi and teres major transfer to the subscapularis

Correct Answer: Latissimus dorsi and teres major transfer to the posterior rotator cuff

Explanation:

Question 13:

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

Options:

Fibromatosis
Well-differentiated liposarcoma
Synovial sarcoma
Schwannoma
Malignant fibrous histiocytoma

Correct Answer: Fibromatosis

Explanation:

DISCUSSION: Fibromatosis is a benign but aggressive fibrous lesion that principally arises from the connective tissue of muscle and the overlying fascia. The peak incidence is between the ages of 25 and 35 years. Most patients have a deep-seated, firm, poorly circumscribed mass that has grown insidiously and causes little or no pain. MRI is helpful in diagnosing the lesion and in assessing the extent of disease prior to surgical intervention. Histologically, the lesion is poorly circumscribed and infiltrates the surrounding tissue. The lesion appears bland with uniform spindle cells separated by abundant collagen, with little or no cell-to-cell contact. Despite its bland microscopic appearance, the tumor frequently behaves in an aggressive manner. These lesions do not metastasize but have a high incidence of recurrence. Treatment options consist
of surgical resection, radiation therapy, chemotherapeutic protocols, hormone modulation, and/or anti-inflammatory medications.
REFERENCES: Weiss SW, Goldblum JR, Enzinger FM: Enzinger and Weiss’s Soft Tissue Tumors, ed 4. Philadelphia, PA, Elsevier, 2001, pp 309-337.
Spear MA, Jennings LC, Mankin HJ, et al: Individualizing management of aggressive fibromatoses. Int J Radiat Oncol Biol Phys 1998;40:637-645.

Question 14:

Arthritic change in cartilage is characterized by which of the following findings?

Options:

Proteoglycan loss in the cartilage matrix
Increased compressive modulus compared to normal cartilage
Increased tensile modulus
Decreased water content
Increase in the shear modulus

Correct Answer: Proteoglycan loss in the cartilage matrix

Explanation:

Question 15:

For patients undergoing a surgical procedure where the risk of requiring a transfusion is less than 10%, the International Committee of Effective Blood Usage suggests

Options:

1 unit of autologous blood.
2 units of autologous blood.
1 unit of direct donated blood.
use of cell saver intraoperatively.
no donation is necessary.

Correct Answer: no donation is necessary.

Explanation:

Question 16:

Which of the following structures is most commonly involved in lateral epicondylitis?

Options:

Anconeus
Extensor digitorum communis
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor carpi ulnaris

Correct Answer: Extensor carpi radialis brevis

Explanation:

Question 17:

Options:

Distal radial ulnar joint (DRUJ) ligament reconstruction
Ulnar head implant arthroplasty
Radial shaft osteotomy
One-bone forearm procedure

Correct Answer: Radial shaft osteotomy

Explanation:

Question 18:

Options:

stress shielding.
humeral osteolysis.
glenoid loosening. 51
progressive glenoid arthritis.

Correct Answer: glenoid loosening. 51

Explanation:

DISCUSSION
The radiograph shows proximal humeral migration and loosening of the glenoid component. Proximal migration of the humeral head may represent rotator cuff dysfunction and can lead to progressive failure of the glenoid component. Stress shielding will not cause lysis or loosening of the glenoid component. Humeral osteolysis is an uncommon finding and is not shown. Progressive glenoid arthrosis is not possible with a resurfaced glenoid.
RECOMMENDED READINGS
Hill JM, Norris TR. Long-term results of total shoulder arthroplasty following bone-grafting of the glenoid. J Bone Joint Surg Am. 2001 Jun;83-A(6):877-83. PubMed PMID: 11407796.
View Abstract at PubMed
Fox TJ, Cil A, Sperling JW, Sanchez-Sotelo J, Schleck CD, Cofield RH. Survival of the glenoid component in shoulder arthroplasty. J Shoulder Elbow Surg. 2009 Nov-Dec;18(6):859-63. doi: 10.1016/j.jse.2008.11.020. Epub 2009 Mar 17. PubMed
PMID: 19297199.
View Abstract at PubMed

Question 19:

Options:

hip and knee extension
hip flexion to 90, knee extension
hip internal rotation, knee flexion to 90
hip and knee flexion to 90
hip extension, knee flexion to 90

Correct Answer: hip and knee extension

Explanation:

Question 20:

Radiating pain associated with a posterolateral thoracic disk herniation typically follows what pattern? Review Topic

Options:

Extending down the spine into the lumbosacral region
Down the inner aspect of either upper extremity
Cephalad up to the cervicothoracic junction
Around or through the chest to the anterior wall
Down the contralateral lower extremity

Correct Answer: Around or through the chest to the anterior wall

Explanation:

Question 21:

Titanium and its alloys are unsuitable candidates for which of the following implant applications?

Options:

Fracture plates
Femoral heads in a hip prosthesis
Bone screws
Intramedullary nails
Porous coatings for bone ingrowth

Correct Answer: Femoral heads in a hip prosthesis

Explanation:

Question 22:

Options:

curettage or en bloc resection.
allograft limb salvage.
injection with 5% phenol.
radiation therapy.
hormonal therapy.

Correct Answer: curettage or en bloc resection.

Explanation:

Question 23:

What is the most common donor site complication following a free vascularized fibular graft for osteonecrosis of the femoral head?

Options:

Sensory deficit
Motor deficit
Flexor hallucis longus contracture
Deep venous thrombosis
Fibular fracture

Correct Answer: Sensory deficit

Explanation:

Question 24:

What is the most anatomic location for placement of the femoral tunnel in anterior cruciate ligament reconstruction?

Options:

As far superior in the notch as possible
As far posterior as possible on the lateral femoral condyle
As far posterior as possible on the medial femoral condyle
Directly across from the posterior cruciate femoral insertion
At resident’s ridge

Correct Answer: As far posterior as possible on the lateral femoral condyle

Explanation:

Question 25:

The attachments of the transverse carpal ligament include which of the following structures?

Options:

Scaphoid and the ulna
Trapezium and the hook of the hamate
Trapezium and the triquetrum
Trapezoid and the hook of the hamate
Trapezoid and the pisiform

Correct Answer: Trapezium and the hook of the hamate

Explanation:

DISCUSSION: The transverse carpal ligament is the volar boundary of the carpal tunnel. It attaches to the scaphoid and trapezium radially and the pisiform and the hook of the hamate ulnarly. The ulna and trapezoid do not receive attachments of the transverse carpal ligament.
REFERENCES: Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 471-472.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 168-170.

Question 26:

Which of the following is the only nonreversible effect of anabolic steroids?

Options:

Muscle hypertrophy
Alterations in high density lipoprotein (HDL) and low density lipoprotein (LDL) ratios
Alopecia
Personality effects
Acne

Correct Answer: Alopecia

Explanation:

Question 27:

Which of the following best describes heat stroke? Review Topic

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 28:

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

Options:

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

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

Explanation:

Question 29:

A 19-year-old man sustains a low-velocity gunshot wound to the forearm. What factor most strongly correlates with the development of compartment syndrome after this injury?

Options:

Fracture comminution
Fracture of both the radius and ulna
Fracture of the proximal third of the forearm
Fracture displacement of more than 10 mm
Retained bullet fragments

Correct Answer: Fracture of the proximal third of the forearm

Explanation:

Question 30:

Talar compression syndrome in ballet dancers typically involves injury to which of the following structures?

Options:

Sustentaculum tali
Lateral process of the talus
Posterior process of the calcaneus
Os tibialis externum
Os trigonum

Correct Answer: Os trigonum

Explanation:

Question 31:

Options:

Midsubstance tear of the lateral ulnar collateral ligament
Proximal avulsion of the ulnar collateral ligament
Proximal avulsion of the lateral ulnar collateral ligament
Distal bony avulsion of the ulnar collateral ligament from the sublime tubercle

Correct Answer: Proximal avulsion of the lateral ulnar collateral ligament

Explanation:

Question 32:

Which muscles are responsible for the displacement of the proximal fragment of the fracture shown in Figure 75?

Options:

Iliopsoas, hip abductors, hip external rotators
Iliopsoas, hip adductors, hip internal rotators
Rectus femoris, hip abductors, hip external rotators
Hamstrings, hip abductors, hip internal rotators

Correct Answer: Iliopsoas, hip abductors, hip external rotators

Explanation:

The radiograph shows a subtrochanteric femoral shaft fracture in a skeletally immature patient. The proximal fragment is displaced into flexion, abduction, and external rotation. Flexion is attributable to the pull of the iliopsoas at the lesser trochanter. Abduction is attributable to the pull of the abductor muscles (gluteus medius and minimus) at the greater trochanter. External rotation is attributable to the pull of the small external rotators, including the piriformis. The majority of the adductor musculature originates on the symphysis pubis and bypasses the proximal femur, inserting further distally on the adductor tubercle. The hamstrings originate on the ischial tuberosity and also bypass the proximal fragment, inserting distally on the proximal tibia and fibula.
(SBQ12TR.39) A 36-year-old male falls from a 10-ft scaffold and suffers the injuries shown in Figures A and B. The patient is placed in a spanning external fixator and brought back to the operating room once his soft tissues are amenable. Planning to use a dual-incision approach, what is the correct interval to use when approaching the medial side?
Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the
authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:

Question 33:

Os naviculare is present in which percentage of normal feet?

Options:

1% to 2%
10% to 14%
25% to 30%
40% to 50%

Correct Answer: 10% to 14%

Explanation:

DISCUSSION
Accessory navicular is found in 10% to 14% of normal feet, is generally asymptomatic, and involves 3 radiographic types. Type I represents a small ossicle embedded within the posterior tibial tendon, type II is larger with a synchondrosis, and type III is fused to the navicular tuberosity. Approximately 50% of patients with symptoms have flexible flatfoot; however, os naviculare is not directly associated with pes planovalgus deformity.
Subtalar arthroereisis describes the use of a sinus tarsi plug or implant to restrict eversion of the subtalar joint. This surgical procedure has been used in combination with tendon reconstruction for treatment of flexible flatfoot deformity. Known complications of subtalar arthroereisis include persistent sinus tarsi pain, foreign body reaction, implant failure, and osteonecrosis of the talus.
The FDL tendon travels within the same compartment adjacent to the posterior tibial tendon and is the most commonly used tendon transfer for treatment of stage II PTTD (strength characteristics are similar). The plantaris has inferior tendon strength to the FDL, and the peroneus longus travels in a different compartment than the FDL.
RECOMMENDED READINGS
Sullivan RJ. Adolescent foot and ankle conditions. In: Pinzur MD, ED. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:47-55.
Alvarez RG, Price J, Marini A, Turner NS, Kitaoka HB. Adult acquired flatfoot deformity and posterior tibial tendon dysfunction. In: Pinzur MD, ED. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:215-229.
Pinney SJ, Lin SS. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int. 2006 Jan;27(1):66-75. Review. PubMed PMID: 16442033.
View Abstract at PubMed
Viladot R, Pons M, Alvarez F, Omaña J. Subtalar arthroereisis for posterior tibial tendon dysfunction: a preliminary report. Foot Ankle Int. 2003 Aug;24(8):600-6. PubMed PMID: 12956565.
View Abstract at PubMed

Question 34:

Options:

Oral antibiotics for staphylococcus
Repeat laboratory studies in 1 week to recheck the ESR
MRI with gadolinium
Biopsy of the surgical disk space
Irrigation and debridement of the surgical wound in the operating room

Correct Answer: MRI with gadolinium

Explanation:

Question 35:

The injection shown in Figures 1a and 1b would most benefit a patient who reports which of the following symptoms?

Options:

Dorsal foot pain extending into the great toe
Foot pain extending along the lateral border of the foot
Pain extending into the foot in a stocking distribution
Anterior thigh and shin pain ending at the ankle
Lateral foot paresthesias

Correct Answer: Dorsal foot pain extending into the great toe

Explanation:

DISCUSSION: The images demonstrate a L5 selective root block as it exits the L5-S1 foramen. This root block best helps relieve pain or paresthesias in the L5 distribution, which is the dorsal first web space and the great toe. The lateral foot is an S1 distribution and would need to be blocked through the posterior first sacral foramen. The anterior shin and thigh represent the
L4 root which exits a level above this at the L4-5 foramen. A stocking distribution is nonanatomic and not indicative of a specific root.
REFERENCES: Magee D: Principles and concepts, in Orthopaedic Physical Assessment, ed 3. Philadelphia, PA, WB Saunders, 1997, pp 1-18.
Aeschbach A, Mekhail NA: Common nerve blocks in chronic pain management. Anesthesiol Clin North Am 2000;18:429-459.

Question 36:

Which of the following factors will adversely affect bone ingrowth in a revision porous-coated stem?

Options:

Pore size of 400 m m
Interface instability of 25 m m of micromotion
Use of a nonmodular implant
Noncircumferential metaphyseal patch coating
Failure of ingrowth in the previous stem

Correct Answer: Noncircumferential metaphyseal patch coating

Explanation:

DISCUSSION: The optimal conditions for bony ingrowth include a pore size of 100 to 400
m
m, interface micromotion of 50
m
m or less, intimate contact between the bone and the implant, circumferential porous coating of the implant, and use of a biocompatible material. Stem designs with patch coatings have a poor record of bony ingrowth, especially in the revision setting. Failure of ingrowth in the previous stem would be the result of its own mechanical milieu and would not necessarily predict results for the new stem.
REFERENCES: Berry DJ, Harmsen WS, Ilstrup D, Lewallen DG, Cabanela ME: Survivorship of uncemented proximally porous-coated femoral components. Clin Orthop 1995;319:168-177.
Cook SD, Thomas KA, Haddad RJ Jr: Histologic analysis of retrieved human porous-coated total joint components. Clin Orthop 1988;234:90-101.
Spector M: Historical review of porous-coated implants. J Arthroplasty 1987;2:163-177.

Question 37:

Options:

a sling, ice, and isometric exercises.
a glenohumeral cortisone injection.
surgical repair of the coracoclavicular ligaments.
chin-ups and latissimus pull-down exercises.
cross-chest stretches.

Correct Answer: a sling, ice, and isometric exercises.

Explanation:

Question 38:

Options:

Calcaneal stress fracture
Hindfoot coalition
Insertional Achilles tendonitis
Plantar fasciitis

Correct Answer: Plantar fasciitis

Explanation:

Question 39:

Options:

emergent open reduction and fixation of the fracture.
skeletal traction and expedient open reduction and fixation of the fracture.
skeletal traction for 6 weeks, followed by physical therapy.
crutches and no weight bearing for 6 weeks.
bed rest for 1 week and follow-up radiographs to see if the fragment has moved.

Correct Answer: skeletal traction and expedient open reduction and fixation of the fracture.

Explanation:

Question 40:

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

Options:

First rib
Intra-articular disk ligament
Costoclavicular ligament
Interclavicular ligament
Posterior sternoclavicular joint capsule

Correct Answer: Posterior sternoclavicular joint capsule

Explanation:

DISCUSSION: Through cadaveric study, Spencer and associates measured anterior and posterior translation of the sternoclavicular joint. The study demonstrated that the posterior sternoclavicular joint capsule is the most important structure for preventing both anterior and posterior translation of the sternoclavicular joint.
REFERENCES: Gilot GJ, Wirth MA, Rockwood CA: Injuries to the sternoclavicular joint, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott, Williams and Wilkins, 2006, vol 2, pp 1373-1374.
Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.

Question 41:

A 13-year-old girl is diagnosed with a stage IIB osteosarcoma of the proximal tibia. Following neoadjuvant chemotherapy, local control should consist of

Options:

wide resection and reconstruction.
wide resection and radiation therapy.
radiation therapy.
curettage and bone grafting.
observation.

Correct Answer: wide resection and reconstruction.

Explanation:

Question 42:

Options:

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

Correct Answer: Posterior labral tear

Explanation:

Question 43:

Options:

open reduction and plating of the radius to restore the radial bow.
open reduction of the ulna and plating.
closed reduction and nailing of the bones with flexible nails.
a long arm cast and follow-up of alignment in 5 days.
a short arm cast for 6 weeks.

Correct Answer: a long arm cast and follow-up of alignment in 5 days.

Explanation:

Question 44:

What is the best option for treatment of the fracture shown in Figure 55?

Options:

A 135-degree sliding hip screw device
A 150-degree sliding hip screw device
A cephalomedullary intramedullary nail
External fixation using hydroxyapatite-coated pins
Hip arthroplasty

Correct Answer: A cephalomedullary intramedullary nail

Explanation:

Question 45:

Options:

Full-length tibia-fibula radiographs
Inability to bear weight
History of recurrent ankle sprains
Presence or absence of medial tenderness
MRI scan

Correct Answer: Full-length tibia-fibula radiographs

Explanation:

The radiographs reveal a medial ankle injury with a widened medial clear space. No fibula fracture is visualized on this view; therefore, full-length radiographs looking for a proximal fibula fracture are required to determine treatment. The presence or absence of medial tenderness has been shown to not be a good predictor of unstable injuries. A history of previous injuries or ankle instability is typically lateral instability, which would not present with this radiographic appearance. An MRI scan can be used to evaluate subtle syndesmotic injuries, but there is a clear widening of the medial clear space in this case. The inability to bear weight is not helpful in determining the treatment options.
(SBQ12TR.24) In each of the following scenarios, atrophic fracture nonunion occurred after initial treatment with intramedullary nail fixation. Which scenario has shown to have the highest rate of osseous union if treated with exchange intramedullary nailing?
Oligotrophic nonunion of a comminuted humeral shaft fracture
Oligotrophic nonunion of a transverse humeral shaft fracture
Oligotrophic nonunion of an oblique distal femur fracture
Oligotrophic nonunion of a comminuted tibial shaft fracture
Oligotrophic nonunion of an oblique tibial shaft fracture
Reamed exchange nailing is recommended for the management of aseptic nonunions of noncomminuted tibial shaft fractures. Union rates have been reported between 76-96% in large studies.
Tibial exchange nailing promotes osseous bone healing of non-unions by providing biological and mechanical support. The biological support is provided by reaming the medullary canal. This increases periosteal blood flow and stimulates periosteal new-bone formation. The mechanical support is provided by a larger-diameter intramedullary nail, which increases the rigidity and strength of the nail.
Brinker et al. reviewed the concept of exchange nailing of nonunited long bone fractures. They showed that exchange nailing is the most successful in the treatment of nonunions following closed or open fractures without substantial bone loss. Aseptic, noncomminuted diaphyseal femoral and tibial shaft fractures showed the highest rates of union with exchange nailing, which were found to be 76-100% and 72-96%, respectively.
Illustration A shows a heterotrophic non-union of the tibia after intramedullary nailing. The patient was treated with exchange nailing with a larger nail. On the right shows a 4 month post-op radiograph after exchange nailing showing osseous union at the fracture site.
Incorrect Answers:
(SBQ12TR.79) A right-hand dominant female sustains a right proximal humerus fracture. The patient is provided a sling, and is recommended pendulum exercises with elbow range of motion to begin in 1 to 2 weeks. Which of the following would be an indication for surgical management?
Age greater than 70 years.
Fracture pattern in Figure A
Significant medical comorbidities.
Fracture pattern in Figure B
Fracture pattern in Figure C
The patient has been treated with non-operative management for her proximal humerus fracture. Operative management should be considered in patients with head splitting proximal humerus fractures and in those with dislocations that cannot be reduced.
Head splitting proximal humerus fractures should be treated with operative management. Open reduction internal fixation versus hemiarthroplasty are used to treat this type of fracture. Surgical management is also considered in proximal humerus fractures in young patients, in fractures where the greater tuberosity is
displaced >5 mm, and in proximal humerus fractures associated with humeral shaft fractures.
Koval et al. studied 104 patients with one-part proximal humerus fractures treated non-operatively, and found 80% with good or excellent results. They also found that 90% of patients treated non-operatively had either no or mild pain about the shoulder at follow-up.
Lefevre-Colau et al. performed a randomized prospective study on 74 patients with an impacted proximal humerus fracture. One group was treated with early mobilization of the shoulder (within 3 days after the fracture) while the other group was immobilized for 3 weeks followed by physiotherapy. They concluded that early mobilization was safe and allowed for quicker return to functional use of the affected limb.
Figure A shows an AP radiograph of a right minimally displaced greater tuberosity proximal humerus fracture. Figure B shows AP and axillary radiographs of a right head split proximal humerus fracture that is posteriorly dislocated. Figure C shows an AP radiograph of a right minimally displaced Salter Harris II proximal humerus fracture. Illustration A shows an AP radiograph of a left valgus impacted proximal humerus fracture with a greater tuberosity fragment displaced >5mm treated with ORIF.
Incorrect Answers:

Question 46:

Options:

MR imaging with contrast
MR imaging without contrast
CT scan along the scaphoid axis
Axial-cut CT scans with reformats

Correct Answer: CT scan along the scaphoid axis

Explanation:

EXPLANATION:
Scaphoid nonunions are difficult to diagnose on plain radiographs, which offer poor reliability when attempting to determine if there is bridging trabeculae crossing the fractures site. CT scans are more useful for diagnosing scaphoid nonunion. When scanned using conventional axial cuts, the slices mayskip through the fracture nonunion site, thereby missing the defect, even with reformats. MR imaging is useful in diagnosing acute scaphoid fractures and has a high sensitivity and diagnostic value for excluding
scaphoid fractures as well. Contrast does not enhance the utility of MR imaging in fracture diagnosis.

Question 47:

A 3-year-old patient with L3 myelomeningocele has bilateral dislocated hips. Management should consist of

Options:

observation.
bilateral open reduction.
bilateral open reduction and psoas transfers.
bilateral open reduction and external oblique transfers.
bilateral valgus osteotomies.

Correct Answer: observation.

Explanation:

Question 48:

Options:

Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty
ORIF of the acetabular fracture and ORIF of the femoral head fracture fragments
ORIF of the acetabular fracture and hemiarthroplasty
Skeletal traction with delayed total hip arthroplasty after the acetabular fracture has healed

Correct Answer: Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty

Explanation:

Question 49:

A 28-year-old man sustains the closed injury shown in Figures 3a through 3c after falling 8 feet while rock climbing. Management should consist of

Options:

open reduction and internal fixation via an anteromedial arthrotomy.
talectomy.
primary tibiotalocalcaneal arthrodesis.
open reduction and internal fixation via a medial malleolar osteotomy and limited anterior lateral arthrotomy.
closed reduction and a non-weight-bearing cast.

Correct Answer: open reduction and internal fixation via a medial malleolar osteotomy and limited anterior lateral arthrotomy.

Explanation:

DISCUSSION: The radiographs show a comminuted talar body fracture. The goal of treatment is to minimize the risks of posttraumatic arthrosis of the ankle and subtalar joint and to maintain vascularity. Open reduction and internal fixation with an attempt at anatomic reduction will lead to improved outcomes. Attempting to repair this fracture via an arthrotomy only is extremely difficult, and the addition of a medial malleolar osteotomy is warranted. A limited anterior lateral arthrotomy with minimal soft-tissue stripping may assist with fixation of anterior-lateral and lateral fragments and allow better assessment of reduction of the major fracture line. Nonsurgical care would lead to inadequate reduction and increased risk of both ankle and hindfoot arthrosis. Talectomy and primary ankle and hindfoot arthrodesis should not be performed as primary surgical reconstructive options in this closed injury pattern.
REFERENCES: Sanders R: Fractures and fracture-dislocations of the talus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp
1465-1518.
Grob D, Simpson LA, Weber BG, Bray T: Operative treatment of displaced talus fractures. Clin Orthop 1985;199:88-96.

Question 50:

A patient has a C6 spinal cord injury. Following stabilization of the spine, the patient should be advised that their expected maximum level of function

Options:

An electric wheelchair with puffer control
An electric wheelchair with hand controls
A manual wheelchair and sliding board transfers
A manual wheelchair and independent transfers
Crutches with long leg braces for short distance ambulation

Correct Answer: A manual wheelchair and sliding board transfers

Explanation:

Question 51:

Options:

Stair climbing ability
Need for a walking aid
Implant failure
Balance impairment
Independent performance of activities of daily living (ADL)

Correct Answer: Stair climbing ability

Explanation:

Question 52:

In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by

Options:

a posterior-lateral approach.
a lateral approach.
a medial approach.
an anterior-medial approach.
rigid cast immobilization.

Correct Answer: a lateral approach.

Explanation:

Question 53:

Compact bone, titanium, stainless steel, cobalt-chrome Modulus of elasticities are as follows in Gpa (psi 3 10 6 ):

Options:

Compact bone: 21 (3)
Titanium: 96 (14)
Stainless steel: 193 (28)
Cobalt-chrome: 235 (34)

Correct Answer: Compact bone: 21 (3)

Explanation:

(1790) Q1-2189:
Which of the following precautionary measures should be taken to prevent a periprosthetic fracture when removing components from a patient with a previous compression hip screw:

Question 54:

Options:

Achilles tendon lengthening.
calcaneal osteotomy and Steindler stripping.
a molded orthosis.
triple arthrodesis.
metatarsal osteotomy.

Correct Answer: a molded orthosis.

Explanation:

Question 55:

Options:

Osteosarcoma
Osteochondroma
Ewing’s sarcoma
Chondrosarcoma
Periosteal chondroma

Correct Answer: Osteosarcoma

Explanation:

Question 56:

What changes in muscle physiology would be expected in an athlete who begins a rigorous aerobic program for an upcoming marathon?

Options:

Hypertrophy of type I muscle fibers
Reduced fatigue resistance
Decreased capillary density
Decreased VO 2 max
Decreased mitochondrial density per muscle cell

Correct Answer: Hypertrophy of type I muscle fibers

Explanation:

Question 57:

Which of the following indicates resolution of a postoperative wound infection? Review Topic

Options:

C-reactive protein (CRP) has normalized and erythrocyte sedimentation rate (ESR) is improving
CRP and ESR remain elevated
CRP and ESR are below normal
CRP has improved to the same degree as the ESR has improved
CRP remains elevated after the ESR has normalized

Correct Answer: C-reactive protein (CRP) has normalized and erythrocyte sedimentation rate (ESR) is improving

Explanation:

Question 58:

Options:

Hanging arm cast
Closed reduction with flexible intramedullary nail fixation
Coaptation splinting and bandaging the arm to the thorax
Closed reduction and external fixation
Locking plate fixation

Correct Answer: Coaptation splinting and bandaging the arm to the thorax

Explanation:

Question 59:

What is the most common non-anesthetic-related reversible cause of sustained changes in intraoperative neurophysiologic monitoring signals during spinal surgery? Review Topic

Options:

Pedicle screw misplacement
Patient positioning
Spinal cord ischemia
Retractor placement
Hypertension

Correct Answer: Patient positioning

Explanation:

Question 60:

What malignant disease most commonly develops in conjunction with chronic osteomyelitis?

Options:

Fibrosarcoma
Basal cell carcinoma
Lymphoma
Osteosarcoma
Squamous cell carcinoma

Correct Answer: Squamous cell carcinoma

Explanation:

Question 61:

Options:

Postural reduction and application of a hyperextension cast
Posterior laminectomy alone
Laminectomy and posterior stabilization
Bed rest for 6 weeks
Anterior L2 corpectomy and iliac crest strut grafting, with or without posterior instrumentation and fusion from L1 to L3

Correct Answer: Anterior L2 corpectomy and iliac crest strut grafting, with or without posterior instrumentation and fusion from L1 to L3

Explanation:

Question 62:

Figure 40 shows the MRI scan of a 23-year-old man with a history of recurrent anterior shoulder instability. What is the most likely diagnosis?

Options:

Humeral avulsion of the inferior glenohumeral ligament (HAGL lesion)
Osseous Bankart lesion
Perthes lesion
Anterior labroligamentous periosteal sleeve avulsion (ALPSA lesion)
Glenolabral articular disruption (GLAD lesion)

Correct Answer: Anterior labroligamentous periosteal sleeve avulsion (ALPSA lesion)

Explanation:

DISCUSSION: The MRI scan shows an ALPSA lesion. This is also known as a medialized Bankart with medial displacement of the torn anterior labrum. During surgical stabilization, the labrum and periosteal sleeve must be mobilized and repaired laterally to reduce recurrent instability. A Perthes lesion is a nondisplaced labral tear. A GLAD lesion represents a nondisplaced anterior labral tear with an associated articular cartilage injury.
REFERENCES: Neviaser TJ: The anterior labroligamentous periosteal sleeve avulsion lesion:
A cause of anterior instability of the shoulder. Arthroscopy 1993;9:17-21.
Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the shoulder. Am J Sports Med 2005;33:1088-1105.

Question 63:

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

Options:

gamma radiation in air.
gamma radiation in nitrogen.
gamma radiation in argon.
gas plasma exposure.
ethylene oxide exposure.

Correct Answer: gamma radiation in air.

Explanation:

Question 64:

Options:

distal Chevron osteotomy.
proximal metatarsal osteotomy with soft-tissue release.
shoe wear modifications.
dorsal cheilectomy with Moberg osteotomy.
hallux metatarsophalangeal joint arthroplasty.

Correct Answer: shoe wear modifications.

Explanation:

Question 65:

ofhat parameter is most commonly used to estimate the maximum tension a muscle can generating?

Options:

Length
Moment arm
Total volume
Physiologic cross-sectional area
Distribution of slow and fast twitch fibers

Correct Answer: Physiologic cross-sectional area

Explanation:

Question 66:

What is the mechanism of action of bisphosphonates?

Options:

Directly stimulating osteoblastic new bone formation
Increasing gut absorption of calcium
Increasing efficiency of 1,25 dihydroxylation of vitamin D in the kidney
Inhibiting bone resorption by osteoclasts
Decreasing release of parathyroid hormone

Correct Answer: Inhibiting bone resorption by osteoclasts

Explanation:

DISCUSSION: Bisphosphonates are stable analogues of pyrophosphate that have a strong affinity for bone hydroxyapatite; these agents inhibit bone resorption by reducing the recruitment and activity of osteoclasts and increasing apoptosis. Bone formed while patients are receiving bisphosphonate treatment is histologically normal. Bisphosphonates have been shown to be effective in decreasing pathologic fractures, bone pain, and the need for radiation therapy in patients with multiple myeloma and metastatic carcinoma to bone. The most effective method of administration is via monthly intravenous infusion. Osteonecrosis of the mandible is sometimes a complication of this treatment.
REFERENCES: Gass M, Dawson-Hughes B: Preventing osteoporosis-related fractures: An overview. Am J Med 2006;119:S3-S11.
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 226-227.

Question 67:

Options:

Bed rest for 6 weeks, followed by mobilization in a thoracolumbosacral orthosis until the fracture has healed
Anterior corpectomy with strut grafting and placement of an anterior plate spanning L1 to L3
Anterior corpectomy with strut grafting, followed by posterior spinal fusion and instrumentation
Posterior spinal fusion and instrumentation from T11 to L4
L2 laminectomy and posterior spinal fusion and instrumentation from T11 to L4

Correct Answer: L2 laminectomy and posterior spinal fusion and instrumentation from T11 to L4

Explanation:

Question 68:

Options:

Exploration of the radial nerve
Exploration of the median nerve
Nerve conduction velocity studies
Tendon transfers after the fracture is stabilized
Observation

Correct Answer: Observation

Explanation:

Question 69:

A subtrochanteric femur fracture in which the lesser trochanter is intact is associated with what deformity?

Options:

Adduction and extension of the proximal fragment
Adduction and flexion of the proximal fragment
Abduction and extension of the proximal fragment
Abduction and flexion of the proximal fragment
Predominantly internal rotation of the proximal fragment

Correct Answer: Abduction and flexion of the proximal fragment

Explanation:

Question 70:

When the great toe deviates into a valgus position, the action of the abductor hallucis muscle becomes one of

Options:

increased abduction.
pronation.
flexion.
flexion and pronation.
extension.

Correct Answer: flexion and pronation.

Explanation:

DISCUSSION: The abductor hallucis muscle inserts together with the medial tendon of the flexor hallucis brevis into the medial base of the proximal phalanx of the great toe. When the hallux assumes a valgus position, the action of the abductor becomes one of flexion and pronation of the first metatarsal.
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 71:

Options:

Knee arthroscopy with drilling of the lesion
Limited activity for 6 to 12 weeks
Removal of the loose body
Biopsy of the lesion
Open reduction and internal fixation

Correct Answer: Limited activity for 6 to 12 weeks

Explanation:

Question 72:

Options:

Superior labral detachment
Os acromiale
Partial-thickness rotator cuff tear on the articular side
Medial subluxation of the long head of the biceps
Moderate arthrosis of the glenohumeral joint

Correct Answer: Partial-thickness rotator cuff tear on the articular side

Explanation:

Question 73:

For a patient with an unstable pelvic fracture, the amount of blood tranfusions required in the first 24 hours has shown to be most predictive for what variable?

Options:

Length of hospital stay
Association with neurological deficit(s)
Length of intensive care stay
Cardiac collapse
Mortality

Correct Answer: Length of hospital stay

Explanation:

Question 74:

Options:

MRI of the left knee to evaluate the lateral compartment.
a CT arthrogram to evaluate the status of the medial and lateral meniscus.
a stress radiograph to evaluate correction of the varus deformity.
a sunrise view to determine the status of the patellofemoral joint.

Correct Answer: a stress radiograph to evaluate correction of the varus deformity.

Explanation:

Question 75:

Options:

Posterior open reduction and fusion with fixation
Anterior open reduction and fusion with fixation
Technetium Tc 99m bone scan
Closed manipulation
MRI

Correct Answer: MRI

Explanation:

Question 76:

Communication breakdown is the leading cause of which of the following?

Options:

Delayed diagnoses
Medication errors
Surgical site infections
1 and 2
All of the above

Correct Answer: Delayed diagnoses

Explanation:

Question 77:

Options:

LMWH is associated with bleeding complications of less than 1% and may be administered immediately after surgery.
LMWH is superior to adjusted-dose warfarin.
LMWH acts on several sites of the coagulation cascade, with its principal action inhibition of factor 10a.
LMWH and unfractionated heparin are equally likely to cause thrombocytopenia.
LMWH may be used in conjunction with regional anesthesia and is not contraindicated in patients with indwelling epidural catheters.

Correct Answer: LMWH acts on several sites of the coagulation cascade, with its principal action inhibition of factor 10a.

Explanation:

Question 78:

Options:

Peroneal spastic flatfoot
Flexible flatfoot with a short Achilles tendon
Calcaneonavicular coalition
Talocalcaneal coalition
Posterior tibial tendon dysfunction

Correct Answer: Talocalcaneal coalition

Explanation:

Question 79:

Options:

Oral cephalosporin
IV cephalexin and dressing changes
Betadine dressing and a short leg cast
Debridement of the wound and removal of the hardware
Debridement of the wound and maintenance of the hardware

Correct Answer: Debridement of the wound and maintenance of the hardware

Explanation:

Question 80:

Figure 43 shows an arthroscopic view of a right shoulder through a lateral portal in the beach chair position. The arrow is pointing to what structure?

Options:

Biceps tendon
Coracohumeral ligament
Superior glenohumeral ligament
Middle glenohumeral ligament
Inferior glenohumeral ligament

Correct Answer: Biceps tendon

Explanation:

DISCUSSION: This view from the lateral portal shows a full-thickness rotator cuff tear. The glenohumeral joint can be visualized through this tear. The glenoid, labrum, and biceps tendon attaching to the superior aspect of the glenoid are easily viewed from this portal, and the arrow is pointing to the biceps tendon. Arthroscopic rotator cuff repair can be performed while visualizing from this portal and using anterior and posterior working portals.
REFERENCES: Mazzocca AD, Noerdlinger M, Cole B, et al: Arthroscopy of the shoulder: Indications and general principles of techniques, in McGinty JB (ed): Operative Arthroscopy,
ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 412-427.
Burkhart, SS: Arthroscopic management of rotator cuff tears, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 508-546.

Question 81:

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

Options:

observation with possible stretching.
serial casting.
medial surgical release.
posterior medial surgical release.
dynamic ankle-foot orthosis.

Correct Answer: observation with possible stretching.

Explanation:

Question 82:

What portion of the pitching phase creates forces approaching the tensile limit of the medial collateral ligament?

Options:

Early cocking phase
Late cocking phase
Early acceleration phase
Follow-through phase
Deceleration phase

Correct Answer: Late cocking phase

Explanation:

Question 83:

Which of the following statements is true regarding articular cartilage?

Options:

The hydrophilicity of type II collagen molecules gives cartilage its viscoelastic properties
Water accounts for approximately 25% of the mass of cartilage
Multiple aggrecan molecules link together to form glycosaminoglycans
The positive charge formed by aggrecan molecules helps to create the high osmotic swelling pressure of cartilage
Type II collagen helps prevent swelling of articular cartilage which would otherwise occur due to high osmotic pressures

Correct Answer: The hydrophilicity of type II collagen molecules gives cartilage its viscoelastic properties

Explanation:

Question 84:

Options:

Arthroscopic posterior capsulolabral repair
Thermal capsulorrhaphy
Open anterior capsulorrhaphy
Intra-articular injection of corticosteroid
Immobilization for 6 weeks in external rotation

Correct Answer: Arthroscopic posterior capsulolabral repair

Explanation:

Question 85:

What is the peak period of onset in children with pauciarticular juvenile rheumatoid arthritis?

Options:

Before age 2 years
Between the ages of 2 and 4 years
Between the ages of 4 and 8 years
Between the ages of 8 and 12 years
During adolescence

Correct Answer: Between the ages of 2 and 4 years

Explanation:

DISCUSSION: Approximately one half of patients with juvenile rheumatoid arthritis (JRA) have the pauciarticular form, which by definition includes only patients with fewer than five joints involved. The peak period of onset is between the ages of 2 and 4 years, with half of the affected children coming to medical attention before age 4 years. The knee is most often affected, with the ankle-subtalar and elbow joints next in frequency. The average duration of the disease is
2 years and 9 months, with half the cases lasting less than 2 years.
REFERENCES: Arthritis, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 3.
St Louis, MO, WB Saunders, 2002, pp 1811-1839.
Griffin PP, Tachdjian MO, Green WT: Pauciarticular arthritis in children. JAMA
1963;184:23-28.

Question 86:

Options:

IV antibiotics.
IV antibiotics and immobilization of the lower extremity.
IV antibiotics, surgical incision and drainage of the abscess, and immobilization of the lower extremity.
IV antibiotics and repeated aspirations of the metaphyseal region.
oral antibiotics with careful monitoring of blood levels.

Correct Answer: IV antibiotics, surgical incision and drainage of the abscess, and immobilization of the lower extremity.

Explanation:

Question 87:

Options:

adhesive wear.
abrasive wear.
fatigue wear.
creep.

Correct Answer: fatigue wear.

Explanation:

Question 88:

Options:

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

Correct Answer: Revision of the acetabular and femoral implants

Explanation:

Question 89:

Which of the following bones is most frequently involved in stress fractures in athletes? Review Topic

Options:

Femur
Tibia
Fibula
Navicular
Fifth metatarsal

Correct Answer: Tibia

Explanation:

Question 90:

Options:

Cardiovascular evaluation
Ophthalmologic evaluation
MRI of the spine
Radiographs of the hip
Genetic testing

Correct Answer: Cardiovascular evaluation

Explanation:

Question 91:

Options:

Per-protocol
Crossover analysis
Intent-to-treat
Bayesian analysis
Effect size

Correct Answer: Bayesian analysis

Explanation:

Question 92:

Options:

Absolute toe pressures of 55 mm Hg
Transcutaneous oxygen level of 20 mm Hg
Arterial brachial indices (ABI) of 1.2 at the level of surgery
ABI 0.3 at the level of surgery
Albumin level of 2.5

Correct Answer: Absolute toe pressures of 55 mm Hg

Explanation:

DISCUSSION: Absolute toe pressures greater than 40 to 50 mm Hg are a good sign of healing potential. An ABI of greater than 0.45 favors healing, but indices greater than 1 are falsely positive due to calcifications in the vessels. Normal albumin is an overall indication of nutritional status.
A transcutaneous oxygen level should be greater than 40 mm Hg for healing.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 113-122.
Pinzur MS, Stuck R, Sage R: Benchmark analysis on diabetics at high risk for lower extremity amputation. Foot Ankle Int 1996;17:695-700.

Question 93:

(3875) Q4-7658:

Options:

Optimum conditions for nerve healing after direct repair include:
Gapping at suture repair site
Early motion of extremity
Tension-free repair
lacing sutures through the endoneurium to increase repair strength
Preservation of all tissue whether devitalized or viable
Tension-free repair is the optimal technique to improve the potential for nerve recovery. Gapping, failure to splint to prevent tension on the nerve with motion, and failure to excise scarred or devitalized nerve tissue are impairments to successful nerve repairs. Suture repairs through the deep nerve segments can damage the axons. Sutures should be placed through the epineurium or, in a grouped fascicular repair, through the perineurium around the fascicles.

Correct Answer: Tension-free repair

Explanation:

True
False
Missile wounds can cause a blast stretch injury to peripheral nerves and may recover with observation. Correct Answer: True

Question 94:

What is the most common secondary malignancy arising in pagetic bone?

Options:

Fibrosarcoma
Chondrosarcoma
Malignant fibrous histiocytoma
Osteosarcoma
Ewing’s sarcoma

Correct Answer: Osteosarcoma

Explanation:

Question 95:

Options:

Use of a hinged knee brace for 6 weeks postoperatively
Use of a continuous passive motion device for 2 weeks postoperatively
Eccentric strengthening starting at week #3
Concentric strengthening starting at week #3
Eccentric strengthening starting at week #12

Correct Answer: Use of a hinged knee brace for 6 weeks postoperatively

Explanation:

Question 96:

Options:

Fracture of the posterior glenoid
Triceps insertion avulsion
Calcific tendinitis
Posterior glenoid exostosis
Loose body

Correct Answer: Posterior glenoid exostosis

Explanation:

Question 97:

Options:

Early passive range-of-motion in a hinged elbow brace
Application of a static spanning external fixator for 6 weeks
Radial head excision, coronoid excision, and repair of the lateral ulnar collateral ligament and medial collateral as needed
Radial head excision, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed
Radial head replacement, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed

Correct Answer: Early passive range-of-motion in a hinged elbow brace

Explanation:

Question 98:

A 52-year-old woman has bicompartmental osteoarthritis following patellectomy. Treatment should consist of

Options:

high tibial osteotomy.
arthroscopic debridement.
patella arthroplasty.
total knee arthroplasty.
knee arthrodesis.

Correct Answer: total knee arthroplasty.

Explanation:

Question 99:

Options:

Thoracic scoliosis
Thoracic hypokyphosis
Lumbar disk degeneration
Thoracolumbar kyphosis
Lumbar hyperlordosis

Correct Answer: Thoracolumbar kyphosis

Explanation:

Question 100:

Options:

Observation and patient education regarding hip dislocation precautions
Revision to a larger-diameter femoral head
Revision to a constrained acetabular component
Application of a hip orthosis for 3 months

Correct Answer: Observation and patient education regarding hip dislocation precautions

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

OITE & ABOS Orthopedic MCQ Exam: Upper Extremity, Trauma & Nerve Part 34

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 34

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index