Trauma, Arthroplasty, Foot & Ankle MCQs - Part 38

About This Board Review Set

This is Part 38 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

This set has been strictly audited and contains 100 100% verified, high-yield multiple-choice questions (MCQs) modelled on the exact format of the Orthopaedic In-Training Examination (OITE) and the American Academy of Orthopaedic Surgeons (AAOS) board examinations.

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Two distinct learning modes are available:

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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 38

This module focuses heavily on: Ankle, Arthroplasty, Foot, Fracture, Hip, Infection, Trauma.

Sample Questions from This Set

Sample Question 1: 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 lo...

Sample Question 2: A 23-year-old woman has had a 14-month history of ankle pain after surgical treatment of multiple injuries resulting from a motor vehicle accident. Weight bearing began 4 months after surgery. The pain occurs with weight bearing and motion,...

Sample Question 3: A collegiate golfer sustains a hook of the hamate fracture. After 12 weeks of splinting and therapy, the hand is still symptomatic. What is the most appropriate management to allow return to competitive activity?...

Sample Question 4: A patient with a grade 2 L5-S1 isthmic spondylolisthesis reports low back pain and bilateral lower extremity pain. Nonsurgical management has failed to provide relief, and the patient is now a candidate for surgical intervention. The...

Sample Question 5: Hip pain of 1-month duration has developed in a 72-year-old man with a previous total hip arthroplasty. He underwent dental work 6 weeks ago. Aspiration shows a white blood cell count of more than 6,000 cells/μL (reference range 4,500 to 11...

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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

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 2

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

Explanation

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

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

Question 3

A collegiate golfer sustains a hook of the hamate fracture. After 12 weeks of splinting and therapy, the hand is still symptomatic. What is the most appropriate management to allow return to competitive activity?

Explanation

DISCUSSION: Excision of the fracture fragment typically leads to rapid return to function. Fixation techniques are difficult to perform because of the size of the bone; hardware prominence is common. Nerve deficits are not typically noted in this injury. The motor branch of the ulnar nerve in Guyon’s canal must be protected during the surgical approach.
REFERENCES: Kulund DN, McCue FC III, Rockwell DA, et al: Tennis injuries: Prevention and treatment: A review. Am J Sports Med 1979;7:249-253.
Morgan WJ, Slowman LS: Acute hand and wrist injuries in athletes: Evaluation and management. J Am Acad Orthop Surg 2001;9:389-400.

Question 4

A patient with a grade 2 L5-S1 isthmic spondylolisthesis reports low back pain and bilateral lower extremity pain. Nonsurgical management has failed to provide relief, and the patient is now a candidate for surgical intervention. The

Explanation

The L5 nerve root is especially vulnerable and prone to injury after the reduction of spondylolisthesis in patients with mid-and high-grade isthmic spondylolisthesis. The genitofemoral nerve is more commonly injured during anterior retroperitoneal approaches to the lumbar spine. Injury to the cauda equina often leads to bowel and bladder dysfunction and lower extremity weakness and is uncommon after reduction maneuvers.

Question 5

Hip pain of 1-month duration has developed in a 72-year-old man with a previous total hip arthroplasty. He underwent dental work 6 weeks ago. Aspiration shows a white blood cell count of more than 6,000 cells/μL (reference range 4,500 to 11,000 cells/μL) and the presence of gram-positive cocci in clusters on Gram stain. The orthopaedic surgeon recommends urgent debridement and irrigation. Fixation of the components is judged to be stable, and the surgeon elects to retain the implants. What is this patient's prognosis for infection resolution?

Explanation

DISCUSSION:
The patient has a late infection of at least 4 weeks symptomatic duration that most likely is hematogenous in etiology. This infection is not an acute hematogenous infection that can successfully be treated with irrigation and debridement. Retention of the implants with debridement and irrigation alone has been associated with a poor prognosis. In a recent study, the success rate was only 44% in a series of 104 patients at a mean 5.7-year follow-up. In one study of 50 infections attributable to MRSA or methicillin-resistant Staphylococcus epidermidis organisms treated with a two-stage protocol, the failure rate was 21%. Patients who experienced successful infection treatment had lower functional outcome measures using the Western Ontario and McMaster Universities Osteoarthritis Index, the University of California Los Angeles Activity Score, and the 12-item Oxford Knee Score, however.

Question 6

The clinical photograph in Figure 27 shows a palsy of what nerve/associated muscle?

Explanation

DISCUSSION: The clinical picture reveals medial scapular winging, which involves the serratus anterior muscle, potentially due to an injury to the long thoracic nerve that innervates this muscle. Injury to the long thoracic nerve is usually due to closed trauma, direct compression, traction or stretching injury, a direct blow, or, very rarely, viral infection such as Parsonage-Tumer syndrome. The nerve is easily injured in surgical dissection of the axilla, and is predisposed to injury due to its relatively long course, it is small in diameter, and it has little surrounding connective tissue. If rehabilitation and time are unsuccessful, both nerve and muscle transfers have been described with mixed results.
REFERENCES: Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop Relat Res 1999;368:17 -27.
Warner JJ, Navarro RA: Serratus anterior dysfunction: Recognition and treatment. Clin Orthop Relat Res 1998;349:139-148.

Question 7

A 14-year-old gymnast presents after a fall from the balance beam with a hyperextension injury to her left knee. She could ambulate with pain but was unable to continue exercise due to pain. On examination she has a swollen knee with painful

Explanation

The patient has a mild to moderately displaced tibial eminence fracture, which can be treated with closed reduction, casting, and supportive care provided successful closed reduction is achieved.
Tibial eminence fractures are rare but occur more often in pediatric populations, often in the setting of sports-related injuries. Debate continues over operative vs nonoperative treatment, as well as fixation type (screw vs suture) for openly treated fractures. Past evidence suggested closed treatment was adequate but there has been an increase in operative management. Closed treatment is suggested for minimally displaced fractures (Type I and reducible Type II) and open treatment for completely displaced fractures (non-reducible Type II and Type III).
Wilfinger et al provide the results of a closed reduction protocol at their institution including 38 patients with long term followup. All patients underwent aspiration and closed reduction in the OR under fluoroscopic guidance followed by long leg casting in hyperextension and graduated weight bearing over weeks. No patients complained of persistent pain, swelling, giving way, or disability at follow up.
However, Edmonds et al in a retrospective review compare open reduction internal fixation (ORIF), arthroscopic-assisted internal fixation (AAIF), and closed reduction with casting (CRC) for pediatric patients with displaced tibial spine fractures. They report improved reduction but also increased arthrofibrosis in ORIF and AAIF groups
compared to CRC, but of the 24% of patients with long term followup results, there was no difference in functional outcomes across all 3 groups. There was a 17% rate of later operation for the CRC group patients. They suggest closed treatment for fractures with <5mm displacement, otherwise ORIF or AAIF.
Gans et al conducted a systematic review focused on the questions of open vs closed reduction, and screw vs suture fixation. The 26-article review found insufficient evidence to have any clear recommendations. They did find reduced laxity and improved range of motion for minimally displaced fractures that had an open reduction, and that completely displaced fractures treated nonoperative had higher rates of nonunion.
Figures A and B are AP and lateral knee radiographs demonstrating a moderately displaced (Meyers and McKeever Type II) tibial spine fracture in a skeletally immature patient.
Incorrect Responses

Question 8

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

Explanation

DISCUSSION: The patient has Becker muscular dystrophy. Patients with this condition have a slower rate of progression of disease compared with patients who have Duchenne muscular dystrophy, and walking may continue into the late teens. The creatine kinase level is not as high as in Duchenne muscular dystrophy, which can range from 20,000 to 30,000 IU/L. Becker muscular dystrophy is allelic to Duchenne muscular dystrophy, resulting in a mutation in the dystrophin gene. Myotonic dystrophy is characterized by a progressive inability to relax the muscles after contracture. The Gower sign is not helpful in this disease. Patients with Charcot-Marie-Tooth disease, one type of which is also known as HMSN type II, do not have elevated creatine kinase levels and usually present with a foot deformity. Spinal muscular atrophy, type II, usually presents with severe weakness in the second year of life.
REFERENCES: Matsuo M: From molecular diagnosis to gene therapy. Brain Dev 1996;18:167-172.
Darras BT: Molecular genetics of Duchenne and Becker muscular dystrophy. J Pediatr 1990;117:1-15.
Gutmann DH, Fischbeck KH: Molecular biology of Duchenne and Becker’s muscular dystrophy: Clinical applications. Ann Neurol 1989;26:189-194.

Question 9

An otherwise healthy year-old woman has pain 2 years after total hip arthroplasty. The clinical photograph in 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 10

A patient who underwent primary total hip arthroplasty 7 years ago that resulted in excellent pain relief and a normal gait now reports pain and a limp. Postoperative and current AP radiographs are shown in Figures 2a and 2b. What is the most likely cause of the pathology seen?

Explanation

DISCUSSION: Osteolysis in the trochanteric bed can result in weakening of the bone and fracture. Nonsurgical management will provide reasonable clinical and radiographic results in patients with limited fracture displacement.
REFERENCES: Claus MC, Hopper RH, Engh CA: Fractures of the greater trochanter induced by osteolysis with the anatomic medullary locking prosthesis. J Arthroplasty 2002;17:706-712.
Heekin RD, Engh CA, Herzwurm MF: Fractures through cystic lesions of the greater trochanter: A cause of late pain after cementless total hip arthroplasty. J Arthroplasty 1996;11:757-760.

Question 11

A 70-year-old healthy man had total knee arthroplasty 18 years ago, and it now is painful. Radiographs reveal aseptic loosening and the range of motion before surgery is 15 to 85 degrees. The strongest indication for performing a tibial tubercle osteotomy to aid in exposure in his knee would be

Explanation

Question 12

A 19-year-old collegiate lacrosse player has bilateral lower extremity pain during training runs and practice sessions. She says her pain is only associated with activity, always begins 4 to 5 minutes into an activity, and resolves within 10 minutes after activity cessation. She reports a feeling of numbness and tingling in her first- and second-toe web space with continued activity. She has no pain while at rest and has tried nonsteroidal anti-inflammatory drugs, ice baths, and rehabilitation techniques with her athletic trainers without experiencing noticeable changes. Which test has the highest specificity and sensitivity for the pathology suspected?

Explanation

DISCUSSION
Chronic exertional compartment syndrome (CECS) is an uncommon cause of pain that is most often encountered in athletes or military populations. The diagnosis is suggested by pain after the start of the activity with resolution of symptoms when the activity stops. Traditionally, the diagnosis was established by measuring intracompartment pressures at 1 and 5 minutes of
activity. Roscoe and associates have shown that using continuous pressure monitoring during the activity until pain forces subjects to stop provides higher sensitivity and specificity than the traditional diagnostic technique. Palpating the leg is not as sensitive or specific as direct pressure monitoring. Although certain changes can be seen on MRI in CECS, this is not the diagnostic study of choice.

Question 13

Item Deleted by AAOS Question 38 - Figure 6 shows the clinical photograph of a 3-year-old boy who started to walk at the age of 10 months and has a gait that is appropriate for his age. His height is in the 40th percentile for his age. Management should consist of

Explanation

The diagnosis is Developmental Genu Valgum. There are several clues in the question that suggest that this is a benign process. First they tell you that the child walked at 10 months of age (within normal limits) which helps rule out several neuromuscular disorders. Second, the child is three years of age. A moderate amount of “knock knees” is considered physiologic up to six years of life. Third, the child is in the 40th percentile for his height (again within normal limits).
The correct treatment for children with physiologic genu valgum up to six years of life is OBSERVATION, if the condition persists past six years standing AP radiographs and a metabolic work-up are indicated. Because response (1) is the only answer not including x-rays, this is the one you should have selected.

Question 14

A 24-year-old man is ejected from his motorcycle and sustains a significant hip injury. The fracture shown in Figures 64a through 64e is best described as what type of fracture?

Explanation

DISCUSSION: The radiographs and CT scans reveal an anterior column acetabular fracture. The fracture has quadrilateral plate extension but does not exit out the posterior column. The CT scans confirm an intact posterior column and no wall fracture. A transverse fracture is best seen on the CT scan and runs in the sagittal plane, not the coronal plane.
REFERENCES: Letournel E, Judet R: Fractures of the Acetabulum, ed 2. New York, NY, Springer-Verlag, 1993, pp 115-140.
Beaule PE, Dorey FJ, Matta JM: Letournel classification of acetabular fractures: Assessment of interobserver and intraobserver reliability. J Bone Joint Surg Am 2003;85:1704-1709.

Question 15

A 72-year-old woman with rheumatoid arthritis who underwent primary total knee arthroplasty 2 years ago has had diffuse knee pain that developed shortly after the surgery. The patient has difficulty with stair descent and arising from chairs. Evaluation for infection is negative. AP and lateral radiographs are shown in Figure 26. Management should now consist of

Explanation

DISCUSSION: The radiographs show posterior flexion instability that is the result of flexion-extension gap imbalance and/or posterior cruciate ligament incompetence after a posterior cruciate-retaining total knee arthroplasty. The radiographs also show anterior femoral displacement on the tibia. Pagnano and associates reported on a series of patients with painful total knee arthroplasties who had been previously diagnosed as having pain of unknown etiology, showing that the pain was secondary to flexion instability. Pain relief was achieved by revision to a posterior stabilized implant.
REFERENCES: Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ: Flexion instability after primary posterior cruciate retaining total knee arthroplasty. Clin Orthop 1998;356:39-46.
Fehring TK, Valadie AL: Knee instability after total knee arthroplasty. Clin Orthop 1994;299:157-162.
Fehring TK, Odum S, Griffin WL, Mason B, Nadaud M: Early failures of total knee arthroplasty. Clin Orthop 2001;392:315-318.

Question 16

A 30-year-old patient has wrist pain. A radiograph and biopsy specimen are shown in Figures 34a and 34b. What is the most likely diagnosis?

Explanation

DISCUSSION: Aneurysmal bone cysts typically present as radiolucent lesions with an expansile remodeled cortex. The histologic appearance consists of blood-filled lakes surrounded by a benign lining that contains fibroblasts, giant cells, and hemosiderin. Although the other lesions are in the radiographic differential diagnosis, these histologic findings indicate an aneurysmal bone cyst.
REFERENCES: Bieselker JL, Marcove RC, Huvos AG, Mike V: Aneurysmal bone cyst: A Clinico-pathologic study of 66 cases. Cancer 1973;26:615.
Martinez V, Sissons HA: A review of 123 cases including primary lesions and those secondary to other bone pathology. Cancer 1988;61:2291.

Question 17

A 72-year-old female presents to your office with a 24-month old painful nonunion of a 3-part fracture of the proximal humerus. She has been treated conservatively with range of motion exercises but continues to complain of debilitating pain and dysfunction. Operative management should include:

Explanation

DISCUSSION: Treatment of a chronic nonunion of the proximal humerus in the elderly should be treated with arthroplasty when possible. Critical attention should be paid to correct all deformities: tuberosity positioning, articular surface realignment, soft tissue balancing, rotator cuff repair (when needed), and treatment of soft tissue contractures. Attempts at internal fixation should be performed with caution in this patient population, due to general osteopenia and significant rates of loss of fracture reduction.
The referenced article by Cheung et al reviews treatment options for proximal humeral nonunions and reports successful use of arthroplasty in treating elderly osteoporotic proximal humeral nonunions as a pain relieving procedure.
Dines reported a case series of 20 chronic post-traumatic proximal humerus fractures including nonunions that were treated with shoulder arthroplasty achieving fair to excellent results in 90% at mid-term follow-up

Question 18

Figure 43 shows the lateral radiograph of a patient who underwent anterior cruciate ligament reconstruction. Based on the tunnel placement shown in the radiograph, evaluation of postoperative knee range of motion will most likely show

Explanation

DISCUSSION: The radiograph shows the correct tibial tunnel and anterior femoral tunnel; therefore, range of motion will most likely show loss of flexion.
REFERENCES: Brown CH Jr, Carson EW: Revision anterior cruciate ligament surgery. Clin
Bernhardt DT, Landry GL: Sports injuries in young athletes. Adv Pediatr 1995;42:465- Sports Med 1999;18:109-171.
Brown HR, Indelicato PA: Complications of anterior cruciate ligament reconstruction. Op Tech Orthop 1992;2:125-135.

Question 19

When using surgery extending to the pelvis to treat long spinal deformity in adults, the addition of anterior interbody structural support at the lumbosacral junction serves what biomechanical function?

Explanation

DISCUSSION: Shufflebarger and others have reported that the placement of anterior interbody structural support at the lumbosacral junction increases the overall construct stiffness and reduces the strain on posterior instrumentation, thereby reducing the risk of screw pull-out or fracture. The stiffness of the posterior instrumentation actually increases, whereas the actual strength of the instrumentation remains the same. Actual strain measured at an adjacent intervertebral disk to a fusion construct is expected to increase.
REFERENCES: Shufflebarger HL: Moss-Miami spinal instrumentation system: Methods of fixation of the spondylopelvic junction, in Margulies JI, Floman Y, Farcy JPC, et al (eds): Lumbosacral and Spinal Pelvic Fixation. Philadelphia, PA, Lippincott-Raven, 1996, pp 381-393.
Cunningham BW: A biomechanical approach to posterior spinal instrumentation: principles and applications, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 588-600.
Kostuik JP, Valdevit A, Chang HG, et al: Biomechanical testing of the lumbosacral spine. Spine 1998;23:1721-1728.

Question 20

Which of the following clinical findings is commonly associated with symptomatic partial-thickness rotator cuff tears?

Explanation

DISCUSSION: In symptomatic partial-thickness rotator cuff tears, a painful arc with active range of motion is common, impingement signs are usually positive, and the lift-off test is normal. Active and passive range of motion measurements are often equal, although active range of motion can be painful. External rotation lag signs are often seen with larger full-thickness tears.
REFERENCES: Hertel R, Ballmer FT, Lambert SM, Gerber C: Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 1996;5:307-313.
McConville OR, Iannotti JP: Partial thickness tears of the rotator cuff: Evaluation and management. J Am Acad Orthop Surg 1999;7:32-43.
Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.
Fukuda H: Partial-thickness rotator cuff tears: A modern view on Codman’s classic. J Shoulder Elbow Surg 2000;9:163-168.

Question 21

The difference between vitamin D-dependent rickets type I (VDDR I) and vitamin D-dependent rickets type II (VDDR II) is

Explanation

VDDR I is a deficiency of an enzyme predominantly found in the kidney. VDDR II is caused by an inactivating mutation of the receptor for 1,25 (OH)2 vitamin D3.
VDDR I is a deficiency of 1a-hydroxylase [converts 25(OH)D to 1a,25(OH)2D3].
Lab tests show hypocalcemia, secondary hyperparathyroidism, elevated alkaline phosphatase (ALP) and low or undetectable calcitriol in the presence of adequate 25(OH)D levels. VDDR II or hereditary vitamin D resistant rickets (HVDRR) (autosomal recessive) is an inactivating mutation in the vitamin D receptor (VDR). Lab tests show low serum calcium and phosphate, elevated ALP and secondary hyperparathyroidism. Serum 25(OH)D values are normal and the 1,25(OH)2D levels are elevated (key difference from VDDR I).
Malloy et al. reviewed genetic disorders in vitamin D action. They state that VDDR I is an inborn error of vitamin D metabolism coded by the gene CYP27B1. Children with VDDR I present with joint pain/deformity, hypotonia, muscle weakness, growth failure, and hypocalcemic seizures or fractures in early infancy. Treatment is with calcitriol or 1a-hydroxyvitamin D (NOT cholecalciferol). Children with VDDR II present with bone pain, muscle weakness, hypotonia, hypocalcemic convulsions, growth retardation, severe dental caries or teeth hypoplasia. Affected children are resistant to therapy and supra-physiologic doses of all forms of vitamin D.
Illustration A shows the differences between VDDR I and VDDR II. Incorrect Answers
in the kidney). The liver enzyme vitamin D 25-hydroxylase (found in hepatocytes) is not responsible for VDDR. VDDR II is caused by an inactivating mutation (rather than an activating mutation).

Question 22

An 18-year-old football player sustains a contact injury to his right lower leg, and radiographs show a closed transverse fracture of the middle third of the tibia. Based on the clinical examination, a compartment syndrome is suspected. When measuring compartment pressures, the highest tissue pressure is recorded how many centimeters proximal or distal to the fracture site?

Explanation

DISCUSSION: Measurements of compartment pressures in patients with tibial fractures and compartment syndrome reveal that the highest tissue pressures are recorded at the level of the fracture or within 5 cm of the fracture. Tissue pressures show a statistically significant decrease when they are recorded at increasing distances proximal and distal to the site of the highest pressure recorded. To reliably determine the location of the highest tissue pressure in patients with tibial fractures, measurements should be obtained, at a minimum, in both the anterior and deep posterior compartments at the level of the fracture, as well as at locations proximal and distal. The highest tissue pressure recorded should serve as a basis for determining the need for fasciotomy.
REFERENCES: Heckman MM, Whitesides TE Jr, Grewe SR, Rooks MD: Compartment pressure in association with closed tibial fractures: The relationship between tissue pressure, compartment, and the distance from the site of the fracture. J Bone Joint Surg Am 1994;76:1285-1292.
Whitesides TE Jr, Heckman MM: Acute compartment syndrome: Update on diagnosis and treatment. J Am Acad Orthop Surg 1996;4:209-218.

Question 23

A 72-year-old woman who was doing well after undergoing total shoulder arthroplasty for arthritis 4 months ago is suddenly unable to elevate her arm. Examination reveals 70 degrees of external rotation compared with 45 degrees on the uninvolved side, and she is unable to lift her hand off her lower back. Radiographs are shown in Figures 43a through 43c. Treatment should consist of

Explanation

DISCUSSION: Results of treatment of subscapularis rupture are best when immediate repair is performed. When the cause of the anterior instability is the result of rupture of the subscapularis tendon and the component position is acceptable, revising the position of the component is unnecessary. Restoring the coracoacromial arch and subacromial decompression are related to superior instability and rotator cuff pathology, respectively, and would not correct the instability caused by subscapularis rupture.
REFERENCES: Moeckel BH, Altchek DW, Warren RF, Wickiewicz TL, Dines DM: Instability of the shoulder after arthroplasty. J Bone Joint Surg Am 1993;75:492-497.
Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am 1996;78:1015-1023.

Question 24

An elderly woman with radiographic evidence of spinal stenosis reports difficulty walking and calf pain that is relieved by rest and a change of position. The most likely cause of pain is ischemia of the

Explanation

Pain and numbness in the buttock, thigh and legs during walking or prolonged standing in the upright posture-that is relieved by various postures-is caused by spinal stenosis. Neurogenic claudication may result from nerve root ischemia secondary to increased epidural pressure, intermittent compression of nerve roots and venous congestion.

Question 25

Figures 18a and 18b show the radiographs of a 13-year-old baseball player who sustained a patellar dislocation with an associated lateral femoral condyle fracture. What ligament is attached to this fragment?

Explanation

DISCUSSION: The anterior cruciate ligament is attached to a portion of the lateral femoral condyle. The posterior cruciate ligament attaches to the medial femoral condyle. The lateral collateral and oblique popliteal ligaments attach proximal to this fragment. The intermeniscal ligament attaches the anterior horns of the menisci.
REFERENCES: Jobe CM, Wright M: Anatomy of the knee, in Fu FH, Harner CD, Vince KG (eds): Knee Surgery. Baltimore, MD, Williams & Wilkins, 1994, pp 1-54.
Moore KL, Dalley AF: Lower limb, in Moore KL, Dalley AF (eds): Clinically Oriented Anatomy, ed 4. Philadelphia, PA, Lippincott, Williams & Wilkins, 1999, pp 503-664.

Question 26

03 A 28-year-old man underwent surgical fixation for an intra-articular distal humeral fracture 8 weeks ago now reports progressively restricted elbow motion. Radiographs at the time of union are shown in Figures 13a and 13b. Management should now consist of

Explanation

The radiographs show HO posteriorly in the triceps tendon and also anteriorly in the tendon. The fracture appears well-healed. At this point, oral indomethacin or single dose irradiation would not help as the HO is already there and these are typically used to prevent HO. Option #3 also would not help since there appears to be more of a bony block than soft tissue contracture. This leaves options 4 and 5. In the past, ectopic bone resection was
delayed until the heterotopic ossification was “mature”. This was signified by a cold bone scan and normal serum alk phos, as well as a mature appearance on xray. It was thought that by waiting until the HO was mature, recurrence would be avoided. However, in the cited reference, out of the widely read Journal of Hand Surgery, the authors obtained good results with increased range of motion, resolution of cubital tunnel syndrome and no recurrence of contractures or loss of motion with excision of ectopic bone and elbow release that was performed once bony union of fracture was obtained. They also used a 5 day course of indomethacin post-op.
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Question 27

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

Explanation

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

Question 28

What is the maximum acceptable amount of divergence of the interference screw in the femoral tunnel from the bone plug of a bone-patellar tendon-bone graft in anterior cruciate ligament (ACL) reconstruction before pull-out strength is statistically decreased?

Explanation

DISCUSSION: In the early 1990s, a transition was made from a two-incision ACL reconstruction to a single-incision ACL reconstruction, and there was concern over divergence of the femoral screws. It was shown radiographically that approximately 5% of the time, divergence of the screw was greater than 15 degrees from the bone plug. In a bovine model, there was significant loss of pull-out strength with an increase in divergence from 15 degrees to 30 degrees. Therefore, attempts should be made to minimize divergence to 15 degrees or less.
REFERENCES: Lemos MJ, Jackson DW, Lee TO, et al: Assessment of initial fixation of endoscopic interference femoral screws with divergent and parallel placement. Arthroscopy 1995;11:37-41.
Lemos MJ, Albert J, Simon T, et al: Radiographic analysis of femoral interference screw placement during ACL reconstruction: Endoscopic versus open technique. Arthroscopy 1993;9:154-158.

Question 29

A 30-year-old man who sustained a work-related injury 6 weeks ago reports persistent back and left-sided buttock pain that has been attributed to lumbar transverse process fractures. A pelvic radiograph and CT scans obtained 2 days ago are seen in Figures 17a through 17c. What is the best treatment for his injury?

Explanation

DISCUSSION: Fortunately, surgical treatment of sub-acute pelvic ring injuries is relatively uncommon as acute management has become more common. Delayed reconstruction of pelvic ring malunion and impending malunion is rare. Nonsurgical management may have a role as long as the hemipelvis does not flex, shorten, and/or externally rotate. The AP pelvic radiograph suggests that all three motions are happening in this patient. These are just a few of the indications to repair the pelvic ring and this is best done with anterior and posterior fixation. Anterior symphyseal plating will help correct most of the deformity. Posterior fixation can and should be added to lessen the forces on the anterior ring reconstruction when repair is performed in a sub-acute or delayed fashion. Posterior fixation can help obtain a more anatomic reduction and helps decrease the risk of anterior hardware failure.
REFERENCES: Mears DC: Management of pelvic pseudarthroses and pelvic malunion. Orthopade 1996;25:441-448.
Matta JM, Dickson KF, Markovich GD: Surgical treatment of pelvic nonunions and malunions. Clin Orthop Relat Res 1996;329:199-206.
McLaren AC, Rorabeck CH, Halpenny J: Long-term pain and disability in relation to residual deformity after displaced pelvic ring fractures. Can J Surg 1990;33:492-494.

Question 30

A 23-year-old national team rower reports pain over the radial dorsum of the forearm that is made worse with flexion and extension of the wrist during competition. His primary physician initially diagnosed de Quervain’s tenosynovitis, and a subsequent corticosteroid injection into the first dorsal compartment at the wrist provided no relief. The patient continues to report pain and audible crepitus that is noted 5 cm proximal to the wrist joint, on the radial aspect. What structures are involved in the continued pathology?

Explanation

DISCUSSION: Intersection syndrome is also known as “squeakers wrist,” “oarsmen wrist,” and crossover tendinitis. It occurs where the first and second dorsal wrist compartment structures pass over one another, resulting in fibrosis, muscular changes, and inflammation of the bursa in this area. The structures involved are the abductor pollicis longus and extensor pollicis brevis (first dorsal compartment) that pass across the second compartment structures (extensor carpi radialis brevis and extensor carpi radialis longus). An audible “squeak” is occasional y heard at the intersection point, which is approximately 4 to 5 cm proximal to the proximal dorsal wrist crease.
REFERENCES: Grundberg AB, Reagan DS: Pathologic anatomy of the forearm: Intersection syndrome. J Hand Surg Am 1985; 10:299-302.
Thorson E, Szabo RM: Common tendinitis problems in the hand and forearm. Orthop Clin North Am 1992;23:65-74.
Williams JG: Surgical management of traumatic non-infective tenosynovitis of the wrist extensors. J Bone Joint Surg Br 1977;59:408-410.
Wood MB, Dobyns JH: Sports-related extraarticular wrist syndromes. Clin Orthop Relat Res 1986;202:93-102.

Question 31

-Figures 55a and 55b are the radiograph and CT scan of a 61-year-old woman who has had neck pain after being involved in a high-speed motor vehicle collision. Examination reveals normal strength and sensation in both upper and lower extremities, normal rectal tone, and no other injuries. The C1-C2 lateral mass overhang measures 8.5 mm. What is the most appropriate treatment option?

Explanation

Question 32

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

Explanation

DISCUSSION: Internal rotators of the shoulder include the subscapularis, pectoralis major, teres major, and latissimus dorsi muscles. The subscapularis has two portions, with the upper portion receiving its innervation from the upper subscapular nerve (C5) and the lower portion from the lower subscapular nerve (C5-6). The two tests commonly performed to isolate the internal rotation to the subscapularis muscle are the lift-off test and the belly press test. Electromyographic findings have shown the lift-off test to be more accurate for the lower portion of the subscapularis and the belly press test to be more sensitive for the upper portion.
REFERENCES: Hintermeister RA, Lange GW, Schultheis JM, Bey MJ, Hawkins RJ: Electromyographic activity and applied load during shoulder rehabilitation exercises using elastic resistance. Am J Sports Med 1998;26:210-220.
Greis PE, Kuhn JE, Schultheis J, Hintermeister R, Hawkins R: Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. Am J Sports Med 1996;24:589-593.

Question 33

below depict the radiographs obtained from a year-old woman who comes to the emergency department after experiencing a fall. She is an unassisted community ambulator with a history of right hip pain. What is the most appropriate surgical treatment for this fracture?

Explanation

DISCUSSION:
This patient has pre-existing right hip osteoarthritis. The most correct option for the treatment of this active patient is a right total hip arthroplasty. Hemiarthroplasty would not address the patient's pain from osteoarthritis, and open reduction and internal fixation would not fix the femoral head issue or the
osteoarthritis.

Question 34

Osteoporotic vertebral compression fractures are associated with

Explanation

DISCUSSION: Osteoporotic vertebral compression fractures are associated with neurologic complications in less than 1% of patients. After the initial fracture however, patients have a 20% risk of further fractures. The mortality rate of patients with vertebral fractures exceeds that of patients with hip fractures when they are followed beyond 6 months.
REFERENCES: Gass M, Dawson-Hughs B: Preventing osteoporosis-related fractures: An overview. Am J Med 2006;119:S3-S11.
Lindsay R, Silverman SL, Cooper C, et al: Risk of new vertebral fracture in the year following a fracture. JAMA 2001;285:320-323.
Kado DM, Duong T, Stone KL, et al: Incident vertebral fractures and mortality in older women: A prospective study. Osteoporos Int 2003;14:589-594.

Question 35

The safest surgical approach to the insertion of the tibial posterior cruciate ligament uses the interval between which of the following muscles?

Explanation

DISCUSSION: Burks and Schaffer described an approach to the tibial insertion of the posterior cruciate ligament that uses the interval between the semimembranosus and the medial gastrocnemius. The medial gastrocnemius muscle is retracted laterally and protects the neurovascular bundle. This approach is used to repair an avulsion of the posterior cruciate ligament tibial attachment or for performing a posterior cruciate ligament tibial

inlay reconstruction.
REFERENCES: Berg EE: Posterior cruciate ligament tibial inlay reconstruction. Arthroscopy 1995;8:95-99.
Burks RT, Schaffer JJ: A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop 1990;254:216-219.

Question 36

Figures below show the radiographs obtained from a 90-year-old woman who is seen in the emergency department after a fall from a height. She has right hip and thigh pain and is unable to bear weight. Based on this patient's history and imaging, what is the best next step?

Explanation

DISCUSSION:
Periprosthetic fracture is the third most common reason (after loosening and infection) for revision surgery after total hip arthroplasty (THA). Late periprosthetic fracture risk is 0.4% to 1.1% after primary
THA and 2.1% to 4% after revision THA. Risk factors for periprosthetic fracture include age over 70 years, decreasing bone mass, and loosening of implants and osteolysis. The risk of concomitant infection in the presence of a periprosthetic fracture is 11%, according to Chevillotte and associates. Obtaining presurgical aspiration or intrasurgical tissue for culture is recommended if concomitant infection is suspected.

Question 37

A 24-year-old female soccer player has had lateral joint line pain and a recurrent effusion in the left knee after sustaining a twisting injury 6 weeks ago. She reports that symptoms worsen with athletic activities. MRI scans are shown in Figures 2a through 2c. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scans show the typical findings of a torn discoid lateral meniscus. The average transverse diameter of the lateral meniscus is 11 or 12 mm. A discoid lateral meniscus is suggested when three or more contiguous 5-mm sagittal sections on the MRI scan show continuity of the menicus between the anterior and posterior horns, or when two adjacent peripheral sagittal 5-mm sections show equal meniscal height. Normally the black “bow tie” would be seen on two contiguous sagittal sections. The presence of a discoid meniscus can be further confirmed if coronal views reveal increased width.
REFERENCES: Jordan MR: Lateral meniscal variants: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:191-200.
Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging. Philadelphia, PA, WB Saunders, 1997, pp 625-630.

Question 38

In revision total hip arthroplasty, an acetabular reconstruction cage is best indicated for which of the following patterns of bone loss?

Explanation

DISCUSSION: Acetabular cage reconstruction is indicated in severe disruption of acetabular bone stock when a cementless acetabular component cannot be stabilized in intimate contact with a sufficient bed of structurally sound and viable host bone, with or without a structural graft. Cages are used in pelvic discontinuity where they provide a bridge between the ilium and the ischium, while supporting a cemented cup. All of the other scenarios are amenable to achieving an adequate rim fit for a cementless component, using a jumbo cup if necessary.
REFERENCES: Whiteside LA: Selection of acetabular component, in Steinberg ME, Garino JP (eds): Revision Total Hip Arthroplasty. Philadelphia, PA, Lippincott Williams and Wilkins, 1999, pp 209-220.
Berry DJ, Muller ME: Revision arthroplasty using an anti-protrusio cage for massive acetabular bone deficiency. J Bone Joint Surg Br 1992;74:711-715.

Question 39

A 45-year-old woman with grade II adult-acquired flatfoot deformity has pain on the lateral side of her foot just distal to the tip of the fibula. Which component of a comprehensive flatfoot reconstruction most likely will address the deformity responsible for this pain?

Explanation

DISCUSSION
Patients develop lateral ankle pain with progression of adult-acquired flatfoot deformity. This is associated with increased hindfoot valgus deformity. Calcaneal fibular impingement has been considered the primary cause of this pain. Studies demonstrate that arthrosis of the posterior facet of the subtalar joint strongly correlates with lateral pain in adult-acquired flatfoot deformity. Both conditions are related to hindfoot valgus deformity. Although lateral column lengthening is a powerful tool for correction of flatfoot deformity, its effect on hindfoot deformity is less defined. Lateral column lengthening provides better correction of the longitudinal arch of the midfoot and realignment of the medial column than other osteotomies. A medializing calcaneal osteotomy has a significant linear effect on hindfoot valgus alignment. Spring ligament reconstruction and medial cuneiform opening-wedge osteotomies have less effect on hindfoot alignment than the medial calcaneal slide.
RECOMMENDED READINGS
Ellis SJ, Deyer T, Williams BR, Yu JC, Lehto S, Maderazo A, Pavlov H, Deland JT. Assessment of lateral hindfoot pain in acquired flatfoot deformity using weightbearing multiplanar imaging. Foot Ankle Int. 2010 May;31(5):361-71. doi: 10.3113/FAI.2010.0361. PubMed PMID:

Question 40

An 18-year old man has a simple oblique fracture of the humeral shaft that requires surgical stabilization to maintain reduction and facilitate mobilization. Which of the following methods will provide the best outcome?

Explanation

DISCUSSION: The patient has a simple fracture pattern that can be reduced anatomically and stabilized with absolute stability by interfragmental compression and protection plating. This will guarantee a 95% to 98% union rate with no radial nerve palsy. Intramedullary nailing does not equal these results in a simple fracture pattern in the humerus. Bridge plating is indicated for multifragmented fracture patterns when anatomic reduction and absolute stability cannot be achieved. External fixation is reserved for severe open fractures.
REFERENCES: Chapman JR, Henley MP, Agel J, Benca PJ: Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-166.
Farragos AF, Schemitsch EH, McKee MD: Complications of intramedullary nailing for fractures of the humeral shaft: A review. J Orthop Trauma 1999;13:258-267.
Modabber M, Jupiter JB: Operative management of diaphyseal fractures of the humerus: Plate versus nail. Clin Orthop 1998;347:93-104.

Question 41

A 52-year-old woman has right hip pain and obvious swelling 3 years after undergoing a resurfacing arthroplasty. Her implant consists of a 42-mm femoral component and 48-mm socket. Her components are well positioned, and her metal ion levels are slightly elevated (less than 4 ppm) with a normal erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level. What is the most likely cause of her discomfort?

Explanation

DISCUSSION
This patient likely has a soft-tissue reaction (pseudotumor) related to metal-on-metal articulation. Although the components are well positioned, patient gender and small head size are both known risk factors for failure of hip resurfacing arthroplasties. Metal ion levels are elevated but are not always markedly increased in the setting of a problematic metal-on-metal articulation. The patient should have a metal artifact reduction sequence MR imaging study to confirm the presence of a pseudotumor. Chronic infection is very unlikely in the setting of normal ESR and CRP findings. Impingement and lumbar disk disease would not explain the swelling around the hip.

Question 42

Figure 6 shows the radiograph of a 14-year-old baseball player who felt a pop and had an immediate onset of pain in his elbow after a hard throw from the outfield. The best course of action should be to

Explanation

DISCUSSION: The valgus stress at the elbow caused by throwing strains the medial collateral ligament. The medial epicondyle, on which the ligament inserts, is the last ossification center to fuse to the distal humerus, and acute avulsion of the medial epicondyle can occur in adolescents. If the elbow is allowed to heal in a displaced position, valgus instability and loss of elbow extension may result. Valgus instability is especially problematic for the throwing athlete. Surgical treatment with rigid internal fixation is the treatment of choice for displaced medial epicondyle avulsion fractures. Valgus instability is prevented, and the rigid fixation allows for early range of motion.
REFERENCES: Case SL, Hennrikus WL: Surgical treatment of displaced medial epicondyle fractures in adolescent athletes. Am J Sports Med 1997;25:682-686.
Woods GW, Tullos HS: Elbow instability and medial epicondyle fractures. Am J Sports Med 1977;5:23-30.

Question 43

What is a common clinical finding in patients with severe hypercalcemia secondary to bony metastasis?

Explanation

DISCUSSION: Increased levels of calcium are known to cause anorexia, nausea, vomiting, dehydration, muscle weakness, polyuria, and polydipsia. Treatment may include hydration, saline diuresis, and bisphosphonates.
REFERENCE: Frassica FJ, Gitelis S, Sim FH: Metastatic bone disease: General principles, pathophysiology, evaluation, and biopsy. Instr Course Lect 1992;41:293-300.

Question 44

In children with moderate to severe osteogenesis imperfecta (OI), intravenous pamidronate therapy has been shown to increase the thickness of cortical bone. This occurs primarily as a consequence of

Explanation

DISCUSSION: Histologic studies have shown that increased bone turnover is the rule in OI. Pamidronate (and all bisphosphonates) reduce osteoclast-mediated bone resorption. Osteoblastic new bone formation on the periosteal surface of long bones is minimally impaired. With inhibition of osteoclastic bone resorption on the endosteal surface, the cortex of the bone can begin to thicken as it does with normal growth in individuals unaffected by OI. Mineralization and collagen matrix organization are not directly affected by pamidronate.
REFERENCES: Zeitlin L, Fassier F, Glorieux FH: Modern approach to children with osteogenesis imperfecta. J Pediatr Orthop B 2003;12:77-87.
Falk MJ, Heeger S, Lynch KA, et al: Intravenous bisphosphonate therapy in children with osteogenesis imperfecta. Pediatrics 2003;111:573-578.
Glorieux FH, Bishop NJ, Plotkin H, et al: Cyclic administration of pamidronate in children with severe osteogenesis imperfecta. N Engl J Med 1998;339:947-952.

Question 45

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

Explanation

DISCUSSION: The contents of the anterior tarsal tunnel are the extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, and the deep peroneal nerve. The term “anterior tarsal tunnel syndrome” is used to specifically describe the compression of the deep peroneal nerve under the inferior extensor retinaculum. With nerve compression, patients report a burning sensation across the dorsum of the foot with paresthesias in the first web space. There also may be wasting and weakness of the extensor digitorum brevis.
REFERENCES: Kuritz HM: Anterior entrapment syndromes. J Foot Surg 1976;15:143-148.
Sarrafian S: The Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993, pp 113-158.

Question 46

A 45-year-old male falls off his motorcycle and injures his arm. AP and lateral radiographs reveal an ulnar shaft fracture, 30 degrees apex anterior, and a radial head dislocation. Which direction is the radial head most likely dislocated?

Explanation

DISCUSSION: A monteggia fracture with apex anterior ulnar shaft fracture is associated with an anterior radial head dislocation (See Illustration A). Bado initially described and classified these injuries. The most common injury pattern is an extension type 1 with anterior radial head dislocation and apex anterior ulnar shaft fracture. The apex of the ulna fracture determines the direction of the radial head subluxation or dislocation. Adults typically require ORIF of the ulna. These fractures in children are often treated non-operatively with closed reduction if the ulna fracture is transverse and stable as illustrated by Fowles' case series, but may also require pinning if the fracture is oblique and unstable.

Question 47

According to Musculoskeletal Infection Society (MSIS) guidelines, which set of patient laboratory study results fits the definition of chronic prosthetic joint infection?

Explanation

DISCUSSION:
The MSIS definition of periprosthetic joint infection was updated in 2014 with two major and six minor criteria. The presence of one major criterion or three minor criteria is diagnostic for infection. The major criteria are two positive cultures with the same organism or a draining sinus tract. The current MSIS minor criteria are 1) an elevated ESR (more than 30 mm/hr) and CRP level (more than 10 mg/L), 2) an elevated synovial WBC count (more than 3,000 cells per/microliter), 3) an elevated synovial fluid polymorphonuclear count (more than 80%), 4) a positive histological analysis of periprosthetic tissue, and 5) a single positive culture.

Question 48

What is the most common complication following surgery for a "terrible triad" elbow fracture-dislocation?

Explanation

Recurrent instability, PIN palsy, infection, and posttraumatic arthritis have all been reported following these injuries; however, elbow contracture or loss of motion is nearly universal following these injuries.

Question 49

When considering a flexor digitorum longus tendon transfer as part of the surgical treatment in patients with symptomatic flatfoot deformity caused by posterior tibial tendon insufficiency, which of the following patients is the most appropriate candidate?

Explanation

DISCUSSION: Transfer of the flexor digitorum longus tendon is a common technique combined with other procedures to treat patients with posterior tibial tendon insufficiency. However, it is contraindicated in patients with a fixed hindfoot deformity, hypermobility, or neuromuscular compromise. It is relatively contraindicated in patients who are obese, and those older than age 60 to 70 years.
REFERENCES: Pedowitz WJ, Kovatis P: Flatfoot in the adult. J Am Acad Orthop Surg 1995;3:293-302.
Mann RA: Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby-Year Book, 1993, pp 167-296.

Question 50

When examining a patient with marked hyperreflexia, which of the following findings best suggests that the condition is not caused by a cerivcal spine pathology?

Explanation

DISCUSSION: A positive jaw jerk reflex suggests that the problem is above the level of the pons. All of the other physical signs are exhibited in patients with cervical myelopathy. Although these signs also may be present in conditions affecting the brain, they do not help differentiate between a brain etiology and a cervical spine etiology. A jaw jerk reflex, however, is not present in patients with cervical myelopathy alone.
REFERENCES: Montgomery DM, Brower RS: Cervical spondylotic myelopathy: Clinical syndrome and natural history. Orthop Clin North Am 1992;23:487-493.
Ono K, Ebara S, Fuji T, Yonenobu K, Fujiwara K, Yamashita K: Myelopathy hand: New clinical signs of cervical cord damage. J Bone Joint Surg Br 1987;69:215-219.
An HS, Simpson JM: Surgery of the Cervical Spine. Baltimore, MD, Williams and

Wilkins, 1994.

Question 51

Which surgical procedure should be considered for treatment of chronic plantar fasciitis?

Explanation

DISCUSSION
Imaging studies in the evaluation of plantar fasciitis should always include weight-bearing foot radiographs to reveal alignment and exclude calcaneal stress fracture, tumor, subtalar arthritis, and insertional posterior spurs. MRI is occasionally indicated in problematic cases. Ultrasound can be helpful to evaluate thickening and disease in the proximal plantar fascia. Ultrasound is quick and much more cost effective than MRI. Laboratory screenings to evaluate inflammatory arthritis are indicated only for patients with bilateral heel pain who may be more likely to have systemic disease.
In the nonsurgical treatment of plantar fasciitis, high-impact loading exercises may make the condition worse. Corticosteroid injections may provide short-term relief only and can occasionally cause plantar fascia rupture. They should be used with caution. PRP injections are expensive and currently not covered by insurance. Studies have not demonstrated long-term pain relief with PRP. Plantar fascia-specific stretching has been shown more effective than Achilles tendon stretching alone.
Surgical treatment is indicated for fewer than 5% of patients. It is not necessary to resect the heel spur because the spur is not attached to the plantar fascia and rarely contributes to a patient's pain. The open extensile approach is associated with a much longer recovery than the open or endoscopic approaches and is no longer justified. Multiple studies have demonstrated the efficacy of endoscopic and open plantar fasciotomy techniques.
RECOMMENDED READINGS
Bader L, Park K, Gu Y, O'Malley MJ. Functional outcome of endoscopic plantar fasciotomy. Foot Ankle Int. 2012 Jan;33(1):37-43. doi: 10.3113/FAI.2012.0037. PubMed PMID:

Question 52

A 51-year-old woman who underwent a total knee arthroplasty 14 months ago for severe degenerative arthritis now reports progressive pain, swelling, and buckling of the knee. She must use crutches and is unable to negotiate stairs. Laboratory testing reveals a normal erythrocyte sedimentation rate and C-reactive protein. Radiographs of the patient are shown in Figures 17a through 17c. What is the most important test to further evaluate this problem?

Explanation

DISCUSSION: The cause of subluxation in this patient is multifactorial, and includes a laterally positioned patellar component, a tibial tray that is internally rotated and translated to the medial side of the proximal tibial surface, and a femoral component that is markedly internally rotated about 10 degrees. All of these findings will be apparent on a CT scan. The long standing radiograph may be helpful but does not show the particular rotational abnormalities of both implants that are causing this problem. Fluoroscopic review may show how unstable the patella is, but the initial Merchant’s view shows the basic problem. A bone scan does not provide information about component malposition. An MRI scan is inferior to a CT scan because of image artifact.
REFERENCES: Stiehl JB: Patellar instability in total knee arthroplasty. J Knee Surg 2003;16:229-235. Berger RA, Crossett LS, Jacobs JJ, et al: Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res 1998;356:144-153.

Question 53

A 53-year-old man with a history of severe left hip pain has a significant limp that is the result of a 5-cm limb-length discrepancy. An AP radiograph is shown in Figure 48. The underlying etiology is most likely related to a history of

Explanation

DISCUSSION: Radiographic abnormalities such as coxa magna, coxa breva secondary to growth arrest, and coxa plana and acetabular deformities are associated with healed Legg-Calve-Perthes disease. Femoral heads that were flat yet congruent with the acetabulum are at risk for disabling arthritis in the sixth decade of life in 50% of these untreated patients. As the normal ball-and-socket joint deforms to a flattened cylinder, the hip loses abduction and rotation capability, while retaining flexion and extension potential. If the femoral head is flat and is not concentric with the acetabulum, early severe arthritis occurs. Hinge abduction and anterior impingement are known sequelae of a flat, incongruent femoral head.
REFERENCE: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopedic Surgeons, 1999, pp 3-23.

Question 54

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

Explanation

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

Question 55

Figure 1 is the clinical photograph of a 42-year-old woman who has a lesion that has failed prior silver nitrate applications. She experiences frequent bleeding from this lesion. A tissue biopsy performed by a dermatologist revealed capillary hypertrophy with lobular arrangement. Which treatment is most appropriate to minimize recurrence?

Explanation

EXPLANATION:
This lesion is a pyogenic granuloma, which is a common benign vascular lesion that can occur on skin or mucosa. The etiology is unclear, although this lesion tends to occur in areas of physical trauma. Initial treatment with silver nitrate with an average of 1.6 applications has a success rate of 85%. This patient, however, has failed silver nitrate applications. Wide surgical excision (Figures below) is associated with the lowest recurrence rate and offers the benefit of a single procedure. Other options often necessitate repeated procedures to completely eradicate this lesion.

Question 56

Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

Explanation

Tension band wiring may not provide adequate stability to prevent displacement in a comminuted fracture. Plate fixation is most commonly recommended for comminuted fractures of the olecranon. Additionally, plate fixation is used for oblique fractures distal to the midpoint of the trochlear notch, fractures that involve the coronoid process, and those associated with Monteggia fracture-dislocations. Tension band wiring is best indicated for simple transverse fractures through the midpoint of the trochlear notch.

Question 57

If a laminectomy for spinal stenosis is performed, which of the following is an indication for concomitant arthrodesis at that level?

Explanation

DISCUSSION: A prospective randomized study of patients with degenerative spondylolisthesis and spinal stenosis by Herkowitz and Kurz showed significantly improved clinical outcomes in patients who also received a lumbar arthrodesis. Patients with a laminectomy at an adjacent level do not have improved outcomes with an arthrodesis. Minimal lumbar scoliosis does not require arthrodesis. Arthrodesis is indicated in cases where there is removal of more than 50% of the facets bilaterally but not with an associated foraminal stenosis.
REFERENCES: Herkowitz HN, Kurz LT: Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 1991;73:802-807.
Garfin SR, Rauschning W: Spinal stenosis. Instr Course Lect 2001;50:145-152.

Question 58

A 45-year-old right-hand dominant woman falls onto an outstretched left hand. Imaging shows a complex elbow dislocation. The postreduction CT scan demonstrates a reduced joint, comminuted radial head fracture, and type I coronoid fracture. Surgical intervention is recommended to address the involved structures. Which component of the intervention adds the most rotational stability?

Explanation

A 68-year-old right-hand dominant woman has experienced progressive right elbow pain and loss of motion for several years. She has failed nonsurgical treatment and elects to undergo a total elbow arthroplasty (TEA). In comparison to a linked prosthesis, an unlinked prosthesis has which reported distinction with extended follow-up?
A. Improved longevity in comparison to the linked prosthesis
B. A significantly larger flexion-extension arc
C. A higher incidence of postsurgical instability
D. Lower frequency of ulnar nerve dysfunction
TEA is a popular option for treatment of end-stage elbow arthritis for elderly, lower-demand patients with rheumatoid arthritis. Good success rates have been published by several authors. The clear benefit of the current nonconstrained prosthesis has yet to be proven. Plaschke and associates investigated the Danish National Patient Registry to compare the longevity of the 2 types of implants. These authors found similar survival rates associated with both linked and unlinked implants at 10 years (88% and 77%, respectively). However, studies have documented an approximate 20% incidence of postsurgical instability with nonconstrained implants.

Question 59

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

Explanation

Treatment of this minimally displaced distal clavicle fracture should begin with nonsurgical management consisting of sling therapy followed by gentle motion therapy. Any form of surgical intervention at this time is unnecessary because this fracture pattern has a high incidence of union. A bone stimulator may be used if healing becomes delayed.

Question 60

Figure 10 shows the radiograph of a 7-year-old patient who has a bilateral Trendelenburg limp and limited range of hip motion but no pain. His work-up should include

Explanation

DISCUSSION: The radiograph shows bilateral flattening of the femoral heads with mottling and “fragmentation” suggestive of Legg-Calve-Perthes disease. However, when these changes occur bilaterally and are symmetric, multiple epiphyseal dysplasia or spondyloepiphyseal dysplasia should be suspected. Skeletal survey will show irregularity of the secondary ossification centers. With these conditions, there is no true osteonecrosis and no evidence that orthotic or surgical “containment” will alter the outcome of progressive degenerative arthritis. Cardiac anomalies and coagulopathies are not associated with the epiphyseal dysplasias.
REFERENCES: Crossan JF, Wynne-Davies R, Fulford GE: Bilateral failure of the capital femoral epiphysis: Bilateral Perthes disease, multiple epiphyseal dysplasia, pseudoachondroplasia, and spondyloepiphyseal dysplasia congenita and tarda. J Pediatr Orthop 1983;3:297-301.
Sponseller PD: The skeletal dysplasias, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001,

pp 269-270.

Question 61

Figures 11a and 11b show the radiographs of a 50-year-old man who was struck by a car. Treatment should consist of

Explanation

DISCUSSION: The patient has a displaced femoral neck fracture. Although the treatment remains controversial, most clinicians advocate either a closed or open reduction in younger active patients. Achieving an anatomic reduction is necessary to avoid loss of reduction, nonunion, or osteonecrosis. An acceptable reduction may have up to 15° of valgus angulation and 10° of posterior angulation. Parallel multiple screws or pins are the most common method of internal fixation. Prosthetic replacement is generally reserved for older and less active individuals.
REFERENCES: Callaghan JJ, Dennis DA, Paprosky WG, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 97-108.
Asnis SE, Wanek-Sgaglione L: Intracapsular fractures of the femoral neck: Results of cannulated screw fixation. J Bone Joint Surg 1994;76A:1793-1803.

Question 62

During treatment of rupture of the subscapularis tendon with associated biceps instability, treatment of the biceps tendon should include which of the following? Review Topic

Explanation

With subscapularis tendon ruptures that have biceps tendon pathology, treatment with tenodesis or tenotomy has improved clinical results. Subluxation or dislocation of the biceps tendon is common with subscapularis rupture. Dislocation of the biceps can occur either beneath the tendon, within the tendon, or extra-articularly. In all cases,
the restraints to medial translations of the biceps have been disrupted. Attempts at recentering the biceps have not been successful, and clinical results appear to be improved when tenodesis or tenotomy is employed in the treatment of the unstable biceps associated with subscapularis tears.

Question 63

A 24-year-old woman was struck by a mini van in a parking lot and sustained a closed segmental tibia fracture that was treated with an intramedullary nail the following morning. Follow-up examinations reveal a slowly progressive clawing of all five toes, a progressive equinocavovarus contracture, and the patient is unable to perform a single heel rise on the affected limb. At 1 year after surgery, the patient now has a 10-degree equinus contracture that is not relieved with knee flexion. Treatment should now consist of

Explanation

DISCUSSION: This is an example of a missed deep posterior compartment syndrome that typically presents 6 months after the injury with progressive clawing due to necrosis, scarring, and contracture of the posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus. Treatment consists of debridement of necrotic muscle and scar tissue with corresponding tendon excision. After debridement and posterior capsule release, if the equinus is relieved with knee flexion, a gastrocnemius slide may be performed. Otherwise, the lengthening should be at the level of the Achilles tendon. Bracing will not address the claw toes.
REFERENCES: Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 212-213.
Manoli A II, Smith DG, Hansen ST Jr: Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res 1993;292:309-314.
Early JS, Ricketts DS, Hansen ST: Treatment of compartmental liquefaction as a late sequelae of a lower limb compartment syndrome. J Orthop Trauma 1994;8:445-448.

Question 64

A 78-year-old woman underwent total hip arthroplasty 15 years ago. She reports a recent history of increasing thigh pain prior to a fall and is now unable to ambulate. Radiographs are shown in Figures 87a and 87b. What is the best treatment for this condition?

Explanation

DISCUSSION: Severe periprosthetic fractures after total hip arthroplasty with a loose implant and progressive bone loss are difficult problems for orthopaedic surgeons, with a high complication rate. Recent literature favors the use of long fluted tapered stems that have a long distal taper that may optimally engage the remaining femoral shaft isthmus. Plating options are problematic because the ability to use screws with the plate is limited by the intramedullary stem. Although not the only solution to this problem (such as allograft-prosthetic composites, impaction grafting, tumor prostheses), long distally fixed stems circumvent this problem by enhancing fracture healing and create a long-term prosthetic solution in these most difficult cases.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 475503.
Kwong LM, Miller AJ, Lubinus P: A modular distal fixation option for proximal bone loss in revision total hip
arthroplasty: A 2- to 6-year follow-up study. J Arthroplasty 2003;18:94-97.

Question 65

Figure 3 shows the AP radiograph of a patient with diabetes mellitus who has knee pain. A semiconstrained knee prosthesis was used in this patient to prevent which of the following complications?

Explanation

DISCUSSION: The radiographic appearance of the joint is highly suspicious for neuropathic joint (Charcot’s joint). Evidence of bone loss on both the tibial and the femoral sides may necessitate the use of metal and/or bone augments. Patients with a neuropathic joint often have excellent range of motion, and postoperative stiffness is not a problem. The main problem with these patients is instability that occurs secondary to ligamentous laxity. Use of a semiconstrained prosthesis prevents the latter complication.
REFERENCES: Parvizi J, Marrs J, Morrey BF: Total knee arthroplasty for neuropathic (Charcot) joints. Clin Orthop 2003;416:145-150.
Kim YH, Kim JS, Oh SW: Total knee arthroplasty in neuropathic arthropathy. J Bone Joint

Surg Br 2002;84:216-219.

Question 66

A 54-year-old man sustained a small superficial abrasion over the left acromioclavicular joint after falling from his bicycle. Examination reveals no other physical findings. Radiographs show a displaced fracture of the lateral end of the clavicle distal to a line drawn vertically to the coracoid process. Management should consist of

Explanation

DISCUSSION: Displaced clavicular fractures lateral to the coracoid process (Neer type II and III) are best managed nonsurgically with sling immobilization and physical therapy, starting with pendulum exercises and progressing to active-assisted exercises when comfortable. Supervised therapy should be performed for 3 months or until full painless motion is achieved. In one study by Robinson and Cairns, this form of treatment provided patients with a 86% chance of avoiding a secondary reconstructive procedure.
REFERENCES: Robinson CM, Cairns DA: Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am 2004;86:778-782.
Deafenbaugh MK, Dugdale TW, Staeheli JW, et al: Nonoperative treatment of Neer type II distal clavicle fractures: A prospective study. Contemp Orthop 1990;20:405-413.

Question 67

A 15-year-old girl has had a painful mass on the medial aspect of her left thigh for the past 5 years. The pain is present only when she is performing athletic activities and is completely relieved with rest. A radiograph and MRI scan are shown in Figures 29a and 29b. The patient and her parents would like to have the mass removed. What further diagnostic studies are required prior to considering surgical resection?

Explanation

DISCUSSION: The radiograph and MRI scan show a pedunculated lesion arising from the medial aspect of the distal femoral metaphysis. The cortex of the lesion is contiguous with the cortex of the underlying normal bone. Similarly, the medullary canal of the lesion is contiguous with that of the normal bone. These findings are diagnostic of osteochondroma. Rarely a secondary chondrosarcoma can arise in a preexisting osteochondroma. This diagnosis is suggested by identifying a cartilage cap that is greater than 1.5-cm thick in a skeletally mature patient. MRI is the best study to rule out a secondary chondrosarcoma. CT also may be used for this purpose but is not indicated in this patient because an MRI has already been obtained. A bone scan is not useful to identify a secondary chondrosarcoma. Similarly, there is no role for biopsy in this patient. No further tests are needed.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.
Murphey MD, Choi JJ, Kransdorf, MJ, et al: Imaging of osteochondroma: Variants and complications with radiologic-pathologic correlation. Radiographics 2000;20:1407-1434.

Question 68

A 17-year-old pitcher reports pain over the medial aspect of the elbow that occurs during the acceleration phase of throwing, and it prevents him from throwing at the velocity needed to be competitive. What structure is most likely injured in this patient? Review Topic

Explanation

The anterior bundle of the ulnar collateral ligament of the elbow is the primary constraint to valgus force of the elbow. In pitchers and in overhead athletes, injury to this portion of the ligament results in valgus instability. Reconstruction of the anterior band of the ulnar collateral ligament is necessary in many elite athletic throwers to allow them to return to this competitive activity.

Question 69

Based on the radiographic findings shown in Figure 41, which of the following wrist ligaments is most likely disrupted?

Explanation

DISCUSSION: The radiograph shows a diastasis of the scapholunate interval, caused by certain failure of the scapholunate interosseous ligament. The lunotriquetral interosseous ligament stabilizes the lunotriquetral joint. The long radiolunate ligament originates in the volar radius and inserts in the lunate. The short radiolunate ligament originates on the ulnar margin of the radius and inserts on the ulnar margin of the lunate. The ulnolunate ligament originates at the ulnar styloid base and inserts on the volar aspect of the lunate.
REFERENCES: Linscheid RL, Dobyns JH, Beabout JW, et al: Traumatic instability of the wrist: Diagnosis, classification, and pathomechanics. J Bone Joint Surg Am 1972;54:1612-1632.
Mayfield JK, Johnson RP, Kilcoyne RK: Carpal dislocations: Pathomechanics and progressive perilunar instability. J Hand Surg Am 1980;5:226-241.
Berger RA: Ligament anatomy, in Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist, Diagnosis and Operative Management. St Louis, MO, Mosby, 1998, pp 73-105.

Question 70

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

Explanation

DISCUSSION: The most common destructive lesions in a patient older than age 40 years are, in decreasing incidence, metastatic carcinoma, multiple myeloma, lymphoma, and chondrosarcoma. Osteosarcoma is found primarily in younger patients.
REFERENCE: CA, January/February 2000, vol 50, no. 1 (Cancer Statistics).

Question 71

What range of motion parameters are required for a patient with posttraumatic elbow stiffness to accomplish all the normal activities of daily living?

Explanation

DISCUSSION: Activities of daily living such as dressing, eating, and bathing can all be performed with elbow motion through a 100 degrees arc of flexion and extension (30 degrees to 130 degrees) and a 100 degrees arc of forearm rotation (50 degrees pronation, 50 degrees supination). Some patients can accomplish these activities of daily living with 10 degrees less motion at each end point. This is referred to as the functional arc of motion.
REFERENCES: Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.
Morrey BF, Askew LJ, Chao EY: A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981;63:872-877.

Question 72

Figures 28a and 28b show the sagittal and axial lumbar MRI scans of a 72-year-old man who reports dull aching back pain that spreads to his legs, calves, and buttocks. He has had the pain for several years and it is precipitated by standing and walking and relieved by sitting. His symptoms have been worsening over the past year and he notes that he is leaning forward while walking to help relieve his symptoms. He has had no treatment to date. What is his prognosis if he chooses to pursue nonsurgical management for this condition?

Explanation

DISCUSSION: The patient has lumbar spinal stenosis and the MRI scans reveal the pathology at L4-5, which is secondary to posterior disk bulging and hypertrophy and infolding of the ligamentum flavum, as well as degenerative facet arthrosis. The degree of spinal stenosis is moderate and his symptoms are positional in nature. Tadokoro and associates reported on a prospective study of 89 patients older than 70 years of age who underwent nonsurgical management for lumbar spinal stenosis. They found the prognosis to be relatively good with patients scoring at “excellent” or “good” for activities of daily living at final follow-up. However, they did note that patients with a complete block on myelography did not respond favorably to nonsurgical management. Amundsen and associates reported on a 10-year prospective study comparing surgical care to nonsurgical management. They concluded that, while the long-term results largely favored surgical treatment, more than half of the nonsurgically managed patients had a satisfactory outcome. They also concluded that a delay of surgery for some months did not worsen the prognosis. Therefore, their recommendation was for an initial primarily nonsurgical approach.
REFERENCES: Amundsen T, Weber H, Nordal HJ, et al: Lumbar spinal stenosis: Conservative or surgical management? A prospective 10-year study. Spine 2000;25:1424-1435.
Hilibrand AS, Rand N: Degenerative lumbar stenosis: Diagnosis and management. J Am Acad Orthop Surg 1999;7:239-249.
Tadokoro K, Miyamoto H, Sumi M, et al: The prognosis of conservative treatments for lumbar spinal stenosis: Analysis of patients over 70 years of age. Spine 2005;30:2458-2463.

Question 73

A 62-year-old man has cervical myelopathy with no evidence of cervical radiculopathy. MRI reveals stenosis at C4-5 and C5-6 with severe cord compression. Examination will most likely reveal which of the following findings?

Explanation

DISCUSSION: Cervical myelopathy involves compression of the spinal cord and presents as an upper motor neuron disorder. Patients commonly have extremity spasticity and problems with ambulation and balance. Hoffman’s sign is often present and is elicited by suddenly extending the distal interphalangeal joint of the middle finger; reflexive finger flexion represents a positive finding. The extremities are usually hyperreflexic with myelopathy. With cervical radiculopathy (lower motor neuron disorder), reflexes are hyporeflexic, and patients report pain along a dermatomal distribution. A hyperactive jaw jerk reflex indicates pathology above the foramen magnum or in some cases, systemic disease. Flaccid paraparesis suggests a lower motor neuron problem.
REFERENCES: Sachs BL: Differential diagnosis of neck pain, arm pain and myelopathy, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 741-742.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 673-680.

Question 74

An 18-year-old man underwent open reduction and internal fixation of a tibial spine avulsion and a posterolateral corner repair. Two years later, he underwent lateral collateral ligament (LCL) and posterolateral corner reconstruction because of instability. Examination reveals a pronounced lateral varus knee thrust when ambulating. Varus stress in 30 degrees of flexion produces a 10-mm opening that is eliminated in extension. The Lachman’s test is 2 mm with a firm end point, and the posterior drawer test is negative. Standing radiographs show widening of the lateral joint space and a 5-degree mechanical varus alignment. What is the most effective course of treatment?

Explanation

DISCUSSION: The patient has chronic posterolateral instability with a varus knee alignment; therefore, the most effective treatment is a valgus-producing HTO. A repeat soft-tissue reconstruction without correction of the varus alignment will most likely fail. An ACL reconstruction is not indicated with a normal Lachman’s test. Physical therapy and bracing will have little effect.
REFERENCES: Naudie DD, Amendola A, Fowler PJ: Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med 2004;32:60-70.
Covey DC: Injuries of the posterolateral corner of the knee. J Bone Joint Surg Am
2001;83:106-118.

Question 75

A 47-year-old man who is right-hand dominant reports lateral-sided elbow pain after playing golf. His symptoms developed gradually and without trauma, and he has pain with gripping and repetitive movements with the hand and wrist. Examination reveals his shoulder and wrist to be normal, and the elbow has no effusion and normal range of movement. He is tender near the lateral epicondyle, and symptoms are exacerbated with resisted wrist extension. Radiographs are shown in Figures 104a and 104b. What is the next most appropriate step in management? Review Topic

Explanation

The patient has lateral epicondylitis of relatively short duration. At this early stage of disease, nonsurgical management is indicated. An eccentric physical therapeutic exercise program has been shown to have a beneficial effect on tendon biology; therefore, it would be the most appropriate initial management. While the diagnosis of lateral epicondylitis may be confused with radial tunnel syndrome, the clinical examination and history are most suggestive of the former. Corticosteroid injection has been shown to help with symptoms in short-term follow-up, but does little to affect the natural progression of the condition; it is more appropriate as a second line of treatment. MRI may be beneficial in patients with refractory disease and/or when the diagnosis is in question. Percutaneous surgical treatment is indicated only when nonsurgical measures fail to provide relief.

Question 76

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 77

A 45-year-old male presented to the trauma department 10 hours after sustaining a fracture-dislocation of his ankle. The patient underwent an attempted closed reduction of his ankle which can be seen in Figures A and B. The splint was removed, and the appearance of the leg is shown in Figure C. Regarding the best next step in management and the intended goals, which of the following is most accurate?

Explanation

The patient has hemorrhagic fracture blisters overlying the expected locations of incisions for definitive fixation of his ankle fracture, and therefore the next best step in treatment is external fixation. An external fixator will reduce the joint and provide relative stability during appropriate blister care until definitive open reduction internal fixation (ORIF).
Patients with high-energy periarticular fractures in the lower extremity are at risk for surgical wound complications due to compromised soft tissues. As in this case, joint dislocations can place harmful tension on the skin that leads to blistering and/or skin necrosis. An urgent reduction is indicated, and if it cannot be obtained with a closed manipulation alone, percutaneous or open treatment is indicated. Staged joint-spanning external fixation can both hold a reduction and allow access for skin or wound care prior to a definitive open reduction of an articular fracture. Fracture healing during external fixation occurs by enchondral ossification by way of the relative stability.
Strauss et al. developed a treatment protocol for the treatment of fracture blisters. They used silver sulfadine to minimize soft tissue complications by promoting re-epithelialization. After providone-iodine prep, each blister was unroofed by removing the overlying epithelium of the fracture. Once the blister was unroofed, silver sulfadiazine was applied and covered with dry gauze. They would then perform bid dressing changes. Extremities were deemed operable when skin wrinkles were visible on the overlying skin of the injured extremity.
Anglen et al. in a review of external fixation, report that fractures of the lower extremity are frequently associated with soft tissue trauma that precludes safe surgical treatment in the early period. They present a technique of temporary joint-spanning external fixation which allows stabilization of length and alignment while awaiting resolution of soft tissue swelling. They report no differences between patients who had a temporary external fixator and those who did not with respect to healing time, time to partial or full weight bearing, or clinical score.
Figures A and B demonstrate a pronation-external rotation type fracture with disruption of the syndesmosis. Figure C demonstrates fracture blisters.
Illustration A demonstrates an ankle-spanning external fixator. Illustration B demonstrates skin wrinkling to indicate that the skin is safe to incise.
Incorrect Answers:

OrthoCash 2020

Question 78

During an anterior approach to the bicipital 53 tuberosity, you encounter a nerve overlying the brachioradialis fascia (Figure 58). It provides innervation to the

Explanation

DISCUSSION
The structure shown is the lateral antebrachial cutaneous nerve (LABC). It is the terminal sensory branch of the musculocutaneous nerve and runs superficial to the brachioradialis. It supplies sensation to the anterolateral surface of the forearm. The flexor pollicis longus is innervated by the anterior interosseous nerve. The extensor indicis proprius is innervated by the radial nerve. The LABC does not innervate the skin of the anteromedial forearm. Careful
identification and protection of this nerve is critical to prevent the most common nerve injury during distal biceps repair.
RECOMMENDED READINGS
Agur AM. Grant's Atlas of Human Anatomy. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999:460.
Hoppenfeld S, deBoer P. Surgical Exposures in Orthopedics. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1994:118-125.
RESPONSES FOR QUESTIONS 59 THROUGH 61

Please select the image that represents the most appropriate response to the question or statement below.

Question 79

Figures 25a through 25c are the axial T1 and postcontrast MRI scans and biopsy specimen of a 35-yearold man with a painless right thigh mass. He noticed the mass about 2 weeks ago and is unsure if it has changed in size. Which translocation most commonly is associated with this type of tumor?

Explanation

Question 80

Which of the following conditions is associated with palmoplantar pustulosis?

Explanation

DISCUSSION: Sternoclavicular hyperotosis is a seronegative and HLA-B27 negative rheumatic disease. In this condition, hyperostosis may appear in the spine, long bones, sacroiliac joints, and the sternoclavicular region. This entity is also associated with palmoplantar pustulosis.
REFERENCES: Wirth MA, Rockwood CA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,

WB Saunders, 2004, vol 2, pp 608-609.
Sonozaki H, Azuma A, Okai K, et al: Clinical features of 22 cases with inter-sterno-costo-clavicular ossification: A new rheumatic syndrome. Arch Orthop Trauma Surg 1979;95:13-22.

Question 81

Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture?

Explanation

Due to radial inclination, a true lateral view of the wrist will not show whether screws from a volar plate are intra-articular; a 23° elevated lateral view is needed to adequately assess this.
The amount of elevation will depend on the degree to which the surgeon restores radial inclination; for example, if the surgeon only restores 15° of radial inclination, then the surgeon would only have to elevate the wrist 15° from a true lateral in order to have the radiographic beam point down the joint line. Failure to diagnose intra-articular screws intraoperatively can lead to degenerative changes.
Tweet et al. performed a survey of orthopedic surgeons regarding their preferred method of visualizing screw placement during wrist fixation. The majority of surgeons reported that they obtain multiple views, including AP/PA wrist views, a 23° lateral inclination view, and a true lateral view. They also performed a cadaveric study looking at different x-ray views and screw penetration. They reported that live rotational fluoroscopy provided the highest sensitivity (93%) and specificity (96%) for the detection of intra-articular screw penetration.
Patel et al. evaluated the ability of surgeons at different levels to critically assess distal radius fixation and screw placement. They found that supplementation with a 23° lateral view increased accuracy and confidence in all position, specialty, and experience groups. Confidence scores were significantly higher following the evaluation of three views versus two views. Residents exhibited the greatest improvements in accuracy and confidence. For first-phase (standard view) assessments, accuracy scores were significantly better for attendings with less than 10 years of post-fellowship experience than those with more.
Illustration A is a non-elevated lateral of the wrist, while illustration B is a 23° elevated lateral radiograph. Illustration C is an example of a skyline view, which assesses for screws penetrating the dorsal cortex.
Incorrect Answers:
check for long distal screws.

OrthoCash 2020

Question 82

A 25-year-old professional baseball pitcher reports a 4-month history of gradually increasing medial elbow pain that occurs during the late cocking and acceleration phases of throwing. The pain occasionally refers distally along the ulnar aspect of the forearm. He denies any weakness; however, he notes occasional paresthesias. A nerve conduction velocity study demonstrates increased latency across the cubital tunnel. Management consisting of 6 weeks of rest and rehabilitation fails to provide relief as the symptoms returned when he resumed throwing. What is the best course of action?

Explanation

DISCUSSION: In the thrower’s elbow, ulnar neuritis is felt to result from both chronic compression and traction on the nerve that occurs during the throwing motion. Occasionally, subluxation of the nerve also can lead to symptoms. If nonsurgical management fails to provide relief, transposition of the nerve to an anterior subcutaneous location is the surgical procedure of choice. The nerve is held in its new position by one or two fascial slings created from the fascia of the common flexor origin.
REFERENCES: Schickendantz MS: Diagnosis and treatment of elbow disorders in the overhead athlete. Hand Clin 2002;18:65-75.
Eaton RG, Crowe JF, Parkes JC III: Anterior transposition of the ulnar nerve using a non-compressing fasciodermal sling. J Bone Joint Surg Am 1980;62:820-825.

Question 83

An orthotic that provides laterally based hindfoot posting support would be most useful for which of the following conditions? Review Topic

Explanation

Lateral support in the form of hindfoot posting would be most beneficial for a patient with a flexible cavovarus foot.
Cavovarus feet may be seen in multiple conditions, including Charcot-Marie-Tooth disease. The initial deformity is plantarflexion of the first ray, which is often followed by compensatory hindfoot varus. In flexible deformities, orthotics that post the lateral forefoot and lateral heel should be utilized.
Schwend et al. review the etiology, diagnosis and management of the cavus foot in children. They note that shoe inserts with lateral support can be used in patients when there is flexibility to the hindfoot. Recession of the orthotic to accommodate a plantarflexed first ray is also beneficial.
Illustration A shows an orthotic with lateral foot posting and a recessed area for the first metatarsal head. Illustration B shows an AP radiograph of the left foot demonstrative of an accessory navicular. This may be associated with a flatfoot deformity. Illustration C shows a lateral radiograph of a right foot with a middle facet coalition. This may give rise to a rigid, painful flatfoot deformity. Illustration D shows a lateral radiograph of a right foot with collapse of the medial longitudinal arch. This patient had a flexible flatfoot that was painful. Illustration E shows an AP radiograph of a left foot with evidence of metatarsus adductus. Note the alignment of the 2nd metatarsal axis relative to the proximal articular surface of the middle cuneiform. In this case, the metatarsus adductus angle (MAA) was 24 degrees (normal is < 20 degrees).
Incorrect Answers:

Question 84

The MRI findings shown in Figure 51 would most likely create which of the following signs and symptoms?

Explanation

DISCUSSION: The MRI scan shows a far lateral disk herniation. With the L4-5 disk, a far lateral herniation abuts the left L4 nerve root. The findings would be consistent with those of a left L4 radiculopathy and would include pain or a sensory deficit on the anteromedial aspect of the knee, diminished patellar tendon reflex, and quadriceps weakness, perhaps making it difficult to walk up and down stairs.
REFERENCES: Fardin DF, Garfin SR (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 329.
O’Hara LJ, Marshall RW: Far lateral lumbar disc herniation: The key to the intertransverse approach. J Bone Joint Surg Br 1997;79:943-947.

Question 85

When performing a posterior cruciate ligament reconstruction with a tibial inlay-type approach, what is the approximate anatomic distance of the popliteal artery from the screws used for fixation of the bone block?

Explanation

DISCUSSION: Miller and associates reported the results of a cadaveric study of the vascular risk of a posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique. The average distance from the screw to the popliteal artery was 21.1 mm
(range, 18.1 mm to 31.7 mm). Other approaches, such as the transtibial tunnel technique which involves drilling an anterior-posterior tunnel, have also been studied in cadavers. Matava and associates noted that increasing flexion reduces but does not completely eliminate the risk of arterial injury during arthroscopic posterior cruciate ligament reconstruction. However, this study did not use the small, medial utility incision recommended by Fanelli and associates, which creates an interval for the surgeon’s finger between the medial gastrocnemius and the posteromedial capsule so that any migration of the guidepin can be palpated and changed prior to any injury to the posterior neurovascular bundle.
REFERENCES: Matava MJ, Sethi NS, Totty WG: Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: Implications for posterior cruciate ligament reconstruction. Arthroscopy 2000;16:796-804.
Miller MD, Kline AJ, Gonzales J, et al: Vascular risk associated with posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique. J Knee Surg 2002;15:137-140.
Johnson DH, Fanelli GC, Miller MD: PCL 2002: Indications, double-bundle versus inlay technique and revision surgery. Arthroscopy 2002;18:40-52.

Question 86

You are evaluating a patient with recurrent patellar instability who has failed conservative management. MRI demonstrates articular cartilage loss in the patella. In addition to a cartilage restoration procedure, you recommend the procedure depicted in Figures A and B. Which of the following imaging findings best supports your decision? Review Topic

Explanation

A tibial tubercle-trochlear groove (TT-TG) distance > 20mm is highly associated with patellar instability secondary to rotational malalignment and is an indication for anteromedialization of the tibial tubercle (AMZ), pictured in Figures A and B, to enhance patellofemoral stability and decrease patellofemoral contact pressures in the setting of cartilage restoration procedures.
Recurrent patellar instability is often associated with chondral lesions of the patellofemoral joint. In addition to managing the cartilage injury, the underlying etiology of the instability must also be addressed to ensure a successful outcome. Patellar instability may arise from coronal or rotational malalignment, patella alta, trochlear dysplasia or damage to soft tissue restraints including the medial patellofemoral ligament (MPFL). Rotational malalignment, defined by a TT-TG distance > 20mm, can be addressed by AMZ. Medialization of the tubercle restores a normal TT-TG distance while anteriorization of the tubercle unloads patellofemoral contact forces.
Beck et al performed a cadaveric study measuring patellofemoral contact pressures on the trochlear surface following AMZ. They found that anteromedialization decreased the mean contact pressures and shifted contact pressures to the medial trochlea. The authors concluded that while this procedure successfully unloads the lateral trochlea, it likely has minimal benefit for central chondral defects and may be detrimental for medial chondral defects where contact pressures are increased.
Strauss et al authored a review article detailing the surgical treatment options for patellofemoral cartilage lesions, including concomitant realignment/unloading procedures. AMZ is designed to correct rotational malalignment while unloading the patellofemoral compartment in the setting of cartilage restoration surgery. While AMZ has demonstrated good outcomes for lesions located in the lateral facet or distal
pole of the patella, poor outcomes have been seen with medial facet or central trochlear lesions.
Figures A and B are the AP and lateral radiographs, respectively, of a knee s/p AMZ, also know as a Fulkerson procedure. Illustration A is an algorithm detailing the approach to recurrent patellar instability in both skeletally immature and mature patients. Illustration B demonstrates how to measure the TT-TG distance, the distance between two lines drawn perpendicular to the posterior condylar axis to the tibial tubercle and deepest portion of the trochlear groove (normal 8-10mm). Illustration C depicts the measurement of the femoral trochlear angle or sulcus angle (normal 137°
+/- 8°). Illustration D shows how to measure lateral patellar tilt (normal < 5°). Illustration E is a postoperative radiograph after AMZ. A long (> 5cm) and thick (> 0.75cm) osteotomy cut is required to allow adequate fixation with two screws.
Incorrect Responses:

Question 87

Figure 61 shows the radiograph of a 28-year-old professional football player who sustained a hyperextension injury to the great toe. He continued to play with pain and loss of push-off strength. What is the most likely diagnosis?

Explanation

Upon review of the radiograph give, there is no evidence of fracture or osteonecrosis. Upon review of the article above the most likely diagnosis is “Turf-Toe” or the disruption of the plantar plate. The patient has mechanism of injury, hyperextension and sequelae, decreased push-off strength, which is consistent with this diagnosis. Rupture of the FHL would most likely result in inability to continue playing while hallux rigidus is a potential chronic sequelae with associated dorsal osteophyte formation.

Question 88

What is the most important preoperative factor predicting conversion to total hip arthroplasty after arthroscopic surgery of the hip?

Explanation

DISCUSSION:
The authors cited in the references examined large databases to determine the risk factors for conversion to total hip arthroplasty after arthroscopic surgery of the hip. In the study by Kester and associates, obesity had an odds ratio (OR) of 5.6 for conversion to hip arthroplasty, whereas age over 60 years had an OR of 3.4, osteoarthritis had an OR of 2.4, and tobacco use had an OR of 1.9.

Question 89

A 30-year-old man has had a 3-day history of severe, incapacitating lower back pain without radiation. He reports improvement with rest. He denies any history of trauma, has no constitutional symptoms, and his neurologic examination is normal. What is the best course of action?

Explanation

DISCUSSION: There are no red flags in the history or examination to warrant MRI. Limited bed rest (less than 3 days) has been shown to be more beneficial to early recovery compared with prolonged bed rest (more than 7 days). No data support the use of epidural or facet steroid injections for acute low back pain.
REFERENCE: Deyo RA, Diehl AK, Rosenthal M: How many days of bed rest for acute low back pain? A randomized clinical trial. N Engl J Med 1986;315:1064-1070.

Question 90

Figures 233a through 233c are the radiographs and biopsy specimen of a 32-year-old woman who has had progressive ankle pain for 6 months. What is the most appropriate treatment option?

Explanation

Question 91

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

Explanation

DISCUSSION: Laminoplasty or any posterior decompressive procedure is contraindicated in patients with cervical spondylotic myelopathy and cervical kyphosis. The residual kyphotic posture of the cervical spine results in persistent spinal cord compression. The other choices are not contraindications for laminoplasty. Concomitant cervical radiculopathy can be addressed at the time of laminoplasty with a keyhole foraminotomy.
REFERENCES: Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-247.

Question 92

Which of the following complications is more likely with an inside-out repair technique compared to an all-inside techniques for a medial meniscus tear? Review Topic

Explanation

All of the answers are possible complications of meniscal repair. There are large volumes of literature evaluating the results of meniscal repair, both for the all-inside technique, as well as the inside-out technique. Failure rates are similar. Intra-articular synovitis occurs with absorbable sutures and absorbable implants. Peroneal nerve injuries are more common with the lateral-sided repairs. Saphenous nerve injuries are more common with medial-sided tears. Because of the incision required and the technique of tying over soft tissue, the risk of a saphenous nerve injury is greater with an inside-out technique than with an all-inside technique.

Question 93

Figure 69 is the radiograph of a 9-year-old who has posterior hindfoot pain while running. What is the most likely diagnosis?

Explanation

DISCUSSION
Sever disease is a traction apophysitis at the Achilles tendon insertion on the calcaneus. Plain radiographs may be unremarkable for this condition. Other osteochondroses of the foot include Kohler disease (tarsal navicular), Freiberg infraction (lesser metatarsal head), and Thiemann disease (great toe phalanx).
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.
Feldman DS. Osteochondrosis. In: Spivak JM, Di Cesare PE, Feldman Ds, et al, eds. Orthopaedic: A Study Guide. New York, NY: McGraw-Hill; 1999:765-766.
Schantz K, Rasmussen F. Thiemann's finger or toe disease. Follow-up of seven cases. Acta Orthop Scand. 1986 Feb;57(1):91-3. PubMed PMID: 3962642. View Abstract at PubMed

Question 94

Which of the following is an important factor in performing a proper biopsy?

Explanation

DISCUSSION: There are a number of important technical details in performing a biopsy. Incisions should always be longitudinal in the extremity. Good hemostasis is important in avoiding contamination from hematoma. The approach should avoid neurovascular structures, and go through a single muscle belly when possible. Although a frozen section should be obtained to ensure adequate viable tissue has been obtained, definitive diagnosis is not necessary at the time of the frozen section.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 29-34.

Question 95

01 (left). What is the most appropriate next step?

Explanation

This patient has a posterior knee dislocation with an ischemic limb that does not reverse following reduction. Emergent vascular exploration and reconstruction is indicated.
Knee dislocations are associated with popliteal artery injury in 18-45% of cases and range from intimal tears to complete transection. Amputation rates of 85% have been reported if revascularization is delayed greater than 6 to 8 hours. Neurologic injury occurs in 15-40% of cases and is most common after posterolateral dislocation. The peroneal nerve is more commonly injured.
Rihn et al. reviewed the acutely dislocated knee. They recommend a vascular consult if pulses are weak, or ABI is compromised. They warn that in arterial injury, pulses, temperature and capillary refill can be normal. If the limb remains ischemic, surgical exploration and revascularization is indicated.
Medina et al. systematically reviewed neurovascular injury after knee dislocation in 862 patients. Vascular injury rate was 18%, and nerve injury rate was 25%. Repair was performed in 80% of vascular injuries, and amputation in 12%. The most vascular injury was seen in KDIIIL injuries (32%) and posterior dislocation (25%).
Figure A is an AP radiograph of a posterior knee dislocation. Figure B is a lateral showing the same injury.
Incorrect Answers:

Question 96

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

Explanation

DISCUSSION: The patient has the findings of classic subacromial impingement. Initial management should consist of stretching exercises directed at the posterior capsule and a program of rotator cuff and deltoid strengthening exercises performed below the horizontal in a “safe” plane. The judicious use of subacromial cortisone injections (one or two) may be helpful. Anterior acromioplasty is reserved for patients who have failed to respond to nonsurgical management.
REFERENCES: Morrison DS, Frogameni AD, Woodworth P: Non-operative treatment of subacromial impingement syndrome. J Bone Joint Surg Am 1997;79:732-737.
Neer CS: Impingement lesions. Clin Orthop 1983;173:70-77.
Blair B, Rokito AS, Cuomo F, et al: Efficacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am 1996;78:1685-1689.

Question 97

When the elbow is extended and an axial load is applied, what percent of stress distribution occurs across the ulnohumeral and radiohumeral articular surface, respectively?

Explanation

DISCUSSION: When load is applied to the wrist, most of the stress is absorbed by the radius. As the load is transferred through the forearm, the interosseous membrane transfers some of the load from the radius to the ulna. The load at the elbow is distributed with 40% at the ulnohumeral articulation and 60% at the radiohumeral articulation.
REFERENCES: Halls AA, Travill R: Transmission of pressure across the elbow joint. Anat Rec 1964;150:243.
Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000.

Question 98

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

Explanation

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

Question 99

Induction coupling stimulates bone growth through all of the following direct effects EXCEPT:

Explanation

Induction coupling stimulates bone growth by increasing expression of BMP7, BMP2, TGF-beta1, and by increasing osteoblasts proliferation. Induction coupling has not been shown to have the effect of decreasing osteoclast differentiation.
In basic science studies, electrical stimulation (i.e. induction coupling), has been shown to promote bone healing via release of growth factors that induce osteoblast differentiation/proliferation. Electrical current can be placed around bone in various ways, creating a current to stimulate growth factor release and subsequent osteoblast proliferation.
Aaron et al. summarized, in a systematic review, the effects of various types of electrical stimulation on bone and bone healing. Regardless of type (i.e. inductive coupling, capacitive coupling, direct current), they report electricity and/or electromagnetic fields promote gene expression of growth factors that promote an osteogenic environment.
Illustration A depicts a cathode placed directly to allograft with a subcutaneously placed electrical stimulator. Illustration B depicts cathodes placed anteriorly and posteriorly around the hip, connected to an outside power source to create the necessary current. Illustration C depicts an inductive coil placed laterally on the skin in order to create an electrical current.
Incorrect answers:

Question 100

A 57-year-old woman experiences pain 1 year after total knee arthroplasty (TKA). She reports sharp anterior pain and a painful catching sensation that is aggravated by rising from a chair or climbing stairs. Physical examination reveals a mild effusion and a range of motion of 2° to 130°, with patellar crepitus. The symptoms are reproduced by resisted knee extension. Radiographs show a well-aligned posterior-stabilized TKA without evidence of component loosening. What is the recommended treatment for this patient?

Explanation

DISCUSSION:
Patellar clunk syndrome is caused by the development of a fibrous nodule on the posterior aspect of the quadriceps tendon at its insertion into the patella. It causes a painful catching sensation when the extensor
mechanism traverses over the trochlear notch as the knee extends from 45° of flexion to 30° from full extension. It characteristically occurs in posterior stabilized total knee arthroplasties and appears to be related to femoral component design. The syndrome can usually be prevented by excising the residual synovial fold just proximal to the patella. Flexion gap instability can also cause a painful total knee arthroplasty but is less common in posterior stabilized implants. Femoral component malrotation can cause pain attributable to a flexion gap imbalance or patellar tracking problems. Polyethylene wear would be unlikely after just 1 year. Patellar clunk syndrome can usually be addressed successfully with arthroscopic synovectomy. Recurrence is uncommon. Physical therapy may help to strengthen the quadriceps following synovectomy but would not resolve the clunk syndrome symptoms. Femoral or tibial insert revision is not indicated if patellar clunk syndrome is the only problem resulting in a painful total knee arthroplasty.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Calcaneal stress fracture
Hindfoot coalition
Insertional Achilles tendonitis
Plantar fasciitis

Correct Answer: Plantar fasciitis

Explanation:

Question 2:

Options:

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

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

Explanation:

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

Question 3:

Options:

Continued observation
Open reduction and internal fixation of the fracture
Excision of the hook of the hamate
Carpal tunnel release
Guyon’s canal release

Correct Answer: Excision of the hook of the hamate

Explanation:

Question 4:

Options:

L4 nerve root
L5 nerve root
S1 nerve root
Genitofemoral nerve
Cauda equina

Correct Answer: L5 nerve root

Explanation:

Question 5:

Options:

Good because it is a gram-positive organism
Good because it is an acute infection
Poor because it is a gram-positive organism
Poor because it is a late infection

Correct Answer: Poor because it is a late infection

Explanation:

DISCUSSION:
The patient has a late infection of at least 4 weeks symptomatic duration that most likely is hematogenous in etiology. This infection is not an acute hematogenous infection that can successfully be treated with irrigation and debridement. Retention of the implants with debridement and irrigation alone has been associated with a poor prognosis. In a recent study, the success rate was only 44% in a series of 104 patients at a mean 5.7-year follow-up. In one study of 50 infections attributable to MRSA or methicillin-resistant
Staphylococcus epidermidis
organisms treated with a two-stage protocol, the failure rate was 21%. Patients who experienced successful infection treatment had lower functional outcome measures using the Western Ontario and McMaster Universities Osteoarthritis Index, the University of California Los Angeles Activity Score, and the 12-item Oxford Knee Score, however.

Question 6:

The clinical photograph in Figure 27 shows a palsy of what nerve/associated muscle?

Options:

Long thoracic/rhomboid
Long thoracic/serratus anterior
Long thoracic/supraspinatus
Dorsal scapular/trapezius
Spinal accessory/trapezius

Correct Answer: Long thoracic/serratus anterior

Explanation:

Question 7:

Options:

Immediate weight-bearing as tolerated with hinged knee brace 0-90 degrees
Transphyseal ACL reconstruction with hamstring autograft
Physeal spearing ACL reconstruction with hamstring autograft
Application of long leg cast following successful fluoroscopic closed reduction
Application of long leg cast for 1-2 weeks with transition to hinged knee brace 0-90 degrees, progressive weight-bearing, and physical therapy for quadriceps strengthening

Correct Answer: Immediate weight-bearing as tolerated with hinged knee brace 0-90 degrees

Explanation:

Question 8:

Options:

Spinal muscular atrophy, type II
Myotonic dystrophy
Duchenne muscular dystrophy
Becker muscular dystrophy
Hereditary motor sensory neuropathy, type II (HMSN)

Correct Answer: Becker muscular dystrophy

Explanation:

Question 9:

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 10:

Options:

Infection
Injury of the superior gluteal nerve
Loosening of the acetabular component
Loosening of the femoral component
Osteolysis

Correct Answer: Osteolysis

Explanation:

Question 11:

Options:

patella baja.
nonresurfaced patella.
isolated femoral revision.
noncemented tibial component.
previous use of the quadriceps turn-down technique.

Correct Answer: patella baja.

Question 12:

Options:

MRI of the affected tibia
Palpation of the affected leg compartments during activity
Compartment pressure monitoring 1 and 5 minutes into the activity
Compartment pressure monitoring continuously during the activity

Correct Answer: Compartment pressure monitoring continuously during the activity

Explanation:

Question 13:

- Item Deleted by AAOS Question 38 - Figure 6 shows the clinical photograph of a 3-year-old boy who started to walk at the age of 10 months and has a gait that is appropriate for his age. His height is in the 40th percentile for his age. Management should consist of

Options:

Follow-up in six months.
AP and lateral radiographs.
AP and lateral radiographs, and a bone scan.
AP and lateral radiographs, and serum levels for ca, ph, and creatinine.
AP and lateral radiographs, blood serum levels for calcium, phosphate, and creatinine, and a 24-hour urine collection for vitamin D metabolites.

Correct Answer: Follow-up in six months.

Explanation:

Question 14:

A 24-year-old man is ejected from his motorcycle and sustains a significant hip injury. The fracture shown in Figures 64a through 64e is best described as what type of fracture?

Options:

Posterior column/posterior wall acetabular
Associated both column acetabular
Transverse plus posterior wall acetabular
Anterior column posterior hemitransverse acetabular
Anterior column acetabular

Correct Answer: Anterior column acetabular

Explanation:

DISCUSSION: The radiographs and CT scans reveal an anterior column acetabular fracture. The fracture has quadrilateral plate extension but does not exit out the posterior column. The CT scans confirm an intact posterior column and no wall fracture. A transverse fracture is best seen on the CT scan and runs in the sagittal plane, not the coronal plane.
REFERENCES: Letournel E, Judet R: Fractures of the Acetabulum, ed 2. New York, NY, Springer-Verlag, 1993, pp 115-140.
Beaule PE, Dorey FJ, Matta JM: Letournel classification of acetabular fractures: Assessment of interobserver and intraobserver reliability. J Bone Joint Surg Am 2003;85:1704-1709.

Question 15:

Options:

anti-inflammatory drugs.
a knee brace.
physical therapy for quadriceps strengthening.
revision to a thicker polyethylene insert.
revision to a posterior stabilized implant.

Correct Answer: revision to a posterior stabilized implant.

Explanation:

Question 16:

A 30-year-old patient has wrist pain. A radiograph and biopsy specimen are shown in Figures 34a and 34b. What is the most likely diagnosis?

Options:

Aneurysmal bone cyst
Giant cell tumor
Brown tumor
Pigmented villonodular synovitis
Telangiectatic osteosarcoma

Correct Answer: Aneurysmal bone cyst

Explanation:

Question 17:

Options:

Closed reduction and percutaneous pinning
Open reduction and internal fixation
Rotator cuff repair with possible latissimus dorsi tendon transfer
Shoulder arthroplasty
Open bone grafting

Correct Answer: Closed reduction and percutaneous pinning

Explanation:

Question 18:

Options:

normal flexion and extension.
loss of extension.
loss of flexion.
loss of flexion and extension.
hyperextension.

Correct Answer: loss of flexion.

Explanation:

Question 19:

Options:

Improves the bone mineral density of the vertebral bodies
Reduces the strain at the adjacent intervertebral disk
Reduces the stiffness of the posterior instrumentation
Reduces the strain on posterior instrumentation
Increases the strength of the posterior instrumentation

Correct Answer: Reduces the strain on posterior instrumentation

Explanation:

Question 20:

Which of the following clinical findings is commonly associated with symptomatic partial-thickness rotator cuff tears?

Options:

Negative impingement signs
Abnormal lift-off test
External rotation lag sign
Painful arc with active range of motion
Mismatch in active and passive motion

Correct Answer: Painful arc with active range of motion

Explanation:

Question 21:

The difference between vitamin D-dependent rickets type I (VDDR I) and vitamin D-dependent rickets type II (VDDR II) is

Options:

VDDR I is caused by an inactivating mutation of the receptor for 1,25 (OH)2 vitamin D3. VDDR II is a deficiency of an enzyme predominantly found in the kidney.
VDDR I is caused by an activating mutation of the receptor for 1,25 (OH)2 vitamin D3. VDDR II is a deficiency of an enzyme predominantly found in the kidney.
VDDR I is a deficiency of an enzyme predominantly found in the kidney. VDDR II is caused by an inactivating mutation of the receptor for 1,25 (OH)2 vitamin D3.
VDDR I is a deficiency of an enzyme predominantly found in the kidney. VDDR II is caused by an activating mutation of the receptor for 1,25 (OH)2 vitamin D3.
VDDR I is a deficiency of an enzyme predominantly found in the liver. VDDR II is caused by an inactivating mutation of the receptor for 1,25 (OH)2 vitamin D3.

Correct Answer: VDDR I is caused by an inactivating mutation of the receptor for 1,25 (OH)2 vitamin D3. VDDR II is a deficiency of an enzyme predominantly found in the kidney.

Explanation:

Question 22:

Options:

0 cm to 5 cm
5 cm to 10 cm
10 cm to 15 cm
15 cm to 20 cm
Greater than 20 cm

Correct Answer: 0 cm to 5 cm

Explanation:

Question 23:

Options:

fascia lata graft to restore the coracoacromial arch.
immediate subscapularis repair.
revision arthroplasty with glenoid reaming to centralize the component.
revision arthroplasty with increased retroversion in the humeral component.
arthroscopic subacromial decompression.

Correct Answer: immediate subscapularis repair.

Explanation:

Question 24:

Options:

Nerve roots
Spinal cord
Sciatic nerve
Peroneal nerve
Conus medullaris

Correct Answer: Nerve roots

Explanation:

Question 25:

Options:

Anterior cruciate
Posterior cruciate
Lateral collateral
Oblique popliteal
Intermeniscal

Correct Answer: Anterior cruciate

Explanation:

Question 26:

Options:

oral indomethacin.
Irradiation with a single dose of 700 cGy.
Physical therapy with dynamic splinting.
Physical therapy and delayed ectopic bone excision at 12 months.
Immediate elbow release and ectopic bone excision. back answer Question 59.03

Correct Answer: Immediate elbow release and ectopic bone excision. back answer Question 59.03

Explanation:

Question 27:

Options:

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

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

Explanation:

Question 28:

Options:

0 degrees
10 degrees
15 degrees
30 degrees
45 degrees

Correct Answer: 15 degrees

Explanation:

Question 29:

Options:

Continued nonsurgical management
Posterior open reduction and internal fixation with tension band plating
Posterior iliosacral screws
Anterior open reduction and internal fixation
Anterior open reduction and internal fixation and posterior fixation

Correct Answer: Anterior open reduction and internal fixation and posterior fixation

Explanation:

DISCUSSION: Fortunately, surgical treatment of sub-acute pelvic ring injuries is relatively uncommon as acute management has become more common. Delayed reconstruction of pelvic ring malunion and impending malunion is rare. Nonsurgical management may have a role as long as the hemipelvis does not flex, shorten, and/or externally rotate. The AP pelvic radiograph suggests that all three motions are happening in this patient. These are just a few of the indications to repair the pelvic ring and this is best done with anterior and posterior fixation. Anterior symphyseal plating will help correct most of the deformity. Posterior fixation can and should be added to lessen the forces on the anterior ring reconstruction when repair is performed in a sub-acute or delayed fashion. Posterior fixation can help obtain a more anatomic reduction and helps decrease the risk of anterior hardware failure.
REFERENCES: Mears DC: Management of pelvic pseudarthroses and pelvic malunion. Orthopade 1996;25:441-448.
Matta JM, Dickson KF, Markovich GD: Surgical treatment of pelvic nonunions and malunions. Clin Orthop Relat Res 1996;329:199-206.
McLaren AC, Rorabeck CH, Halpenny J: Long-term pain and disability in relation to residual deformity after displaced pelvic ring fractures. Can J Surg 1990;33:492-494.

Question 30:

Options:

Abductor pollicis brevis and extensor pollicis brevis
Abductor pollicis brevis and extensor pollicis longus
Abductor pollicis longus and extensor pollicis brevis
Abductor pollicis longus and extensor pollicis longus
Adductor pollicis and extensor pollicis longus

Correct Answer: Abductor pollicis longus and extensor pollicis brevis

Explanation:

DISCUSSION: Intersection syndrome is also known as “squeakers wrist,” “oarsmen wrist,” and crossover tendinitis. It occurs where the first and second dorsal wrist compartment structures pass over one another, resulting in fibrosis, muscular changes, and inflammation of the bursa in this area. The structures involved are the abductor pollicis longus and extensor pollicis brevis (first dorsal compartment) that pass across the second compartment structures (extensor carpi radialis brevis and extensor carpi radialis longus). An audible “squeak” is occasiona
l
y heard at the intersection point, which is approximately 4 to 5 cm proximal to the proximal dorsal wrist crease.
REFERENCES: Grundberg AB, Reagan DS: Pathologic anatomy of the forearm: Intersection syndrome. J Hand Surg Am 1985; 10:299-302.
Thorson E, Szabo RM: Common tendinitis problems in the hand and forearm. Orthop Clin North Am 1992;23:65-74.
Williams JG: Surgical management of traumatic non-infective tenosynovitis of the wrist extensors. J Bone Joint Surg Br 1977;59:408-410.
Wood MB, Dobyns JH: Sports-related extraarticular wrist syndromes. Clin Orthop Relat Res 1986;202:93-102.

Question 31:

Options:

Halo-vest orthosis
C1-C2 posterior cervical fusion
Occiput to C2 posterior cervical fusion
Cervical traction and closed reduction
Open reduction and internal fixation of C1

Correct Answer: C1-C2 posterior cervical fusion

Question 32:

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

Options:

in adduction and the arm in external rotation.
in adduction and the arm in neutral rotation.
with the dorsum of the hand on the buttocks.
with the dorsum of the hand on the midlumbar level.
with the palm of the hand pressing against the belly.

Correct Answer: with the palm of the hand pressing against the belly.

Explanation:

Question 33:

Options:

Cemented unipolar hemiarthroplasty B. Cemented bipolar hemiarthroplasty C. Total hip replacement
Open reduction and internal fixation

Correct Answer: Cemented unipolar hemiarthroplasty B. Cemented bipolar hemiarthroplasty C. Total hip replacement

Explanation:

Question 34:

Osteoporotic vertebral compression fractures are associated with

Options:

neurologic deterioration in 33% of patients.
osteomalacia in 50% of patients.
a further fracture risk rate of 20%.
chronic pain in 75% of patients.
a 2-year mortality rate that is less than that associated with hip fractures.

Correct Answer: a further fracture risk rate of 20%.

Explanation:

DISCUSSION: Osteoporotic vertebral compression fractures are associated with neurologic complications in less than 1% of patients. After the initial fracture however, patients have a 20% risk of further fractures. The mortality rate of patients with vertebral fractures exceeds that of patients with hip fractures when they are followed beyond 6 months.
REFERENCES: Gass M, Dawson-Hughs B: Preventing osteoporosis-related fractures: An overview. Am J Med 2006;119:S3-S11.
Lindsay R, Silverman SL, Cooper C, et al: Risk of new vertebral fracture in the year following a fracture. JAMA 2001;285:320-323.
Kado DM, Duong T, Stone KL, et al: Incident vertebral fractures and mortality in older women: A prospective study. Osteoporos Int 2003;14:589-594.

Question 35:

The safest surgical approach to the insertion of the tibial posterior cruciate ligament uses the interval between which of the following muscles?

Options:

Semimembranosus and medial gastrocnemius
Semimembranosus and semitendinosus
Medial and lateral gastrocnemius
Lateral gastrocnemius and biceps femoris tendon
Popliteus and lateral gastrocnemius

Correct Answer: Semimembranosus and medial gastrocnemius

Explanation:

DISCUSSION: Burks and Schaffer described an approach to the tibial insertion of the posterior cruciate ligament that uses the interval between the semimembranosus and the medial gastrocnemius. The medial gastrocnemius muscle is retracted laterally and protects the neurovascular bundle. This approach is used to repair an avulsion of the posterior cruciate ligament tibial attachment or for performing a posterior cruciate ligament tibial
inlay reconstruction.
REFERENCES: Berg EE: Posterior cruciate ligament tibial inlay reconstruction. Arthroscopy 1995;8:95-99.
Burks RT, Schaffer JJ: A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop 1990;254:216-219.

Question 36:

Options:

Hip revision and implantation of a proximal femoral replacement
Hip revision and implantation of a tapered fluted stem
Open reduction and internal fixation with a locked plate and allograft struts
Erythrocyte sedimentation rate and C-reactive protein laboratory studies

Correct Answer: Erythrocyte sedimentation rate and C-reactive protein laboratory studies

Explanation:

Question 37:

Options:

Osteochondral fracture of the lateral femoral condyle
Trabecular injury of the lateral tibial plateau
Lateral meniscal tear with a parameniscal cyst
Fibular collateral ligament tear
Discoid lateral meniscal tear

Correct Answer: Discoid lateral meniscal tear

Explanation:

Question 38:

In revision total hip arthroplasty, an acetabular reconstruction cage is best indicated for which of the following patterns of bone loss?

Options:

Enlarged acetabular rim
Cavitary central defect
Superior migration of 2 cm
Deficient anterior wall
Pelvic discontinuity

Correct Answer: Pelvic discontinuity

Explanation:

Question 39:

Options:

Spring ligament reconstruction
Lateral column lengthening
Medial-displacing calcaneal osteotomy
Medial cuneiform opening-wedge osteotomy

Correct Answer: Medial-displacing calcaneal osteotomy

Explanation:

Question 40:

Options:

Unreamed intramedullary nail
Reamed statically locked intramedullary nail
External fixation
Plate fixation and interfragmentary compression
Bridge plate stabilization

Correct Answer: Plate fixation and interfragmentary compression

Explanation:

Question 41:

Options:

Pseudotumor from a local reaction to metal debris from the bearing surface
Chronic periprosthetic infection
Impingement of the femoral neck on the edge of the cup
Referred pain from lumbar disk disease

Correct Answer: Pseudotumor from a local reaction to metal debris from the bearing surface

Explanation:

Question 42:

Options:

obtain stress radiographs of the elbow.
obtain an MRI scan of the elbow.
apply a splint and initiate early range-of-motion exercises.
apply a cast in 90° of flexion for 4 weeks.
perform open reduction and internal fixation.

Correct Answer: perform open reduction and internal fixation.

Explanation:

Question 43:

What is a common clinical finding in patients with severe hypercalcemia secondary to bony metastasis?

Options:

Atrial fibrillation
Seizures
Urinary retention
Muscle weakness
Hyperreflexia

Correct Answer: Muscle weakness

Explanation:

Question 44:

In children with moderate to severe osteogenesis imperfecta (OI), intravenous pamidronate therapy has been shown to increase the thickness of cortical bone. This occurs primarily as a consequence of

Options:

increased bone turnover in the cortical area.
inhibition of osteoclast-mediated bone resorption.
improved mineralization of cortical bone.
improved osteoblast organic matrix production.
improved organization of collagen matrix.

Correct Answer: inhibition of osteoclast-mediated bone resorption.

Explanation:

DISCUSSION: Histologic studies have shown that increased bone turnover is the rule in OI. Pamidronate (and all bisphosphonates) reduce osteoclast-mediated bone resorption. Osteoblastic new bone formation on the periosteal surface of long bones is minimally impaired. With inhibition of osteoclastic bone resorption on the endosteal surface, the cortex of the bone can begin to thicken as it does with normal growth in individuals unaffected by OI. Mineralization and collagen matrix organization are not directly affected by pamidronate.
REFERENCES: Zeitlin L, Fassier F, Glorieux FH: Modern approach to children with osteogenesis imperfecta. J Pediatr Orthop B 2003;12:77-87.
Falk MJ, Heeger S, Lynch KA, et al: Intravenous bisphosphonate therapy in children with osteogenesis imperfecta. Pediatrics 2003;111:573-578.
Glorieux FH, Bishop NJ, Plotkin H, et al: Cyclic administration of pamidronate in children with severe osteogenesis imperfecta. N Engl J Med 1998;339:947-952.

Question 45:

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

Options:

Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve
Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, superficial peroneal nerve
Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve, superficial peroneal nerve
Extensor hallucis brevis, extensor hallucis longus, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve
Dorsalis pedis artery, deep peroneal nerve, superficial peroneal nerve

Correct Answer: Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve

Explanation:

Question 46:

Options:

Lateral
Posterior
Posterolateral
Anterior
Anteromedial

Correct Answer: Lateral

Explanation:

Question 47:

According to Musculoskeletal Infection Society (MSIS) guidelines, which set of patient laboratory study results fits the definition of chronic prosthetic joint infection?

Options:

ESR 25 mm/hr, CRP 7 mg/L, joint aspiration WBC count 252, 82% neutrophils, and negative leukocyte esterase
Erythrocyte sedimentation rate (ESR) 50 mm/hr, C-reactive protein (CRP) 8 mg/L, joint aspiration white blood cell (WBC) count 542, 62% neutrophils, and positive leukocyte esterase
ESR 42 mm/hr, CRP 12 mg/L, joint aspiration WBC count 3,540, 72% neutrophils, and positive leukocyte esterase
ESR 20 mm/hr, CRP 15 mg/L, joint aspiration WBC count 4,135, 54% neutrophils, and negative leukocyte esterase

Correct Answer: Erythrocyte sedimentation rate (ESR) 50 mm/hr, C-reactive protein (CRP) 8 mg/L, joint aspiration white blood cell (WBC) count 542, 62% neutrophils, and positive leukocyte esterase

Explanation:

Question 48:

What is the most common complication following surgery for a "terrible triad" elbow fracture-dislocation?

Options:

Arthritis
Infection
Re-dislocation
Restricted range of elbow motion
Posterior interosseous nerve (PIN) palsy

Correct Answer: Restricted range of elbow motion

Explanation:

Question 49:

Options:

A 45-year-old woman with a hypermobile foot
A 45-year-old man with a rigid hindfoot valgus deformity
A thin 55-year-old woman with mild hemiparesis affecting the symptomatic foot from a previous stroke
An active 55-year-old woman with a progressively worsening supple hindfoot valgus
A moderately obese 70-year-old woman with a supple hindfoot

Correct Answer: An active 55-year-old woman with a progressively worsening supple hindfoot valgus

Explanation:

Question 50:

When examining a patient with marked hyperreflexia, which of the following findings best suggests that the condition is not caused by a cerivcal spine pathology?

Options:

Positive finger adduction test and finger escape sign
Positive grip and release test and rapid opening and closing of the hand
Positive jaw jerk reflex
Extensor Babinski response
Loss of proprioception in the great toes

Correct Answer: Positive jaw jerk reflex

Explanation:

Question 51:

Which surgical procedure should be considered for treatment of chronic plantar fasciitis?

Options:

Endoscopic or open plantar fasciotomy
Heel spur excision
Achilles tendon lengthening
Extensile approach, medial and plantar, to include release of tarsal tunnel and complete plantar fasciotomy

Correct Answer: Endoscopic or open plantar fasciotomy

Explanation:

Question 52:

Options:

Long standing anterior-posterior radiograph of the hip-knee-ankle
Axial CT views from the supracondylar distal femur to the proximal tibia below the tibial tubercle
Fluoroscopic stress views to demonstrate the position of subluxation
Bone scan
MRI scan

Correct Answer: Axial CT views from the supracondylar distal femur to the proximal tibia below the tibial tubercle

Explanation:

Question 53:

Options:

septic arthritis.
slipped capital femoral epiphysis.
femoral head fracture (Pipkin I).
developmental dysplasia of the hip.
Legg-Calve-Perthes disease.

Correct Answer: Legg-Calve-Perthes disease.

Explanation:

Question 54:

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

Options:

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

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

Explanation:

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

Question 55:

Options:

Sclerotherapy
Shave excision with cautery
Cryotherapy
Wide surgical excision

Correct Answer: Wide surgical excision

Explanation:

EXPLANATION:
This lesion is a
pyogenic granuloma
, which is a common benign vascular lesion that can occur on skin or mucosa. The etiology is unclear, although this lesion tends to occur in areas of physical trauma. Initial treatment with silver nitrate with an average of 1.6 applications has a success rate of 85%. This patient, however, has failed silver nitrate applications. Wide surgical excision (Figures below) is associated with the lowest recurrence rate and offers the benefit of a single procedure. Other options often necessitate repeated procedures to completely eradicate this lesion.

Question 56:

Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

Options:

Comminuted fractures
Fractures that involve the coronoid process
Fractures associated with Monteggia fracture-dislocations
Oblique fractures distal to the midpoint of the trochlear notch
Transverse fractures through the midpoint of the trochlear notch

Correct Answer: Transverse fractures through the midpoint of the trochlear notch

Explanation:

Question 57:

If a laminectomy for spinal stenosis is performed, which of the following is an indication for concomitant arthrodesis at that level?

Options:

Prior laminectomy at an adjacent level
Ten degrees of degenerative scoliosis
Removal of 25% of each facet joint at surgery
Degenerative spondylolisthesis at the level of the laminectomy
Foraminal stenosis at the level of the laminectomy

Correct Answer: Degenerative spondylolisthesis at the level of the laminectomy

Explanation:

Question 58:

Options:

ixation of the coronoid fragment
Radial head arthroplasty
Repair or reconstruction of the lateral collateral ligament (LCL) complex
Repair or reconstruction of the medial collateral ligament (MCL) This represents a terrible triad injury, with elbow dislocation, radial head fracture, and coronoid fracture. The LCL complex is typically disrupted in this injury pattern. Repair or reconstruction of this structure provides the greatest increase in rotational stability of the elbow.

Correct Answer: Repair or reconstruction of the lateral collateral ligament (LCL) complex

Explanation:

Question 59:

Options:

Intramedullary pinning
Bone stimulator
Sling for comfort, followed by gentle range-of-motion exercises
Open reduction and internal fixation with a plate and screws
Arthroscopic distal clavicle resection

Correct Answer: Sling for comfort, followed by gentle range-of-motion exercises

Explanation:

Question 60:

Figure 10 shows the radiograph of a 7-year-old patient who has a bilateral Trendelenburg limp and limited range of hip motion but no pain. His work-up should include

Options:

a skeletal survey.
genetic evaluation.
cardiac evaluation.
coagulation studies.
MRI of the hips.

Correct Answer: a skeletal survey.

Explanation:

Question 61:

Figures 11a and 11b show the radiographs of a 50-year-old man who was struck by a car. Treatment should consist of

Options:

cemented bipolar hemiarthroplasty.
cementless bipolar hemiarthroplasty.
hybrid total hip arthroplasty.
cementless total hip arthroplasty.
open reduction and internal fixation.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 62:

During treatment of rupture of the subscapularis tendon with associated biceps instability, treatment of the biceps tendon should include which of the following? Review Topic

Options:

Tenosynovectomy
Recentering
Deepening of the bicipital groove
Tenodesis or tenotomy
Lysis of sheath adhesion

Correct Answer: Tenodesis or tenotomy

Explanation:

Question 63:

Options:

physical therapy and bracing.
reassurance that these problems will resolve with time.
posterior capsule release, Achilles tendon lengthening, and excision of the scarred muscle and tendon in the leg and foot.
Achilles tendon lengthening, and flexor digitorum longus and flexor hallucis longus tenotomies at the individual digits with transfer of the posterior tibial tendon to the dorsum of the foot.
flexor digitorum longus and flexor hallucis longus tenotomies at the individual digits with midfoot capsular release and hallux interphalangeal fusion.

Correct Answer: posterior capsule release, Achilles tendon lengthening, and excision of the scarred muscle and tendon in the leg and foot.

Explanation:

DISCUSSION: This is an example of a missed deep posterior compartment syndrome that typically presents 6 months after the injury with progressive clawing due to necrosis, scarring, and contracture of the posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus. Treatment consists of debridement of necrotic muscle and scar tissue with corresponding tendon excision. After debridement and posterior capsule release, if the equinus is relieved with knee flexion, a gastrocnemius slide may be performed. Otherwise, the lengthening should be at the level of the Achilles tendon. Bracing will not address the claw toes.
REFERENCES: Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 212-213.
Manoli A II, Smith DG, Hansen ST Jr: Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res 1993;292:309-314.
Early JS, Ricketts DS, Hansen ST: Treatment of compartmental liquefaction as a late sequelae of a lower limb compartment syndrome. J Orthop Trauma 1994;8:445-448.

Question 64:

Options:

Surgical traction for 6 weeks followed by application of a cast brace
Application of a femoral cable plate
Femoral revision with a cemented long stem prosthesis
Application of cerclage wired double allograft femoral struts
Femoral revision with a cementless long taper fluted modular stem and proximal allograft strut supplementation

Correct Answer: Femoral revision with a cementless long taper fluted modular stem and proximal allograft strut supplementation

Explanation:

Question 65:

Figure 3 shows the AP radiograph of a patient with diabetes mellitus who has knee pain. A semiconstrained knee prosthesis was used in this patient to prevent which of the following complications?

Options:

Infection
Instability
Stiffness
Bone loss
Malalignment

Correct Answer: Instability

Explanation:

DISCUSSION: The radiographic appearance of the joint is highly suspicious for neuropathic joint (Charcot’s joint). Evidence of bone loss on both the tibial and the femoral sides may necessitate the use of metal and/or bone augments. Patients with a neuropathic joint often have excellent range of motion, and postoperative stiffness is not a problem. The main problem with these patients is instability that occurs secondary to ligamentous laxity. Use of a semiconstrained prosthesis prevents the latter complication.
REFERENCES: Parvizi J, Marrs J, Morrey BF: Total knee arthroplasty for neuropathic (Charcot) joints. Clin Orthop 2003;416:145-150.
Kim YH, Kim JS, Oh SW: Total knee arthroplasty in neuropathic arthropathy. J Bone Joint
Surg Br 2002;84:216-219.

Question 66:

Options:

open reduction and plate fixation.
a figure-of-8 bandage for 4 to 6 weeks.
a sling for comfort, followed by physical therapy when pain-free.
excision of the outer end of the clavicle.
a tension band and Kirschner wires.

Correct Answer: a sling for comfort, followed by physical therapy when pain-free.

Explanation:

Question 67:

Options:

Bone scan
CT
Needle biopsy
Incisional biopsy
No further tests are needed

Correct Answer: No further tests are needed

Explanation:

DISCUSSION: The radiograph and MRI scan show a pedunculated lesion arising from the medial aspect of the distal femoral metaphysis. The cortex of the lesion is contiguous with the cortex of the underlying normal bone. Similarly, the medullary canal of the lesion is contiguous with that of the normal bone. These findings are diagnostic of osteochondroma. Rarely a secondary chondrosarcoma can arise in a preexisting osteochondroma. This diagnosis is suggested by identifying a cartilage cap that is greater than 1.5-cm thick in a skeletally mature patient. MRI is the best study to rule out a secondary chondrosarcoma. CT also may be used for this purpose but is not indicated in this patient because an MRI has already been obtained. A bone scan is not useful to identify a secondary chondrosarcoma. Similarly, there is no role for biopsy in this patient. No further tests are needed.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.
Murphey MD, Choi JJ, Kransdorf, MJ, et al: Imaging of osteochondroma: Variants and complications with radiologic-pathologic correlation. Radiographics 2000;20:1407-1434.

Question 68:

Options:

Radial collateral ligament
Posterior bundle of the ulnar collateral ligament
Anterior bundle of the ulnar collateral ligament
Flexor carpi ulnaris
Pronation teres

Correct Answer: Anterior bundle of the ulnar collateral ligament

Explanation:

Question 69:

Based on the radiographic findings shown in Figure 41, which of the following wrist ligaments is most likely disrupted?

Options:

Short radiolunate
Long radiolunate
Scapholunate
Ulnolunate
Lunotriquetral

Correct Answer: Scapholunate

Explanation:

Question 70:

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

Options:

Metastatic carcinoma
Osteosarcoma
Lymphoma
Multiple myeloma
Chondrosarcoma

Correct Answer: Metastatic carcinoma

Explanation:

Question 71:

What range of motion parameters are required for a patient with posttraumatic elbow stiffness to accomplish all the normal activities of daily living?

Options:

Flexion and extension of 10 degrees to 110 degrees, pronation of 50 degrees, and supination of 50 degrees
Flexion and extension of 10 degrees to 130 degrees, pronation of 50 degrees, and supination of 50 degrees
Flexion and extension of 30 degrees to 110 degrees, pronation of 60 degrees, and supination of 30 degrees
Flexion and extension of 30 degrees to 130 degrees, pronation of 50 degrees, and supination of 50 degrees
Flexion and extension of 30 degrees to 130 degrees, pronation of 60 degrees, and supination of 30 degrees

Correct Answer: Flexion and extension of 30 degrees to 130 degrees, pronation of 50 degrees, and supination of 50 degrees

Explanation:

Question 72:

Options:

He can expect complete resolution of his symptoms during the first month.
All patients experience relief within 3 months and continue to improve over the next 4 years.
Most patients experience some pain relief within the first 3 months.
He may experience some improvement but if he requires surgery at a later date he will have a poorer result because of the delay.
The patient requires immediate surgery to avoid permanent nerve damage.

Correct Answer: Most patients experience some pain relief within the first 3 months.

Explanation:

DISCUSSION: The patient has lumbar spinal stenosis and the MRI scans reveal the pathology at L4-5, which is secondary to posterior disk bulging and hypertrophy and infolding of the ligamentum flavum, as well as degenerative facet arthrosis. The degree of spinal stenosis is moderate and his symptoms are positional in nature. Tadokoro and associates reported on a prospective study of 89 patients older than 70 years of age who underwent nonsurgical management for lumbar spinal stenosis. They found the prognosis to be relatively good with patients scoring at “excellent” or “good” for activities of daily living at final follow-up. However, they did note that patients with a complete block on myelography did not respond favorably to nonsurgical management. Amundsen and associates reported on a 10-year prospective study comparing surgical care to nonsurgical management. They concluded that, while the long-term results largely favored surgical treatment, more than half of the nonsurgically managed patients had a satisfactory outcome. They also concluded that a delay of surgery for some months did not worsen the prognosis. Therefore, their recommendation was for an initial primarily nonsurgical approach.
REFERENCES: Amundsen T, Weber H, Nordal HJ, et al: Lumbar spinal stenosis: Conservative or surgical management? A prospective 10-year study. Spine 2000;25:1424-1435.
Hilibrand AS, Rand N: Degenerative lumbar stenosis: Diagnosis and management. J Am Acad Orthop Surg 1999;7:239-249.
Tadokoro K, Miyamoto H, Sumi M, et al: The prognosis of conservative treatments for lumbar spinal stenosis: Analysis of patients over 70 years of age. Spine 2005;30:2458-2463.

Question 73:

Options:

Spastic gait and a positive Hoffman’s sign
Severe arm pain with upper extremity hyporeflexia
Normal neurologic findings
Hyperactive jaw jerk reflex with extremity numbness
Flaccid paraparesis

Correct Answer: Spastic gait and a positive Hoffman’s sign

Explanation:

Question 74:

Options:

Physical therapy for quadriceps strengthening
Functional bracing
Anterior cruciate ligament (ACL) reconstruction
Revision reconstruction of the LCL and posterolateral corner
Valgus-producing high tibial osteotomy (HTO)

Correct Answer: Valgus-producing high tibial osteotomy (HTO)

Explanation:

Question 75:

Options:

Subtendinous epicondylar corticosteroid injection
Corticosteroid injection into the radial tunnel
MRI of the elbow
Percutaneous extensor carpi radialis brevis tenotomy
Physical therapy for an eccentric conditioning and strengthening program

Correct Answer: Physical therapy for an eccentric conditioning and strengthening program

Explanation:

Question 76:

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 77:

Options:

Repeat closed reduction and splinting under anesthesia to achieve absolute stability
Closed reduction and temporary transarticular fixation using 1.6 mm Kirschner-wires to achieve absolute stability
Definitive open reduction and internal fixation of the ankle to achieve absolute stability
Definitive open reduction and internal fixation of the ankle to achieve relative stability
Temporary external fixation of the ankle to achieve relative stability

Correct Answer: Definitive open reduction and internal fixation of the ankle to achieve absolute stability

Explanation:

Question 78:

During an anterior approach to the bicipital 53 tuberosity, you encounter a nerve overlying the brachioradialis fascia (Figure 58). It provides innervation to the

Options:

flexor pollicis longus.
skin on the anteromedial forearm.
skin on the anterolateral forearm.
extensor indicis proprius.

Correct Answer: skin on the anterolateral forearm.

Explanation:

Question 79:

Options:

t(2;13)(q35;q14)
t(12;22)(q13;q12)
t(12;16)(q13;p11)
t(X;18)(p11;q11)
t(17;22)(q22;q13)

Correct Answer: t(12;16)(q13;p11)

Question 80:

Which of the following conditions is associated with palmoplantar pustulosis?

Options:

Condensing osteitis
Sternoclavicular hyperostosis
Friedreich’s disease
Scleroderma
Reiter syndrome

Correct Answer: Sternoclavicular hyperostosis

Explanation:

DISCUSSION: Sternoclavicular hyperotosis is a seronegative and HLA-B27 negative rheumatic disease. In this condition, hyperostosis may appear in the spine, long bones, sacroiliac joints, and the sternoclavicular region. This entity is also associated with palmoplantar pustulosis.
REFERENCES: Wirth MA, Rockwood CA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,
WB Saunders, 2004, vol 2, pp 608-609.
Sonozaki H, Azuma A, Okai K, et al: Clinical features of 22 cases with inter-sterno-costo-clavicular ossification: A new rheumatic syndrome. Arch Orthop Trauma Surg 1979;95:13-22.

Question 81:

Which of the following fluoroscopic views is used to assess intra-articular screw penetration during volar fixation of a distal radius fracture?

Options:

Dorsal skyline view
AP wrist view
PA wrist view
23° elevated lateral view
45° oblique lateral view

Correct Answer: 45° oblique lateral view

Explanation:

Question 82:

Options:

Further rehabilitation
Corticosteroid injection
Reconstruction of the medial collateral ligament
Subcutaneous transposition of the ulnar nerve
Arthroscopic debridement of medial osteophytes

Correct Answer: Subcutaneous transposition of the ulnar nerve

Explanation:

Question 83:

An orthotic that provides laterally based hindfoot posting support would be most useful for which of the following conditions? Review Topic

Options:

Painful accessory navicular
Middle facet coalition
Flexible flat foot
Metatarsus adductus
Flexible cavovarus foot

Correct Answer: Painful accessory navicular

Explanation:

Question 84:

The MRI findings shown in Figure 51 would most likely create which of the following signs and symptoms?

Options:

Weakness of the left extensor hallucis longus and a sensory deficit in the first dorsal web space
Diminished right Achilles tendon reflex and weakness of the gastrocnemius-soleus complex
Pain radiating into the anteromedial aspect of the left knee, diminished patellar tendon reflex, and difficulty climbing stairs
Numbness in the right first dorsal web space and a slap foot gait
Urinary retention and right quadriceps weakness with diminished patellar tendon reflex

Correct Answer: Pain radiating into the anteromedial aspect of the left knee, diminished patellar tendon reflex, and difficulty climbing stairs

Explanation:

Question 85:

Options:

5 mm
10 mm
15 mm
20 mm
25 mm

Correct Answer: 20 mm

Explanation:

Question 86:

Options:

Open tibial apophysis
Medial patellar cartilage defect
Femoral trochlear sulcus angle = 165°
Tibial tubercle-trochlear groove distance = 25mm
Patella tilt = 25°

Correct Answer: Open tibial apophysis

Explanation:

Question 87:

Options:

Hallux rigidus
Fracture of the sesamoid
Disruption of the plantar plate
Osteonecrosis of the metatarsal head
Rupture of the flexor hallucis longus

Correct Answer: Disruption of the plantar plate

Explanation:

Question 88:

What is the most important preoperative factor predicting conversion to total hip arthroplasty after arthroscopic surgery of the hip?

Options:

Age over 60 years
Morbid obesity
Diagnosis of osteoarthritis
Tobacco use

Correct Answer: Morbid obesity

Explanation:

Question 89:

Options:

Facet injections
Epidural steroid injection
MRI of the lumbar spine
Bed rest for 2 weeks with continued restrictions
Early return to activities as his symptoms allow

Correct Answer: Early return to activities as his symptoms allow

Explanation:

Question 90:

Figures 233a through 233c are the radiographs and biopsy specimen of a 32-year-old woman who has had progressive ankle pain for 6 months. What is the most appropriate treatment option?

Options:

Radiotherapy alone
Intralesional curettage
Intralesional curettage with adjuvants
Wide surgical resection and radiotherapy
Neoadjuvant chemotherapy and wide resection

Correct Answer: Intralesional curettage with adjuvants

Question 91:

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

Options:

Space available for the cord of less than 8 mm
Ossification of the posterior longitudinal ligament
Fixed cervical kyphosis
Previous posterior surgery
Concomitant cervical radiculopathy

Correct Answer: Fixed cervical kyphosis

Explanation:

DISCUSSION: Laminoplasty or any posterior decompressive procedure is contraindicated in patients with cervical spondylotic myelopathy and cervical kyphosis. The residual kyphotic posture of the cervical spine results in persistent spinal cord compression. The other choices are not contraindications for laminoplasty. Concomitant cervical radiculopathy can be addressed at the time of laminoplasty with a keyhole foraminotomy.
REFERENCES: Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-247.

Question 92:

Which of the following complications is more likely with an inside-out repair technique compared to an all-inside techniques for a medial meniscus tear? Review Topic

Options:

Failure
Intra-articular synovitis
Peroneal nerve injury
Saphenous nerve injury
Arthrofibrosis

Correct Answer: Saphenous nerve injury

Explanation:

Question 93:

Figure 69 is the radiograph of a 9-year-old who has posterior hindfoot pain while running. What is the most likely diagnosis?

Options:

Kohler disease
Thiemann disease
Freiberg infraction
Sever disease

Correct Answer: Sever disease

Explanation:

Question 94:

Which of the following is an important factor in performing a proper biopsy?

Options:

Staying carefully in the proper intermuscular planes
Placing multiple drains
Dissecting and protecting critical neurovascular structures
Using longitudinal incisions in the extremity
Avoiding the use of a tourniquet

Correct Answer: Using longitudinal incisions in the extremity

Explanation:

DISCUSSION: There are a number of important technical details in performing a biopsy. Incisions should always be longitudinal in the extremity. Good hemostasis is important in avoiding contamination from hematoma. The approach should avoid neurovascular structures, and go through a single muscle belly when possible. Although a frozen section should be obtained to ensure adequate viable tissue has been obtained, definitive diagnosis is not necessary at the time of the frozen section.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 29-34.

Question 95:

01 (left). What is the most appropriate next step?

Options:

Splint the knee and admit the patient for hourly ankle brachial index monitoring
Emergent vascular surgical exploration
Emergent external fixation and reassessment of perfusion
CT angiography and admit the patient for hourly neurovascular checks
Interventional radiology consult for formal angiography and stenting

Correct Answer: Emergent external fixation and reassessment of perfusion

Explanation:

Question 96:

Options:

a program of stretching exercises and rotator cuff strengthening exercises.
a series of six cortisone injections.
arthroscopic acromioplasty.
arthroscopic acromioplasty and laser capsulorrhaphy.
open acromioplasty.

Correct Answer: a program of stretching exercises and rotator cuff strengthening exercises.

Explanation:

Question 97:

When the elbow is extended and an axial load is applied, what percent of stress distribution occurs across the ulnohumeral and radiohumeral articular surface, respectively?

Options:

20% and 80%
40% and 60%
50% and 50%
60% and 40%
80% and 20%

Correct Answer: 40% and 60%

Explanation:

Question 98:

Options:

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

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

Explanation:

Question 99:

Induction coupling stimulates bone growth through all of the following direct effects EXCEPT:

Options:

Increased proliferation of osteoblasts
Decreased osteoclast differentiation
Increase release of TGF-beta1
Increased expression of BMP2
Increased expression of BMP7

Correct Answer: Increased proliferation of osteoblasts

Explanation:

Question 100:

Options:

Physical therapy
Arthroscopic synovectomy
Tibial insert revision
Femoral component revision

Correct Answer: Arthroscopic synovectomy

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

Orthopedic MCQ Exam: Trauma, Arthroplasty, Foot & Ankle | Part 38

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 38

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index