Orthopedic Board Prep MCQs: Trauma & Arthroscopy Pt. 4

About This Board Review Set

This is Part 4 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 4

This module focuses heavily on: Arthroscopy, Foot, Fracture, Hip, Knee.

Sample Questions from This Set

Sample Question 1: A 23-year-old man is involved in a motor vehicle accident. An AP radiograph is shown in Figure 29a, and axial and sagittal CT scans are shown in Figures 29b and 29c. Neurologic examination shows 1/5 strength of his quadriceps and iliopsoas ...

Sample Question 2: A 16-year-old football player sustains a direct blow to the anterior aspect of his flexed right knee. Examination reveals a contusion over the anterior tibial tubercle and a small effusion. MRI scans are shown in Figures 33a through 33c. Wh...

Sample Question 3: A 22-year-old ballet dancer undergoes hip arthroscopy for increasing hip pain and popping with activity. She experiences complete resolution of signs and symptoms post-operatively. Her pre- and post-operative magnetic resonance sagittal ima...

Sample Question 4: Locked lateral plate fixation of the proximal tibia is most appropriate for what Schatzker type fracture?...

Sample Question 5: A 36-year-old woman is brought to the emergency department intubated and sedated following a motor vehicle accident. She is moving her upper and lower extremities spontaneously. She cannot follow commands. CT scans are shown in Figures 7a t...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

A 23-year-old man is involved in a motor vehicle accident. An AP radiograph is shown in Figure 29a, and axial and sagittal CT scans are shown in Figures 29b and 29c. Neurologic examination shows 1/5 strength of his quadriceps and iliopsoas on the right, with 1/5 quadriceps function on the left. Definitive treatment of his injury should consist of

Explanation

DISCUSSION: The imaging studies show a fracture-dislocation. Surgical treatment of this injury consists of a decompression reduction, stabilization, and fusion. A posterolateral decompression can also be performed as necessary. An isolated anterior procedure in this type of injury is contraindicated. The anterior longitudinal ligament is most likely intact; therefore, an anterior procedure further destabilizes the spine. Reduction by an anterior approach would also be difficult. Nonsurgical management of the neurologic injury in this patient is not indicated.
REFERENCES: Theiss SM: Thoracolumbar and lumbar spine trauma, in Stannard JP, Schmidt AH, Kregor PJ (eds): Surgical Treatment of Orthopaedic Trauma. New York, NY, Thieme, 2007, pp 179-207.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 2

A 16-year-old football player sustains a direct blow to the anterior aspect of his flexed right knee. Examination reveals a contusion over the anterior tibial tubercle and a small effusion. MRI scans are shown in Figures 33a through 33c. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scans show disruption of the fibers of the PCL. Patients sustaining an isolated acute PCL injury can present with only minimal discomfort and have full range of motion. When examination reveals a contusion over the tibial tubercle and discomfort with the posterior drawer examination, with or without instability, a possible injury to the PCL should be considered. In acute injuries, the reported accuracy of MRI imaging for diagnosing PCL tears ranges from 96% to 100%.
REFERENCES: Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging. Philadelphia, PA, WB Saunders, 1997, pp 699-700.
Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.
Fischer SP, Fox JM, Del Pizzo W, Friedman MJ, Snyder SJ, Ferkel RD: Accuracy of diagnoses from magnetic imaging of the knee: A multi-center analysis of one thousand and fourteen patients. J Bone Joint Surg Am 1991;73:2-10.

Question 3

A 22-year-old ballet dancer undergoes hip arthroscopy for increasing hip pain and popping with activity. She experiences complete resolution of signs and symptoms post-operatively. Her pre- and post-operative magnetic resonance sagittal images shown in Figure A (left, pre-operative; right, post-operative). Which of the following pre-operative physical examination findings may have been positive? Review Topic

Explanation

This patient has internal snapping hip (coxa saltans), which is caused by the psoas tendon sliding over femoral head, iliopectineal ridge, lesser trochanter exostoses, or iliopsoas bursa.
Snapping hip exists in 3 forms: (1) external snapping hip, which is caused by the iliotibial band (ITB) sliding over the greater trochanter, (2) internal snapping hip, and
(3) intraarticular snapping hip, which is caused by loose bodies (traumatic, or from synovial chondromatoses) or labral tears. While painless snapping hip requires no treatment, painful snapping hip may be addressed with activity modification, physical therapy, steroid injections. Surgical release (ITB z-plasty or psoas tenotomy) is indicated if nonoperative management is unsuccessful.
Ilizaliturri et al. evaluated the results of endoscopic iliopsoas tendon release at the lesser trochanter (10 patients) vs endoscopic transcapsular psoas release from the peripheral compartment (9 patients). There were improvements in WOMAC scores in both groups, and no difference between groups. They conclude that both techniques are equally effective.
Marquez Arabia et al. evaluated if the psoas tendon regenerates after tenotomy in 27 patients. At 23 months, they found that tendon regeneration occurred in all patients, to
a mean circumference of 84% of the original. One patient had persistent pain, but all had 5/5 hip flexion strength. They hypothesize that the bulk of iliopsoas muscle fibers attaches directly to the proximal femoral shaft without a tendon, preventing retraction and allowing regeneration to occur easily.
Figure A shows pre- and post-operative arthroscopic psoas tenotomy magnetic resonance sagittal images. Illustration A shows the psoas tendon (white arrows) prior to transection. Illustration B shows the psoas tendon after transection (green arrows, proximal tendon segment; yellow arrows, distal segment). Illustration C and D are diagrams showing release at the level of the lesser trochanter and hip joint respectively.
Incorrect
90 degrees, but full external rotation. Answer 2: Decreased internal rotation and a positive impingement test (forced
flexion, adduction, femoroacetabular Answer 4: These
and internal
rotation) are classic findings
findings may
be found with intra-articular
for cam-type impingement loose bodies.

Question 4

Locked lateral plate fixation of the proximal tibia is most appropriate for what Schatzker type fracture?

Explanation

Locked lateral plate fixation of the proximal tibia has proven effective for bicondylar fractures (Schatzker types V and VI). The laterally based plate provides support for the lateral condyle fracture and locked proximal screws support the medial fragment from varus collapse. A medial antiglide plate can be used in conjunction with the locked plate. Lateral locked plate fixation has not been shown to have advantages for pure lateral fractures (Schatzker types I, II, and III) that require buttress plating or support of depressed articular components. Pure medial fractures (Schatzker type IV) are best treated with medial fixation.

Question 5

A 36-year-old woman is brought to the emergency department intubated and sedated following a motor vehicle accident. She is moving her upper and lower extremities spontaneously. She cannot follow commands. CT scans are shown in Figures 7a through 7c. The initial survey does not reveal any other injuries. Initial management of the cervical injury should consist of immediate

Explanation

DISCUSSION: The patient has a bilateral facet dislocation of C6-C7 with preservation of at least some neurologic function. Urgent reduction is necessary. However, because she is sedated and unable to follow commands, an MRI scan is necessary before any closed or open posterior reduction to look for an associated disk herniation. If a disk herniation is present, it must be removed prior to any reduction maneuver to prevent iatrogenic neurologic injury. It is very unlikely that this injury can be reduced with an open anterior procedure alone.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 189-199.
Kwon BK, Vaccaro AR, Grauer JN, et al: Subaxial cervical spine trauma. J Am Acad Orthop Surg 2006;14:78-89.

Question 6

A biopsy of the involved physis in a patient with slipped capital femoral epiphysis (SCFE) would most likely reveal

Explanation

DISCUSSION: Vascular invasion, histologically similar to granulation tissue, has been noted between the columns in the zone of hypertrophy, leading to the theory of microtrauma as an etiology. SCFE is also associated with conditions that increase the height of the zone of hypertrophy, including the adolescent growth spurt and endocrinopathies. The perichondral ring has been shown to decrease in thickness with age. Normal undulations in the growth plate also decrease during this time, possibly further destabilizing the physis. Abnormal accumulations of proteoglycan have been reported.
REFERENCES: Chung SM, Batterman SC, Brighton CT: Shear strength of the human femoral capital epiphyseal plate. J Bone Joint Surg Am 1976;58:94-103.
Raney EM, Ogden JA: Slipped capital femoral epiphysis. Current Ortho 1995;9:111-116.

Question 7

What is the most common nonanesthetic-related reversible cause of changes in intraoperative neurophysiologic monitoring data? Review Topic

Explanation

Patient positioning that results in local nerve compression, plexus traction, or improper neck alignment is the most common nonanesthetic-related cause of changes in intraoperative neurophysiologic monitoring data during spinal surgery.

Question 8

A 40-year-old woman reports the atraumatic onset of severe knee pain and swelling after undergoing an uncomplicated elective cholecystectomy 1 week ago. She denies any history of diabetes mellitus or HIV but has had occasional episodes of mild knee pain and swelling that have always responded to nonsteroidal anti-inflammatory drugs. Radiographs are shown in Figures 5a and 5b. A knee aspiration yields a WBC count of 35,000/mm 3 . The aspirate should also yield which of the following findings?

Explanation

DISCUSSION: The radiographs reveal chondrocalcinosis of the menisci. This is caused by calcium pyrophosphate crystals, which are weakly positive birefringent rhomboid-shaped crystals. Frequently, this condition is asymptomatic; however, routine abdominal surgery may cause precipitation of these crystals and pain. Gout, which is caused by strongly negative birefringent needle-shaped sodium urate crystals, is not associated with chondrocalcinosis and is rare in younger women. Gross blood is uncommon without trauma. Infection is not likely in a healthy patient who underwent uncomplicated surgery.
REFERENCES: Fisseler-Eckhoff A, Muller KM: Arthroscopy and chondrocalcinosis. Arthroscopy 1992;8:98-104.
Hough AJ Jr, Webber RJ: Pathology of the meniscus. Clin Orthop 1990;252:32-40.

Question 9

A 2-year-old child is being evaluated for limb-length and girth discrepancy. As a newborn, the patient was large for gestational age and had hypoglycemia. Current examination shows enlargement of the entire right side of the body, including the right lower extremity and foot. The skin shows no abnormal markings, and the neurologic examination is normal. The spine appears normal. Radiographs confirm a 2-cm discrepancy in the lengths of the lower extremities. Additional imaging studies should include

Explanation

DISCUSSION: The patient may have Beckwith-Wiedemann syndrome (BWS), which consists of exophthalmos, macroglossia, gigantism, visceromegaly, abdominal wall defects, and neonatal hypoglycemia. Hemihypertrophy develops in approximately 15% of patients with BWS. Patients with hemihypertrophy that is the result of BWS have a 40% chance of developing malignancies such as Wilms’ tumor or hepatoblastoma; therefore, frequent ultrasound screening is recommended until about age 7 years. The absence of nevi and vascular markings helps to rule out other causes of hemihypertrophy, such as neurofibromatosis, Proteus syndrome, and Klippel-Trenaunay syndrome. Bone age estimations are not accurate at this young age but may become more useful later to help predict the timing of epiphysiodesis procedures.
REFERENCES: DeBaun MR, Tucker MA: Risk of cancer during the first four years of life in children from The Beckwith-Wiedemann Syndrome Registry. J Pediatr 1998;132:398-400.
Ballock RT, Wiesner GL, Myers MT, et al: Hemihypertrophy concepts and controversies.

J Bone Joint Surg Am 1997;79:1731-1738.
Carpenter CT, Lester EL: Skeletal age determination in young children: Analysis of three regions of the hand/wrist film. J Pediatr Orthop 1993;13:76-79.

Question 10

A 16-year-old competitive female swimmer has a 1-year history of left shoulder pain. She denies any specific injury to her shoulder. She reports that the pain is worse with swimming but also has pain with daily activities. She also notes similar occasional symptoms in her right shoulder. Examination reveals symmetric range of motion and rotator cuff strength. Examination of the left shoulder reveals 2+ anterior and posterior translation with pain in both directions and a 2-cm sulcus sign. The right shoulder also has 2+ anterior and posterior translation and a 2-cm sulcus sign with no pain. She also has hyperextension of the elbows and the ability to touch the radial border of her thumb to her forearm. What is the next step in management? Review Topic

Explanation

The patient has symptomatic multidirectional instability. A comprehensive program involving physical therapy to restore dynamic stability to her shoulder is indicated as a first-line treatment. Periscapular strengthening focusing on the serratus anterior and rhomboids and rotator cuff strengthening should be emphasized. A sling might be used occasionally for comfort but will not provide long-term relief of her symptoms. Thermal capsulorrhaphy, although widely used in the past for shoulder instability, has been abandoned because of a high complication rate. Surgical interventions, such as capsular plications or open capsular shift procedures, might be indicated if rehabilitation fails to relieve her symptoms.

Question 11

Figure 46 shows the radiograph of a 65-year-old man who reports restricted range of motion and pain with sitting 18 months after undergoing right side revision total hip arthroplasty. What is the most appropriate management? L Intensive physiotherapy

Explanation

DISCUSSION: The presence of Brooker grade 1 or 2 heterotopic ossification (HO) does not influence the outcome of total hip arthroplasty, whereas restricted range of motion and pain may occur in patients with more severe grade 3 or 4 HO. Treatment may be nonsurgical or surgical. Nonsurgical management includes intensive physiotherapy during the maturation phase of the disease in an attempt to limit the final stiffness. There appears to be no data regarding the effectiveness of this treatment. There is no role for NSAIDs or radiotherapy as a treatment for preexisting HO. Surgical treatment involves excision of the heterotopic bone and can be expected to improve the functional outcome. Bisphosphonates have been used in the past, but their use has been discontinued as they only postpone ossification until treatment is stopped.
REFERENCES: Board TN, Karva A, Board RE, et al: The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty. J Bone Joint Surg Br 2007;89:434-440.
Harkess JW, Crockarell JR: Arthroplasty of the hip, in Canale ST, Beaty JH (eds): Campbell’s Operative
Orthopaedics, ed 11. Philadelphia, PA, Mosby Elsevier, 2008, vol 1, pp 314-483.

Question 12

The mangled extremity severity score (MESS) utilizes all of the following variables EXCEPT:

Explanation

DISCUSSION: The MESS is a tool utilized to help predict limb salvage success versus primary amputation at the time of presentation. As a screening tool for amputation, this scoring system has a high specificity but low sensitivity, as scores lower than 7 may also ultimately need amputation. All of the variables except choice #5 are part of the scoring system.
The scoring system is as follows: 1. Skeletal / soft-tissue injury: Low energy = 1; Medium energy = 2; High energy = 3; very high energy = 4; 2. Limb ischemia: Pulse reduced or absent but perfusion normal = 1; Pulseless = 2; Cool, paralyzed, insensate = 3; 3. Shock: normotensive = 0; transient hypotension = 1; persistent hypotension = 2; 4. Age:
< 30 = 0; 30-50 = 1; >50 = 2. Limb category scores are doubled for ischemia > 6 hours. The system's original designers reported a cutoff of 7 as predicting amputation.
The referenced study by Ly et al found that the scoring system did not predict functional outcomes at 6 or 24 months. They also found that the Limb Salvage Index; the Predictive Salvage Index; the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score; and the Hannover Fracture Scale-98 all did not predict outcomes at 6 or 24 months.

Question 13

Which of the following design features of a femoral component used in a total knee arthroplasty best minimizes the patellar component contact stresses?

Explanation

DISCUSSION: Several studies have shown that design of the femoral component, especially the trochlear groove portion, largely influences patellar tracking and patellofemoral contact stresses. A deep, curved anatomic femoral trochlear groove has been shown to have the lowest contact stresses.
REFERENCES: Petersilge WJ, Oishi CS, Kaufman KR, Irby SE, Colwell CW Jr: The effect of trochlear design on patellofemoral shear and compressive forces in total knee arthroplasty. Clin Orthop 1994;309:124-130.
Theiss SM, Kitziger KJ, Lotke PS, Lotke PA: Component design affecting patellofemoral complications after total knee arthroplasty. Clin Orthop 1996;326:183-187.
Healy WL, Wasliewski SA, Takei R, Oberlander M: Patellofemoral complications following total knee arthroplasty:. Correlation with implant design and patient risk factors. J Arthroplasty 1995;10:197-201.

Question 14

Risk for vascular injury during transtibial drilling for reconstruction of this injury is increased by

Explanation

DISCUSSION
The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, 1 major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading.
In Question 12, the scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-
producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag.
Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used. Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk for vascular injury.

Question 15

Figure 26 shows the clinical photograph of a patient who has developed a residual limb ulcer following a traumatic transtibial amputation 2 years ago. What is the preferred treatment to resolve the ulcer?

Explanation

DISCUSSION: The first step in the treatment of an amputation residual limb (stump) ulcer is local wound care and adjustment of the residual limb-prosthetic interface, as well as adjusting prosthetic alignment. Surgical revision should be undertaken only when prosthetic modification is unsuccessful.
REFERENCES: Murnaghan JJ, Bowker JH: Musculoskeletal complications, in Smith DG, Michael JW, Bowker JH (eds): Atlas of Amputations and Limb Deficiencies, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 683-700.
Smith DG, Ferguson JR: Transtibial amputations. Clin Orthop Relat Res 1999;361:108-115.

Question 16

Which of the following best describes athletic pubalgia?

Explanation

DISCUSSION: Athletic pubalgia refers to a distinct syndrome of lower abdominal and adductor pain that is mostly commonly seen in high performance male athletes. This condition must be distinguished from others such as painful inflammation of the symphysis pubis, referred to as osteitis pubis. Symptoms attributable to the iliopsoas tendon are most commonly associated with snapping of the tendon. Stress fracture of the pubic ramus may cause symptoms in this area, but it is usually confirmed by imaging studies. Neurapraxia of the pudendal nerve is associated with pressure from the seat in cycling sports and also as a complication associated with traction during surgical procedures.
REFERENCES: Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR: Management of severe lower abdominal or inguinal pain in high-performance athletes: PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000;28:2-8.
Albers SL, Spritzer CE, Garrett WE Jr, Meyers WC: MR findings in athletes with pubalgia. Skeletal Radiol 2001;30:270-277.

Question 17

A 51-year-old butcher has an 18-month history of recalcitrant medial elbow pain, which is affecting his occupational demands. He describes the pain as mainly anterior and distal to the medial epicondyle. His symptoms are exacerbated with resisted wrist flexion and forearm pronation. On examination, he is also found to have a positive Tinel's sign at the elbow with weakness of intrinsic strength. He has attempted physical therapy, activity modification, bracing, and anti-inflammatory medication without any significant improvement. Presurgical counseling should include the understanding that

Explanation

Although less common in comparison with lateral elbow tendinopathy, medial elbow tendinopathy remains a significant cause of elbow disability. Fortunately, most patients can anticipate resolution of symptoms with nonsurgical management. For patients with recalcitrant symptoms, surgical intervention should be discussed as a treatment alternative. The literature reports successful results with surgical intervention via debridement
of pathologic tissue, release of the flexor carpi radialis - pronator teres origin, and/or repair of the flexor carpi radialis - pronator teres origin. Several authors have raised concern of the impact of concomitant ulnar neuropathy on results following surgical treatment for medial epicondylitis. Kurvers and Verhaar and Gabel and Morrey, among others, have reported a statistically significant association between concomitant ulnar neuropathy and worse outcomes following surgery. Most patients can anticipate a return to prior activity levels after surgery without any consistently reported loss of flexor/pronator strength. Prior corticosteroid injections
have not been found to impact results.

Question 18

A 70-year-old former baseball catcher reports long-standing pain in the ring and little fingers. A gradient-echo MRI scan is shown in Figure 26. What is the most likely diagnosis?

Explanation

DISCUSSION: The gradient-echo MRI scan highlights the ulnar and radial arteries,

as indicated by the arrow. This technique suppresses the signal of the surrounding fat

and causes the stationary surrounding tissues to become intermediate in signal intensity.

The flowing blood is then easily identified with a bright signal because it does not absorb the radiofrequency pulse. Based on the findings, the diagnosis is an ulnar artery aneurysm, most likely caused by years of repetitive trauma as the result of catching baseballs. Neurolemmoma and giant cell tumor of the tendon sheath would be intermediately enhanced on this image sequence, and the continuity with the ulnar artery, demonstrated here, would not be expected. Lipomas are not enhanced using the gradient-echo technique. The chronic nature of the patient’s symptoms is not indicative of a hematoma, and the hematoma would be dark on this imaging sequence since it is stationary tissue.
REFERENCES: Koman LA, Ruch DS, Patterson Smith B, et al: Vascular disorders, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, vol 2, pp 2254-2302.
Holder LE, Merine DS, Yang A: Nuclear medicine, contrast angiography, and magnetic resonance imaging for evaluating vascular problems in the Hand: Vasospastic disorders. Hand Clin 1993;9:95-113.

Question 19

A 25-year-old lineman is referred to your office for a second opinion. 1 year ago, he underwent an arthroscopic procedure for shoulder instability. He complains of persistent sense of instability despite the surgery. Which of the following is a contraindication to revision arthroscopic labral repair for recurrent anterior glenohumeral instability? Review Topic

Explanation

Capsular attenuation or postthermal capsular necrosis from prior thermal capsulorraphy is a contraindicated to arthroscopic repair.
Thermal capsulorrhaphy utilizes heat generated by radiofrequency or laser ablation to cause capsular shrinkage in an effort to treat shoulder instability. However, high recurrence rates have been found, especially around two to three weeks after the index procedure, when the capsular tissue is the weakest. In the setting of recurrence following thermal capsulorrhaphy, open revision is recommended.
Creighton et al. reported on a series of 18 patients undergoing revision arthroscopic stabilization. Of the 18, 3 failed with recurrent instability, all with previous thermal capsulorrhaphy.
Miniaci et al. reviewed the outcomes following thermal capsulorrhaphy noting high rates of recurrent instability, especially in the setting of initial treatment for multidirectional instability.
Park et al. reported on a series of 14 patients undergoing revision following thermal capsulorrhaphy. Ten out of 14 patients had signs of capsular thinning, insufficiency and attenuation.
Wong et al. surveyed 379 shoulder surgeons on the complications following thermal capsulorrhaphy. Capsular insufficiency and thinning were commonly associated with recurrent instability.
Hecht et al. performed thermal capsulorrhaphy and biomechanical analysis of the capsule in a sheep model. The authors found that the capsule was weakest at the 2-3 week post-operative timepoint, leading to the highest rate insufficiency, attenuation and mechanical failure at this time.
Incorrect answers:

Question 20

During a revision total knee arthroplasty (TKA), there is difficulty gaining exposure and a tibial tubercle osteotomy (TTO) is performed. The final components are stable and include a stemmed tibial component that bypasses the osteotomy site. The tibial tubercle is reattached to the osteotomy site with multiple cerclage wires. Following closure of the arthrotomy, the knee is flexed to 90 degrees, and there is no observed displacement of the TTO. What is the best next step in postsurgical rehabilitation?

Explanation

DISCUSSION
TTO is a recognized technique for improving exposure when performing TKA in a stiff knee. TTO has been reported to enhance surgical exposure and not adversely affect outcomes after TKA, but there is a 5% complication rate. The postsurgical routine following TTO
includes full weight-bearing activity and range of motion as tolerated. Caution should be exercised when manipulation is performed to improve knee flexion following a TTO.

Question 21

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 most likely cause of this patient's pain?

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.

Question 22

Figure 2 shows the radiograph of a 72-year-old woman who reports pain after a fall. History includes several years of increasing thigh pain and limb shortening. Management consisting of an extensive work-up for infection reveals normal laboratory studies, a positive bone scan, and a negative hip aspiration. What is the most likely etiology of this complication?

Explanation

DISCUSSION: The patient has a midstem periprosthetic fracture, which commonly results in loosening of the prosthesis. Patients who have a large amount of bone loss may require an allograft with the surgical reconstruction. Although the patient reported a fall, her history is also consistent with preexisting loosening of the prosthesis. Chronic infection has been shown in up to 16% of these fractures; however, the patient’s work-up revealed no infection.
REFERENCES: Garbuz DS, Masri BA, Duncan CP: Periprosthetic fractures of the femur: Principles of prevention and management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 237-242.
Bethea JS III, DeAndrade JR, Fleming LL, Lindenbaum SD, Welch RB: Proximal femoral fractures following total hip arthroplasty. Clin Orthop 1982;170:95-106.
Kelley SS: Periprosthetic femoral fractures. J Am Acad Orthop Surg 1994;2:164-172.

Question 23

A 22-year-old volleyball player reports the insidious onset of superior and posterior shoulder pain. Radiographs are normal. An MRI scan is shown in Figure 25. What is the most specific physical examination finding?

Explanation

DISCUSSION: Overhead athletes are prone to a number of problems involving the shoulder. Pitchers and volleyball players are susceptible to posterior superior labral tears and internal impingement. These patients will have posterior superior shoulder pain, a positive relocation sign, and a positive active compression test. Occasionally, these posterior superior labral tears are associated with a spinoglenoid cyst as seen in the MRI scan. These cysts cause compression of the suprascapular nerve which manifests primarily as weakness of the infraspinatus, resulting in weakness of external rotation.
REFERENCES: Romeo AA, Rotenberg DD, Bach BR Jr: Suprascapular neuropathy. J Am Acad Orthop Surg 1999;7:358-367.
Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment. J Bone Joint Surg Am 2000;82:415-424.

Question 24

In the anterior cruciate ligament-deficient knee, what structure provides an important secondary restraint to anterior tibial translation? Review Topic

Explanation

Cadaveric studies have demonstrated the important role of the posterior horn of the medial meniscus in stabilizing the anterior cruciate ligament-deficient knee with significantly greater resultant force in the medial meniscus when subjected to anterior tibial loads. The posterior horn of the medial meniscus is thought to limit anterior tibial translation by acting as a buttress by wedging against the posterior aspect of the medial femoral condyle. The other soft tissues mentioned do not play any significant role in prevention of anterior tibial translation in the anterior cruciate ligament-deficient knee.

Question 25

..Figures 112a and 112b are the anteroposterior and lateral radiographs of a 65-year-old man who has a significant history of tobacco abuse and a 6-week history of right thigh pain. Axial and sagittal MRI scans are seen in Figures 112c and 112d. His MR angiogram is shown in Figure 112e. A biopsy of a lesion is shown in Figure 112f. What is the most likely diagnosis?

Explanation

CLINICAL SITUATION FOR QUESTIONS 113 THROUGH 116
Figures 113a and 113b are the radiographs of a 68-year-old-man who has increasing pain in his left groin with weight-bearing activities and a Trendelenburg gait. Radiographs reveal a lytic lesion of the greater trochanter. An initial diagnosis of adenocarcinoma of the lung was made 1 year before this presentation. His lung cancer treatment consisted of partial lobectomy and postsurgical radiation therapy.

Question 26

An 82-year-old woman reports activity-related knee pain. History reveals that she underwent total knee arthroplasty 16 years ago. AP and lateral radiographs and a bone scan are shown in Figures 38a through 38c. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs reveal a large femoral metaphyseal lytic lesion with

well-defined borders. Joint space narrowing medially is consistent with polyethylene wear.

The most likely diagnosis is particle-mediated osteolysis. Metastatic tumors and primary sarcomas adjacent to an arthroplasty are extremely rare. In addition, malignant tumors and infection would more likely reveal a destructive lesion with poorly defined borders and increased uptake on a bone scan. Stress shielding with massive bone loss has not been described in knee arthroplasty literature, although this entity has been observed in fully porous-coated femoral implants in total hip arthroplasty.
REFERENCES: Robinson EJ, Mulliken BD, Bourne RB, et al: Catastrophic osteolysis in total knee replacement: A report of 17 cases. Clin Orthop Relat Res 1995;321:98-105.
Archibeck MJ, Jacobs JJ, Roebuck KA, et al: The basic science of periprosthetic osteolysis. Instr Course Lect 2001;50:185-195.
Bugbee WD, Culpepper WJ, Engh CA Jr, et al: Long-term clinical consequences of stress-shielding after total hip arthroplasty without cement. J Bone Joint Surg Am 1997;79:1007-1012.

Question 27

Figure 45 shows the radiograph of a 2-year-old patient who has progressive lumbar scoliosis as the result of hemivertebra. Examination reveals no associated cutaneous lesions, and an MRI scan shows no associated intraspinal anomalies. Treatment should consist of

Explanation

DISCUSSION: In a retrospective review of 10 patients treated with hemivertebra excision for hemivertebra in the levels of T12 to L3, the procedure was found to be safe and effective. The procedure provided an average curve correction of 67° and was greatest in patients who were younger than age 4 years at the time of surgery. Long anterior and posterior fusion with instrumentation is not the treatment of choice at this age. Either anterior hemiepiphyseodesis or posterior hemiarthrodesis in this isolated hemivertebra setting would be inadequate. Brace treatment is ineffective in management of the primary curvature.
REFERENCE: Callahan BC, Georgopoulos G, Eilert RE: Hemivertebral excision for congenital scoliosis. J Pediatr Orthop 1997;17:96-99.

Question 28

78A B Figures 78a and 78b are the emergency department radiographs of an 83-year-old woman who tripped and braced herself against a wall; this was followed by shoulder pain. Which intervention would provide optimal treatment for this patient?

Explanation

DISCUSSION
Low-energy fractures in elderly patients typically are treated with nonsurgical care that involves early immobilization followed by early rehabilitation/therapy, especially when proximal humerus and distal humerus fractures are involved. Physical therapy should be initiated within the first 2 weeks. If surgery is needed ORIF is preferred for most fractures, but replacement may improve outcomes for unreconstructable fractures. The use of hemiarthroplasty vs reverse shoulder replacement is currently being debated.
For treatment of distal radius fractures in elderly patients, cast immobilization for about 6 weeks will allow for optimal fracture healing. This should be followed by aggressive therapy to improve range of motion and function. Moderately displaced fractures in elderly patients will result in satisfactory outcomes even though reduction may not be "anatomic."
RECOMMENDED READINGS
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53. doi: 10.2106/JBJS.J.01597. PubMed PMID: 22159849. View Abstract
at PubMed
Tejwani NC, Liporace F, Walsh M, France MA, Zuckerman JD, Egol KA. Functional outcome following one-part proximal humeral fractures: a prospective study. J Shoulder Elbow Surg. 2008 Mar-Apr;17(2):216-9. doi: 10.1016/j.jse.2007.07.016. Epub 2008 Jan 22. PubMed
PMID: 18207430. View Abstract at PubMed
Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma. 2009 Feb;23(2):113-9. doi: 10.1097/BOT.0b013e31819344bf. PubMed PMID:

Question 29

What factor induces myofibrillar muscle protein synthesis (MPS)? Review Topic

Explanation

Resistance exercise induces myofibrillar MPS that drives muscle hypertrophy. Growth hormone/testosterone does not influence MPS in acute response to exercise or adaptive response of muscle hypertrophy to resistance exercise. Recombinant growth hormone administration does not affect MPS. Anabolic steroids do not drive adaptation in humans; an intrinsic autocrine/paracrine factor and mechanotransduction process is involved. Exercise above 60% 1-RM represents anabolic ceiling. There is a sigmoidal dose response to resistance exercise, maximum MPS occurs at > 60% 1-RM. Aerobic-zone exercise does not result in hypertrophy of skeletal muscle, but it does increase oxidative capacity.

Question 30

What are the most likely symptoms and examination findings related to the mass in zone 2 of Guyon’s canal seen in Figure 17?

Explanation

DISCUSSION: The lesion lies in zone II of the ulnar tunnel. In that zone the deep motor branch of the ulnar nerve is susceptible to compression. Distal to the hook of the hamate, the motor branch of the ulnar nerve dives deep to innervate the interossei as it begins to move from an ulnar to radial direction. Because of its course, it has little or no give in response to a mass effect from the floor of Guyon’s canal. Ganglions are the most common cause of ulnar nerve entrapment in the wrist. Lesions in zone I can affect both sensory and motor aspects of the ulnar nerve as well as the motor innervation of the hypothenar muscles. Lesions at the elbow or mid-to-proximal forearm are associated with dorsal hand numbness and tingling.
REFERENCES: Kuschner SH, Gelberman RH, Jennings C: Ulnar nerve compression at the wrist. J Hand Surg Am 1988;13:577-580.
Posner MA: Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instr Course Lect 2000;49:305-317.

Question 31

A 20-year-old man involved in a motor vehicle accident is brought to the emergency department with a C6-7 unilateral facet dislocation. His neurologic examination reveals a focal left-sided C7 nerve root palsy. He is awake and cooperative with questioning and has no other obvious traumatic injuries. What is the most appropriate treatment at this time? Review Topic

Explanation

In the patient who is neurologically intact or has an incomplete injury from a cervical facet dislocation, a closed reduction with weighted tong traction is appropriate when the patient is awake, alert, and cooperative. Although there is a risk that a cervical facet dislocation could occur with an underlying cervical disk herniation, Vaccaro and associates have shown that closed reduction can be safely carried out in the awake, responsive patient. Closed reduction can be performed in the emergency department with traction with skull tongs or a halo ring. A slow stepwise application of weight is added until a reduction is achieved. Any worsening of the neurologic status of the patient requires immediate termination of the closed reduction and further diagnostic imaging before proceeding with further treatment.

Question 32

Figure 1 is the MR image of a 55-year-old man who sustained an acute traumatic injury to his right shoulder with loss of active range of motion. He was initially evaluated by his primary care physician and treated with physical therapy without success. He was referred to an orthopaedist for surgical consultation 8 weeks after sustaining the injury. The orthopaedic surgeon performs a successful arthroscopic repair but notes poor tendon quality at the repair site. The treating surgeon keeps the patient in a sling full time for 6 weeks without formal therapy. One year after surgery, in comparison to early therapy, this rehabilitation program will likely result in

Explanation

Stemless shoulder arthroplasty prostheses have recently been suggested as an alternative to traditional stemmed replacement. Advantages of the stemless surgical technique would include

A. better glenoid exposure than with stemmed prostheses.

B. reliable use in four-part proximal humerus fracture reconstruction.

C. use in proximal humeral malunion without the need for an osteotomy. D. improved long-term survivorship profile.

Question 33

Which Morton neuroma histology is most common?

Explanation

DISCUSSION
Morton neuroma is a compressive neuropathy of the interdigital nerves of the forefoot that most commonly is noted in the third web space. Perineural fibrosis is commonly noted on microscopic examination of resected tissue. This accounts for the relatively higher failure rate of neuroma decompression by transection of the intermetatarsal ligament as opposed to resection. Wallerian degeneration is seen following axonal transection in the distal part of the nerve. Distal axonopathy is degeneration of the axon and myelin and is associated with "stocking-glove" distribution neuropathy. Segmental demyelination is characterized by breakdown of myelin with an intact axon
and is associated with lead poisoning and hereditary sensory motor neuropathy.
RECOMMENDED READINGS
Akermark C, Crone H, Saartok T, Zuber Z. Plantar versus dorsal incision in the treatment of primary intermetatarsal Morton's neuroma. Foot Ankle Int. 2008 Feb;29(2):136-41. doi: 10.3113/FAI.2008.0136. PubMed PMID: 18315967.View Abstract at PubMed
Ha'Eri GB, Fornasier VL, Schatzker J. Morton's neuroma--pathogenesis and ultrastructure. Clin Orthop Relat Res. 1979 Jun;(141):256-9. PubMed PMID: 477115. View Abstract at PubMed
Graham CE, Graham DM. Morton's neuroma: a microscopic evaluation. Foot Ankle. 1984 Nov-Dec;5(3):150-3. PubMed PMID: 6519606. View Abstract at PubMed

Question 34

A 35-year-old patient has right hip pain. Figures 34a and 34b show the coronal MRI scan and the biopsy specimen. What is the most likely diagnosis?

Explanation

DISCUSSION: Alcohol abuse, steroids, Caisson disease, sickle cell disease, and radiation therapy are the leading causes of nontraumatic osteonecrosis of the femoral head.
REFERENCES: Arlet J: Nontraumatic avascular necrosis of the femoral head: Past, present, and future. Clin Orthop 1992;277:12-21.
Stulberg BN, Bauer TW, Belhobek GH, Levine M, Davis A: A diagnostic algorithm for osteonecrosis of the femoral head. Clin Orthop 1989;249:176-182.

Question 35

A 17-year-old high school football player is seen for follow-up after sustaining an injury 3 days ago. He reports that he tackled a player, felt numbness throughout his body, and could not move for approximately 15 seconds. A spinal cord injury protocol was initiated on the field. Evaluation in the emergency department revealed a normal neurologic examination and full painless neck motion. He states that he has no history of a similar injury. An MRI scan of the cervical spine is normal. During counseling, the patient and his family should be informed that he has sustained

Explanation

DISCUSSION: The long-term effect of transient quadriplegia is unknown. Based on a history of one brief episode of transient quadriplegia and normal examination and MRI findings, the risk of permanent spinal cord injury with a return to play is low. There is a risk of recurrent episodes of transient quadriplegia after the initial episode.
REFERENCES: Morganti C, Sweeney CA, Albanese SA, et al: Return to play after cervical spine injury. Spine 2001;26:1131-1136.
Odor JM, Watkins RG, Dillin WH, et al: Incidence of cervical spinal stenosis in professional and rookie football players. Am J Sports Med 1990;18:507-509.
Torg JS, Naranja RJ Jr, Palov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Vaccaro AR, Watkins B, Albert TJ, et al: Cervical spine injuries in athletes: Current return-to-play criteria. Orthopedics 2001;24:699-703.

Question 36

A 32-year-old man has swelling of the knee as a result of falling with the knee flexed and his foot in plantar flexion. A Lachman’s test reveals an apparent increase in anterior translation. Passive external tibial rotation at 30 degrees and 90 degrees is equal to the contralateral side, and the quadriceps active test is positive on the affected side. The neurovascular examination is normal. Treatment should consist of

Explanation

The question describes a patient with an isolated PCL injury. The mechanism of most athletic PCL injuries is a fall on the flexed knee with the foot in plantar flexion. The results of the physical examination—Lachman’s test with increased anterior translation and a positive quadriceps active test—suggests a PCL injury. The passive external tibial rotation at 30 degrees and 90 degrees being equal to the contralateral side suggest an intact posterolateral corner. In light of these findings, the patient appears to have an isolated PCL injury. In acute isolated posterior cruciate ligament tears with less than 10mm of posterior laxity at 90 degrees of flexion, current knowledge suggests nonoperative treatment that stresses aggressive quadriceps rehabilitation.

Question 37

An obese 62-year-old man reports a 10-year history of progressive flatfoot deformity and a 3-month history of a painful callus along the plantar medial midfoot that has not improved with custom shoe wear, pedorthics, and callus care. There is no hindfoot motion, but functional ankle motion remains. He does not have diabetes mellitus. Radiographs are shown in Figures 27a and 27b. What is the best surgical option at this point?

Explanation

DISCUSSION: The deformity is long-standing, the hindfoot is immobile, and the radiographs reveal severe degenerative arthritis involving the entire hindfoot, severe deformity, and talonavicular dislocation. The “exostosis” responsible for the callus is the talar head; resection would severely destabilize the foot. Degenerative arthritis and fixed deformity preclude lateral column lengthening, medial slide calcaneal osteotomy, and talonavicular arthrodesis. Triple arthrodesis is the only viable option.
REFERENCES: Johnson JE, Yu JR: Arthrodesis techniques in the management of Stage II and III acquired adult flatfoot deformity. Instr Course Lect 2006;55:531-542.
Pinney SJ, Lin SS: Current concept review: Acquired adult flatfoot deformity. Foot Ankle Int 2006;27:66-75.

Question 38

What is the most common cause for late revision (> 2 years post op) total knee arthroplasty?

Explanation

DISCUSSION: There are multiple causes for failure of total knee arthroplasty, and more than one may exist at the same time. Sharkey and associates reviewed a series of revision total knee arthroplasties, and found that polyethylene failure was the most common cause of failure followed closely by component loosening. The most common cause of early failure (< 2 years post op) was infection. Instability and malalignment are both complications of surgical technique, and if these categories are combined, they would be the most common cause of all total knee failures.
REFERENCE: Sharkey PF, Hozack WJ, Rothman RH, et al: Insall Award paper: Why are total knee arthroplasties failing today? Clin Orthop Relat Res 2002;404:7-13.

Question 39

Among the options listed below, what is the best treatment for the complication shown in Figure 10c?

Explanation

DISCUSSION
Proximal femur fractures can be treated using a variety of implants including intramedullary nails, blade plates, and locking plates (now precontoured proximal femur plates). The comminution and lack of medial cortical support may predispose these fractures to nonunion.
The recent popularity of locking plates for proximal femur treatment has increased their use for this fracture; however, a disproportionately high rate of failure of these plates, including early implant failure with plate and screw breakage, cut out with varus collapse, and nonunion have been reported.?
Malreduction predisposes these fractures to failure. The initial postoperative radiographs do not reveal a varus malreduction because the tip of the greater trochanter is below the center of the femoral head.
Once failure occurs, the best fixation method among the options detailed is an intramedullary nail (second generation with screws into the femoral head) and restoration of alignment. THA is usually not recommended for treatment of subtrochanteric femur fractures in young patients.
RECOMMENDED READINGS
Wirtz C, Abbassi F, Evangelopoulos DS, Kohl S, Siebenrock KA, Krüger A. High failure rate of trochanteric fracture osteosynthesis with proximal femoral locking compression plate.
Injury. 2013 Jun;44(6):751-6. doi: 10.1016/j.injury.2013.02.020. Epub 2013 Mar 21. PubMed PMID: 23522837. View Abstract at PubMed
Floyd JC, O'Toole RV, Stall A, Forward DP, Nabili M, Shillingburg D, Hsieh A, Nascone JW. Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures. J Orthop Trauma. 2009 Oct;23(9):628-33. doi: 10.1097/BOT.0b013e3181b04835. PubMed PMID: 19897983. View Abstract at PubMed Glassner PJ, Tejwani NC. Failure of proximal femoral locking compression plate: a case series. J Orthop Trauma. 2011 Feb;25(2):76-83. doi: 10.1097/BOT.0b013e3181e31ccc.
PubMed PMID: 21245709. View Abstract at PubMed

Question 40

A 14-year-old girl has a painful hallux valgus deformity that has not responded to shoe modifications. Figure 21 shows a standing AP radiograph. What is the most appropriate surgical procedure?

Explanation

DISCUSSION: The radiograph reveals an increased first-second intermetatarsal angle

and a congruent metatarsophalangeal joint with an abnormal distal metatarsal articular

angle. Correction of both of these abnormalities requires a proximal and distal first

metatarsal osteotomy.
REFERENCES: Coughlin M: Juvenile bunions, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby, 1993, pp 297-339.
Peterson HA, Newman SR: Adolescent bunion treated with double osteotomy and longitudinal pin fixation of the first ray. J Pediatr Orthop 1993;13:80-84.

Question 41

The swelling pressure in cartilage is predominantly due to the association of exchangeable water with which of the following substances? Review Topic

Explanation

Biglycan and versican are two of the small proteoglycans in cartilage. Biglycan plays a role in molecular association between cartilage and other molecules. Versican is more associated with the cell surface and plays multiple roles. Aggrecan has a longer core protein with multiple keratin sulfate and chondroitin sulfate chains. The molecular weight is around 1,000,000. Aggrecan aggregates on hyaluronic acid with link proteins. Aggrecan can associate with 50 times its weight in water. The resulting swelling pressure is retained by 20% by type II collagen. This results in the physiologic properties of articular cartilage. Type IX collage plays a role in matrix molecule association with type II collagen.

Question 42

A 2-year-old girl has had a swollen right knee for the past 7 weeks. There is no history of significant trauma, and she has not had a fever or been ill. Her parents report that she is stiff in the morning but otherwise does not report pain. A CBC count and erythrocyte sedimentation rate are normal. Treatment with naproxen at appropriate doses for the past 2 weeks has resulted in some improvement. Radiographs show only soft-tissue swelling. Examination reveals a healthy-appearing child with a warm and swollen right knee that is only slightly tender but lacks full extension by 20 degrees. What is the next most appropriate step in management?

Explanation

DISCUSSION: Up to 30% of children with juvenile rheumatoid arthritis (increasingly known now as juvenile idiopathic arthritis or JIA) already have potentially damaging uveitis at the time of diagnosis. This patient has typical oligoarticular JRA (JIA) and therefore is at significant risk for uveitis. MRI, radioisotope scanning, or an ACE level most likely would not provide additional useful diagnostic information because intra-articular derangement, osteomyelitis, or sarcoidosis are all unlikely. Arthrocentesis and triamcinolone hexacetonide joint injection might be indicated if continued use of nonsteroidal medication does not result in improvement, but should be held off for at least an additional 4 to 6 weeks to see if continued use of naproxen results in control of the arthritis.
REFERENCES: Wolf MD, Lichter PR, Ragsdale CG: Prognostic factors in the uveitis of juvenile rheumatoid arthritis. Ophthalmology 1987;94:1242.
Cassidy JT, Petty RE: Textbook of Pediatric Rheumatology. Philadelphia, PA, WB Saunders, 2001, p 220.
Chalom ED, Goldsmith DP, Koehler MA, et al: Prevalence and outcome of uveitis in a regional cohort of patients with juvenile rheumatoid arthritis. J Rheumatol 1997;24:2031-2034.

Question 43

A 56-year-old male sustains a Type IIIB open, comminuted tibial shaft fracture distal to a well-fixed total knee arthroplasty that is definitively treated with a free flap and external fixation. Nine months after fixator removal, he presents with a painful oligotrophic nonunion. Laboratory workup for infection is negative. Passive knee range of motion is limited to 15 degrees. What is the most appropriate treatment for his nonunion?

Explanation

DISCUSSION: At 9 months, observation is no longer an option, as the fracture is not healing and is adjacent to a arthrofibrotic joint. Plate osteosynthesis has been shown to be an effective method of treatment for patients who have had an open fracture of the tibia that has failed to unite after external fixation and/or immobilization in a cast.
Wiss et al reported a series of fifty tibial non-unions with a similar clinical scenario. He reported that, with compression plating, 92% of the nonunions healed without further intervention. In their study, 39/50 patients, had autogenous bone grafting in addition to compression plating.

Question 44

Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive quadriceps active test, and normal Lachman test finding. If the patient chooses surgical reconstruction, he should be advised that, when compared with a transtibial technique, the tibial inlay technique has been shown to provide

Explanation

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading. The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be
appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag. Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used. Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk for vascular injury.

Question 45

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

Explanation

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

Question 46

Figures 36a and 36b show the MRI scans of a patient who has shoulder weakness. What is the most likely diagnosis?

Explanation

DISCUSSION: The sagittal image reveals increased signal and decreased size of the supraspinatus and infraspinatus muscles, indicating muscle atrophy. The rotator cuff tendon signal is normal. The subscapularis and teres minor muscles are unaffected. Muscular dystrophy and thoracic outlet syndrome would be expected to have a more global effect. Although muscular atrophy can occur in the setting of a rotator cuff tear, the coronal image shows an intact supraspinatus. The suprascapular nerve supplies the supraspinatus and infraspinatus muscles. Therefore, suprascapular nerve entrapment would result in atrophy of these muscles with sparing of the surrounding musculature. Any lesion within the suprascapular notch, including neoplastic disease, a venous varix, or neuroma, can place pressure on the suprascapular nerve. Suprascapular nerve entrapment most commonly results from extension of a paralabral cyst or ganglion, often with associated labral pathology. Spinal accessory nerve disruption would show trapezius muscle atrophy.
REFERENCES: Resnick D, Kang HS (eds): Internal Derangement of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 308-317.
El-Khoury G: MRI of the Musculoskeletal System. Philadelphia, PA, JB Lippincott, 1998, p 123.

Question 47

A 78-year-old woman falls onto her nondominant left elbow and sustains the injury shown in Figure A. What treatment option allows her the shortest recovery time and highest likelihood of good function and range of motion? Review Topic

Explanation

Total elbow arthroplasty has become the treatment of choice for complex, comminuted distal humeral fractures in patients older than age 70 years. It yields a faster recovery with more predictable functional outcomes, although limitations of lifting weight of more than 5 pounds must be followed to avoid loosening.

Question 48

A patient reports persistent anterior shoulder pain following a forceful external rotation injury to the shoulder. An MRI scan is shown in Figure 4. The patient remains symptomatic despite 3 months of nonsurgical management. Treatment should now consist of Review Topic

Explanation

The MRI scan reveals a subscapularis tear with a biceps that is out of the groove. Treatment in this patient is most predictable if the subscapularis is repaired. The biceps should either be tenodesed or tenotomized since it is unstable. Recentering of the biceps has been found to be unpredictable. Treatment of these lesions has been shown to have better results if the biceps is either released or tenodesed. This prevents recurrent biceps symptoms that can be source of surgical failure.

Question 49

Figures 7a and 7b show the radiographs of a 51-year-old woman who injured her left leg after falling off a stepladder. Surgical reconstruction is performed with a compression screw and side plate; the postoperative radiograph is shown in Figure 7c. Following gradual progression of weight bearing, she reports that she slipped again and placed full weight on the extremity. She now notes a new onset of increased pain in her left thigh and hip region. Follow-up radiographs are shown in Figures 7d and 7e. Reconstruction should consist of

Explanation

DISCUSSION: The initial fracture was an unstable reverse oblique intertrochanteric fracture with subtrochanteric extension. Initial fixation with a high-angled screw and side plate construct may not provide stability as well as a 95 degree fixed-angle device or a intramedullary hip screw device. The follow-up radiographs show loss of fixation and further propagation of the fracture distally. Reconstruction would best be accomplished with hardware removal and conversion to a long intramedullary nail with femoral head fixation or a 95 degree angled plate and screw device. Conversion to a longer plate does not improve the biomechanical situation at the primary fracture site. In situ bone grafting would not provide any additional stability and would not correct the deformity. The proximal femoral fracture is not amenable to retrograde nailing. Cerclage wiring will not sufficiently enhance stability and is not indicated.
REFERENCES: Bridle SH, Patel AD, Bircher M, Calvert PT: Fixation of intertrochanteric fractures of the femur: A randomized prospective comparison of a gamma nail and dynamic hip screw. J Bone Joint Surg Br 1991;73:330-334.
DeLee JC: Fractures and dislocations of the hip, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 1659-1825.
Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.

Question 50

After reduction and pinning, the radial pulse is absent by both palpation and Doppler. Capillary refill in the fingers appears normal. What is the most likely explanation?

Explanation

DISCUSSION
This is a classic extension-type supracondylar elbow fracture typically caused by a fall on an outstretched hand. The medial comminution of this fracture renders it predictably unstable and susceptible to varus malunion. Extra attention with fixation is required. In general, use of lateral-entry pins alone is effective for most supracondylar humeral fractures. The best technique for fixation with lateral-entry pins only involves maximization of pin separation at the fracture site, engaging sufficient bone in both the proximal segment and the distal fragment and using more than 2 lateral entry pins (if needed) for stability. In the presence of medial comminution, medial fixation also may be necessary.
Brachial artery spasm is the usual cause of absence of radial pulse if capillary refill is normal. Close postsurgical monitoring is warranted after reduction and pinning.

Question 51

Figure 12 shows the radiograph of a patient who has anterior knee pain. History reveals a femoral fracture at age 5 years. What is the most likely cause of the deformity?

Explanation

DISCUSSION: The radiograph shows a recurvatum deformity of the proximal tibia with growth arrest of the tibial tubercle apophysis. This deformity has been described in association with femoral shaft fractures in children and has been attributed to a clinically silent, concommitant injury to the proximal tibial physes and also to iatrogenic injury associated with a proximal tibial traction pin. Overlengthened hamstrings and rupture of the posterior cruciate ligament may lead to knee hyperextension; however, these problems should not cause bone deformity. Osgood-Schlatter disease occurs when growth is nearly complete and usually leads to prominence of the tibial tubercle. Patellar tendon rupture is rare in children and would not cause this deformity unless the repair was performed with screws across the apophysis.
REFERENCES: Hresko MT, Kasser JR: Physeal arrest about the knee associated with non-physeal injuries of the lower extremity. J Bone Joint Surg Am 1989;71:698-703.
Bowler JR, Mubarak SJ, Wenger DR: Tibial physeal closure and genu recurvatum after femoral fracture: Occurrence without a tibial traction pin. J Pediatric Orthop 1990;10:653-657.

Question 52

A minimally invasive plate osteosynthesis is seen in Figure 15. The resultant fracture healing can best be attributed to a fixation construct that was

Explanation

Locked plating constructs with long-working lengths provide flexible but stable constructs that promote (not inhibit) endochondral ossification. Because of the longer working length they are not stiff, and these fractures do not heal with intramembranous ossification which occurs in bones like the calvarium. Direct osteonal healing is usually seen with constructs where absolute stability is achieved through interfragmentary compression, unlike in this case.

Question 53

After making a tackle, a football player is found prone and unconscious without spontaneous respirations. Initial management should consist of

Explanation

DISCUSSION: The on-field evaluation and management of a seriously injured athlete requires that health care teams have a game plan in place and proper equipment that is readily available. The initial step, which consists of stabilizing the head and neck by manually holding them in a neutral position, is then followed by assessment of breathing, pulses, and level of consciousness. If the athlete is breathing, management should consist of mouth guard removal and airway maintenance. If the athlete is not breathing, the face mask should be removed, with the chin strap left in place. The airway must be established, followed by initiation of assisted breathing. CPR is instituted only when breathing and circulation are compromised. In the unconscious athlete or if a cervical spine injury is suspected, the helmet must not be removed until the athlete has been transported to an appropriate facility and the cervical spine has been completely evaluated.
REFERENCES: McSwain NE, Garnelli, RL: Helmet removal from injured patients. Bull of Am Coll Surg 1997;82:42-44.
Vegso JJ: Field evaluation and management of head and neck injuries. Post Grad Adv Sport Med 1987;10:2-10.

Question 54

A 12-year-old boy falls from a bicycle. A radiograph of his injured shoulder is shown in Figure 41. What is the optimal method of treatment?

Explanation

DISCUSSION: The radiograph reveals a distal clavicle fracture. In children, a periosteal sleeve will remain attached to the intact coracoclavicular ligament, and as such, remodeling can be expected. Therefore, nonsurgical management with a sling is preferred. Surgical treatment is not necessary, and a shoulder spica cast offers no advantage over a simple sling.
REFERENCES: Bishop JY, Flatow EL: Pediatric shoulder trauma. Clin Orthop Relat Res 2005;432:41-48.

Question 55

A 12-year-old girl who is 3 months postmenarchal undergoes full-time brace treatment for scoliosis. The posteroanterior radiograph (Figure A ) taken at that time reveals a right thoracic curve measures 28 degrees, and the left lumbar curve measures 23 degrees. At age 15, after 3 years of bracing, a repeat posteroanterior radiograph is obtained, now revealing a right thoracic curve measuring 11 degrees and the left lumbar curve measuring 19 degree, and Risser 4. Which statement best represents the indicated course of action in this patient? Review Topic

Explanation

This patient has adolescent idiopathic scoliosis (AIS) and has reached skeletal maturity. Bracing was successful and discontinuation of bracing is appropriate.
Curves <25° can be treated with observation, while flexible curves from 25° to 45° in skeletally immature patients (Risser 0, 1, 2) should be treated with bracing. Bracing success is most commonly defined as <5° curve progression and failure is 6° or more curve progression at orthotic discontinuation (skeletal maturity), absolute progression to >45° either before or at skeletal maturity, or discontinuation in favor of surgery. Skeletal maturity is defined Risser sign 4, <1cm change in height over 2 visits 6 months apart, 2 years postmenarchal.
Richards et al. attempted to define parameters for future AIS bracing studies. Outcome measures should include patients with (1) <5° curve progression vs >6° progression at maturity, (2) curves exceeding 45° at maturity, or those who have had surgery recommendation/undergone.
Negrini et al. performed a Cochrane systematic review. Basing conclusions on 2
studies, they found that (1) a brace treated curve progression (74% success) better than observation (34% success) and electrical stimulation (33% success), and (2) a rigid brace is more successful than an elastic one (SpineCor) at curbing curve progression.
A
is
a
standing
PA
radiograph
showing.
Incorrect

Question 56

A 19-year-old man was struck by a car and is seen in the emergency department with a grade IIIC open distal tibia and fibula fracture. Examination reveals that the toes are cool and dusky with a sluggish capillary refill. Angiography reveals a lesion in the posterior tibial artery amenable to repair. There is no sensation on the plantar aspect of the foot, and he is unable to flex his toes. A clinical photograph and radiograph are shown in Figures 2a and 2b. What is the next most appropriate step in management?

Explanation

DISCUSSION: In the past, loss of plantar sensation in this grade IIIC tibial fracture would have been an indication for below-knee amputation regardless of the potential for vascular repair. However the 2002 LEAP study divided 55 patients with loss of plantar sensation into two groups, the insensate amputation group and the insensate limb salvage group, with 55% of patients in the insensate salvage group regaining normal sensation 2 years after injury. Furthermore, those in the salvage group who remained insensate after 2 years had equivalent outcomes to those in the amputation group. Because of these findings, limb salvage with vascular repair and external stabilization with delayed closure is deemed appropriate treatment. Immediate intramedullary fixation is not indicated. Because ischemia, contusion, and stretch can adversely affect the tibial nerve, the additional insult of exploration of the nerve is also not advisable given the soft-tissue compromise.
REFERENCES: Bosse MJ, McCarthy ML, Jones AL, et al: The insensate foot following severe lower extremity trauma: An indication for amputation? J Bone Joint Surg Am 2005;87:2601-2608.
Lange RH, Bach AW, Hansen ST Jr, et al: Open tibial fractures with associated vascular injuries: Prognosis for limb salvage. J Trauma 1985;25:203-208.
Mackenzie EJ, Bosse MJ, Kellam JF, et al: Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma 2002;52:641-649.
Baumgaertner MR, Tornetta P III (eds): Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 65-74.

Question 57

Which nerve is most commonly injured after total knee arthroplasty?

Explanation

DISCUSSION
The tibial or peroneal nerves usually are not injured during total knee arthroplasty. Incidence of peroneal nerve damage is highest in knees with a valgus deformity and an associated flexion contracture attributable to nerve stretch. This nerve injury occurs in as many as 9% of patients undergoing knee arthroplasty. Tibial nerve injury is a rare occurrence and usually an iatrogenic transection injury. The infrapatellar branch of the saphenous nerve and its nerve plexus is commonly injured after the medial parapatellar approach, and altered sensation attributable to injury is reported in up to 70% of cases. Injury typically manifests as numbness inferior to the patella. The sartorial branch of the saphenous nerve provides sensation distal to the knee and is uncommonly injured with a medial parapatellar approach. These concepts are illustrated in video 57, “Selective Exposures in Orthopaedic Surgery: The Knee, 2nd Edition.”
RECOMMENDED READINGS
Clarke HD, Bush-Joseph CA, Wolf BR. Selective Exposures in Orthopaedic Surgery: The Knee, 2nd Edition [DVD]. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2012.
Hunter LY, Louis DS, Ricciardi JR, O'Connor GA. The saphenous nerve: its course and importance in medial arthrotomy. Am J Sports Med. 1979 Jul-Aug;7(4):227-30. PubMed PMID: 474860.View Abstract at PubMed
Mistry D, O'Meeghan C. Fate of the infrapatellar branch of the saphenous nerve post total knee arthroplasty. ANZ J Surg. 2005 Sep;75(9):822-4. PubMed PMID: 16174002.View Abstract at PubMed
Schinsky MF, Macaulay W, Parks ML, Kiernan H, Nercessian OA. Nerve injury after primary total knee arthroplasty. J Arthroplasty. 2001 Dec;16(8):1048-54. PubMed PMID: 11740762.View Abstract at PubMed

Question 58

A 58-year-old man with insulin-dependent diabetes mellitus underwent primary total knee arthroplasty (TKA). A full-thickness skin slough measuring 3 cm by 4 cm developed, with postsurgical exposure of the patellar tendon. No change is observed in the appearance of the wound after 2 weeks of wet-to-dry dressing changes. What is the best next treatment step for the soft-tissue defect?

Explanation

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

Question 59

In an acute closed boutonniere injury, what is the most appropriate splinting technique for the proximal interphalangeal joint?

Explanation

DISCUSSION: Rupture of the central slip of the extensor mechanism and a varying degree of lateral band volar migration are the pathologic entities in an acute boutonniere injury. Splinting the proximal interphalangeal joint in full extension allows reapproximation of the central slip to the base of the middle phalanx. Distal interphalangeal joint flexion is permitted to allow movement of the lateral bands distally and dorsally, preventing contracture.
REFERENCES: Newport ML: Extensor tendon injuries in the hand. J Am Acad Orthop Surg 1997;5:59-66.
Lovet WL, McCalla MA: Management and rehabilitation of extensor tendon injuries. Orthop Clin North Am 1983;14:811-826.

Question 60

A 55-year-old woman undergoes an anterior cervical diskectomy and fusion at C5-C6 through a left-sided approach. One year later, she requires an anterior cervical diskectomy and fusion on another level. Which of the following is considered a contraindication to performing a right-sided approach for the revision procedure?

Explanation

DISCUSSION: When attempting a revision anterior cervical approach from the side opposite the original approach, it is important to evaluate the function of the vocal cords. If this evaluation reveals dysfunction of the vocal cord on the side of the original approach, then an approach on the contralateral side should not be attempted. Injury to the stellate ganglion, which causes a Horner’s syndrome, should not preclude an approach on the contralateral side. While the side of the symptomatology can influence the surgeon’s choice as to the side of an anterior approach, it does not preclude a certain approach. When approaching the lower cervical spine from the right side, the recurrent laryngeal nerve can cross the surgical field and should be preserved. Excessive intraoperative pressure on the esophagus can increase the incidence of dysphagia, but its incidence is no different with either approach.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 387-394.
Edwards CC II, Riew KD, Anderson PA, et al: Cervical myelopathy: Current diagnostic and treatment strategies. Spine J 2003;3:68-81.

Question 61

What is the most common complication requiring reoperation after dorsal plating for a distal radius fracture?

Explanation

DISCUSSION: The most common complication of dorsal plating is extensor tenosynovitis, which often causes pain and is a frequent reason for hardware removal. Other less frequent complications include loss of reduction and extensor tendon ruptures, with flexor tendon ruptures occuring to an even lesser degree.
REFERENCES: Rozental TD, Beredjiklian PK, Bozentka DJ: Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Joint Surg Am 2003;85:1956-1960.
Kambouroglou GK, Axelrod TS: Complications of the AO/ASIF titanium distal radius plate system (pi plate) in internal fixation of the distal radius: A brief report. J Hand Surg Am 1998;23:737-741.

Question 62

Which of the following findings is considered a contraindication for posterior decompression (with or without fusion) for myelopathy?

Explanation

DISCUSSION: Although cervical instability is a contraindication to posterior decompression alone, segmental instability in the myelopathic cervical spine can be addressed with concomitant posterior fusion with instrumentation. Cervical lordosis represents the ideal scenario for posterior decompressive procedures for myelopathy (laminectomy and laminoplasty) because compression from anterior osteophytes, if present, is relieved as the spinal cord migrates posteriorly. The anteroposterior diameter of the spinal canal does not have an impact on the selection of surgical approach. Posterior unroofing-type procedures in kyphotic cervical spines, however, are ineffective because anterior impingement on the spinal cord will remain; therefore, kyphosis of more than 10° is considered a contraindication for posterior decompression.
REFERENCES: Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Malone DG, Benzel EC: Laminotomy and laminectomy for spinal stenosis causing radiculopathy or myelopathy, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 817-823.

Question 63

Which of the following provocative tests would most likely be positive in a patient with medial epicondylitis? Review Topic

Explanation

A provocative test for medial epicondylitis can be elicited by applying resistance to a patient with their fist clenched, wrist flexed and pronated.
Medial epicondylitis is an overuse syndrome of the flexor-pronator mass. The pronator teres (PT) and flexor carpi radialis (FCR) are thought to be most affected with this condition. It is most common in the dominant arm and occurs with activities that require repetitive wrist flexion/forearm pronation. Patients are most tender over the origin of PT and FCR at the medial epicondyle. Resisting a patient with their fist clenched, wrist flexed and pronated can cause worsening of their pain. This maneuver can be used as a provocative test for this condition.
Cain et al. reviewed elbow injuries in throwing athletes. They comment that the common flexor-pronator muscle origin provides dynamic support to valgus stress in the throwing elbow, especially during early arm acceleration and help produce wrist flexion during ball release.
Amin et al. reviewed the evaluation and management of medial epicondylitis. They report that medial epicondylitis typically occurs in the fourth through sixth decades of life, the peak working years, and equally affects men and women. Physical therapy and rehabilitation is the main aspect of recovery from medial epicondylitis, once acute symptoms have been alleviated.
Illustration A shows a video of this provocative test for medial epicondylitis. Incorrect Answers:

Question 64

An 18-year-old football player is injured after making a tackle with his left shoulder. He has decreased sensation over the lateral aspect of the left shoulder and radial aspect of the forearm. Motor examination reveals weakness to shoulder abduction and external rotation as well as elbow flexion. He has decreased reflexes of the biceps tendon on the left side but full, nontender range of motion of the cervical spine. What anatomic site has been injured?

Explanation

DISCUSSION: The athlete has symptoms referable to the axillary, musculocutaneous, and suprascapular nerves resulting from an injury to the upper trunk of the brachial plexus. This portion of the plexus is formed by contributions of the fourth through sixth cervical nerve roots. This area is often contused or stretched following a tackling maneuver that results in either depression of the shoulder from contact at Erb’s point or traction of the upper plexus from forced stretching of the neck to the contralateral side.
REFERENCES: Schenck CD: Anatomy of the innervation of the upper extremity, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face, ed 2. St Louis, MO, Mosby-Year Book, 1991.
Hershman EB: Brachial plexus injuries. Clin Sports Med 1990;9:311-329.

Question 65

A 17-year-old basketball player and pole vaulter who has had anterior knee pain for the past 18 months now reports a recent inability to jump. Based on the MRI scan shown in Figure 11, management should consist of

Explanation

DISCUSSION: The MRI scan reveals a partial patellar tendon rupture in conjunction with chronic patellar tendinitis. Mild and moderate patellar tendinitis may be treated nonsurgically with rest, stretching, strengthening, and anti-inflammatory drugs. Severe tendinopathy or extensor mechanism disruption is best treated surgically with tendon debridement and repair.
REFERENCES: Al-Duri ZA, Aichroth PM: Surgical aspects of patella tendonitis: Techniques and results. Am J Knee Surg 2001;14:43-50.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 218-219.

Question 66

A 45-year-old man with a painful varus knee is being considered for an upper tibial osteotomy. Which of the following factors is considered the most compelling argument against this procedure?

Explanation

DISCUSSION: Proximal tibial osteotomy is appropriate for the younger and/or athletic patient who has mild to moderate medial compartment osteoarthritis. Relative contraindications include limited range of motion (eg, flexion contracture of 15°), anatomic varus of greater than 10°, advanced patellofemoral arthritis, and tibial subluxation. Inflammatory arthritides involve all the compartments and are a contraindication to osteotomies around the knee.
REFERENCE: Kelly MA: Nonprosthetic management of the arthritic knee, in Callaghan JJ, Dennis DA, Paprosky WG, Rosenberg AG (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 245-249.

Question 67

A B C Figures 30a through 30c are the radiograph and MR images of a 54-year-old woman who has severe leg pain with walking. Her treatment has included 12 weeks of physical therapy, anti-inflammatory medications, and narcotic pain relievers, and she is interested in surgery. Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is recommended. When compared with open TLIF, MIS TLIF is associated with

Explanation

DISCUSSION
MIS TLIF involves a steep learning curve but is associated with similar longterm outcomes as open TLIF, arguably comparable or possibly lower complication rates, and equivalent fusion rates. The major distinguishing feature comparing open to minimally invasive surgery for this and other spinal diagnoses has been shorter hospital stays.
RECOMMENDED READINGS
Peng CW, Yue WM, Poh SY, Yeo W, Tan SB. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976). 2009 Jun 1;34(13):1385-9. doi: 10.1097/BRS.0b013e3181a4e3be. PubMed PMID: 19478658. View
Abstract at PubMed
Lee KH, Yue WM, Yeo W, Soeharno H, Tan SB. Clinical and radiological outcomes of open versus minimally invasive transforaminal lumbar interbody fusion. Eur Spine J. 2012 Nov;21(11):2265-70. doi: 10.1007/s00586-012-2281-4. Epub 2012 Mar 28. PubMed PMID:

Question 68

A 28-year-old anesthesia resident has aching pain in his dominant right forearm after injuring it while playing basketball 1 week ago. He reports that he is unable to perform regional anesthesia that requires manipulation of a needle. Examination reveals that he is unable to flex the interphalangeal joint of the thumb, and flexion of the distal interphalangeal joint of the index finger is weak. Management should consist of

Explanation

DISCUSSION: The patient has anterior interosseous nerve palsy. Initial management should consist of splinting followed by observation; surgical decompression may be required if there is no improvement in the functional deficit in 6 months. Anterior interosseous nerve palsy is classically described as an inability to flex the interphalangeal joint of the thumb because of flexor pollicis longus paralysis and a weakness or inability to flex the distal interphalangeal joint of the index finger because of weakness and/or paralysis of the flexor digitorum profundus to the index finger. There has been some controversy in the literature as to whether this represents a true peripheral compression neuropathy or neuritis. Recent recommendations have been to extend the period of observation from 3 to 6 months before surgical decompression, as most cases will resolve within 6 months.
REFERENCES: Miller-Breslow A, Terrono A, Millender LH: Nonoperative treatment of anterior interosseous nerve paralysis. J Hand Surg Am 1990;15:493-496.
Stern PJ, Fassler PR: Anterior interosseous nerve compression syndrome, in Gelberman RH (ed): Operative Nerve Repair and Reconstruction. Philadelphia, PA, 1991, vol 2, pp 983-1002.

Question 69

Figure 6 shows the lateral radiograph of a 22-year-old woman who has painful Scheuermanns’s kyphosis in the middle and lower thoracic spine. When planning surgical correction using instrumentation, the distal aspect of the instrumentation should ideally extend to the

Explanation

DISCUSSION: Posterior constructs for Scheuermann’s kyphosis ideally should extend from the most superior to the most inferior aspect of the Cobb angulation. However, the most distal fusion level must be in a stable or lordotic position to avoid the development of junctional kyphosis. Lowe reported that failure to incorporate the first lordotic segment of the lumbar spine is associated with a higher risk of junctional kyphosis. The first lordotic segment of the lumbar spine is typically at least one level below the distal aspect of the curve as measured by the Cobb technique and most commonly is in the upper part of the lumbar spine.
REFERENCES: Lowe TG: Scheuermann’s disease. Orthop Clin North Am 1999;30:475-487.
Lenke LG: Kyphosis of the thoracic and thoracolumbar spine in the pediatric patients: Prevention and treatment of surgical complications. Instr Course Lect 2004;53:501-510.

Question 70

A patient who underwent total knee arthroplasty 6 years ago now reports knee pain for the past 3 days following dental surgery. Cultures of the aspirate are positive for Staphylococcus epidermidis. Management should consist of

Explanation

DISCUSSION: The patient has an early prosthesis infection as a result of hematogenous seeding from dental surgery. Irrigation and debridement with polyethylene exchange and IV antibiotics have been successful in early postoperative infections; it is less likely to be effective for a late hematogenous infection. Immediate total component exchange also may be effective, but it should be reserved for failure of irrigation and debridement.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 323-337.
Goldman RT, Scuderi GR, Insall JN: 2-stage reimplantation for infected total knee replacement. Clin Orthop 1996;331:118-124.

Question 71

..Figures 87a through 87e are the radiograph, MRI scans, and biopsy specimen of an 83-year-old woman who is experiencing pain in her distal thigh with activity and at night. She has undergone total hip arthroplasty for hip osteoarthritis. The most appropriate treatment is

Explanation

CLINICAL SITUATION FOR QUESTIONS 88 through 92
Figures 88a and 88b are the radiographs of a 70-year-old woman with a remote history of localized renal cell carcinoma. She has insidious onset of right shoulder pain that worsens with any activity and at night. She appears otherwise healthy.

Question 72

Kyphosis from a vertebral osteoporotic compression fracture often results in progressive kyphosis due to Review Topic

Explanation

Kayanja and associates, in a number of biomechanical studies, showed that in a kyphotic spine the strain is located at the apex of the deformity, the force is transmitted to the superior adjacent vertebrae, and that realignment and cement augmentation effectively normalize the load transfer.

Question 73

The MRI scan shown in Figure 33 reveals the sequelae of an acute traumatic anteroinferior shoulder dislocation. The image reveals the typical separation of what two commonly injured structures? Review Topic

Explanation

The MRI scan reveals the sequelae of an anteroinferior dislocation, specifically separation of the anteroinferior labrum from the bony glenoid. The separation does not classically occur only at the cartilage-labral junction, but extends to the bony surface of the medial glenoid neck. Separation of the biceps tendon from its origin on the supraglenoid tubercle (SLAP lesion) or separation of the anterior capsule with the proximal humerus (HAGL lesion) may occur but are not the most common sequelae and are not demonstrated in this MRI image. Anteroinferior shoulder dislocations normally do not affect the posterior labral structures. In their landmark study, Rowe and associates noted that this demonstrated lesion was the most common lesion, present in 85% of their series.

Question 74

A patient undergoes excision of a 3- x 3-cm soft-tissue sarcoma. The final histology results show tumor at the surgical margin. The surgical procedure performed is classified as

Explanation

DISCUSSION: Surgical margins are classified according to the plane of dissection in relation to the tumor. An intralesional procedure is where the plane of dissection passes through the tumor. A marginal resection involves a resection where the plane of dissection is through the reactive zone of the tumor. A wide resection is through completely normal tissue outside of the reactive zone. A radical resection removes all of the muscles and/or bone of the compartment that are involved by the tumor.
REFERENCE: Enneking WF, Spanier SS, Goodman MA: A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop 1980;153:106-120.

Question 75

Which of the following is considered the most useful screening method for the evaluation of protective foot sensation in a patient with diabetes mellitus?

Explanation

DISCUSSION: Patients with diabetes mellitus should be screened for the presence of protective foot sensation. In the absence of protective foot sensation, patients are at increased risk for the development of neuropathic ulcerations and neuropathic arthropathy. The most reliable screening tool for the presence of protective sensation is the ability to feel the 5.07 Semmes-Weinstein monofilament.
REFERENCES: Pinzur MS, Shields N, Trepman E, Dawson P, Evans A: Current practice patterns in the treatment of Charcot foot. Foot Ankle Int 2000;21:916-920.
Smith KD, Emerzian GJ, Petrov O: A comparison of calibrated and non-calibrated 5.07 nylon monofilaments. Foot Ankle Int 2000;21:852-855.

Question 76

below depict the radiographs obtained from a year-old woman with a painful total knee arthroplasty. She describes an uneventful recovery with no wound-healing issues and was pain free for the first 10 years. Although reporting no trauma or inciting event, she now describes pain in the entire knee that is most severe with her first few steps. She has begun to notice night pain and, more recently, constant swelling. What is the most appropriate work-up at this time?

Explanation

DISCUSSION:
An evaluation of the painful total knee must be supported by an understanding of the potential etiologies of pain. They may include, aseptic loosening, infection, osteolysis, gap imbalance, referred pain, stiffness, and complex regional pain syndrome. In this case, the patient demonstrates start-up pain and had no prior history of infections. Her radiographs show subsidence of the tibia, indicating a loose prosthesis. Knowing that the prosthesis is already loose precludes the need for a bone scan. It is, however, important to rule out infection in this case; therefore, CRP and ESR testing is essential. Aspiration is also recommended when going into knee arthroplasty, and infection is a concern.

Question 77

In the United States, groups at risk for community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) within the pediatric and adolescent populations include

Explanation

CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 68
Figures 64a through 64d are the radiographs of an 11-year-old boy with a prolonged history of activity-related ankle pain. An examination is notable for restricted subtalar motion and moderate pes planovalgus.

Question 78

What is the most common type of malalignment after intramedullary nailing of distal 1/3 tibia fractures?

Explanation

DISCUSSION: Puloski et al determined the incidence and severity of tibial malrotation following reamed intramedullary nail fixation as measured by computerized tomography. Malrotation was defined as an internal/external rotation deformity greater than 10 degrees. They found that 5 (22%) of the tibia were malrotated greater than 10 degrees, and of those 5 tibia, 4 were distal 1/3 fractures.
McKee et al randomized 85 patients undergoing intramedullary tibial nailing using manual traction with the leg draped free versus standard fracture table positioning and traction. They found that manual traction is an effective technique that can save a significant amount of time without sacrificing the quality of reduction or fixation of tibial shaft fractures.

Question 79

A 56-year-old man has a chief complaint of leg weakness and inability to walk. Examination reveals 5 out of 5 motor strength in all lower extremity muscle groups tested and normal sensation to light touch in both lower extremities. The patient is slow in getting up from a seated position and has an unsteady wide-based

Explanation

The patient is having gait problems suspicious for spinal cord compression. MRI of the thoracic and cervical spine should be performed to evaluate for spinal cord compression. Reports of leg weakness in the absence of discrete motor weakness on manual testing, and the appearance of an unsteady wide-based gait are more consistent with myelopathy as a cause of the gait difficulty rather than lumbar stenosis. Although the MRI scan of the lumbar spine shows multilevel spinal stenosis that is mild to moderate, it does not clearly explain the patient's signs and symptoms. Electromyography and nerve conduction velocity studies of the lower extremities are unlikely to add significantly to the diagnosis. Epidural steroid injections are not indicated. Lumbar decompression is unlikely to help the patient because the source of the patient's problem does not originate in the lumbar spine. MRI of the brain could be considered as a secondary imaging study if the cervical and thoracic MRI scans fail to identify an obvious cause for gait instability.

Question 80

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 81

The addition of which of the following food supplements may lead to a decrease in neural tube defects?

Explanation

DISCUSSION: The use of folic acid in developed countries has lead to a decrease in neural tube defects. The incidence of neural tube defects is increased in third world countries.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 111-122.
Lemke L, Dias L: Spina bifida, in Cramer KE, Scherl SA, Einhom TA (eds): Orthopaedic Surgery Essentials: Pediatrics. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 203-210.

Question 82

Which of the following is considered a risk factor for the development of low back pain?

Explanation

DISCUSSION: Risk factors associated with low back pain include poor physical fitness, smoking, a history of repetitive bending or stooping on the job, or whole body vibration exposure. Some radiographic factors such as stenosis, spondyloarthropathy, severe deformity, or instability are also associated with low back pain. Gender, weight, transitional anatomy, or facet trophism are not associated with low back pain.
REFERENCE: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 627-643.

Question 83

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

Explanation

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

Question 84

Figures 189a through 189d are the radiograph and MR images of the right hip of a 28-year-old woman who has had right hip pain for 3 years. The pain is felt in the groin area, is exacerbated by weight-bearing activities, and interferes with her activities of daily living. She has been seen several times and has attempted anti-inflammatory medications, physical therapy, and an intra-articular steroid injection with minimal relief. What is the most appropriate next step?

Explanation

DISCUSSION

Video 189 for reference
This patient has dysplasia with a lack of lateral femoral head coverage. The MR images do not demonstrate a labral tear. There is still preserved joint space and she is young, so it would be preferable to delay THA in her case. A Ganz periacetabular osteotomy can provide more adequate coverage of the femoral head and is a multiplanar correction of the dysplastic acetabulum. This osteotomy is an effective treatment for symptomatic dysplasia in prearthritic young adult hips. A femoral osteotomy is not likely to be effective in this scenario.
CLINICAL SITUATION FOR QUESTIONS 190 THROUGH 192
Eighteen years after undergoing right total hip arthroplasty (THA), a 79-year-old woman experiences several weeks of right groin pain. A hip examination reveals that she is walking with a mild limp with a walker. Hip radiographs reveal moderate polyethylene wear with well-fixed components and mild osteolysis in the greater trochanter. Analysis of a CT scan reveals that the acetabular component is osteointegrated in 49 degrees of abduction and 25 degrees of anteversion. Erythrocyte sedimentation rate and C-reactive protein findings are within defined limits.

Question 85

Diagnostic work-up concluded that the patient has metastatic lymphoma. He has no neurologic deficit.Based on these findings, what is the most appropriate management for this spinal condition?

Explanation

DISCUSSION FOR QUESTIONS 107 THROUGH 109:
Patients with no prior diagnosis of cancer may present with vertebral lesions. After obtaining initial radiographs, the next most appropriate step is to obtain an MRI with gadolinium. To determine the primary site of the disease, a CT of the chest, abdomen, and pelvis is the next step in establishing a diagnosis. Radiation therapy is the first line of treatment in spinal metastatic disease from lymphoma because it is a highly radiosensitive tumor.

Question 86

Which of the following represents a contraindication for interspinous process decompression for the treatment of lumbar spinal stenosis? Review Topic

Explanation

Kondrashov and associates noted stable good outcomes at 4 years in 14 of 18 patients treated with X-STOP interspinous process decompression as defined as an improvement over preoperative Oswestry scores of 15 points or more. Similar results were seen after 1 year in a European study by Siddiqui and associates. Exclusion and inclusion criteria for these studies varied somewhat, but cauda equina syndrome was the only exclusion criteria listed in both studies. All of the other choices did not represent exclusion criteria in either study.

Question 87

A 25-yo man sustains the injury shown in Figures 29a and 29b as a result of high-speed trauma. Examination reveals diffuse weakness in the lower extremities that is slightly worse on the right side, and decreased rectal tone and sensation. A CT scan is shown in figures 29c and 29d. Definitive treatment of the injury to the spine is delayed because of a severe pulmonary contusion. At 15 days after the injury, the patient’s neurological status remains unchanged. Management should now consist of

Explanation

Anterior decompression is preferred for patients who have incomplete neurologic injury with a compression or burst fracture, if the posterior ligament complex has not been disrupted. Progressive ambulation with a TLSO may be indicated for a simple wedge compression fracture. If the compression is greater than 40% and no neural deficit, then posterior stabilization may be indicated to prevent further collapse and neural deficit. Wedge compression with subluxation or dislocation indicates disruption of posterior ligament complex requiring posterior instrumentation and fusion. Compression and distraction injuries of the middle complex should be treated by Harrington or C-D distraction and compression instrumentation. (Bohlman: The Spine, 1992 pp1047-1056)

Question 88

Figures 52a and 52b show the radiographs of a left proximal femoral lesion noted serendipitously following minor trauma to the left hip. The patient has no thigh pain and is fully active without limitation. What is the most likely diagnosis of this bony lesion?

Explanation

DISCUSSION: The radiographs reveal a geographic lesion of the proximal femur with the classic “ground glass” appearance noted in fibrous dysplasia. This intramedullary lesion is modestly expansile, demonstrates some minimal cortical thinning, and has no aggressive features. Chondroblastoma, giant cell tumor, and osteoblastoma are more lytic in appearance, and the location is not typical for giant cell tumor or chondroblastoma. While enchondroma may be considered, the uniform ground glass appearance, lack of punctuate mineralization, and distinct margination of the lesion make that diagnosis less likely.
REFERENCE: Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 89

A college basketball player is struck in the eye by a player’s hand while driving to the basket. Fluorescein evaluation reveals the injury shown in Figure 18. Management should consist of

Explanation

DISCUSSION: The athlete has a corneal abrasion. Fluorescein staining identifies the break in the epithelium when examined with ultraviolet light. Topical antibiotics are used as prophylaxis against secondary bacterial infection, and the patch, applied with the lid closed, is used for comfort and to promote epithelial healing. The accompanying symptoms, including pain, tearing, and photophobia, are usually too intense to allow a return to play. Surgery is reserved for a corneal laceration with associated loss of the anterior chamber. While a proper fundoscopic examination may be a consideration, increased intraocular pressure is not typically associated with this injury. Traumatic hemorrhage in the anterior chamber (hyphema) necessitates strict bed rest during the early phases of healing; examination will most likely reveal the red fluid level of blood settling inferiorly in the anterior chamber. It is often associated with increased intraocular pressure.
REFERENCES: Brucker AJ, Kozart DM, Nichols CW, et al: Diagnosis and management of injuries to the eye and orbit, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face. St Louis, MO, Mosby-Year Book, 1991, pp 650-670.
Zagelbaum BM: Treating corneal abrasions and lacerations. Phys Sports Med 1997;25:38-44.

Question 90

A 12-year-old boy reports limping and chronic knee pain that is now inhibiting his ability to participate in sports. Clinical examination and radiographs of the knee are normal. Additional evaluation should include

Explanation

DISCUSSION: While all of the answers may be appropriate, radiating pain from hip pathology must be excluded. At this age, a slipped capital femoral epiphysis is likely. Therefore, the hip must be examined.
REFERENCES: Kocher MS, Bishop JA, Weed B, et al: Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics 2004;113:322-325.
Matava MJ, Patton CM, Luhmann S, et al: Knee pain as the initial symptom of slipped capital femoral epiphysis: An analysis of initial presentation and treatment. J Pediatr Orthop 1999;19:455-460.

Question 91

A 17-year-old male lacrosse player sustains an ACL tear. Imaging reveals closed physes and you recommend a transphyseal ACL reconstruction. His mother asks whether a “cadaver tendon” can be used to reconstruct his ACL instead of using his own tendon. What is the most appropriate response regarding the use of allograft compared to autograft for ACL reconstruction in an active adolescent? Review Topic

Explanation

In an active adolescent, anterior cruciate ligament reconstruction (ACLR) with allograft has a significantly higher risk of graft failure and need for revision surgery compared to ACLR with autograft.
The incidence of anterior cruciate ligament (ACL) injuries in adolescent athletes has significantly increased over the recent years, now comprising 24.5% of all ligamentous knee injuries in high school athletes. In skeletally mature adolescents, transphyseal ACLR is often performed, similar to adult patients. Proposed advantages of allograft reconstruction in patients of all ages include lack of donor-site morbidity, absence of size limitation, preservation of knee flexor/extensor mechanism, less risk of postoperative knee stiffness/pain and cosmetic appearance. Benefits of autografts include strong structural and fixation properties as well as optimal biologic incorporation.
Kraeutler et al. performed a meta-analysis comparing bone-patellar tendon-bone (BPTB) autograft to allograft for ACLR. Patients who underwent ACLR with BPTB autograft demonstrated lower rates of graft rupture, lower levels of knee laxity, improved single-legged hop test results and were more satisfied postoperatively compared to ACLR with BPTB allograft. The authors therefore recommended BPTB
autograft
ACLR,
particularly
in
young
active
patients.
Engelman et al. performed a case-control study comparing ACLR in an adolescent cohort using autograft or allograft. Postoperative knee laxity and use of allograft were significantly related to graft failure and need for revision surgery. There was no difference in functional outcome scores, knee range of motion, infection or growth disturbance. There was no difference in graft survival between low-dose (<2 Mrad) gamma-irradiated allografts and nonirradiated allografts.
Pallis et al reported a prospective cohort study of 122 ACLR performed in cadets prior to matriculation at the United States Military Academy (USMA). Cadets who entered the USMA with an allograft ACLR were 7.7 times more likely to experience graft failure compared to BPTB and hamstring (HS) autograft groups. There was no significant difference in failure between the BPTB and HS autograft groups. The authors recommend autograft ACLR for young, active individuals.
Incorrect
Responses:

Question 92

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

Explanation

Scheuermann’s Disease classically presents with >45o thoracic kyphosis and anterior wedging (5o or more) at three sequential vertebrae. Disc narrowing, end-plate irregularities, scoliosis, spondylosis, and Schmorl’s nodes are also seen. It’s more common in adolescents and males. Normally, these patients are treated (1) in a brace if the curve is progressive and Risser 3 or less,
(2) with surgical fusion if >75o and Risser 3 or less, (3) with surgical fusion if >65o and Risser 4/5 if necessary or symptomatic. Posterior instrumentation, anterior release and interbody fusion is the treatment of choice for curves >75o, or those >55o on hyperextension. Other causes of kyphosis include trauma, infection, spondylitis, bone dysplasia, neoplasia, neurofibromatosis.

Question 93

A 23-year-old man sustained an injury to his left foot when a forklift rolled over it at work. Examination reveals marked swelling of the midfoot and forefoot, with tenderness to palpation over the medial hindfoot and dorsomedial forefoot. The distal dorsalis pedis pulse is audible on Doppler examination, and his sensation is intact to touch. Radiographs are shown in Figures 33a and 33b. Management should consist of

Explanation

DISCUSSION: The best results after dislocations of the tarsometatarsal joints are seen with anatomic reduction; this is best achieved by open reduction and maintained with internal fixation with either pins or screws. Open reduction provides a means of debriding small bony fragments from the joint and allowing direct inspection of the reduction. Associated crush or shearing fractures of the cuboid or tarsal navicula are signs that suggest a Lisfranc injury. Because patients can function quite well despite the development of arthrosis in the Lisfranc joint, primary arthrodesis is not indicated in the management of this injury.
REFERENCES: Resch S, Stenstrom A: The treatment of tarsometatarsal injuries. Foot Ankle 1990;11:117-123.
Schenck RC Jr, Heckman JD: Fractures and dislocations of the forefoot: Operative and nonoperative treatment. J Am Acad Orthop Surg 1995;3:70-78.
Kuo RS, Tejwani NC, Digiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.

Question 94

A 45-year-old man who underwent an ankle arthrodesis reports that for the first 6 years he had significant pain relief after the fusion healed. However, he now has increasing pain in the sinus tarsi. AP and lateral radiographs are shown in Figures 8a and 8b. What is the most likely cause of the patient’s symptoms?

Explanation

DISCUSSION: The patient has a solid ankle fusion radiographically. With a tibiotalar arthrodesis, the adjacent joints (subtalar and transverse tarsal) take additional stress. Over time, progressive degenerative arthritis will occur in these adjacent joints, often necessitating further surgery.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 613-631.
Coester LM, Saltzman CL, Leupold J, Pontarelli W: Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 2001;83:219-228.

Question 95

An 18-year-old man sustained closed humeral shaft and forearm fractures of his dominant arm in a motor vehicle accident. Neurovascular examination is intact, and his condition is stable. The best course of action for management of the injuries should be

Explanation

DISCUSSION: Fractures above and below the elbow constitute floating elbow injuries and are best treated with internal fixation to allow early range of motion and to prevent elbow stiffness. Use of a long arm cast would promote elbow stiffness. External fixation is indicated primarily for open injuries.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Bell MJ, Beachamp CG, Kellam JK, McMurtry RY: The results of plating humeral shaft fractures in patients with multiple injuries: The Sunnybrook experience. J Bone Joint Surg Br 1985;67:293-296.

Question 96

What posterior pelvic ring injury is most commonly associated with neurologic compromise?

Explanation

This question requires one to recall pelvic/sacral anatomy along with classification of sacral fractures which according to the first cited article ) Denis, Clinical Orthopedics, 1988) include the following 3 zones: Zone 1-Ala region, lateral to the foraminal line (i.e. distracters #1 and #5);
associated with partial damage to the 5th lumbar root (5.9%). Zone 2-Sacral foramina region, outside of the sacral canal (i.e. distracters #3 and #4); associated with sciatica (28.4%) but rarely bladder dysfunction. Zone 3-Central sacral canal (AKA: Transverse Fx) (i.e. correct answer #2); associated with saddle anesthesia and loss of sphincter tone; neurologic damage (56.7%) and involvement of bowel, bladder, and sexual dysfunction (76.1%).

Question 97

A 61-year-old right-hand-dominant woman falls down the stairs, resulting in a left anteroinferior dislocation and noncomminuted greater tuberosity fracture. A closed glenohumeral reduction with intravenous sedation is performed in the emergency department. After reduction, the greater tuberosity fragment remains displaced by 2 mm. What is the most appropriate treatment?

Explanation

Greater tuberosity fractures and rotator cuff tears associated with a traumatic dislocation are more commonly seen in women >60 years. Greater tuberosity fractures that are displaced <5 mm in the general population and
<3 mm in laborers and professional athletes can be treated successfully without surgery. Early passive range
of motion is important to avoid stiffness.

Question 98

Following its exit from the sciatic notch, the sciatic nerve passes between what two muscles?

Explanation

DISCUSSION: Though anatomic variations exist, both divisions of the sciatic nerve most commonly pass between the piriformis and superior gemellus. This anatomic consideration is relevant during the posterior approach to the hip, where careful retraction of the rotators avoids sciatic nerve injury.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, pp 335-348.
Anderson JE (ed): Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Williams & Williams,

1978, Figure 4-34.
FOR ALL MCQS CLICK THE LINK ORTHO MCQ BANK

Question 99

-Video 3 shows the physical examination of the right hip of a 14-day-old full-term female infant. There is no history of breech presentation, she was born vaginally, and is the second child born to her mother. She is otherwise healthy and has been eating and gaining weight appropriately. What is the most appropriate course of action at this time?

Explanation

Question 100

An orthopaedic surgeon frequently uses hip and knee prostheses from a specific manufacturer. The surgeon becomes acquainted with the manufacturer’s representative who provides the support for these prostheses in the hospital. They develop a personal relationship outside of work through a common interest in sailing. Together they become interested in buying a sailboat. The manufacture’s representative suggests a partnership in a boat costing $200,000. The manufacture’s representative would purchase a 90% interest and the surgeon a 10% interest in the boat. There would be no restrictions on use of the boat by the surgeon. What should the orthopaedic surgeon do?

Explanation

Rejecting this proposal is the only appropriate course of action. Accepting it would, in essence, be receiving a huge gift from industry in the form of a sailboat. Physicians frequently assert that they are not influenced by gifts and relationships with industry representatives, but evidence is to the contrary. Such an arrangement constitutes a tremendous incentive to use the manufacturer’s products. The fact that the boat
partnership seems completely outside of the orthopaedic business relationship does not excuse it. Conflicts of interest should always be resolved and in the best interest of patient care, and in this case the best course clearly is to avoid the conflict of interest totally. An equal interest in the boat does not eliminate the conflict of interest.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

anterior corpectomy with interbody strut.
posterior fusion with instrumentation and posterolateral decompression.
closed reduction and a thoracolumbosacral orthosis (TLSO).
anterior reduction and instrumentation.
supine bed rest for 6 weeks, followed by immobilization in a TLSO.

Correct Answer: posterior fusion with instrumentation and posterolateral decompression.

Explanation:

DISCUSSION: The imaging studies show a fracture-dislocation. Surgical treatment of this injury consists of a decompression reduction, stabilization, and fusion. A posterolateral decompression can also be performed as necessary. An isolated anterior procedure in this type of injury is contraindicated. The anterior longitudinal ligament is most likely intact; therefore, an anterior procedure further destabilizes the spine. Reduction by an anterior approach would also be difficult. Nonsurgical management of the neurologic injury in this patient is not indicated.
REFERENCES: Theiss SM: Thoracolumbar and lumbar spine trauma, in Stannard JP, Schmidt AH, Kregor PJ (eds): Surgical Treatment of Orthopaedic Trauma. New York, NY, Thieme, 2007, pp 179-207.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 2:

Options:

Partial tear of the patellar tendon
Osteochondral fracture of the femur
Anterior cruciate ligament (ACL) tear
Posterior cruciate ligament (PCL) tear
Patella fracture

Correct Answer: Posterior cruciate ligament (PCL) tear

Explanation:

Question 3:

Options:

Pain with internal and external rotation of her hip with her hip and knee in an extended position
Limited motion when moving the hip from flexion-abduction-external rotation to flexion-adduction-internal rotation
Moving from hip flexion-abduction-external rotation to neutral triggers a popping sensation
Limitation in active hip range of motion with catching, locking and grinding noted on passive motion
Pain with a half sit-up and tenderness at the pubic ramus

Correct Answer: Pain with a half sit-up and tenderness at the pubic ramus

Explanation:

Question 4:

Locked lateral plate fixation of the proximal tibia is most appropriate for what Schatzker type fracture?

Options:

I - lateral plateau split
II - lateral plateau split/depression
III - lateral plateau depression
IV - medial plateau fracture
V - bicondylar tibial plateau fracture

Correct Answer: V - bicondylar tibial plateau fracture

Explanation:

Question 5:

Options:

immobilization with a halo ring and vest with reduction when medically stable.
closed traction reduction using Gardner-Wells tongs.
posterior open reduction, stabilization, and fusion.
cervical MRI followed by reduction.
anterior open reduction, stabilization, and fusion.

Correct Answer: cervical MRI followed by reduction.

Explanation:

DISCUSSION: The patient has a bilateral facet dislocation of C6-C7 with preservation of at least some neurologic function. Urgent reduction is necessary. However, because she is sedated and unable to follow commands, an MRI scan is necessary before any closed or open posterior reduction to look for an associated disk herniation. If a disk herniation is present, it must be removed prior to any reduction maneuver to prevent iatrogenic neurologic injury. It is very unlikely that this injury can be reduced with an open anterior procedure alone.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 189-199.
Kwon BK, Vaccaro AR, Grauer JN, et al: Subaxial cervical spine trauma. J Am Acad Orthop Surg 2006;14:78-89.

Question 6:

A biopsy of the involved physis in a patient with slipped capital femoral epiphysis (SCFE) would most likely reveal

Options:

a dense perichondral ring.
an abnormally thick zone of proliferation.
increased undulations or irregularity of the growth plate.
granulation tissue between the columns in the zone of hypertrophy.
normal proteoglycan content.

Correct Answer: granulation tissue between the columns in the zone of hypertrophy.

Explanation:

Question 7:

What is the most common nonanesthetic-related reversible cause of changes in intraoperative neurophysiologic monitoring data? Review Topic

Options:

Pedicle screw misplacement
Patient positioning
Spinal cord ischemia
Retractor placement
Hypotension

Correct Answer: Patient positioning

Explanation:

Question 8:

Options:

Strongly negative needle-shaped crystals
Weakly positive birefringent rhomboid-shaped crystals
Gross blood
Gram-positive cocci
Gram-negative rods

Correct Answer: Weakly positive birefringent rhomboid-shaped crystals

Explanation:

Question 9:

Options:

bone age of the left wrist.
MRI of the spine.
MRI of the brain.
renal and abdominal ultrasonography.
hip ultrasonography.

Correct Answer: renal and abdominal ultrasonography.

Explanation:

DISCUSSION: The patient may have Beckwith-Wiedemann syndrome (BWS), which consists of exophthalmos, macroglossia, gigantism, visceromegaly, abdominal wall defects, and neonatal hypoglycemia. Hemihypertrophy develops in approximately 15% of patients with BWS. Patients with hemihypertrophy that is the result of BWS have a 40% chance of developing malignancies such as Wilms’ tumor or hepatoblastoma; therefore, frequent ultrasound screening is recommended until about age 7 years. The absence of nevi and vascular markings helps to rule out other causes of hemihypertrophy, such as neurofibromatosis, Proteus syndrome, and Klippel-Trenaunay syndrome. Bone age estimations are not accurate at this young age but may become more useful later to help predict the timing of epiphysiodesis procedures.
REFERENCES: DeBaun MR, Tucker MA: Risk of cancer during the first four years of life in children from The Beckwith-Wiedemann Syndrome Registry. J Pediatr 1998;132:398-400.
Ballock RT, Wiesner GL, Myers MT, et al: Hemihypertrophy concepts and controversies.
J Bone Joint Surg Am 1997;79:1731-1738.
Carpenter CT, Lester EL: Skeletal age determination in young children: Analysis of three regions of the hand/wrist film. J Pediatr Orthop 1993;13:76-79.

Question 10:

Options:

Open inferior capsular shift
Arthroscopic thermal capsulorrhaphy
Sling at all times until the pain resolves
Arthroscopic anterior and posterior capsular plication
Physical therapy for rotator cuff and scapulothoracic strengthening

Correct Answer: Physical therapy for rotator cuff and scapulothoracic strengthening

Explanation:

Question 11:

Options:

Alendronate
Indomethacin
Radiotherapy
Excision

Correct Answer: Alendronate

Explanation:

Question 12:

The mangled extremity severity score (MESS) utilizes all of the following variables EXCEPT:

Options:

Limb ischemia
Shock
Patient age
Skeletal and soft tissue injury
Time from admission to surgery

Correct Answer: Limb ischemia

Explanation:

Question 13:

Which of the following design features of a femoral component used in a total knee arthroplasty best minimizes the patellar component contact stresses?

Options:

Shallow, flat anatomic femoral trochlear groove
Deep, curved anatomic femoral trochlear groove
Narrow femoral trochlear groove
Universal trochlear groove (same for right and left)
Thickened anterior flange

Correct Answer: Deep, curved anatomic femoral trochlear groove

Explanation:

Question 14:

Risk for vascular injury during transtibial drilling for reconstruction of this injury is increased by

Options:

accessory incisions.
use of tapered drill bits.
use of oscillating drills.
greater knee extension.

Correct Answer: greater knee extension.

Explanation:

Question 15:

Options:

Avoid wearing the prosthesis until the ulcer is healed and perform local wound care.
Obtain a new prosthesis with an energy-storing foot to dampen impact.
Perform local wound care in conjunction with modification of the prosthetic socket and cushioned liner.
Excise the wound and advance the soft-tissue envelope.
Perform a distal tibiofibular bone bridge and advance the soft-tissue envelope.

Correct Answer: Perform local wound care in conjunction with modification of the prosthetic socket and cushioned liner.

Explanation:

DISCUSSION: The first step in the treatment of an amputation residual limb (stump) ulcer is local wound care and adjustment of the residual limb-prosthetic interface, as well as adjusting prosthetic alignment. Surgical revision should be undertaken only when prosthetic modification is unsuccessful.
REFERENCES: Murnaghan JJ, Bowker JH: Musculoskeletal complications, in Smith DG, Michael JW, Bowker JH (eds): Atlas of Amputations and Limb Deficiencies, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 683-700.
Smith DG, Ferguson JR: Transtibial amputations. Clin Orthop Relat Res 1999;361:108-115.

Question 16:

Which of the following best describes athletic pubalgia?

Options:

A syndrome of lower abdominal and adductor pain
Painful symptoms emanating from the symphysis pubis
Painful symptoms associated with dysfunction of the iliopsoas tendon
Stress fracture of the pubic ramus
Entrapment of the pudendal nerve

Correct Answer: A syndrome of lower abdominal and adductor pain

Explanation:

Question 17:

Options:

concomitant ulnar neuropathy is a potential poor prognostic factor.
a change in occupation will likely be required after surgery.
weakness in wrist flexion strength will result postoperatively.
prior corticosteriod injections are a potential poor prognostic factor.

Correct Answer: concomitant ulnar neuropathy is a potential poor prognostic factor.

Explanation:

Question 18:

A 70-year-old former baseball catcher reports long-standing pain in the ring and little fingers. A gradient-echo MRI scan is shown in Figure 26. What is the most likely diagnosis?

Options:

Giant cell tumor of the tendon sheath
Ulnar artery aneurysm
Lipoma
Hematoma
Neurolemmoma

Correct Answer: Ulnar artery aneurysm

Explanation:

DISCUSSION: The gradient-echo MRI scan highlights the ulnar and radial arteries,
as indicated by the arrow. This technique suppresses the signal of the surrounding fat
and causes the stationary surrounding tissues to become intermediate in signal intensity.
The flowing blood is then easily identified with a bright signal because it does not absorb the radiofrequency pulse. Based on the findings, the diagnosis is an ulnar artery aneurysm, most likely caused by years of repetitive trauma as the result of catching baseballs. Neurolemmoma and giant cell tumor of the tendon sheath would be intermediately enhanced on this image sequence, and the continuity with the ulnar artery, demonstrated here, would not be expected. Lipomas are not enhanced using the gradient-echo technique. The chronic nature of the patient’s symptoms is not indicative of a hematoma, and the hematoma would be dark on this imaging sequence since it is stationary tissue.
REFERENCES: Koman LA, Ruch DS, Patterson Smith B, et al: Vascular disorders, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, vol 2, pp 2254-2302.
Holder LE, Merine DS, Yang A: Nuclear medicine, contrast angiography, and magnetic resonance imaging for evaluating vascular problems in the Hand: Vasospastic disorders. Hand Clin 1993;9:95-113.

Question 19:

Options:

Glenoid bone loss of 10%
Capsular attenuation from prior thermal capsulorraphy
Anterior labral periosteal sleeve avulsion (ALSPA ) lesion
Glenoid labral articular defect (GLAD) lesion
Combined Superior Labrum from Anterior to Posterior tear (SLAP) and recurrent Bankart lesion

Correct Answer: Glenoid bone loss of 10%

Explanation:

Question 20:

Options:

Limit flexion to 90 degrees with nonweight-bearing activity with crutches for the first 6 weeks
Limit flexion to 30 degrees for the first week, progress 10 degrees per week, and allow partial weight-bearing activity with crutches
The knee should be immobilized in extension; partial weight-bearing activity with crutches may be allowed for the first 6 weeks
An initial range-of-motion restriction to 90 degrees or weight-bearing restriction is not needed

Correct Answer: An initial range-of-motion restriction to 90 degrees or weight-bearing restriction is not needed

Explanation:

Question 21:

Options:

Patellar clunk syndrome
Flexion gap instability
Polyethylene wear
Femoral component malrotation

Correct Answer: Patellar clunk syndrome

Explanation:

Question 22:

Options:

Loosening of the prosthesis
Modulus mismatch
Chronic infection
Osteoporosis
Metastatic tumor

Correct Answer: Loosening of the prosthesis

Explanation:

Question 23:

Options:

Positive impingement sign
Positive apprehension
Positive active compression
Weakness of external rotation
Weakness of abduction

Correct Answer: Weakness of external rotation

Explanation:

Question 24:

In the anterior cruciate ligament-deficient knee, what structure provides an important secondary restraint to anterior tibial translation? Review Topic

Options:

Anterior horn of the lateral meniscus
Posterior cruciate ligament
Posterior horn of the medial meniscus
Popliteus tendon
Quadriceps muscle

Correct Answer: Posterior horn of the medial meniscus

Explanation:

Question 25:

Options:

Secondary sarcoma in a pre-existing condition
Angiosarcoma
Metastatic lung carcinoma
Fibrous dysplasia DISCUSSION… The figures show an aggressive destructive lesion in a bone that is already involved with Paget disease, and the pathology shows highly malignant cells. This represents a secondary sarcoma arising in Pagetoid bone. Secondary sarcomas occurring in Pagetic bone include malignant fibrous histiocytoma and chondrosarcomas, but osteosarcomas are the most common malignancy in these patients. Most patients are older than age 60 and have new pain in the setting of known Paget disease. The prognosis is generally poor because this is a very aggressive sarcoma that is difficult to treat in an older population. Wide surgical removal and chemotherapy are most commonly employed. The pathology does not show rudimentary vessels or channels which are expected with angiosarcoma, effectively excluding that diagnosis. A lack of nests or gland formation excludes metastatic lung carcinoma, and the absence of fibrous stroma intermixed with bone islands or “Chinese characters” excludes fibrous dysplasia.

Correct Answer: Secondary sarcoma in a pre-existing condition

Explanation:

Question 26:

Options:

Particle-mediated osteolysis
Metastatic carcinoma
Stress shielding
Septic joint
Osteosarcoma

Correct Answer: Particle-mediated osteolysis

Explanation:

DISCUSSION: The radiographs reveal a large femoral metaphyseal lytic lesion with
well-defined borders. Joint space narrowing medially is consistent with polyethylene wear.
The most likely diagnosis is particle-mediated osteolysis. Metastatic tumors and primary sarcomas adjacent to an arthroplasty are extremely rare. In addition, malignant tumors and infection would more likely reveal a destructive lesion with poorly defined borders and increased uptake on a bone scan. Stress shielding with massive bone loss has not been described in knee arthroplasty literature, although this entity has been observed in fully porous-coated femoral implants in total hip arthroplasty.
REFERENCES: Robinson EJ, Mulliken BD, Bourne RB, et al: Catastrophic osteolysis in total knee replacement: A report of 17 cases. Clin Orthop Relat Res 1995;321:98-105.
Archibeck MJ, Jacobs JJ, Roebuck KA, et al: The basic science of periprosthetic osteolysis. Instr Course Lect 2001;50:185-195.
Bugbee WD, Culpepper WJ, Engh CA Jr, et al: Long-term clinical consequences of stress-shielding after total hip arthroplasty without cement. J Bone Joint Surg Am 1997;79:1007-1012.

Question 27:

Options:

hemivertebra excision.
anterior and posterior spinal fusion with instrumentation from T4 to L4.
convex anterior hemiepiphyseodesis.
convex posterior hemiarthrodesis.
an orthosis.

Correct Answer: hemivertebra excision.

Explanation:

Question 28:

Options:

- Nonsurgical treatment with closed reduction and immobilization
- Early mobilization with physical therapy initiated within 2 weeks
- Open reduction and internal fixation (ORIF) with locked implants
- Use of supplemental bone graft or substitutes
- Arthroplasty
- Workup for osteoporosis and counseling

Correct Answer: - Early mobilization with physical therapy initiated within 2 weeks

Explanation:

DISCUSSION
Low-energy fractures in elderly patients typically are treated with nonsurgical care that involves early immobilization followed by early rehabilitation/therapy, especially when proximal humerus and distal humerus fractures are involved. Physical therapy should be initiated within the first 2 weeks. If surgery is needed ORIF is preferred for most fractures, but replacement may improve outcomes for unreconstructable fractures. The use of hemiarthroplasty vs reverse shoulder replacement is currently being debated.
For treatment of distal radius fractures in elderly patients, cast immobilization for about 6 weeks will allow for optimal fracture healing. This should be followed by aggressive therapy to improve range of motion and function. Moderately displaced fractures in elderly patients will result in satisfactory outcomes even though reduction may not be "anatomic."
RECOMMENDED READINGS
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53. doi: 10.2106/JBJS.J.01597. PubMed PMID: 22159849.
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Abstract
at PubMed
Tejwani NC, Liporace F, Walsh M, France MA, Zuckerman JD, Egol KA. Functional outcome following one-part proximal humeral fractures: a prospective study. J Shoulder Elbow Surg. 2008 Mar-Apr;17(2):216-9. doi: 10.1016/j.jse.2007.07.016. Epub 2008 Jan 22. PubMed
PMID: 18207430.
View Abstract at PubMed
Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma. 2009 Feb;23(2):113-9. doi: 10.1097/BOT.0b013e31819344bf. PubMed PMID:

Question 29:

What factor induces myofibrillar muscle protein synthesis (MPS)? Review Topic

Options:

Aerobic exercise
Anabolic hormones (growth hormone/testosterone)
Resistance exercise above 60% 1-repetition maximum (RM)
High-repetition exercise at mid intensity (30% 1-RM)

Correct Answer: Resistance exercise above 60% 1-repetition maximum (RM)

Explanation:

Question 30:

What are the most likely symptoms and examination findings related to the mass in zone 2 of Guyon’s canal seen in Figure 17?

Options:

Numbness and tingling in the little finger and the ulnar side of the ring finger
Weakness and atrophy of the first dorsal interosseous
Hypothenar muscle atrophy
Dorsal ulnar hand numbness and tingling
Weakness of the interossei of the hand and numbness and tingling of the little finger and the ulnar side of the ring finger

Correct Answer: Weakness and atrophy of the first dorsal interosseous

Explanation:

DISCUSSION: The lesion lies in zone II of the ulnar tunnel. In that zone the deep motor branch of the ulnar nerve is susceptible to compression. Distal to the hook of the hamate, the motor branch of the ulnar nerve dives deep to innervate the interossei as it begins to move from an ulnar to radial direction. Because of its course, it has little or no give in response to a mass effect from the floor of Guyon’s canal. Ganglions are the most common cause of ulnar nerve entrapment in the wrist. Lesions in zone I can affect both sensory and motor aspects of the ulnar nerve as well as the motor innervation of the hypothenar muscles. Lesions at the elbow or mid-to-proximal forearm are associated with dorsal hand numbness and tingling.
REFERENCES: Kuschner SH, Gelberman RH, Jennings C: Ulnar nerve compression at the wrist. J Hand Surg Am 1988;13:577-580.
Posner MA: Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instr Course Lect 2000;49:305-317.

Question 31:

Options:

Further imaging studies, including MRI
An awake closed reduction with Gardner-Wells traction with neurologic examination
Immobilization in a halo skeletal fixation for definitive treatment
Closed reduction under general anesthesia
Immediate open reduction and internal fixation in the surgical suite

Correct Answer: An awake closed reduction with Gardner-Wells traction with neurologic examination

Explanation:

Question 32:

Options:

no difference in terminal range of motion.
a lower functional outcome score. C. a clinically significant reduction in passive forward flexion and external rotation.
a higher retear rate of the rotator cuff repair. Historically, orthopaedic surgeons considered early range-of-motion programs following rotator cuff surgery secondary to concerns about potential postsurgical stiffness. Although this may have been a concern with primary open repair, arthroscopic surgery appears to substantially decrease this risk. More recently, investigators are reporting similar results in terms of range of motion, retear rate, and functional outcome scores among patients who undergo early versus delayed rehabilitation programs.

Correct Answer: no difference in terminal range of motion.

Explanation:

Stemless shoulder arthroplasty prostheses have recently been suggested as an alternative to traditional stemmed replacement. Advantages of the stemless surgical technique would include
A. better glenoid exposure than with stemmed prostheses.
B. reliable use in four-part proximal humerus fracture reconstruction.
C. use in proximal humeral malunion without the need for an osteotomy. D. improved long-term survivorship profile.

Question 33:

Which Morton neuroma histology is most common?

Options:

Perineural fibrosis
Wallerian degeneration
Distal axonopathy
Segmental demyelination

Correct Answer: Perineural fibrosis

Explanation:

DISCUSSION
Morton neuroma is a compressive neuropathy of the interdigital nerves of the forefoot that most commonly is noted in the third web space. Perineural fibrosis is commonly noted on microscopic examination of resected tissue. This accounts for the relatively higher failure rate of neuroma decompression by transection of the intermetatarsal ligament as opposed to resection. Wallerian degeneration is seen following axonal transection in the distal part of the nerve. Distal axonopathy is degeneration of the axon and myelin and is associated with "stocking-glove" distribution neuropathy. Segmental demyelination is characterized by breakdown of myelin with an intact axon
and is associated with lead poisoning and hereditary sensory motor neuropathy.
RECOMMENDED READINGS
Akermark C, Crone H, Saartok T, Zuber Z. Plantar versus dorsal incision in the treatment of primary intermetatarsal Morton's neuroma. Foot Ankle Int. 2008 Feb;29(2):136-41. doi: 10.3113/FAI.2008.0136. PubMed PMID: 18315967.
View Abstract at PubMed
Ha'Eri GB, Fornasier VL, Schatzker J. Morton's neuroma--pathogenesis and ultrastructure. Clin Orthop Relat Res. 1979 Jun;(141):256-9. PubMed PMID: 477115.
View Abstract at
PubMed
Graham CE, Graham DM. Morton's neuroma: a microscopic evaluation. Foot Ankle. 1984 Nov-Dec;5(3):150-3. PubMed PMID: 6519606.
View Abstract at PubMed

Question 34:

A 35-year-old patient has right hip pain. Figures 34a and 34b show the coronal MRI scan and the biopsy specimen. What is the most likely diagnosis?

Options:

Degenerative cyst with collapse
Osteonecrosis
Chondroblastoma
Metastatic carcinoma
Clear cell chondrosarcoma

Correct Answer: Osteonecrosis

Explanation:

Question 35:

Options:

a spinal cord injury and he cannot participate in contact sports.
no obvious injury and can return to all sports without risk of recurrence.
no obvious injury, but he is at a high risk for breaking his neck in athletic competition.
transient quadriplegia only, but this places him at greater risk for future spinal cord injury and he should refrain from all contact sports.
transient quadriplegia and that there is no evidence of increased risk of permanent spinal cord injury should he return to contact sports.

Correct Answer: transient quadriplegia and that there is no evidence of increased risk of permanent spinal cord injury should he return to contact sports.

Explanation:

DISCUSSION: The long-term effect of transient quadriplegia is unknown. Based on a history of one brief episode of transient quadriplegia and normal examination and MRI findings, the risk of permanent spinal cord injury with a return to play is low. There is a risk of recurrent episodes of transient quadriplegia after the initial episode.
REFERENCES: Morganti C, Sweeney CA, Albanese SA, et al: Return to play after cervical spine injury. Spine 2001;26:1131-1136.
Odor JM, Watkins RG, Dillin WH, et al: Incidence of cervical spinal stenosis in professional and rookie football players. Am J Sports Med 1990;18:507-509.
Torg JS, Naranja RJ Jr, Palov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Vaccaro
AR
, Watkins B, Albert TJ, et al: Cervical spine injuries in athletes: Current return-to-play criteria. Orthopedics 2001;24:699-703.

Question 36:

- A 32-year-old man has swelling of the knee as a result of falling with the knee flexed and his foot in plantar flexion. A Lachman’s test reveals an apparent increase in anterior translation. Passive external tibial rotation at 30 degrees and 90 degrees is equal to the contralateral side, and the quadriceps active test is positive on the affected side. The neurovascular examination is normal. Treatment should consist of

Options:

An anterior cruciate functional knee brace.
A physical therapy program.
Reconstruction of the posterior cruciate ligament and the posterolateral corner.
Reconstruction of the posterior cruciate ligament.
Reconstruction of the anterior cruciate ligament.

Correct Answer: A physical therapy program.

Explanation:

Question 37:

Options:

Exostectomy
Lateral column lengthening
Medial slide calcaneal osteotomy
Talonavicular arthrodesis
Triple arthrodesis

Correct Answer: Triple arthrodesis

Explanation:

DISCUSSION: The deformity is long-standing, the hindfoot is immobile, and the radiographs reveal severe degenerative arthritis involving the entire hindfoot, severe deformity, and talonavicular dislocation. The “exostosis” responsible for the callus is the talar head; resection would severely destabilize the foot. Degenerative arthritis and fixed deformity preclude lateral column lengthening, medial slide calcaneal osteotomy, and talonavicular arthrodesis. Triple arthrodesis is the only viable option.
REFERENCES: Johnson JE, Yu JR: Arthrodesis techniques in the management of Stage II and III acquired adult flatfoot deformity. Instr Course Lect 2006;55:531-542.
Pinney SJ, Lin SS: Current concept review: Acquired adult flatfoot deformity. Foot Ankle Int 2006;27:66-75.

Question 38:

What is the most common cause for late revision (> 2 years post op) total knee arthroplasty?

Options:

Infection
Polyethylene wear
Instability
Patellar complications
Malalignment

Correct Answer: Polyethylene wear

Explanation:

Question 39:

Among the options listed below, what is the best treatment for the complication shown in Figure 10c?

Options:

- Removal of hardware and bone grafting
- Removal of hardware and total hip arthroplasty (THA)
- Removal of hardware and revision using a first-generation femoral nail
- Removal of hardware and revision using a second-generation femoral nail

Correct Answer: - Removal of hardware and revision using a second-generation femoral nail

Explanation:

DISCUSSION
Proximal femur fractures can be treated using a variety of implants including intramedullary nails, blade plates, and locking plates (now precontoured proximal femur plates). The comminution and lack of medial cortical support may predispose these fractures to nonunion.
The recent popularity of locking plates for proximal femur treatment has increased their use for this fracture; however, a disproportionately high rate of failure of these plates, including early implant failure with plate and screw breakage, cut out with varus collapse, and nonunion have been reported.?
Malreduction predisposes these fractures to failure. The initial postoperative radiographs do not reveal a varus malreduction because the tip of the greater trochanter is below the center of the femoral head.
Once failure occurs, the best fixation method among the options detailed is an intramedullary nail (second generation with screws into the femoral head) and restoration of alignment. THA is usually not recommended for treatment of subtrochanteric femur fractures in young patients.
RECOMMENDED READINGS
Wirtz C, Abbassi F, Evangelopoulos DS, Kohl S, Siebenrock KA, Krüger A. High failure rate of trochanteric fracture osteosynthesis with proximal femoral locking compression plate.
Injury. 2013 Jun;44(6):751-6. doi: 10.1016/j.injury.2013.02.020. Epub 2013 Mar 21. PubMed PMID: 23522837.
View Abstract at PubMed
Floyd JC, O'Toole RV, Stall A, Forward DP, Nabili M, Shillingburg D, Hsieh A, Nascone JW. Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures. J Orthop Trauma. 2009 Oct;23(9):628-33. doi: 10.1097/BOT.0b013e3181b04835. PubMed PMID: 19897983.
View Abstract at PubMed
Glassner PJ, Tejwani NC. Failure of proximal femoral locking compression plate: a case series. J Orthop Trauma. 2011 Feb;25(2):76-83. doi: 10.1097/BOT.0b013e3181e31ccc.
PubMed PMID: 21245709.
View Abstract at PubMed

Question 40:

A 14-year-old girl has a painful hallux valgus deformity that has not responded to shoe modifications. Figure 21 shows a standing AP radiograph. What is the most appropriate surgical procedure?

Options:

Distal soft-tissue realignment
Distal first metatarsal osteotomy with distal soft-tissue realignment
Proximal first metatarsal osteotomy with distal soft-tissue realignment
Proximal and distal first metatarsal osteotomy
Osteotomy of the proximal phalanx

Correct Answer: Proximal and distal first metatarsal osteotomy

Explanation:

DISCUSSION: The radiograph reveals an increased first-second intermetatarsal angle
and a congruent metatarsophalangeal joint with an abnormal distal metatarsal articular
angle. Correction of both of these abnormalities requires a proximal and distal first
metatarsal osteotomy.
REFERENCES: Coughlin M: Juvenile bunions, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby, 1993, pp 297-339.
Peterson HA, Newman SR: Adolescent bunion treated with double osteotomy and longitudinal pin fixation of the first ray. J Pediatr Orthop 1993;13:80-84.

Question 41:

The swelling pressure in cartilage is predominantly due to the association of exchangeable water with which of the following substances? Review Topic

Options:

Biglycan
Type II collagen
Type IX collagen
Aggrecan
Versican

Correct Answer: Aggrecan

Explanation:

Question 42:

Options:

MRI
Arthrocentesis for synovial fluid cell count and bacterial culture
Ophthalmology consultation
Angiotensin converting enzyme (ACE) level
Technetium radioisotope bone scan

Correct Answer: Ophthalmology consultation

Explanation:

DISCUSSION: Up to 30% of children with juvenile rheumatoid arthritis (increasingly known now as juvenile idiopathic arthritis or JIA) already have potentially damaging uveitis at the time of diagnosis. This patient has typical oligoarticular JRA (JIA) and therefore is at significant risk for uveitis. MRI, radioisotope scanning, or an ACE level most likely would not provide additional useful diagnostic information because intra-articular derangement, osteomyelitis, or sarcoidosis are all unlikely. Arthrocentesis and triamcinolone hexacetonide joint injection might be indicated if continued use of nonsteroidal medication does not result in improvement, but should be held off for at least an additional 4 to 6 weeks to see if continued use of naproxen results in control of the arthritis.
REFERENCES: Wolf MD, Lichter PR, Ragsdale CG: Prognostic factors in the uveitis of juvenile rheumatoid arthritis. Ophthalmology 1987;94:1242.
Cassidy JT, Petty RE: Textbook of Pediatric Rheumatology. Philadelphia, PA, WB Saunders, 2001, p 220.
Chalom ED, Goldsmith DP, Koehler MA, et al: Prevalence and outcome of uveitis in a regional cohort of patients with juvenile rheumatoid arthritis. J Rheumatol 1997;24:2031-2034.

Question 43:

Options:

Knee manipulation under anesthesia
Cast immobilization and use of a bone stimulator
Unilateral external fixation
Intramedullary nailing
Compression plating

Correct Answer: Knee manipulation under anesthesia

Explanation:

Question 44:

Options:

stronger initial graft fixation.
more anatomic positioning of tibial fixation.
more natural knee kinematics during deep flexion.
more graft protection during cyclic loading.

Correct Answer: more graft protection during cyclic loading.

Explanation:

Question 45:

Options:

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

Correct Answer: aspiration.

Explanation:

Question 46:

Figures 36a and 36b show the MRI scans of a patient who has shoulder weakness. What is the most likely diagnosis?

Options:

Suprascapular nerve entrapment
Supraspinatus and infraspinatus tendon tear
Muscular dystrophy
Thoracic outlet syndrome
Spinal accessory nerve disruption

Correct Answer: Suprascapular nerve entrapment

Explanation:

Question 47:

Options:

Total elbow arthroplasty
Open reduction and internal fixation
Radial head arthroplasty
Sling and swathe
Bone stimulator

Correct Answer: Total elbow arthroplasty

Explanation:

Question 48:

Options:

repair of the superior labrum.
isolated supraspinatus repair.
biceps recentering.
subscapularis repair and biceps tenodesis.
subscapularis repair and recentering of the biceps tendon.

Correct Answer: subscapularis repair and biceps tenodesis.

Explanation:

Question 49:

Options:

conversion to a longer side plate with the same compression screw and tube angle.
in situ bone grafting.
hardware removal and reconstruction with an intramedullary device that provides fixation into the femoral head and neck.
hardware removal and retrograde femoral nailing.
revision reconstruction with cerclage wiring.

Correct Answer: hardware removal and reconstruction with an intramedullary device that provides fixation into the femoral head and neck.

Explanation:

Question 50:

After reduction and pinning, the radial pulse is absent by both palpation and Doppler. Capillary refill in the fingers appears normal. What is the most likely explanation?

Options:

Laceration of the brachial artery during reduction
Compression of the brachial artery by a pin
Abnormal arterial supply
Spasm in the brachial artery

Correct Answer: Spasm in the brachial artery

Explanation:

Question 51:

Figure 12 shows the radiograph of a patient who has anterior knee pain. History reveals a femoral fracture at age 5 years. What is the most likely cause of the deformity?

Options:

Osgood-Schlatter disease
Patellar tendon rupture
Posterior cruciate ligament rupture
Overlengthened hamstrings
Tibial tubercle growth arrest

Correct Answer: Tibial tubercle growth arrest

Explanation:

Question 52:

A minimally invasive plate osteosynthesis is seen in Figure 15. The resultant fracture healing can best be attributed to a fixation construct that was

Options:

stiff and stable.
flexible and stable.
facilitating direct osteonal healing.
inhibitory to endochondral ossification.
stimulatory to intramembranous ossification.

Correct Answer: flexible and stable.

Explanation:

Question 53:

After making a tackle, a football player is found prone and unconscious without spontaneous respirations. Initial management should consist of

Options:

log roll to a supine position, helmet removal, and initiation of assisted breathing.
log roll to a supine position, head and neck stabilization, face mask removal, and CPR.
log roll onto a spine board, head and neck stabilization, face mask removal, and CPR.
head and neck stabilization, log roll to a supine position, helmet removal, and initiation of assisted breathing.
head and neck stabilization, log roll to a supine position, face mask removal, and initiation of assisted breathing.

Correct Answer: head and neck stabilization, log roll to a supine position, face mask removal, and initiation of assisted breathing.

Explanation:

Question 54:

A 12-year-old boy falls from a bicycle. A radiograph of his injured shoulder is shown in Figure 41. What is the optimal method of treatment?

Options:

Suture of the coracoclavicular ligament
Temporary plate fixation across the acromioclavicular joint
Immobilization in a shoulder spica cast
Sling immobilization
Reduction and temporary intramedullary fixation across the acromioclavicular joint

Correct Answer: Sling immobilization

Explanation:

DISCUSSION: The radiograph reveals a distal clavicle fracture. In children, a periosteal sleeve will remain attached to the intact coracoclavicular ligament, and as such, remodeling can be expected. Therefore, nonsurgical management with a sling is preferred. Surgical treatment is not necessary, and a shoulder spica cast offers no advantage over a simple sling.
REFERENCES: Bishop JY, Flatow EL: Pediatric shoulder trauma. Clin Orthop Relat Res 2005;432:41-48.

Question 55:

Options:

Discontinuation of bracing as she has reached skeletal maturity.
Continue full-time bracing until skeletal maturity.
Continue nocturnal bracing until skeletal maturity.
Posterior spinal fusion.
MRI of the cervical, thoracic and lumbar spine.

Correct Answer: Discontinuation of bracing as she has reached skeletal maturity.

Explanation:

Question 56:

Options:

Irrigation and debridement with immediate intramedullary fixation, vascular repair, and primary closure
Irrigation and debridement with external fixation, vascular repair, and delayed closure
Irrigation and debridement with external fixation, vascular repair, exploration of the tibial nerve, and delayed closure
Guillotine amputation at the fracture site with delayed closure
Immediate below-knee amputation

Correct Answer: Irrigation and debridement with external fixation, vascular repair, and delayed closure

Explanation:

DISCUSSION: In the past, loss of plantar sensation in this grade IIIC tibial fracture would have been an indication for below-knee amputation regardless of the potential for vascular repair. However the 2002 LEAP study divided 55 patients with loss of plantar sensation into two groups, the insensate amputation group and the insensate limb salvage group, with 55% of patients in the insensate salvage group regaining normal sensation 2 years after injury. Furthermore, those in the salvage group who remained insensate after 2 years had equivalent outcomes to those in the amputation group. Because of these findings, limb salvage with vascular repair and external stabilization with delayed closure is deemed appropriate treatment. Immediate intramedullary fixation is not indicated. Because ischemia, contusion, and stretch can adversely affect the tibial nerve, the additional insult of exploration of the nerve is also not advisable given the soft-tissue compromise.
REFERENCES: Bosse MJ, McCarthy ML, Jones AL, et al: The insensate foot following severe lower extremity trauma: An indication for amputation? J Bone Joint Surg Am 2005;87:2601-2608.
Lange RH, Bach AW, Hansen ST Jr, et al: Open tibial fractures with associated vascular injuries: Prognosis for limb salvage. J Trauma 1985;25:203-208.
Mackenzie EJ, Bosse MJ, Kellam JF, et al: Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma 2002;52:641-649.
Baumgaertner MR, Tornetta P III (eds): Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 65-74.

Question 57:

Which nerve is most commonly injured after total knee arthroplasty?

Options:

Tibial nerve
Superficial peroneal nerve
Infrapatellar branch of the saphenous
nerve 52
Sartorial branch of the saphenous nerve

Correct Answer: Infrapatellar branch of the saphenous

Explanation:

DISCUSSION
The tibial or peroneal nerves usually are not injured during total knee arthroplasty. Incidence of peroneal nerve damage is highest in knees with a valgus deformity and an associated flexion contracture attributable to nerve stretch. This nerve injury occurs in as many as 9% of patients undergoing knee arthroplasty. Tibial nerve injury is a rare occurrence and usually an iatrogenic transection injury. The infrapatellar branch of the saphenous nerve and its nerve plexus is commonly injured after the medial parapatellar approach, and altered sensation attributable to injury is reported in up to 70% of cases. Injury typically manifests as numbness inferior to the patella. The sartorial branch of the saphenous nerve provides sensation distal to the knee and is uncommonly injured with a medial parapatellar approach. These concepts are illustrated in video 57, “Selective Exposures in Orthopaedic Surgery: The Knee, 2nd Edition.”
RECOMMENDED READINGS
Clarke HD, Bush-Joseph CA, Wolf BR. Selective Exposures in Orthopaedic Surgery: The Knee, 2nd Edition [DVD]. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2012.
Hunter LY, Louis DS, Ricciardi JR, O'Connor GA. The saphenous nerve: its course and importance in medial arthrotomy. Am J Sports Med. 1979 Jul-Aug;7(4):227-30. PubMed PMID: 474860.
View Abstract at PubMed
Mistry D, O'Meeghan C. Fate of the infrapatellar branch of the saphenous nerve post total knee arthroplasty. ANZ J Surg. 2005 Sep;75(9):822-4. PubMed PMID: 16174002.
View Abstract at PubMed
Schinsky MF, Macaulay W, Parks ML, Kiernan H, Nercessian OA. Nerve injury after primary total knee arthroplasty. J Arthroplasty. 2001 Dec;16(8):1048-54. PubMed PMID: 11740762.
View Abstract at PubMed

Question 58:

Options:

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

Correct Answer: Continued dressing changes

Explanation:

Question 59:

In an acute closed boutonniere injury, what is the most appropriate splinting technique for the proximal interphalangeal joint?

Options:

Static splint in 30° of flexion
Static splint in full extension
Dynamic extension splint
30° extension block splint
Buddy taping to the adjacent finger

Correct Answer: Static splint in full extension

Explanation:

Question 60:

Options:

Revision surgery caudad to C6
Persistent left cervical radiculopathy
History of a left-sided Horner’s syndrome
Transient dysphagia following the initial anterior cervical procedure
Nonfunctional left vocal cord

Correct Answer: Nonfunctional left vocal cord

Explanation:

DISCUSSION: When attempting a revision anterior cervical approach from the side opposite the original approach, it is important to evaluate the function of the vocal cords. If this evaluation reveals dysfunction of the vocal cord on the side of the original approach, then an approach on the contralateral side should not be attempted. Injury to the stellate ganglion, which causes a Horner’s syndrome, should not preclude an approach on the contralateral side. While the side of the symptomatology can influence the surgeon’s choice as to the side of an anterior approach, it does not preclude a certain approach. When approaching the lower cervical spine from the right side, the recurrent laryngeal nerve can cross the surgical field and should be preserved. Excessive intraoperative pressure on the esophagus can increase the incidence of dysphagia, but its incidence is no different with either approach.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 387-394.
Edwards CC II, Riew KD, Anderson PA, et al: Cervical myelopathy: Current diagnostic and treatment strategies. Spine J 2003;3:68-81.

Question 61:

What is the most common complication requiring reoperation after dorsal plating for a distal radius fracture?

Options:

Extensor tenosynovitis
Extensor tendon rupture
Flexor pollicus longus tendon rupture
Loss of reduction
Dorsal impingement

Correct Answer: Extensor tenosynovitis

Explanation:

Question 62:

Which of the following findings is considered a contraindication for posterior decompression (with or without fusion) for myelopathy?

Options:

Subluxation of more than 3.5 mm at one or more motion segments
Dynamic angulation of more than 11° at one or more motion segments
Subaxial cervical lordosis of more than 25° (as measured from C2 to C7)
Fixed kyphosis of more than 10°
Anteroposterior spinal canal diameter of less than 8 mm

Correct Answer: Fixed kyphosis of more than 10°

Explanation:

Question 63:

Which of the following provocative tests would most likely be positive in a patient with medial epicondylitis? Review Topic

Options:

Resisted forearm pronation and wrist flexion with a clenched fist
Resisted forearm supination and wrist extension with a clenched fist
Dynamic valgus stress test
Milking maneuver
Pinch grip test

Correct Answer: Milking maneuver

Explanation:

Question 64:

Options:

Fourth cervical nerve root
Upper trunk of the brachial plexus
Middle trunk of the brachial plexus
Lateral cord of the brachial plexus
Axillary nerve

Correct Answer: Upper trunk of the brachial plexus

Explanation:

Question 65:

Options:

debridement and repair.
cast immobilization.
aggressive overload eccentric strengthening.
ice massage and continued athletic participation.
steroid injection.

Correct Answer: debridement and repair.

Explanation:

Question 66:

A 45-year-old man with a painful varus knee is being considered for an upper tibial osteotomy. Which of the following factors is considered the most compelling argument against this procedure?

Options:

Flexion contracture of 5°
Subchondral cyst in the medial tibial condyle
Lateral meniscal degeneration seen in an MRI scan
Rheumatoid arthropathy
Previous medial meniscectomy

Correct Answer: Rheumatoid arthropathy

Explanation:

Question 67:

Options:

shorter hospital stay.
lower rates of fusion.
higher complication rates.
worse long-term outcomes.

Correct Answer: shorter hospital stay.

Explanation:

DISCUSSION
MIS TLIF involves a steep learning curve but is associated with similar longterm outcomes as open TLIF, arguably comparable or possibly lower complication rates, and equivalent fusion rates. The major distinguishing feature comparing open to minimally invasive surgery for this and other spinal diagnoses has been shorter hospital stays.
RECOMMENDED READINGS
Peng CW, Yue WM, Poh SY, Yeo W, Tan SB. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976). 2009 Jun 1;34(13):1385-9. doi: 10.1097/BRS.0b013e3181a4e3be. PubMed PMID: 19478658.
View
Abstract at PubMed
Lee KH, Yue WM, Yeo W, Soeharno H, Tan SB. Clinical and radiological outcomes of open versus minimally invasive transforaminal lumbar interbody fusion. Eur Spine J. 2012 Nov;21(11):2265-70. doi: 10.1007/s00586-012-2281-4. Epub 2012 Mar 28. PubMed PMID:

Question 68:

Options:

stretching of the forearm in pronation, wrist flexion, and splinting.
primary tendon repair of the flexor pollicis longus and flexor digitorum profundus to the index finger, followed by immobilization.
electrodiagnostic examination, followed by decompression of the anterior interosseous nerve within the next 2 to 3 weeks.
splinting followed by observation; surgical decompression of the median nerve may be required if no improvement in seen in 3 months.
splinting followed by observation; surgical decompression of the anterior interosseous nerve may be required if no improvement is seen in 6 months.

Correct Answer: splinting followed by observation; surgical decompression of the anterior interosseous nerve may be required if no improvement is seen in 6 months.

Explanation:

Question 69:

Options:

first lordotic segment of the lumbar spine.
distal aspect of the curve as measured by the Cobb technique.
lower thoracic spine.
lower lumbar spine.
sacrum.

Correct Answer: first lordotic segment of the lumbar spine.

Explanation:

Question 70:

Options:

IV antibiotics.
arthroscopic irrigation and debridement, following by IV antibiotics.
irrigation and debridement, polyethylene exchange, and IV antibiotics.
one-stage component removal and reimplantation, followed by IV antibiotics.
two-stage component removal and reimplantation, with IV antibiotics in the interim period.

Correct Answer: irrigation and debridement, polyethylene exchange, and IV antibiotics.

Explanation:

Question 71:

Options:

external beam radiation.
curetting and cementation.
radiofrequency ablation.
wide local resection. DISCUSSION.. The imaging shows a cartilaginous lesion with destruction and a malignant extraosseous mass most consistent with a dedifferentiated chondrosarcoma. The histology demonstrates a high-grade spindle-cell sarcoma abutting a cartilaginous tumor, confirming this diagnosis. Treatment in this patient would be wide resection. The role of chemotherapy in this tumor is unproven, and an 85-year-old patient is an unlikely candidate for such treatment. Radiofrequency ablation, curettage, and radiation do not play a role in the treatment of this tumor.

Correct Answer: wide local resection. DISCUSSION.. The imaging shows a cartilaginous lesion with destruction and a malignant extraosseous mass most consistent with a dedifferentiated chondrosarcoma. The histology demonstrates a high-grade spindle-cell sarcoma abutting a cartilaginous tumor, confirming this diagnosis. Treatment in this patient would be wide resection. The role of chemotherapy in this tumor is unproven, and an 85-year-old patient is an unlikely candidate for such treatment. Radiofrequency ablation, curettage, and radiation do not play a role in the treatment of this tumor.

Explanation:

Question 72:

Kyphosis from a vertebral osteoporotic compression fracture often results in progressive kyphosis due to Review Topic

Options:

progressive increase in lumbar lordosis.
load transfer to the superior adjacent vertebra.
normalization of load transfer with working kyphosis.
reduced strain at the occipito-cervical junction.
reduced strain at the apex of the deformity.

Correct Answer: load transfer to the superior adjacent vertebra.

Explanation:

Question 73:

Options:

Anteroinferior labrum from the bony glenoid
Anteroinferior labrum from the cartilaginous surface of the glenoid
Biceps tendon from its origin on the supraglenoid tubercle
Anterior capsule from the proximal humerus
Posteroinferior labrum from the bony glenoid

Correct Answer: Anteroinferior labrum from the bony glenoid

Explanation:

Question 74:

A patient undergoes excision of a 3- x 3-cm soft-tissue sarcoma. The final histology results show tumor at the surgical margin. The surgical procedure performed is classified as

Options:

intralesional.
marginal.
wide.
wide contaminated.
radical.

Correct Answer: intralesional.

Explanation:

Question 75:

Which of the following is considered the most useful screening method for the evaluation of protective foot sensation in a patient with diabetes mellitus?

Options:

Sharp two-point discrimination
Light touch sensation
Hot and cold sensation
Vibratory sensation
07 Semmes-Weinstein monofilament sensation

Correct Answer: 07 Semmes-Weinstein monofilament sensation

Explanation:

Question 76:

Options:

Knee aspiration with cell count/cultures, C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), CT
Knee aspiration with cell count/cultures, CRP, ESR
Fresh-frozen specimen at the time of revision knee arthroplasty only
Technetium-99m bone scan, knee aspiration with cell count/cultures

Correct Answer: Knee aspiration with cell count/cultures, CRP, ESR

Explanation:

Question 77:

In the United States, groups at risk for community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) within the pediatric and adolescent populations include

Options:

tennis players.
toddlers in daycare.
children who are home schooled.
African Americans.

Correct Answer: toddlers in daycare.

Explanation:

DISCUSSION
CA-MRSA is a growing problem in the United States. Groups at risk for CA-MRSA include athletes in contact sports and children in daycare. Tennis players, golfers, and runners are at lowest risk because their sports do not require close contact with teammates or competitors. Outbreaks have been noted in Alaskan native, Native American, and Pacific Islander minority populations.
CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 68
Figures 64a through 64d are the radiographs of an 11-year-old boy with a prolonged history of activity-related ankle pain. An examination is notable for restricted subtalar motion and moderate pes planovalgus.

Question 78:

What is the most common type of malalignment after intramedullary nailing of distal 1/3 tibia fractures?

Options:

Varus
Valgus
Translational
Rotational
Apex anterior

Correct Answer: Varus

Explanation:

Question 79:

Options:

Electromyography and nerve conduction velocity studies of bilateral lower extremities
Multilevel lumbar laminectomy
MRI of the thoracic and cervical spine
MRI of the brain
Epidural steroid injections

Correct Answer: MRI of the thoracic and cervical spine

Explanation:

Question 80:

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 81:

The addition of which of the following food supplements may lead to a decrease in neural tube defects?

Options:

Vitamin D-1,25
Vitamin B-12
Niacin
Folic Acid
Thiamine

Correct Answer: Folic Acid

Explanation:

Question 82:

Which of the following is considered a risk factor for the development of low back pain?

Options:

Gender
Facet trophism
Vibration exposure
Weight
Transitional vertebrae

Correct Answer: Vibration exposure

Explanation:

Question 83:

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

Options:

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

Correct Answer: no donation is necessary.

Explanation:

Question 84:

Options:

Hip arthroscopy and debridement
Periacetabular osteotomy
Femoral varus-producing osteotomy
Total hip arthroplasty (THA)

Correct Answer: Periacetabular osteotomy

Explanation:

DISCUSSION
Video 189 for reference
This patient has dysplasia with a lack of lateral femoral head coverage. The MR images do not demonstrate a labral tear. There is still preserved joint space and she is young, so it would be preferable to delay THA in her case. A Ganz periacetabular osteotomy can provide more adequate coverage of the femoral head and is a multiplanar correction of the dysplastic acetabulum. This osteotomy is an effective treatment for symptomatic dysplasia in prearthritic young adult hips. A femoral osteotomy is not likely to be effective in this scenario.
CLINICAL SITUATION FOR QUESTIONS 190 THROUGH 192
Eighteen years after undergoing right total hip arthroplasty (THA), a 79-year-old woman experiences several weeks of right groin pain. A hip examination reveals that she is walking with a mild limp with a walker. Hip radiographs reveal moderate polyethylene wear with well-fixed components and mild osteolysis in the greater trochanter. Analysis of a CT scan reveals that the acetabular component is osteointegrated in 49 degrees of abduction and 25 degrees of anteversion. Erythrocyte sedimentation rate and C-reactive protein findings are within defined limits.

Question 85:

Diagnostic work-up concluded that the patient has metastatic lymphoma. He has no neurologic deficit.Based on these findings, what is the most appropriate management for this spinal condition?

Options:

Cement augmentation
En bloc resection
Chemotherapy
Radiation therapy
Intralesional excision

Correct Answer: Radiation therapy

Explanation:

Question 86:

Which of the following represents a contraindication for interspinous process decompression for the treatment of lumbar spinal stenosis? Review Topic

Options:

Grade I degenerative spondylolisthesis
Inability to walk at least 100 feet
Cauda equina syndrome
Fixed sensory deficit
Intermittent foot drop

Correct Answer: Cauda equina syndrome

Explanation:

Question 87:

- A 25-yo man sustains the injury shown in Figures 29a and 29b as a result of high-speed trauma. Examination reveals diffuse weakness in the lower extremities that is slightly worse on the right side, and decreased rectal tone and sensation. A CT scan is shown in figures 29c and 29d. Definitive treatment of the injury to the spine is delayed because of a severe pulmonary contusion. At 15 days after the injury, the patient’s neurological status remains unchanged. Management should now consist of

Options:

Posterior fusion at T10-L3 with segmental instrumentation
Laminectomy and fusion of T12-L2 with segmental instrumentation
Bed rest in a hyperextension brace
L1 vertebrectomy and anterior decompression with strut graft fusion and instrumentation
Progressive ambulation as tolerated in a custom-molded thoracolumbosacral orthosis

Correct Answer: L1 vertebrectomy and anterior decompression with strut graft fusion and instrumentation

Explanation:

Question 88:

Options:

Chondroblastoma
Enchondroma
Giant cell tumor
Fibrous dysplasia
Osteoblastoma

Correct Answer: Fibrous dysplasia

Explanation:

DISCUSSION: The radiographs reveal a geographic lesion of the proximal femur with the classic “ground glass” appearance noted in fibrous dysplasia. This intramedullary lesion is modestly expansile, demonstrates some minimal cortical thinning, and has no aggressive features. Chondroblastoma, giant cell tumor, and osteoblastoma are more lytic in appearance, and the location is not typical for giant cell tumor or chondroblastoma. While enchondroma may be considered, the uniform ground glass appearance, lack of punctuate mineralization, and distinct margination of the lesion make that diagnosis less likely.
REFERENCE: Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 89:

A college basketball player is struck in the eye by a player’s hand while driving to the basket. Fluorescein evaluation reveals the injury shown in Figure 18. Management should consist of

Options:

administration of ophthalmic corticosteroids and antibiotics with application of an eye patch.
evaluation of intact visual fields and pupillary responses prior to a return to play.
consultation with an ophthalmologist prior to emergent repair of the damaged structure.
measurement of ocular pressure and fundoscopic examination in a properly lit examination room.
strict bed rest with the head elevated, minimizing head motion during the healing process.

Correct Answer: administration of ophthalmic corticosteroids and antibiotics with application of an eye patch.

Explanation:

Question 90:

Options:

mechanical alignment radiographs.
stress radiographs of the knee.
comparison radiographs of both knees.
an erythrocyte sedimentation rate and a C-reactive protein.
examination of the hip.

Correct Answer: examination of the hip.

Explanation:

DISCUSSION: While all of the answers may be appropriate, radiating pain from hip pathology must be excluded. At this age, a slipped capital femoral epiphysis is likely. Therefore, the hip must be examined.
REFERENCES: Kocher MS, Bishop JA, Weed B, et al: Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics 2004;113:322-325.
Matava MJ, Patton CM, Luhmann S, et al: Knee pain as the initial symptom of slipped capital femoral epiphysis: An analysis of initial presentation and treatment. J Pediatr Orthop 1999;19:455-460.

Question 91:

Options:

There is a significantly higher risk of infection.
There is a significantly higher risk of growth disturbance.
There is a significantly higher risk of arthrofibrosis and loss of knee motion.
There is a significantly higher risk of graft failure and need for revision surgery.
There is a significantly higher risk of graft failure in low-dose (<2 Mrad) gamma-irradiated allografts only.

Correct Answer: There is a significantly higher risk of infection.

Explanation:

Question 92:

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

Options:

observation and exercises
bracing with a thoracolumbar orthosis
fusion of the posterior spine
fusion of the anterior spine
fusion of the anterior and posterior spine

Correct Answer: observation and exercises

Explanation:

Question 93:

Options:

closed reduction and cast immobilization for 6 weeks.
closed reduction and percutaneous pin fixation.
open reduction of the tarsal navicular and closed management of the Lisfranc joint.
open reduction and internal fixation of the Lisfranc joint, the tarsal navicula, and second metatarsal neck fractures.
open reduction and primary arthrodesis of the Lisfranc joint and internal fixation of the tarsal navicula and second metatarsal neck fractures.

Correct Answer: open reduction and internal fixation of the Lisfranc joint, the tarsal navicula, and second metatarsal neck fractures.

Explanation:

Question 94:

Options:

Nonunion
Tarsal tunnel syndrome
Degenerative arthritis of the hindfoot joints
Sinus tarsi syndrome
Chronic osteomyelitis of the distal tibia

Correct Answer: Degenerative arthritis of the hindfoot joints

Explanation:

Question 95:

Options:

external fixation of the forearm fracture and functional bracing of the humeral shaft fracture.
external fixation of both fractures.
open reduction and internal fixation of both fractures.
open reduction and the internal fixation of the forearm fracture and functional bracing of the humeral shaft fracture.
application of a long arm cast.

Correct Answer: open reduction and internal fixation of both fractures.

Explanation:

Question 96:

- What posterior pelvic ring injury is most commonly associated with neurologic compromise?

Options:

Sacral fracture lateral to the foramina
Sacral fracture medial to the foramina
Sacroiliac fracture-dislocation
Sacroiliac dislocation
Iliac wing fracture

Correct Answer: Sacral fracture medial to the foramina

Explanation:

Question 97:

Options:

Open reduction internal fixation with transosseous sutures
Arthroscopic fixation using a suture bridge technique
Nonsurgical treatment with early passive range of motion
Nonsurgical treatment with sling immobilization for 4 weeks

Correct Answer: Nonsurgical treatment with early passive range of motion

Explanation:

Question 98:

Following its exit from the sciatic notch, the sciatic nerve passes between what two muscles?

Options:

Piriformis and superior gemellus
Superior gemellus and obturator internus
Inferior gemellus and quadratus femoris
Gluteus medius and minimus
Quadratus femoris and gluteus maximus

Correct Answer: Piriformis and superior gemellus

Explanation:

DISCUSSION: Though anatomic variations exist, both divisions of the sciatic nerve most commonly pass between the piriformis and superior gemellus. This anatomic consideration is relevant during the posterior approach to the hip, where careful retraction of the rotators avoids sciatic nerve injury.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, pp 335-348.
Anderson JE (ed): Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Williams & Williams,
1978, Figure 4-34.
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Question 99:

Options:

Observation, with a repeat clinical examination in 2 weeks
Application of a hip abduction device and early follow-up to confirm reduction
Arthrogram and closed reduction of the right hip under general anesthetic, followed by spica casting
Open reduction of the right hip with a capsulorrhaphy DISCUSSION-The video shows an unstable right hip in a female infant. The visual ”clunk“ of the positive Barlow and Ortolani tests is readily evident. Initial treatment in a young infant consists of application of an abduction device to achieve and maintain hip location. Confirmation of successful hip location is usually performed by ultrasound examination. In the United States, the Pavlik harness remains the most commonly used hip abduction device, although others, such as hip abduction braces and the Frejka pillow, are available and have been shown to have similar success. Observation is not necessary when the examination shows clear instability. Arthrogram, closed manipulation, and spica casting are reserved for an older age group (those between 6 and 18 months of age). Open reduction is appropriate if the hip remains dislocated after 18 months of age.

Correct Answer: Application of a hip abduction device and early follow-up to confirm reduction

Question 100:

Options:

Accept the offer because it would allow the physician to have a boat and enjoy a hobby of sailing with a minimal financial outlay.
Accept this offer because it would have nothing to do with the orthopaedic practice and because the physician feels strongly that it would have no influence on practice decisions.
Reject the offer because it represents an unacceptable conflict of interest.
Accept the offer but disclose the relationship to patients when using the representative’s products.
Accept the offer but only with a equal interest arrangement in the purchase and use of the boat

Correct Answer: Reject the offer because it represents an unacceptable conflict of interest.

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

Orthopedic Board Prep MCQs: Trauma, Arthroscopy & Lower Extremity Part 4

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 4

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index