OITE & ABOS Orthopedic Board Exam: Spine, Trauma & Extremities | Part 46

An 18-year-old lacrosse player is diagnosed with infectious mononucleosis. What is the recommendation for return to play? Review Topic

What is the most common complication after distal biceps tendon repair at the elbow?

Which of the following are considered characteristic features of degeneration of a disk?

A 68-year-old man reports a 4-week history of progressive left-sided lower back and hip pain. The pain is in the posterior buttock region with radiation to the groin and to the left anterior knee region. The pain is aggravated with walking and improves with rest. There is no history of previous trauma. Radiographs are seen in Figures 14a and 14b, and MRI scans are seen in Figures 14c through 14e. What is the most appropriate treatment option at this time?

What radiographic measurement is best used to assess the adequacy of deformity correction for the patient shown in Figure 22?

A 12-year-old boy sustained a both bone forearm fracture 10 weeks ago and underwent closed reduction and casting. Examination now reveals that the injury is healed, but he is unable to extend his little and ring fingers of the injured hand with his wrist extended. Full extension is possible with the wrist flexed. A radiograph and clinical photograph are shown in Figures 15a and 15b. The remainder of his hand and wrist examination and neurologic evaluation in the hand are normal. What is the most likely diagnosis?

A 21-year-old hockey player who has recurrent shoulder subluxations undergoes an anterior capsulorrhaphy under general anesthesia, and an interscalene block is used to relieve postoperative pain. At the 1-week follow-up examination, he reports loss of sensation over the lateral region of the shoulder and is unable to actively contract the deltoid muscle. The remainder of the examination is normal. What is the best course of action at this time?

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

An adult patient has a closed humeral fracture that was treated nonsurgically and a concomitant radial nerve injury. Six weeks after injury, electromyography shows no evidence of recovery. Management should now consist of

Figure 62 is an arthroscopic view of the intercondylar notch of a right knee from an anterolateral portal. What is the main function of the structure delineated by the black asterisks? Review Topic

A 23-year-old man reports a 6-year history of recurrent instability in the right dominant shoulder. He has not undergone surgery and has essentially stopped all of his sporting activities. On examination, he has instability and apprehension in the midrange of motion (abduction of 45 to 60 degrees with external rotation) and a palpable clunk representing a transient dislocation over the anterior glenoid rim. A three-dimensional CT scan is shown in Figure 31. What is the most appropriate surgical intervention to provide him with reliable stability postoperatively?

A 70-year-old woman has a preoperative anterior interscalene block prior to undergoing a total shoulder arthroplasty. After seating her in the beach chair position, she becomes acutely hypotensive. What is the most likely cause for the hypotension?

A 65-year-old woman has nausea, vomiting, and abdominal distention after undergoing total knee arthroplasty 48 hours ago. An abdominal radiograph is shown in Figure 14. Associated risk factors for this disorder include

The flap shown in the clinical photograph seen in Figure 51 is based on what arterial supply?

An 8-month-old infant has an infection of the fingertip as shown in Figure 22. If neglected, the anticipated path of ascending infection is the fingertip, the flexor sheath, and the

Figure 68 is the radiograph of a 33-year-old runner who recently decided to begin running barefoot on trails. Since his transition to running without shoes 3 months ago, he has been having pain in the second metatarsophalangeal (MTP) joint. He feels like he is walking on a stone, notes edema in the ball of his foot, and has started to see a deviation of the second toe. What is the most likely etiology of these symptoms and findings?

Which of the following is not considered to be a part of the constellation of the clinical entities known as the female athlete triad? Review Topic

An axial T 1 -weighted MRI scan of the pelvis is shown in Figure 35. Which of the following structures is enclosed by the circle?

The mother of a 26-month-old boy reports that he has been unwilling to bear weight on his left lower extremity since he awoke this morning. She denies any history of trauma. He has a temperature of 99.4°F (37.4°C), and examination reveals that abduction of the left hip is limited to 30°. Laboratory studies show a WBC of 11,000/mm 3 and an erythrocyte sedimentation rate of 22 mm/h. A radiograph of the pelvis is shown in Figure 13. Management should consist of

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

A 10‘/2-year-old boy sustained the injury shown in Figure 72 when he fell out of a tree. This is a closed, neurologically intact injury and the patient has no head injury or loss of consciousness. He weighs 115 pounds and is otherwise healthy. What is the optimal treatment option for this injury?

Which set of patient characteristics has the highest risk of developing osteonecrosis after an intracapsular femoral neck fracture?

A 35-year-old man who is an avid weight lifter competing in local tournaments reports new onset pain and loss of motion in his dominant right shoulder. Examination reveals joint line tenderness, active elevation to 100 degrees, and external rotation to 10 degrees. His contralateral shoulder reveals 170 degrees forward elevation and 50 degrees external rotation. Radiographs are shown in Figures 46a and 46b. What is the next most appropriate step in management? Review Topic

• A 7-year old boy has a painless abductor limp and limited hip abduction. Radiographs show varus of the proximal femur, with a narrow upper femoral epiphysis that has the shape of an inverted "Y". Which of the following factors best predicts the risk that the deformity will become worse?

A 44-year-old man who sustained an elbow dislocation 3 months ago now reports pain and restricted elbow motion. Radiographs are shown in Figures 27a and 27b. Management should consist of

When do most symptomatic thromboembolic events occur after total joint arthroplasty?

A 63-year-old woman has a femoral neck fracture. A biopsy specimen obtained from the fracture site at the time of her hemiarthroplasty reveals metastatic carcinoma. Seven days after surgery, she becomes confused and lethargic. Which of the following laboratory values is most likely implicated in the patient’s symptoms at this time?

When treating thoracolumbar spine fractures, which of the following is considered the major advantage of using a thoracolumbosacral orthosis (TLSO) when compared to a three-point fixation brace (Jewett)?

Injury to the popliteal artery during total knee arthroplasty (TKA) is most likely when placing a sharp retractor

A 45-year-old man has had left thigh pain for the past 4 months. An AP radiograph, bone scan, MRI scans, and biopsy specimens are shown in Figures 6a through 6f. What is the most appropriate treatment?

A year-old man with a body mass index of 31 had a month gradual onset of right medial knee pain. Examination revealed a small effusion, stable ligaments, a normally tracking patella, and mild medial joint line tenderness. Standing radiographs show mild medial joint space narrowing. Effective treatment at this stage of early medial compartmental osteoarthritis includes

When compared with fresh-frozen bone allograft, freeze-dried bone allograft (FDBA) is characterized by

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

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

Figures  below  show  the  radiographs  obtained  from  a  75-year-old  woman  who  underwent  right  total  hip arthroplasty in 2009. She did well until last month, when a right posterior hip dislocation occurred after she fell from her bed to the floor. Successful closed reduction was performed. She sustained two more posterior dislocations requiring closed reduction under anesthesia. The surgical report from the index arthroplasty notes a 54-mm monoblock acetabular component with a 28-mm inner diameter compression molded polyethylene and a high offset neck cementless stem with a +8-mm length, 28-mm head. What is the best next step?

Which clinical sign is the most sensitive for the diagnosis of compartment syndrome in a child with a supracondylar humerus fracture?

Figure 11 shows the radiograph of an 18-year-old soccer player who reports recurrent lateral foot pain after sustaining an inversion injury. History reveals that 6 months ago he had been treated in a non-weight-bearing cast for a fifth metatarsal fracture. Management should consist of

Figures 1 through 4 are the wrist MR images of a 43-year-old right-hand-dominant bricklayer who reports gradually progressive left hand weakness for 4 months. He describes difficulty gripping objects, tying his shoes, and holding utensils. He denies any numbness, paresthesias, or a previous injury. An examination reveals intact sensation in a median, radial, and ulnar nerve distribution. He has atrophy of hand interossei and a positive Froment sign finding. He has no Tinel sign finding at the wrist or elbow and no exacerbation of symptoms with elbow hyperflexion. Electromyography shows signs of denervation in an ulnar nerve distribution distal to the wrist. What is the best next step?

5 mg/dL), vitamin D 50 ng/mL (reference range, 30-100 ng/mL), and urine phosphorus 2 g/24-hour collection (reference range, 0.4-1.3 g). What effect would treatment with only Calcitriol (1,25 dihydroxy vitamin D3) have?

What is the advantage of percutaneous pedicle screw fixation over open instrumentation and fusion for a thoracolumbar burst fracture without neurologic deficit?

Figure 38 shows the radiograph of a 5-year-old child who sustained a type III supracondylar fracture. Examination reveals the absence of a radial pulse, but an otherwise well-perfused hand. Following closed reduction and percutaneous pinning, the radial pulse remains absent; however, the hand is pink and well perfused. Management should now include

A 29-year-old man reports a 2-week history of severe neck pain after being struck sharply on the back of the head and neck while moving a refrigerator down a flight of stairs. Initial evaluation in the emergency department revealed no obvious fracture and he was discharged in a soft collar. Neurologic examination is within normal limits, and radiographs taken in the office are shown in Figures 21a through 21c. Subsequent MRI scans show intra-substance rupture of the transverse atlantal ligament. What is the most appropriate treatment option at this time? Review Topic

Which of the following statements correctly describes the results of gamma irradiation of musculoskeletal allograft?

A previously healthy 35-year-old man was involved in a rollover motor vehicle accident 2 days ago. He was placed in a semi-rigid cervical orthosis. He now reports mostly axial neck pain with attempted range of motion. Examination reveals the mechanical neck pain but no obvious neurologic deficits. AP, flexion, and extension radiographs are shown in Figures 10a through 10c, and sagittal and coronal CT scans are shown in Figures 10d and 10e. What is the most appropriate management at this time?

A 60-year-old man who underwent left partial knee arthroplasty 6 months earlier was doing well until he experienced left knee pain and swelling for 4 weeks following a dental procedure. The left knee aspirate was  bloody,  with  a  white  blood  cell  count  of  8,000  and  70%  neutrophils.  Culture  grew  group  B Streptococcus (Granulicatella adiacens), and serologies were elevated, with an erythrocyte sedimentation rate of 55 mm/h (reference range: 0 to 20 mm/h) and a C-reactive protein level of 24 mg/L (reference range: 0.08 to 3.1 mg/L). What is the best next step?

At the time of acetabular revision, retention of well-fixed femoral components inserted with first-generation cementing technique is most commonly associated with which of the following factors?

In the pediatric population, CECS most commonly presents in females involved in running sports. In this cohort, recurrence occurs at a rate of 18%. Wound complications are the next most common at a rate of 11.2%. A 15-year-old male ice hockey player is hit in the chest by a puck and immediately falls to the ground unconscious. What has been shown to predict survival in the treatment of this condition?

…Figure 53 is the emergency department radiograph of a 7-year-old boy who has pain and is unwilling to use his right arm after a fall on the playground. What is the most appropriate initial treatment?

• A 19-year-old man sustains a complete spinal cord injury at the C7 level as a result of diving into a lake. He has a blood pressure of 90/50 mm Hg, a pulse of 60/min, and respirations of 20/min. These values most likely signify

A 34-year-old man sustained a gunshot wound to the knee 18 months ago and was treated with bullet removal and a 10 day course of oral antibiotics. He now complains of 12 months duration of pain in the thigh and recent ulceration and drainage of the skin near the site of his gunshot wound. Physical exam is notable for a draining sinus tract, erythema and tenderness of the mid-thigh. He is afebrile. An MRI image of this patient is shown in Figure A. Which of the following is the most appropriate management?

A 45-year-old man reports severe discomfort following a twisting injury to his right ankle and foot. Plain radiographs are negative; however, the CT scans shown in Figures 39a and 39b reveal a fracture. Management should consist of

A 14-year-old boy with a history of cerebral palsy has a clawed hallux, cavus foot deformity, and associated pain. Examination reveals pain under the first metatarsal head and a rigid first tarsometatarsal joint. Treatment should consist of

A 10-year-old boy sustained an injury to the left knee. The radiographic findings shown in Figure 19 are most commonly associated with injury to which of the following structures?

..Further imaging shows pulmonary metastases without an obvious primary tumor of origin and an incomplete fracture of the right distal femur. A decision is made to surgically treat his distal femur fracture. What is the role of establishing a preoperative histologic diagnosis for this patient?

A 74-year-old man has had worsening left shoulder pain for the past 3 years. Extensive nonsurgical management has provided only minimal relief. Examination reveals limitations in motion due to pain but good rotator cuff strength. Radiographs are shown in Figures 53a and 53b. What surgical procedure is most appropriate?

A 40-year-old man fell 10 feet from a tree and sustained the closed isolated injury shown in Figures 35a and 35b. Management consists of splinting. At his 2-week follow-up visit, he clinically passes the wrinkle test. He agrees to open reduction and internal fixation. What is the best surgical approach to obtain anatomic reduction and limit wound dehiscence?

• Which of the following rehabilitation methods should be used for the first 24 hours following a blunt injury to the quadriceps musculature to avoid short-term stiffness?

3 degrees Celsius and heart rate of 105 bpm. A clinical photograph, results of synovial fluid analysis, and a polarizing microscopy image are seen in Figures A through C. Synovial fluid gram stain and cultures are pending. What is the most appropriate next step in management?

A 25-year-old construction worker lands on his outstretched hand in a fall. The position of his wrist at the time of impact causes a force that leads to hyperextension, ulnar deviation, and intercarpal supination. Radiographs are shown in Figures 48a and 48b. Management should consist of

A 60-year-old woman has activity-related hip pain after undergoing arthroplasty 5 years ago. She has severe Parkinsonism and denies fevers or chills. Radiographs are shown in Figures 45a and 45b. What is the most likely cause of her pain?

A B

Figure 1 is an MRI scan of the right hip of a 19-year-old woman with a 6-month history of right groin pain. She was diagnosed with a stress fracture and was treated with 3 months of limited weight bearing. Figure 2 is a repeat MRI scan in which the edema pattern changed minimally but the pain worsened. Ibuprofen alleviates most of her pain. What is the best next step?

When comparing the overall outcomes of surgical versus nonsurgical treatment of stable thoracolumbar burst fractures in patients without neurologic injury, 5 years following injury, the principle differences lie in Review Topic

Figures 2a and 2b show the radiograph and MRI scan of a 56-year-old woman who has low back pain and right leg pain. She has grade 3/5 toe and ankle dorsiflexion strength on the right side. Nonsurgical management has failed to provide relief; therefore, surgery should include Review Topic

The primary function of structure “A” in Figure 29 is to limit

A 62-year-old man who underwent total knee arthroplasty 6 months ago now reports pain after falling on the anterior portion of the knee. Examination reveals weakness of knee extension but no extensor lag. Flexion that had once measured 115 degrees is now limited to 70 degrees because of pain. A radiograph is shown in Figure 25. Management should now consist of

Figure 12 shows the radiograph of an 80-year-old woman who has had an 8-month history of back pain after a fall. What is the most likely diagnosis based on the radiographic findings at the fractured vertebrae?

A 32-year-old male sustains an APC-III pelvic ring disruption after a motor vehicle collision. Which of the following imaging techniques best describes the correct utilization of intraoperative flouroscopy for percutaneous iliosacral screw placement across S1?

A 2-year-old child has refused to bear weight on his leg for the past 2 days. His parents report that he will crawl, has no fever, and has painless full range of motion of his hip and knee. Examination reveals no deformity or bruising, but there is mild swelling and tenderness over the anterior tibia. C-reactive protein, WBC count, and erythrocyte sedimentation rate studies are normal. Radiographs are negative. What is the best course of action?

A 38-year-old woman has persistent elbow pain but is unable to recall a specific traumatic event. Examination reveals that the patient exhibits apprehension when the elbow is placed in valgus with forearm supination and axial loading. Because of chronicity and failure to respond to nonsurgical management, what is the most appropriate treatment? Review Topic

A 23-year-old baseball pitcher reports pain in the posterior aspect of his dominant shoulder during the late cocking phase of throwing. With the dominant shoulder positioned in 90 degrees of abduction from the body and with the scapula stabilized, examination reveals 135 degrees of external rotation and 20 degrees of internal rotation. Examination of the opposite shoulder reveals 100 degrees of external rotation and 75 degrees of internal rotation. Both shoulders are stable on examination. Radiographs and MRI scans are unremarkable. What is the primary cause of his pain?

A researcher experimenting with limb patterning removes some tissue from 1 part of the limb bud (which we shall call Site A) and transplants it along the anteroposterior (AP) axis to create a mirror-hand duplication. Which of the following is true?

Poor pre-injury cognitive function has been proven to increase mortality for which of the following injuries?

Radiographs of the femur are unremarkable. A radionuclide bone scan demonstrates abnormal uptake in the mid-femur. A radionuclide bone marrow scan demonstrates decreased uptake within the marrow. Which of the following is the best step in management?

A 3-year-old boy is referred to you because of "abnormal radiographs". The child's radiographs are shown in Figures A and B. This patient is at increased risk for all of following conditions EXCEPT: Review Topic

What vessel is marked with an asterisk in Figure 44?

In a hypothetical study, an investigator uses pedometers to determine that the 20 women in his activity study averaged 2.1 million steps per year, whereas the 20 men averaged 1.8 million. The p-value for this difference was 0.09. Which of the following is a correct interpretation of the outcome of this study?

Locked plating techniques have been shown to have biomechanical advantages over standard plating in which of the following scenarios?

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

Overgrowth of a limb in a patient with neurofibromatosis type 1 (NF1) is most likely associated with the presence of

The patient returns 4 days after surgery and says he has noticed a red, swollen knee since yesterday. He reports a fever of 38.0°C since last evening and denies traumatic injury. He has an erythematous knee with a large, tense effusion; his range of motion is limited; and the surgical incisions are not draining. Radiographs taken in the office show no change from the immediate postsurgical images. Aspiration in the office returns 50 cc of cloudy, blood-tinged synovial fluid, and analysis of the fluid reveals a white blood cell count of 92000 (reference range 4500-11000 /µL). Which bacteria is most commonly responsible for this clinical scenario?

Figure 3 shows the radiograph of an asymptomatic 10-year-old boy. Management should consist of

A patient has right shoulder pain. Figure 1a shows a gadolinium-enhanced transverse MRI scan at the level of the coracoid. Figure 1b shows an arthroscopic view of the anterior structures from a posterior portal. These images reveal which of the following findings?

You have been waiting to enroll a patient into your recent institutional review board (IRB)-approved clinical research protocol. A patient is admitted who, upon initial screening, meets all inclusion criteria. However, he has late-stage dementia, and you are told by your research coordinator that this condition is an exclusionary criterion. This scenario demonstrates the need for which aspect of proper informed consent?

Which of the following statements is true regarding the superomedial fragment of an intra-articular calcaneus fracture?

What is the most important genetic element that distinguishes community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) from hospital-acquired MRSA? Review Topic

-The patient has no postsurgical complications and begins physical therapy rehabilitation. The boy and his parents stress they “want to get the therapy over with as fast as possible” to expedite his return to sports,and the surgeon and rehabilitation team consider their request. Compared to nonaccelerated rehabilitation,patients who follow an early accelerated rehabilitation protocol experience

A 78-year-old woman undergoes an uneventful semiconstrained total elbow arthroplasty through a Bryan-Morrey approach. Her immediate postoperative management should include which of the following? Review Topic

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. The injured structure is composed of an

What type of nerve palsy is most common following elbow arthroscopy?

Figure 53 shows the arteriogram of a 45-year-old man who has severe vasculitis. What do the findings show?

A 32-year-old volleyball player has dull posterior shoulder pain. An examination reveals moderate external rotation weakness with his arm at his side, but normal strength on supraspinatus isolation. Deltoid and supraspinatus bulk appear normal, although there appears to be mild infraspinatus atrophy. Sensation is normal throughout the shoulder and shoulder girdle. What is the most likely diagnosis?

A 66-year-old male sustains an open crush injury to his right lower leg with significant skin loss. His history is significant for COPD, diabetes controlled with an insluin pump, and testicular cancer treated with bleomycin twenty years ago. A radiograph of the chest shows a pneumothorax which is treated with a thoracostomy tube. Which of the following is not a contraindication to hyperbaric oxygen treatment for this patient?

Figure 1 is the MRI scan of a patient with recurrent knee instability, which persists after a period of nonsurgical treatment. Anatomic reconstruction of the torn ligament is recommended. What radiographic finding is the most important independent predictor of recurrent instability following surgery?

A 68-year-old woman with serologically proven rheumatoid arthritis underwent an open synovectomy and radial head resection 10 years ago. She now has severe pain that has failed to respond to nonsurgical management. Examination reveals a flexion arc of greater than 90 degrees. Radiographs are shown in Figures 15a and 15b. What is the most appropriate management?

A 4-month-old infant is unable to flex her elbow as a result of an obstetrical brachial plexus palsy. This most likely illustrates a predominate injury to what structure?

A 10-year-old boy with a history of retinoblastoma now reports right knee pain. AP and lateral radiographs are shown in Figures 3a and 3b. What is the most likely diagnosis?

A 37-year-old man has had isolated chronic knee swelling for the past 6 months. He denies any history of specific trauma. Examination reveals a large effusion with a stable knee, but the remainder of the examination is normal. Plain radiographs are unremarkable. An MRI scan reveals a large effusion without meniscal injury. An arthroscopic image of the suprapatellar pouch is shown in Figure 23. What is the most likely diagnosis?

Figure 21 is the intraoperative fluoroscopic image of a 40-year-old man who felt a pop during a twisting injury to his right ankle. He underwent open reduction and internal fixation (ORIF) of a bimalleolar ankle fracture. During the surgery the medial and lateral malleoli fractures were reduced and rigidly was internally fixed. Following fracture fixation, which additional test is recommended to ensure mortise stability?

A 77-year-old man has had increasing right knee pain for the past 3 months. A radiograph and coronal T 1 -weighted MRI scan are shown in Figures 19a and 19b. A biopsy specimen is shown in Figure 19c. What is the most likely diagnosis?