OITE & ABOS Orthopedic Board Prep MCQs | Part 50

About This Board Review Set

This is Part 50 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 50

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

Sample Questions from This Set

Sample Question 1: The load versus deformation curve of the functional spinal unit (FSU) is made up of the neutral zone, the elastic zone, and the plastic zone. What is the plastic zone of the curve believed to represent?...

Sample Question 2: A 21-year-old female college athlete sustained a stress fracture of the fifth metatarsal 1 year ago which was treated successfully with surgical stabilization and she returned to normal activities. She now has a tension-sided femoral neck f...

Sample Question 3: Which of the following injuries is most likely associated with the fracture seen in Figure A?...

Sample Question 4: A 22-year-old patient sustained a jamming injury to the right little finger. The lateral radiograph shown in Figure 18 reveals comminution of the base of the middle phalanx, with palmar and dorsal metaphyseal cortical involvement. The artic...

Sample Question 5: The anterior portal of a hip arthroscopy places what structure at greatest risk for injury?...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

The load versus deformation curve of the functional spinal unit (FSU) is made up of the neutral zone, the elastic zone, and the plastic zone. What is the plastic zone of the curve believed to represent?

Explanation

DISCUSSION: Plastic deformation of viscoelastic tissues represents deformation of the soft tissues to the point of failure. The lining up of collagen fibers would be in the “toe region” of the curve, which, in the case of the FSU, would be mainly in the neutral zone. Elastin is a minor contributor to the composition of the ligaments and would be protected by the stiffer collagen fibers. The transition between flexion and extension occurs in the neutral zone, and reversible elongation occurs in the elastic zone.
REFERENCES: Fardon DF, Garfin SR, Abitbol J, et al (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 15-23.
Panjabi MM, White AA: Physical properties and functional biomechanics of the spine, in White AA, Panjabi MM: Clinical Biomechanics of the Spine, ed 2. Philadelphia, PA, JB Lippincott, 1990, pp 1-83.

Question 2

A 21-year-old female college athlete sustained a stress fracture of the fifth metatarsal 1 year ago which was treated successfully with surgical stabilization and she returned to normal activities. She now has a tension-sided femoral neck fracture. Along with surgical fixation of the fracture, what is the next step in management? Review Topic

Explanation

Stress fractures can be seen in female athletes who develop the female athletic triad including amenorrhea, osteoporosis, and eating disorders. Any female athlete with a history of stress fractures should undergo a workup for this disorder. Workup should include obtaining a menstrual history, obtaining a nutritional consultation, and obtaining a bone density. When properly counseled, these athletes may return to high endurance sports activities. Although these athletes may require a change in training intensity or psychiatric consultation, it would not be the next step in management. Psychiatric consultation may not be necessary unless an eating disorder has been diagnosed. Serum calcium levels are normal in these patients. Tension-sided stress fractures of the femoral neck require surgical stabilization with internal fixation as opposed to compression-sided stress fractures that can be treated with rest and nonsurgical management.

Question 3

Which of the following injuries is most likely associated with the fracture seen in Figure A?

Explanation

Lateral meniscal tears are most commonly associated with Schatzker II tibial plateau fractures (split/depressed).
Soft tissue pathology is common in tibial plateau fractures. In general, fractures that are largely displaced and/or a result of high energy trauma are more likely to have associated soft tissue pathology. A majority of meniscal injuries that occur in the setting of tibial plateau fractures are meniscocapsular detachments. This has important implications for healing (more reliable healing in the vascular zone). Additionally, the meniscus usually remains in close contact with the femoral condyle, while the tibial plateau widens around it. It is generally agreed upon that meniscal tears should be repaired, if possible, at the time of internal fixation to decrease the likelihood of
postraumatic arthritis.
Gardner et al. review 62 patients with Schatzker II tibial plateau fractures that had an MRI preoperatively. For displaced fractures, the incidence of lateral meniscal tears was 83%, while the incidence of lateral collateral and posterior cruciate ligament injuries was 30%.
Ringus et al. attempted to determine if the degree of lateral tibial plateau fracture depression on computed tomography (CT) images predicted the presence of lateral meniscus tears. Fractures with > 9mm depression had an eight-fold increase in lateral meniscal tears, and those younger than 48 years-old had a four-fold increase in lateral meniscal tears.
Illustration A shows an MRI of a Schatzker II tibial plateau fracture with a lateral meniscal detachment and a medial meniscal tear. Illustration B shows the Schatzker Classification, I-VI.
Incorrect Answers:

Question 4

A 22-year-old patient sustained a jamming injury to the right little finger. The lateral radiograph shown in Figure 18 reveals comminution of the base of the middle phalanx, with palmar and dorsal metaphyseal cortical involvement. The articular surface also is disrupted. Management should consist of

Explanation

DISCUSSION: This fracture, known as a pilon fracture, represents comminution of the base of the middle phalanx with both palmar and dorsal cortical disruption. The treatment method that allows the best function and fewest complications is indirect reduction achieved through specific dynamic splinting or the use of specifically designed proximal interphalangeal joint external fixators. Early mobilization can be achieved by either of these techniques. Volar plate arthroplasty is indicated for a simple fracture-dislocation of the proximal interphalangeal joint with comminution of the volar fracture fragment and dorsal dislocation of the remaining articular surface. Open reduction and internal fixation or percutaneous pinning adds surgical risks and scarring and typically will not provide added stability. Cast immobilization will not achieve the goal of early range of motion.
REFERENCES: Stern PJ, Roman RJ, Kiefhaber TR, McDonough JJ: Pilon fractures of the proximal interphalangeal joint. J Hand Surg Am 1991;16:844-850.
Krakauer JD, Stern PJ: Hinged device for fractures involving the proximal interphalangeal joint. Clin Orthop 1996;327:29-37.

Question 5

The anterior portal of a hip arthroscopy places what structure at greatest risk for injury?

Explanation

DISCUSSION: The average location of the anterior portal is 6.3 cm distal to the anterior superior iliac spine. The lateral femoral cutaneous nerve typically has divided into three or more branches at the level of the anterior portal. The portal usually passes within several millimeters of the most medial branch. Injury to the nerve can lead to meralgia paresthetica. The femoral nerve lies an average minimum distance of 3.2 cm from the anterior portal. The ascending branch of the lateral circumflex artery lies approximately 3.7 cm inferior to the anterior portal. Neither the ascending branch of the medial circumflex artery nor the superior gluteal nerve are

at risk.
REFERENCES: Byrd JWT: Operative Hip Arthroscopy. New York, NY, Thieme Medical Publishers, 1998, pp 83-91.
Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 281-289.

Question 6

A 60-year-old man is evaluated in the ICU after a rollover motor vehicle accident 3 days ago. He has multiple upper and lower extremity trauma and was found unresponsive at the accident scene. Surgery is planned for the extremity trauma once the patient is medically stable. He remains intubated and the cervical spine is immobilized in a semi-rigid collar. Examination reveals mild erythema in the posterior occipital cervical region. Initial AP and lateral radiographs of the cervical spine have not revealed any obvious fracture. What is the most appropriate treatment option at this time? Review Topic

Explanation

Ackland and associates demonstrated that the failure to achieve early spinal clearance in an unconscious blunt trauma patient predisposed the patient to increased morbidity secondary to the prolonged used of cervical immobilization. They demonstrated that the four significant predictors of collar-related ulcers were ICU admission, mechanical ventilation, the necessity for cervical MRI, and the time to cervical spine clearance and collar removal. The risk of pressure-related ulceration increased by 66% for every 1-day increase in Philadelphia collar time and this highlights the need for definitive C-spine clearance.

Question 7

03 advancement at age 6 years. What is the most likely diagnosis?

Explanation

Figure 15a shows areas of permeative lucency and sclerosis in the proximal femur as well as evidence of a screw (from the previous trochanteric advancement). Figure 15b shows the CT scan of the femur with possible thickening of the cortex and a moth eaten appearance of the bone. Figure 15c shows the biopsy specimen with mixed inflammatory cells. These are all indicative of osteomyelitis. The first radiographic sign of osteomyelitis tends to be an ill-defined area of lucency, followed by areas of sclerosis and periosteal new bone formation as the bone reacts to the infection. Biopsy specimens should show mixed inflammatory cells.
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Question 8

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 Review Topic

Explanation

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.

Question 9

With the arm abducted 90 degrees and fully externally rotated, which of the following glenohumeral ligaments resists anterior translation of the humerus?

Explanation

DISCUSSION: With the arm in the abducted, externally rotated position, the anterior band of the inferior glenohumeral ligament complex moves anteriorly, preventing anterior humeral head translation. Both the coracohumeral ligament and the superior glenohumeral ligament restrain the humeral head to inferior translation of the adducted arm, and to external rotation in the adducted position. The middle glenohumeral ligament is a primary stabilizer to anterior translation with the arm abducted to 45 degrees. The posterior band of the inferior glenohumeral ligament complex resists posterior translation of the humeral head when the arm is internally rotated.
REFERENCES: Harryman DT II, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.
Wang VM, Flatow EL: Pathomechanics of acquired shoulder instability: A basic science perspective. J Shoulder Elbow Surg 2005;14:2S-11S.

Question 10

Sclerostin and dickkopf-1 (Dkk-1) are direct inhibitors of what pathway related to bone and/or cartilage regulation?

Explanation

RESPONSES FOR QUESTIONS 3 THROUGH 6
Adhesive wear
Abrasive wear
Fatigue wear
Delamination
For each scenario below, please choose the most likely dominant mechanism of wear from the list
above.

Question 11

During placement of an external fixator for a distal radius fracture, the most commonly injured nerve is a branch of which of the following nerves? Review Topic

Explanation

Post-surgical mortality rates are significantly lower after total hip arthroplasty compared to hemiarthroplasty
Internal fixation shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to arthroplasty
Bipolar hemiarthroplasty shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to unipolar hemiarthroplasty
A delay in surgery greater than 48 hours is recommended if the patient has multiple medical comorbiditiesm which are not fully optimized
Dislocation rates are equivalent between total hip arthroplasty and hemiarthroplasty
Moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes. However, patients with significant medical comorbidity should be fully optimized before surgery.
Although several studies have shown a benefit to surgery within 48 hours, no definitive time frame has been elucidated. The majority of literature has shown improved outcomes in regards to pain, complications, and length of stay with early surgery. Patients with significant medical comorbidities have been shown to have the highest mortality rates.
Moran et al. aimed to determine whether a delay in surgery for hip fractures had an affect on postoperative mortality among elderly patients. In an observational study of 2660 patients, they showed that mortality following hip fracture surgery was 9% at 30-days, 19% at 90-days, and 30% at 12-months. Patients with medical comorbidities had 2.5 times the risk of death within 30-days of surgery. In addition, individuals who had surgery delayed beyond 4 days had increased mortality at 90-days and 12-months.
Papakostidis et al. examined the timing of internal fixation of intracapsular fractures of the neck of femur on the development of late complications, particularly osteonecrosis of femoral head (ONFH) and non-union. They showed no benefit of
early surgery on incidence of AVN. However, delay of internal fixation of more than
24 hours showed increased rates of non-union.
Figure A shows a displaced right femoral neck fracture. Incorrect Answers:

Question 12

A normal functioning posterior tibialis tendon is best confirmed by which of the following physical findings?

Explanation

The main function of the Tib. Post. Tendon is inversion of the subtalar joint and adduction of the forefoot. This initial inversion stabilizes the subtalar joint allowing the gastrosoleus complex to forcibly invert the joint while plantarflexing the ankle. Heel inversion begins during flatfoot when the Tib Post. fires at 7% of the walking cycle. The gastrosoleus kicks in at 30% of the cycle to maintain inversion, which locks the midfoot for push-off.

Question 13

A 65-year-old woman has significant neck pain after falling and striking her head. A radiograph and sagittal CT scan are shown in Figures 23a and 23b. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph shows a displacement of C5 on C6 of approximately 25%. The CT scan shows a perched facet at C5-6. There is no evidence of a facet fracture. A bilateral facet dislocation would show a displacement of more than 50%.
REFERENCES: Rothman RH, Simeone FA (eds): The Spine, ed 4. Philadelphia PA, WB Saunders, 1999, pp 927-937.
Vaccaro AR, Betz RR, Zeidman SM (eds): Principles and Practice of Spine Surgery. St Louis, MO, Mosby, 2003, pp 455-458.

Question 14

Which modality has the broadest application for the reduction of postsurgical transfusion?

Explanation

DISCUSSION:
TXA is easy to administer, inexpensive, and safe for virtually all patients. Multiple studies have demonstrated transfusion rates lower than 3% for total knee arthroplasty and lower than 10% for total hip arthroplasty. Regional and hypotensive anesthesia effectively reduce transfusion; however, they cannot be used in as wide a range of patients as can TXA. A reduced transfusion trigger must be considered along with patient symptoms when determining the need for transfusion.

Question 15

Reverse total shoulder arthroplasty with a latissimus dorsi transfer would be the most appropriate treatment for which of the following patients? Review Topic

Explanation

Reverse total shoulder arthroplasty with a latissimus dorsi transfer would be most appropriate in a patient with failed shoulder hemiarthroplasty and the inability to perform active external rotation with the arm abducted
R-TSA has become the mainstay treatment for rotator cuff arthropathy. In the presence of severe loss of active elevation and external rotation, combined latisimus dorsi transfer and reverse total shoulder arthroplasty can restore elevation and external rotation, respectively. This may be used in the primary or revision setting.
Frankle et al. report the results of sixty patients with rotator cuff deficiency and glenohumeral arthritis who were followed for a minimum of two years. All were
treated with R-TSA. Their study showed that forward flexion increased from 55 to
105 degrees, and abduction increased from 41 to 102 degrees.
Boileau et al. followed 45 patients with severe cuff tear arthropathy and advanced atrophy/fatty infiltration of the infraspinatus or teres minor muscles. All patients were treated with R-TSA and a modified L'Episcopo procedure (latissimus dorsi and teres major transfer). Mean active elevation increased from 74 degrees preoperatively to
149 postoperatively, and external rotation increased from -21 to 13 degrees.
Illustrations A and B show the classic findings of rotator cuff arthropathy. There is significant acromial acetabularization and femoralization of humeral head. Other features include: asymmetric superior glenoid wear, osteopenia, "snowcap sign" due to subchondral sclerosis and anterosuperior escape. Illustration C shows a left shoulder after conversion from hemiarthroplasty to reverse total shoulder arthropathy.
Incorrect Answers:

Question 16

Figure 12 shows a lateral radiograph of the elbow. What is the most likely diagnosis?

Explanation

DISCUSSION: The figure shows a supracondylar process, which is a normal anatomic variant. An osteochondroma tends to occur more toward the end of bones, and the medullary space of the underlying bone extends into the base of the osteochondroma. The presence of a supracondylar process is usually asymptomatic. However, the ligament of Struthers that always extends from the supracondylar process to the medial epicondyle can result in median nerve entrapment secondary to trauma.
REFERENCE: Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, pp 132-133.
Keats TE, Anderson MW: Atlas of Normal Roentgen Variants That May Simulate Disease, ed 7. St Louis, MO, Mosby Inc, 2001, p 497.

Question 17

Figures 27a and 27b show the radiographs of a 32-year-old woman who was involved in a high-speed motor vehicle accident. She is neurologically intact. After stabilization and assessment, treatment should consist of

Explanation

DISCUSSION: The radiographs show a fracture-dislocation with translation in both the coronal and sagittal planes, evidence of significant instability requiring surgical stabilization. Anterior instrumentation is not as effective as posterior instrumentation in restoring stability, and because there is little bony destruction, the anterior column can be successfully reconstructed with simple realignment. The treatment of choice is multisegment posterior fusion with instrumentation.
REFERENCES: Lewandrowski KU, McLain RF: Thoracolumbar fractures: Evaluation, classification, and treatment, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 817-843.
Carl AL: Adult spine trauma, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 406-423.

Question 18

A 12-year-old girl sustains an acute injury to the right elbow in a fall. An AP radiograph is shown in Figure 5. Nonsurgical management will most likely result in

Explanation

DISCUSSION: The patient has a significantly displaced medial epicondyle fracture. The only absolute indication for surgical treatment is irreducible incarceration in the joint. Nonsurgical management usually results in a painless nonunion with good elbow function and little elbow instability. Prolonged immobilization should be avoided to prevent stiffness. Tardy ulnar nerve palsy and cubitus varus are not complications of medial epicondyle fractures.
REFERENCES: Chamber HG, Wilkins KE: Part IV: Apophyseal injuries of the distal humerus, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 801-812.
Farsetti P, Potenza V, Caterini R, Ippolito E: Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am 2001;83:1299-1305.

Question 19

A 46-year-old patient with cervical myelopathy undergoes a multilevel posterior cervical laminectomy from C3 to C7. The risk of postlaminectomy kyphosis is greatest with removal of which of the following structures?

Explanation

DISCUSSION: Removal of more than 50% of a facet joint can lead to segmental instability and compromises the overall strength of the joint. Removal of the lamina, interspinous ligament, and ligamentum flavum are standard features of a cervical laminectomy. Most surgeons favor fusion with instrumentation of a laminectomized cervical spine. If the anterior part of the spine is already ankylosed from previous surgery or from degenerative conditions, or a posterior fusion with instrumentation is included, then the risk of kyphosis or instability is reduced.
REFERENCE: Zdeblick TA, Abitol JJ, Kunz DN, et al: Cervical stabilization after sequential capsule resection. Spine 1993;18:2005-2008.

Question 20

What is the most common organism found following a nail puncture wound through tennis shoes in a host without immunocompromise?

Explanation

DISCUSSION: The association of a nail puncture wound with a gram-negative infection (Pseudomonas aeruginosa) has been attributed to the local environmental factors in shoes. Osteomyelitis is rare, occurring only in about 1% of patients. Tetanus prophylaxis should be given if it is not up to date. While the remaining organisms listed are periodically involved, they are more common in patients who are immunocompromised or who have diabetes mellitus. Therefore, obtaining a culture of the infected wound is appropriate in such individuals because of the multifactorial nature of the infection.
REFERENCES: Green NE, Bruno J III: Pseudomonas infections of the foot after puncture wounds. South Med J 1980;73:146-149.
Riegler HF, Routson GW: Complications of deep puncture wounds of the foot. J Trauma 1979;19:18-22.

Question 21

A 16-year-old girl who swims on her high school team reports pain in the shoulder after swimming. History reveals a glenohumeral dislocation at age 14 years while doing the backstroke. Examination shows a positive anterior apprehension sign. Treatment at this time should consist of

Explanation

p.579: “The Putti-Platt procedure is contraindicated in multidirectional instability (AMBRI); tightening the front of the shoulder will only increase the likelihood of posterior instability. In traumatic instability (TUBS) the data suggest that such a procedure, which limits external rotation is not necessary if the Bankart lesion is solidly repaired.”
p. 577: “A vigorous effort to stabilize the shoulder with exercises is particularly indicated in patients with multidirectional or posterior instability and in athletes requiring a completely normal or supranormal range of motion.”
p. 989: “If the [swimmer] has symptoms of subluxation, a conservative program that strengthens the external rotators is warranted. Surgery is seldom indicated.”

Question 22

A 12-year-old pitcher has had a 2-month history of pain in his right dominant shoulder after throwing. He reports that the pain has gradually progressed to the point where he cannot throw without pain. He also notes that the pain now awakens him at night if he has been active. Anti-inflammatory drugs have failed to provide relief. Examination reveals no abnormalities except for some localized tenderness over the proximal humerus. Figures 32a and 32b show radiographs of both shoulders. What is the most likely diagnosis?

Explanation

DISCUSSION: The history, examination, and radiographs are pathognomonic for Little League shoulder, a stress syndrome of the proximal humeral physis caused by overuse. Complete fracture rarely occurs, and recovery usually occurs with rest. Night pain is always a serious concern and further work-up is needed if the patient does not respond to activity modification. Occult instability is not a real concern in this patient, although it should be included in the differential diagnosis.
REFERENCES: Albert MJ, Drvaric DM: Little League shoulder: Case report. Orthopedics 1990;13:779-781.
Barnett LS: Little League shoulder syndrome: Proximal humeral epiphyseolysis in adolescent baseball pitchers. A case report. J Bone Joint Surg Am 1985;67:495-496.

Question 23

A 24-year-old man is involved in a motor vehicle accident at 60 mph. He sustains multiple injuries including an intra-abdominal injury requiring a splenectomy and a closed right femoral shaft fracture. Which variable will best indicate the patient's resuscitation status when deciding whether to proceed with definitive care of the fracture at the conclusion of the laparotomy? Review Topic

Explanation

A metabolic parameter such as the base deficit or lactate level has been shown to better reflect the resuscitation status and survival after trauma. Normalization of hemodynamic parameters does not accurately reflect the resuscitation status and a patient can be in compensated shock (occult tissue hypoperfusion) despite normalization of the heart rate and blood pressure. The use of temporizing measures with delayed definitive fracture treatment has been shown to decrease systemic complications in these patients with occult hypoperfusion.

Question 24

What property of titanium alloys accounts for their high corrosion resistance in vivo?

Explanation

DISCUSSION: In both room temperature air and physiologic fluids, titanium alloys self-passivate or spontaneously form a layer of titanium oxide very rapidly. This layer makes titanium alloys resistant to surface breakdown.
REFERENCES: Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA, Lippincott, 2003, vol 1, pp 269-278.
Lemons JE: Metallic alloys, in Morrey BF (ed): Joint Replacement Arthroplasty, ed 3. Philadelphia, PA, Churchill-Livingstone, 2003, pp 19-27.

Question 25

What is the most common location of osteosarcoma?

Explanation

DISCUSSION: The most common location of osteosarcoma is the knee area (50% to 55%), followed by the proximal humerus and iliac wing. The most commonly involved long bone is the femur (40% to 45%), followed by the tibia (15% to 25%). Within these bones, tumors are typically adjacent to the epiphyses in most patients. The flat bones of the pelvis and spine are less frequently involved.
REFERENCES: Malawer MM, Sugarbaker PH, Malawer M: Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Kluwer Academic Publishers, 2001.
Wold LA, et al: Osteogenic Sarcoma: Atlas of Orthopedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 14-15.

Question 26

A 25-year-old man reports wrist pain following a motorcycle accident. Examination reveals minimal swelling, slightly limited active range of motion, and point tenderness in the snuff box region. AP and oblique radiographs are shown in Figures 40a and 40b. Management should consist of

Explanation

DISCUSSION: The radiographs reveal a scaphoid fracture with displacement and comminution and an unstable fracture pattern. Treatment should consist of open reduction and internal fixation. In displaced scaphoid fractures and fractures with unstable fracture patterns, closed reduction is ineffective and is likely to lead to nonunion. Limited intercarpal fusion and proximal row carpectomy are used to correct a variety of traumatic and posttraumatic problems of the wrist.
REFERENCES: Amadio PC, Taleisnik J: Fractures of the carpal bone, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,

pp 809-823.
Rettig ME, Kozin SH, Cooney WP: Open reduction and internal fixation of acute displaced scaphoid waist fractures. J Hand Surg Am 2001;26:271-276.
Cooney WP, Dobyns JH, Linscheid RL: Fractures of the scaphoid: A rational approach to management. Clin Orthop 1980;149:90-97.
Szabo RM, Manske D: Displaced fractures of the scaphoid. Clin Orthop 1988;230:30-38.

Question 27

A patient with rheumatoid arthritis with both ankle and subtalar involvement was treated as shown in Figures 11a and 11b. What complication is unique to this type of fixation?

Explanation

DISCUSSION: The interlocking screws at the proximal end of the rod can act as a stress riser and lead to fracture. Postoperative pain at this level should prompt inclusion of this diagnosis in the differential. Removing the screws following bone union can decrease the chances of this occurring. A short rod that avoids the diaphyseal area may also be beneficial. Rotatory deformity is controlled by the perpendicularly oriented distal transfixion screws. Talar osteonecrosis would be unusual since the dissection can be minimized with an intramedullary rod. Any type of hardware can fail if the construct does not lead to a solid arthrodesis.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 236-237.
Thordarson DB, Chang D: Stress fractures and tibial cortical hypertrophy after tibiotalocalcaneal arthrodesis with an intramedullary nail. Foot Ankle Int 1999;20:497-500.
Hammett R, Hepple S, Forster B, et al: Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail: The results of 52 procedures. Foot Ankle Int 2005;26:810-815.

Question 28

Second impact syndrome (SIS) after head injury is characterized by which of the following? Review Topic

Explanation

SIS is a devastating but preventable complication of head injury. It occurs when return to activities is allowed prior to complete resolution of the symptoms of the first head injury. A second, sometimes trivial, head injury can lead to a devastating series of events that can result in sudden death. The symptoms tend to progress rapidly and often involve the brain stem. The prognosis is poor.

Question 29

An 11-year-old girl is struck in the leg by a loaded sled while sledding and is seen in the emergency department; she is reporting severe knee pain. Radiographs are read as normal. Examination reveals that she is exquisitely tender over the proximal tibial physis. The neurovascular examination is normal. What is the next step in management? Review Topic

Explanation

The anatomic lesion in this patient is not exactly defined, but she has most likely sustained an injury about the knee. A Salter-Harris type I proximal tibial physeal fracture is likely. The normal radiograph reading can be misleading because these injuries may displace and spontaneously reduce. The child is at risk of compartment syndrome although she is currently not displaying signs of it. Thus, even though this injury may seem trivial by radiographic findings, it should be treated like a knee dislocation with a risk of late developing compartment syndrome. MRI or CT may be necessary to define the injury. She does not require emergent treatment, but merits close observation for possible compartment syndrome. Any of the possible injuries about the knee can be unstable and require internal fixation after reduction.

Question 30

A 47-year-old obese man with a body mass index of 42 comes into the office with left knee pain 1 year after undergoing an uncomplicated left medial unicompartmental knee arthroplasty (UKA). Radiographs show a loose tibial component in varus. What is the most appropriate next step to treat this failed construct?

Explanation

DISCUSSION:
This patient likely is experiencing failure of the UKA secondary to poor patient selection. In this young, heavy man, the component likely loosened due to the ongoing varus alignment of the knee and his elevated
weight. Despite this likely scenario, the next step is determining whether an infection is the cause of his pain. Prior to obtaining an aspiration, the surgeon can order ESR and CRP studies to determine whether aspiration is warranted. If the laboratory studies are unremarkable, the surgeon likely can forgo the aspiration and proceed to a revision TKA with possible augments on standby.

Question 31

A 79-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing right shoulder pain for the past year, and nonsurgical management has failed to provide relief. Her neurologic examination is entirely normal, but she is unable to elevate her arm against gravity. An AP radiograph is shown in Figure 13. Treatment should consist of

Explanation

DISCUSSION: Because the patient has end-stage rheumatoid arthritis with glenoid and rotator cuff deficiency, humeral arthroplasty is the treatment of choice. When a patient has an intact rotator cuff and there is sufficient glenoid bone stock to implant a glenoid component, total shoulder arthroplasty is the preferred method because it appears to provide more predictable pain relief. Glenohumeral arthrodesis is generally avoided when there is a functional deltoid or rotator cuff. Open synovectomy is appropriate in early rheumatoid disease before articular changes are present. Anterior acromioplasty with coracoacromial ligament resection is avoided in patients with rheumatoid arthritis because this procedure compromises the coracoacromial arch and may result in anterosuperior instability.
REFERENCES: Neer CS II, Watson KC, Stanton FJ: Recent experience in total shoulder replacement. J Bone Joint Surg Am 1982;64:319-337.
Neer CS II: Glenohumeral arthroplasty, in Neer CS II (ed): Shoulder Reconstruction. Philadelphia, PA, WB Saunders, 1990, pp 143-271.
Pollock RG, Deliz ED, McIlveen ST, et al: Prosthetic replacement in rotator cuff deficient shoulders. J Shoulder Elbow Surg 1992;1:173-186.
Sneppen O, Fruensgaard S, Johannsen HV, Olsen BS, Sojbjerg JO, Anderson NH: Total shoulder replacement in rheumatoid arthritis: Proximal migration and loosening. J Shoulder Elbow Surg 1996;5:47-52.

Question 32

The Musculoskeletal Infection Society (MSIS) has adopted a definition of periprosthetic joint infection (PJI). This definition includes 2 major criteria and 5 minor criteria. Infection is present if 1 of 2 major criterions or 3 of 5 minor criterions are met. These criterions are

Explanation

DISCUSSION
In 2014, the MSIS published its revised PJI definition for clinical and research use. If 1 of 2 major criterions is met (phenotypically identical organisms obtained from 2 separate cultures or a draining sinus tract), then PJI is diagnosed. Alternatively, if 3 of 5 minor criterions are met, PJI is diagnosed.

Question 33

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 34

Which complication is most common after syndesmotic fixation?

Explanation

DISCUSSION
The injury radiographs reveal a supination external rotation IV ankle fracture with evidence of medial clear space widening exceeding 4 mm and an increase relative to the superior tibiotalar clear space. This indicates injury to the deltoid ligament and necessitates surgical reduction and fixation to restore and maintain ankle stability. Following stabilization of the fibula, an intraoperative stress examination of the syndesmosis such as an external rotation stress test under fluoroscopy or lateral pull on the fibula (the Cotton test) should be performed to determine the integrity of the syndesmosis. Radiographic evidence of tibiofibular clear space widening, medial clear space widening with external rotation, and lateral displacement of the distal fibula when pulled is consistent with syndesmotic injury. In contrast to the presurgical stress test, once the fibula has been reduced and stabilized lateral talar translation can occur only if the syndesmosis is injured in addition to the deltoid ligament. Failure of the syndesmotic screw without evidence of malalignment of the mortise and a pain-free ankle are not indications for further surgery because these patients have satisfactory outcomes when compared to those who have intact or removed screws. Hardware removal following fibula ORIF is indicated when patients have pain directly related to hardware prominence. Resolution of joint pain or stiffness is not a reliable outcome following hardware removal. Although fibular fracture can occur, this is a rare complication. Malreduction of the syndesmosis is the most common complication following ORIF of the syndesmosis and is improved with direct visualization; however, malreduction still may occur with direct visualization.
RECOMMENDED READINGS
Manjoo A, Sanders DW, Tieszer C, MacLeod MD. Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma. 2010 Jan;24(1):2-6. doi: 10.1097/BOT.0b013e3181a9f7a5. PubMed PMID: 20035170. View
Abstract at PubMed
Jenkinson RJ, Sanders DW, Macleod MD, Domonkos A, Lydestadt J. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma. 2005 Oct;19(9):604-9. PubMed PMID: 16247304. View Abstract at PubMed
Stark E, Tornetta P 3rd, Creevy WR. Syndesmotic instability in Weber B ankle fractures: a clinical evaluation. J Orthop Trauma. 2007 Oct;21(9):643-6. PubMed PMID: 17921840. View Abstract at PubMed
Brown OL, Dirschl DR, Obremskey WT. Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma. 2001 May;15(4):271-4. PubMed PMID: 11371792. View Abstract at PubMed

Question 35

A 55-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing left shoulder pain for the past 2 years despite nonsurgical management. No focal weakness is noted during examination of the shoulder. AP and axillary radiographs are shown in Figures 47a and 47b. Treatment should consist of

Explanation

DISCUSSION: Unconstrained total shoulder arthroplasty has been found to yield satisfactory results in a high percentage of patients with rheumatoid involvement of the glenohumeral joint. Pain relief has been more predictable with total shoulder arthroplasty than humeral arthroplasty, and a glenoid component is favored when there is sufficient glenoid bone stock and an intact rotator cuff. Constrained or fixed-fulcrum devices have an unacceptably high failure rate because of loosening. Glenohumeral arthrodesis is avoided when the deltoid or rotator cuff is functioning because the functional results after arthroplasty are superior when compared with results of arthrodesis. Arthroscopic synovectomy may be helpful in early stages of the disease before extensive cartilage damage has occurred.
REFERENCES: Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing. J Arthroplasty 1990;5:329-336.
Kelly IG, Foster RS, Fisher WD: Neer total shoulder replacement in rheumatoid arthritis. J Bone Joint Surg Br 1987;69:723-726.

Question 36

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

Explanation

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

Question 37

A mother brings in her 6-month-old infant with a knee deformity. The child had previously been treated with serial casting in flexion for 3 month at an outside facility. Examination reveals passive hyperextension to 25° and passive flexion to 15° as shown in Figures A and B respectively. A lateral radiograph of the knee is shown in Figure C. What is the most appropriate next step in treatment? Review Topic

Explanation

The clinical presentation is consistent with recurrent Grade III congenital dislocation of the knee (CDK) that has not responded to casting in a six month old infant. VY quadricepsplasty (VYQ) is is the most appropriate next step in treatment.
Congenital knee dislocation is rare. The etiology is thought to be quadriceps contracture. It is associated with developmental dysplasia of the hip (DDH) and clubfoot (CTEV). In newborn infant, casting or bracing with the knee in flexion
should be performed. If this fails, percutaneous or open VY quadricepsplasty, followed by above-knee casting, is indicated.
Abdelaziz et al. proposed a new grading system (Tarek CDK grading system-see Illustrations A and B) and treatment protocol as follows: (1) Serial casting for Grade 1 regardless of age and in neonates with grade 2 <1mth. If flexion to >90° is achieved within 4 weeks, then serial casting is continued; if range remains <90°, percutaneous quadriceps recession (PQR) is performed. (2) PQR is performed in Grade 2 CDK in infants >1 month of age upon presentation. (3) VY quadricepsplasty is indicated in patients with Grade 3 CDK or in recurrent cases.
Klingele et al. describe ACL shortening and reinforcement in 2 patients with congenital knee dislocation who developed ACL incompetence due to elongation. They conclude that stabilizing and reinforcing the ACL may prevent long-term anterior instability, hyperextension and recurrent deformity.
Figures A and B show the range of motion of the knee (25deg hyperextension to 15deg flexion). Figure C is a lateral radiograph showing congenital dislocation of the knee. Illustrations A and B show the Tarek grading system. Illustration C shows the different techniques of quadricepsplasty (upper row, structures divided and skin incisions used; lower row, how lengthening of the quadriceps mechanism is achieved). The most common PQR is the Roy-Crawford technique. The most common VYQ is the Curtis-Fisher technique.
Incorrect Answers:

Question 38

A 37-year-old man who works in a factory has isolated, lateral unicompartmental pain about his knee with activities. Nonsurgical management has failed to provide relief. The radiograph shown in Figure 45 reveals a tibiofemoral angle of approximately 15 degrees which is clinically correctable to neutral. What is the best surgical option in this patient?

Explanation

DISCUSSION: Patients with a valgus alignment about the knee can have lateral compartment arthritis. Similar to a high tibial osteotomy, a supracondylar femoral osteotomy is indicated in younger patients who have a more active lifestyle and isolated unicompartmental disease. In this young patient who works in a factory and has a valgus knee, a medial closing wedge supracondylar femoral osteotomy is the treatment of choice. The role of arthroplasty is limited in younger patients.
REFERENCES: Mathews J, Cobb AG, Richardson S, et al: Distal femoral osteotomy for lateral compartment osteoarthritis of the knee. Orthopedics 1998;21:437-440.
Cameron HU, Botsford DJ, Park YS: Prognostic factors in the outcome of supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee. Can J Surg 1997;40:114-118.

Question 39

A 4-year-old boy with arthrogryposis has little active motion of his knees or elbows. Both elbows are in full extension with good triceps strength, but he is unable to bring his hand to his face or feed himself. Management should consist of

Explanation

DISCUSSION: Elbow release and triceps transfer to restore motion can be performed in children who are age 4 years and older. The ability to flex the elbow either actively or passively is of great assistance in activities of daily living.
REFERENCES: Van Heest A, Waters PM, Simmons BP: Surgical treatment of arthrogrypsosis of the elbow. J Hand Surg Am 1998;23:1063-1070.
Caroll RE, Hill NA: Triceps transfer to restore elbow flexion: A study of fifteen patients with paralytic lesions and arthrogryposis. J Bone Joint Surg Am 1970;52:239-244.

Question 40

What tendon has an intra-articular (instrasynovial) location in the knee joint?

Explanation

DISCUSSION: The popliteal tendon arises from the posterior aspect of the tibia and courses through the knee joint through the popliteus hiatus of the lateral meniscus before attaching on the lateral femur anterior to the lateral collateral ligament. It is the only tendon in the knee joint that can be viewed directly on arthroscopy.
REFERENCES: Kimura M, Shirakura K, Hasegawa A, Kobayashi Y, Udagawa E: Anatomy and pathophysiology of the popliteal tendon area in the lateral meniscus: 1. Arthroscopic and anatomical investigation. Arthroscopy 1992;8:419-423.
Arnoczky SP, Skyhar MJ, Wickiewicz TL: Basic science of the knee, in McGinty JB (ed): Operative Arthroscopy. New York, NY, Raven Press, 1991, pp 155-182.

Question 41

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 42

Figure 6a shows the radiograph of a 50-year-old man who sustained an anterior dislocation of the shoulder. He undergoes closed reduction, and the postreduction radiograph is shown in Figure 6b. Management should now consist of

Explanation

DISCUSSION: Displaced greater tuberosity fractures often will block abduction and/or external rotation by impinging on the underside of the acromion or posterior glenoid. The indications for open reduction and internal fixation are 1 cm of displacement or 45 degrees of rotation of the tuberosity fracture. Surgical treatment has recently been recommended for 0.5 cm of tuberosity displacement.
REFERENCES: Neer CS II: Displaced proximal humeral fractures: II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090-1103.
Flatow EL, Cuomo F, Maday MG, et al: Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am 1991;73:1213-1218.

Question 43

CLINICAL SITUATION Figures 1 and 2 are the radiographs of a 19-year-old man with a closed right humeral shaft fracture as well as a right femoral shaft fracture and a left ankle fracture-dislocation after a motor vehicle collision. On initial examination, he is noted to have a complete radial nerve palsy of his right upper extremity. Postoperative radiographs are shown in Figures 3 and 4. How does the plate function?

Explanation

Discussion: The patient sustained a comminuted extra-articular distal humeral diaphyseal fracture. In isolation, this fracture would still be amenable to an attempt at closed treatment. His radial nerve palsy alone does not warrant open management, as early exploration has not shown a significant benefit in a closed fracture. In addition, despite the comminution and distal extent of the fracture, it is still amenable to closed treatment, though it may be at higher risk for malunion. However, in this patient with multiple lower extremity injuries, fixation of the humerus can facilitate early mobilization and weight-bearing with his right upper extremity, representing a relative indication for surgical management.
The posterior triceps-reflecting approach described can be extended proximally to the level of the axillary nerve. The radial nerve must be found and protected, but the dissection can be carried well proximal to it and the medial triceps origin. The anatomic neck of the humerus cannot be visualized through this approach.
The plate functions as a neutralization plate, as multiple lag screws are seen placed outside of the plate, suggesting anatomic reduction and fixation of the fracture prior to applying the plate.
The working length of the plate is the distance between the proximal and distal screws closest to the fracture. The length of screw purchase in bone represents the working length of the screw, not the plate. The other answer choices describe dimensions of the plate and the fixation construct, not its working length.

Question 44

When a structure like a long bone is under a bending load, its maximum stress is most dependent on what factor?

Explanation

DISCUSSION: The maximum stress in a bone occurs at the periosteal surface (the greatest distance from the center of the bone). The magnitude of the stress is equal to the magnitude of the applied moment (M) multiplied by the distance to the surface (roughly the radius of the bone, r) divided by the area moment of inertia (I), so that stress = Mr/I. Of the possible answers, only area moment of inertia of the cross section contains any of these three items. The stress can also depend on the length of the bone, but it cannot be determined without knowing the location at which the bending load is applied, information that was not given in the problem. The type of structural support may influence local stresses where the support contacts the bone, but it has little effect on the maximum stress in the bone. The cross-sectional area is not as important as the area moment of inertia because the stress is not evenly distributed over the cross-section. Plastic modulus is a material property, not a geometric or structural property, and it does not affect stress.
REFERENCES: Hayes WC, Bouxsein ML: Biomechanics of cortical and trabecular bone: Implications for assessment of fracture risk, in Mow VC, Hayes WC (eds): Basic Orthopaedic Biomechanics, ed 2. New York, NY, Lippincott-Raven, 1997, pp 76-82.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 161-167.

Question 45

Figures 26a and 26b show the radiograph and MRI scan of an 18-year-old man who fell from a trampoline. Examination reveals exquisite local tenderness at the thoracolumbar junction, but he is neurologically intact. Management should consist of

Explanation

DISCUSSION: Based on the radiographic findings of marked disruption of the posterior ligamentous complex with a relatively small anterior bony fracture, the patient has a classic Chance-type ligamentous flexion-distraction injury. The pathology is mostly in soft tissues with limited healing potential. The treatment of choice is posterior reconstruction of the tension band with a short segment fusion with instrumentation. Casting or bracing may result in a painful kyphosis with ligamentous insufficiency. The anterior bony column is mostly intact, so anterior reconstruction is not necessary.
REFERENCES: Carl AL: Adult spine trauma, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 406-423.
Lewandrowski KU, McLain RF: Thoracolumbar fractures: Evaluation, classification, and treatment, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 817-843.

Question 46

A number of potential complications are associated with the direct lateral approach to the lumbar spine; which complication is most common?

Explanation

DISCUSSION
Sofianos and associates examined the cases of 45 patients who underwent the lateral transpsoas approach and found that 18 of 45 patients (40%) experienced at least 1 complication. The most common complication was postsurgical weakness of the iliopsoas, which was an issue for 10 of 45 patients (22.2%). The second-most-common complication in this series was anterior thigh hypoesthesia. This occurred in 8 of 45 patients (17.8%). A series of 600 patients by Rodgers and associates noted that thigh pain and psoas weakness following a direct lateral approach to the lumbar spine were both "nearly universal" but almost "always transient."
RECOMMENDED READINGS
Sofianos DA, Briseño MR, Abrams J, Patel AA. Complications of the lateral transpsoas approach for lumbar interbody arthrodesis: a case series and literature review. Clin Orthop Relat Res. 2012 Jun;470(6):1621-32. doi: 10.1007/s11999-011-2088-3. Review. PubMed
PMID: 21948287.View Abstract at PubMed
Lee YP, Regev GJ, Chan J, Zhang B, Taylor W, Kim CW, Garfin SR. Evaluation of hip flexion strength following lateral lumbar interbody fusion. Spine J. 2013 Oct;13(10):1259-62. doi: 10.1016/j.spinee.2013.05.031. Epub 2013 Jul 12. PubMed PMID: 23856656. View Abstract at PubMed
Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976). 2011 Jan 1;36(1):26-32. doi: 10.1097/BRS.0b013e3181e1040a. PubMed PMID: 21192221. View
Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 21 AND 22
Figures 21a through 21c are the preoperative lateral standing radiograph, axial T2-weighted MR image at L4-5, and supine sagittal MR image of a 45-year-old woman who has had back and leg pain for 2 years. Treatment had included nonsteroidal anti-inflammatory drugs, physical therapy, and epidural corticosteroid injections. Her pain limited her activities of daily living; she could walk only 1 to 2 blocks before her pain became intolerable.

21A

Question 47

During a posterior cruciate ligament (PCL)-retaining total knee arthroplasty, a critical principle to remember is to

Explanation

DISCUSSION:
Maintenance of the joint line and accurately tensioning the PCL are critical in the proper execution of a PCL-retaining total knee arthroplasty. Appropriate tension helps ensure femoral rollback and avoid stiffness or instability. Raising the joint line to help ensure full extension should be avoided in cruciate- retaining knees, because doing so creates an unfavorable kinematic environment. The three important principles of surgical technique needed to maintain appropriate tensioning of the PCL include 1) choosing the proper femur size to reproduce the native femoral anterior/posterior dimension, 2) reproducing the joint line by resecting as much tibia from the healthy side as will be replaced by the smallest thickness of the tibial component and, 3) ensuring that full extension is achieved by soft-tissue releases and not by taking additional distal femur, as may be done in a posterior stabilized approach. Another important principle is to re-create the natural degree of the patient’s posterior tibial slope to avoid tightness in
flexion.

Question 48

A 40-year-old man who is an avid weight lifter has had chronic pain in the proximal anterior shoulder for the past year. He denies any history of trauma. Examination reveals tenderness at the intertubercular groove, a positive speed test, and a positive Neer impingement sign. Nonsurgical management has failed to provide relief, and he is now considering surgery. Arthroscopic findings in the glenohumeral joint are shown in Figure 31. Based on these findings, treatment should consist of

Explanation

DISCUSSION: The arthroscopic image shows a tear through more than 50% of the biceps tendon; therefore, treatment should consist of tenodesis or tenotomy of the tendon. However, because this patient is relatively young and active, the treatment of choice is tenodesis of the biceps tendon.
REFERENCES: Sethi N, Wright R, Yamaguchi K: Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999;8:644-654.
Eakin CL, Faber KJ, Hawkins RJ, et al: Biceps tendon disorders in athletes. J Am Acad Orthop Surg 1999;7:300-310.
Burkhead WZ, Arcand MA, Zeman C, et al: The biceps tendon, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1996.

Question 49

A patient with an acromioclavicular dislocation has a very prominent distal clavicle. Examination reveals that the deformity increases rather than reduces with an isometric shoulder shrug. Which of the following structures is most likely intact?

Explanation

DISCUSSION: Severely displaced acromioclavicular injuries disrupt the deltotrapezial fascia and muscular origin in addition to the ligaments (acromioclavicular and coracoclavicular or trapezoid and conoid). When the deltoid is still attached to the clavicle, an isometric shoulder shrug will tend to reduce the displacement. When the deltoid is detached but the trapezius is attached, this manuever will increase the deformity and surgery may be indicated.
REFERENCE: Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU: Surgical treatment of complete acromioclavicular dislocations. Am J Sports Med 1995;23:324-331.

Question 50

A previously healthy 29-year-old man reports a 2-day history of severe atraumatic lower back pain. He denies any bowel or bladder difficulties and no constitutional signs. Examination is consistent with mechanical back pain. No focal neurologic deficits or pathologic reflexes are noted. What is the most appropriate management? Review Topic

Explanation

In general, a previously healthy patient with an acute onset of nontraumatic lower back pain does not need diagnostic imaging before proceeding with therapeutic treatment. In the absence of any “red flags” during the history and physical examination, such as trauma or constitutional symptoms (ie, fevers, chills, weight loss), the appropriate treatment for acute onset lower back pain is purely symptomatic treatment including limited analgesics and early range of motion. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful and symptoms are prolonged. Miller and associates suggested that the use of radiographs can lead to better patient satisfaction but not necessarily better outcomes.

Question 51

A 42-year-old man has increasing pain and, to a lesser extent, some occasional left knee instability. Several years earlier he sustained a noncontact twisting injury to his knee. He had some initial soreness and pain but was able to resume his normal activities while avoiding sports. On examination, the patient has medial joint line pain, a grade 2+ Lachman, and a slight varus thrust. His radiographs reveal mild-to-moderate medial compartment osteoarthritis with varus alignment. What surgical treatment strategy likely will alleviate his pain? Review Topic

Explanation

This patient had a previous anterior cruciate ligament (ACL) and posterolateral complex injury. With chronic instability and osteoarthritis, the best option is HTO with a decrease in the tibial slope to reduce anterior laxity. Distal femoral osteotomy is better suited to address valgus malalignment. The lateral closing-wedge osteotomy would not allow for adequate correction of the tibial slope. Unicompartmental knee replacement is not indicated when there is ligament instability. If the patient continues to experience instability following correction of the varus malalignment, reconstruction of the ACL and posterolateral corner would be appropriate at that time.

Question 52

A 30-year-old accountant and recreational softball player, who is seen at the end of his baseball season, reports a several month history of pain along the medial side of his dominant elbow. He cannot identify a specific injury and notes it only hurts when he throws the ball in from the outfield. Besides the pain, he remarks that his speed and distance while throwing have diminished considerably. Examination reveals tenderness along the medial elbow but no weakness or gross instability is found. Radiographs are normal. Based on the history, what is the most likely diagnosis? Review Topic

Explanation

Throwing athletes frequently develop medial collateral ligament sprain related to the repeated valgus stress that occurs on the medial elbow during the acceleration phase of throwing. This has the effect of not only causing pain, but also resulting in loss of velocity and distance during the throwing activity. The injury is generally well tolerated in most activities of daily living and only becomes problematic during the vigorous, stressful act of throwing. Absence of neurologic signs or symptoms makes ulnar nerve pathology unlikely. Pronator syndrome causes pain on the volar aspect of
the forearm during resisted forearm pronation and is not associated with the throwing motion in particular. Valgus extension overload may mimic medial collateral ligament injury, not varus extension injuries. Medial epicondylitis may be confused with ligament insufficiency but the examination and a history of pain only while throwing make this an unlikely diagnosis.

Question 53

An otherwise healthy 15-year-old wrestler has a 6-cm cutaneous lesion on the posterior aspect of his right elbow that he reports as a spider bite. What is the most likely diagnosis? Review Topic

Explanation

Patients who have skin and soft-tissue infections caused by CA-MRSA often describe the lesion as a spider bite. The cytotoxin Panton-Valentine leukocidin that is produced by many strains of CA-MRSA causes tissue necrosis, resulting in rapid development of an abscess and the appearance of a spider bite. Patients with psoriasis have thick, red skin with flaky, silver-white patches. Tinea corporis is a general term for a cutaneous fungal infection. The lesion appears as a well-demarcated erythematous plaque with a raised border and central hypopigmentation, giving it a ring-like appearance. Primary infection with herpes simplex virus can produce constitutional symptoms with burning, tingling, or stinging at the site. Grouped vesicles with clear fluid 1 to 2 mm in size form on an erythematous base and then rupture, leaving moist ulcers or crusted plaques.
(SBQ07SM.48) Carbohydrate loading is a common practice among endurance athletes that works by what mechanism? Review Topic
Increasing serum fructose levels
Maximizing stored muscle glycogen for endurance after 90 minutes of exercise
Diuresis
Decreasing serum glucose levels
Maximizing stored liver glycogen for endurance after 60 minutes of exercise
Carbohydrate loading is a strategy that involves changes to training and nutrition which can maximize muscle glycogen stores prior to endurance exercise lasting longer than 90 minutes.
There continues to be varying scientific opinions as to whether athletes should eat low vs. high glycemic index foods, and how this will affect the amount that the serum glucose levels rise. Fructose is able to be converted to glycogen in the liver but not muscle, therefore high-fructose containing foods are suboptimal. This practice is recommended for athletes participating in events that are longer than 90 minutes (after the bodies normal supply of glycogen is depleted).
Coyle et al. analyzed 10 trained cyclists who performed two bicycle ergometer exercise tests 1 wk apart. They found that blood glucose concentration was 20-40% higher during the exercise after carbohydrate ingestion than during the exercise without carbohydrate feeding. The exercise-induced decrease in plasma insulin was prevented by carbohydrate feeding. Ultimately, fatigue was postponed by carbohydrate feeding during exercise in seven out of the ten subjects.
Costill et al. examined the effect of carbohydrates on muscle glycogen resynthesis in trained runners and found that muscle glycogen levels could be normalized with the proper use of carbohydrates after strenuous activity.
Sherman et al. used muscle biopsies to determine the effects of moderate- or high-carbohydrate diets on muscle glycogen and performance in runners and cyclists over 7 consecutive days of training. They found that a high carbohydrate diet restored muscle glycogen to more normal levels than a moderate carbohydrate diet but did not find any difference in the effect on performance.
Illustration A is a graph depicting the typical carbohydrate depletion/loading regimen that endurance athletes utilize to maximize muscle glycogen stores prior to endurance exercise. This typically involves a hard workout followed by three days of a low-carb diet, another hard workout, and another three days of a high-carb diet.
Incorrect

Question 54

Why is tendon considered an anisotropic material?

Explanation

DISCUSSION: Anisotropic materials have mechanical properties that vary based on the direction of loading. The relative values of Young’s modulus for tendon, ligament, and bone are not relevant to isotropy. The mechanical properties of tendon do change with preconditioning, but this change is related to viscoelasticity. The intrinsic mechanical properties of tendon do vary with the rate of loading, but this variance is related to viscoelasticity.
REFERENCES: Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 134-180.
Lu L, Kaufman KR, Yaszemski MJ: Biomechanics, in Einhorn TA, O’Keefe RJ,

Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, in press.

Question 55

A 55-year-old woman with a history of untreated idiopathic scoliosis has had neurogenic claudication for the past several months. MRI reveals spinal stenosis at L2-L3, L3-L4, and L4-L5. Radiographs show a 45° lumbar curve from T10 to L4, with a degenerative spondylolisthesis at L4-L5. Laminectomy at the stenotic levels and stabilization of the deformity are planned. Which of the following is NOT considered an absolute indication for extending the fusion to the sacrum, rather than stopping at L5?

Explanation

DISCUSSION: There are several indications for extending adult scoliosis fusions to the sacrum, rather than stopping in the lower lumbar spine. These indications include posterior column deficiencies at L5-S1, such as spondylolysis and laminectomy, and deformities extending to the sacrum, such as fixed tilt of L5-S1 or sagittal imbalance. MRI signal changes in the L5-S1 disk do not preclude stopping the fusion at L5. Some surgeons use diskography or diagnostic facet blocks to evaluate the integrity of the L5-S1 level prior to stopping the fusion at L5. Long scoliosis fusions stopping at L5 have a significant risk of failure, highlighting the importance of careful selection of fusion levels.
REFERENCES: Bradford DS, Tay BK, Hu SS: Adult scoliosis: Surgical indications, operative management, complications, and outcomes. Spine 1999;24:2617-2629.
Bridwell KH: Where to stop the fusion distally in adult scoliosis: L4, L5, or the sacrum? Instr Course Lect 1996;45:101-107.
Edwards CC II, Bridwell KH, Patel A, et al: Long adult deformity fusions to L5 and the sacrum: A matched cohort analysis. Spine 2004;29:1996-2005.

Question 56

Following total elbow arthroplasty, patients should be instructed to Review Topic

Explanation

Current recommendations are for a lifetime restriction of load bearing and avoidance of impact activities following total elbow arthroplasty (TEA). TEA is a very effective procedure in reducing pain or reconstructing previously unreconstructable fractures. However, its usage must be tempered with the limitations of currently available prostheses. Aggressive triceps strengthening must be delayed following TEA to allow healing of the triceps attachment, regardless of the surgical approach. Wrist and hand mobilization should begin immediately postoperatively to prevent stiffness. Pronation and supination should not stress a humeral ulnar arthroplasty.

Question 57

What is the most common presenting sign or symptom in an adult with lumbar pyogenic infection?

Explanation

DISCUSSION: Pain is very common but is often nonspecific; therefore, the diagnosis of spinal infection is often delayed. Fever and sepsis can occur but are not common. Neurologic manifestations also can occur but are absent in most patients. In findings reported by Carragee, the urinary tract is a common source for hematogenous spinal infection, but the source was found in only 27% of 111 patients. Direct inoculation during spinal surgery is uncommon.
REFERENCES: Carragee EJ: Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am 1997;79:874-880.
Frazier DD, Campbell DR, Garvey TA, et al: Fungal infections of the spine: Report of eleven patients with long-term follow-up. J Bone Joint Surg Am 2001;83:560-565.
Hadjipavlou AG, Mader JT, Necessary JT, et al: Hematogenous pyogenic spinal infections and their surgical management. Spine 2000;25:1668-1679.

Question 58

Sterilization of ultra-high molecular weight polyethylene by gamma irradiation in air will degrade its wear performance because of

Explanation

DISCUSSION: Gamma irradiation has long been used as a sterilization method for polyethylene. Exposure to gamma irradiation causes breakage of the chemical bonds in the polyethylene, and oxidation will occur if the material is subsequently exposed to air. The amount of oxidation and decrease in wear performance is also related to the length of time that the gamma-irradiated polyethylene is exposed to oxygen.
REFERENCES: Collier JP, Sutula LC, Currier BH, et al: Overview of polyethylene as a bearing material: Comparison of sterilization methods. Clin Orthop 1996;333:76-86.
McKellop H, Shen FW, Lu B, et al: Effect of sterilization method and other modifications on the wear resistance of acetabular cups made of ultra-high molecular weight polyethylene: A hip-simulator study. J Bone Joint Surg Am 2000;82:1708-1725.
Sychterz CJ, Young AM, Orishimo K, et al: The relationship between shelf life and in vivo wear for polyethylene acetabular liners. J Arthroplasty 2005;20:168-173.

Question 59

A 17-year-old male soccer player sustains repeated lateral patellar dislocations refractory to physical therapy, bracing, and taping. After a workup including radiographs and MRI, the orthopaedic surgeon considers an isolated tibial tubercle osteotomy (TTO). He plans a 60-degree anteromedialization to address instability and to unload the patellofemoral joint. What is a relative contraindication to this procedure?

Explanation

CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 41
A healthy, active 18-year-old man has acute-onset right knee pain and an inability to fully extend his knee following an attempt to stand from a seated position yesterday. He sustained a noncontact injury to his right knee while playing basketball 2 years ago and underwent primary anterior cruciate ligament (ACL) reconstruction with bone-patella-tendon-bone autograft and medial meniscus repair. He sustained another noncontact injury to the same knee 8 months later and underwent a revision ACL reconstruction using soft-tissue allograft and revision medial meniscus repair. He reports multiple episodes of “giving way” of his knee, but no pain prior to yesterday’s acute injury.

Question 60

During total shoulder replacement for rheumatoid arthritis, fracture of the humeral shaft occurs. An intraoperative radiograph shows a displaced short oblique fracture at the tip of the prosthesis. At this point, the surgeon should

Explanation

DISCUSSION: The risk of intraoperative fracture in osteopenic rheumatoid bone is significant. Fractures may occur with dislocation of the head and canal reaming, especially while extending and externally rotating the shoulder. If the fracture occurs at the distal tip of the prosthesis, the use of a long-stemmed prosthesis to bypass the fracture site and supplementation with wire cables has been reported with good results.
REFERENCES: Wright TW, Cofield RH: Humeral fractures after shoulder arthroplasty. J Bone Joint Surg Am 1995;77:1340-1346.
Boyd AD Jr, Thornhill TS, Barnes CL: Fractures adjacent to humeral protheses. J Bone Joint Surg Am 1992;74:1498-1504.
Petersen SA, Hawkins RJ: Revision of failed total shoulder arthroplasty. Orthop Clin North Am 1998;29:519-533.

Question 61

A 31-year-old man sustained a closed injury to his arm in a motor vehicle accident 16 months ago. Treatment of the fracture consisted of intramedullary nailing of the humerus. He now reports pain with minimal activities. Clinical examination and laboratory studies suggest no signs of infection. Radiographs are seen in Figures 12a through 12c. Treatment should now consist of

Explanation

DISCUSSION: The use of locked nailing for the treatment of established nonunion of the humerus has produced poor results. Since humeral nailing has already failed, exchange humeral nailing without bone grafting has an even less change of success. To increase the likelihood of achieving bony union, the treatment of choice is removal of the humeral nail, dynamic compression plating, and bone grafting.
REFERENCES: Zuckerman J, Giordanno C, Rosen H: Treatment of humeral shaft non-unions, in Bigliani L (ed): Complications of shoulder surgery. Baltimore, MD, William & Wilkins, 1993, pp 173-190.
Jupiter JB: Complex non-union of the humeral diaphysis: Treatment with a medial approach,

an anterior plate, and a vascularized fibular graft. J Bone Joint Surg Am 1990;72:701-707.

Question 62

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

Explanation

DISCUSSION: The PCBMN originates from the median nerve proper between 3 and 21 cm proximal to the wrist with moderate variation. It virtually always originates from the radial side of the nerve and travels distally with the median nerve, radial to the palmaris longus, and ulnar to the flexor carpi radialis.
REFERENCES: Hobbs RA, Magnussen PA, Tonkin MA: Palmar cutaneous branch of the median nerve. J Hand Surg Am 1990;15:38-43.
Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System: Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy, 1991, vol 8,

p 52.

Question 63

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads?

Explanation

DISCUSSION: The annulus fibrosis has a multilayer lamellar architecture mode of type I collagen fibers. Each successive layer is oriented at 30 degrees to the horizontal in the opposite direction, leading to a “criss-cross” type pattern. This composition allows the annulus, which has the highest tensile modulus, to resist torsional, axial, and tensile loads.
REFERENCE: Rhee JM, Schaufele M, Abdu WA: Radiculopathy and the herniated lumbar disc: Controversies regarding pathophysiology and management. J Bone Joint Surg Am 2006;88:2070-2080.

Question 64

A 51-year-old woman with shoulder pain responds transiently to a subacromial injection and physical therapy exercise program. When her symptoms recur, an arthroscopic subacromial decompression is recommended. During the surgery, a partial-thickness articular-sided supraspinatus tear is noted. The supraspinatus footprint is exposed for 3 mm from the articular margin. The remaining intra-articular structures are normal. Inspection from the bursal surface reveals the tendon to be intact. What is the most appropriate course of management? Review Topic

Explanation

The patient has a partial articular supraspinatus tendon avulsion (PASTA) lesion. Outcome studies suggest that articular-sided tears of this magnitude do well with arthroscopic decompression and debridement alone. Determination of lesion thickness is important in recommending treatment, and may be done with a variety of methods. Tears that involve exposure of less than 5 mm of the rotator cuff footprint likely measure less than half of the tendon thickness. In the absence of other associated pathology, bicipital tenotomy or synovectomy would be unnecessary. Completion of the tear or transtendinous repair would be considered for lesions of greater than 50% thickness.

Question 65

What radiographic view will best reveal degeneration of the pisotriquetral joint in a patient who is being evaluated for pisotriquetral arthrosis?

Explanation

DISCUSSION: The pisotriquetral joint is best seen on a lateral view in 30 degrees of supination. The carpal tunnel view provides visualization of the joint but to a lesser extent. The other views do not provide clear and accurate visualization.
REFERENCES: Paley D, McMurty RY, Cruickshank B: Pathologic conditions of the pisiform and pisotriquetral joint. J Hand Surg Am 1987;12:110-119.
Steinmann SP, Linsheid RL: Pisotriquetral loose bodies. J Hand Surg 1997;22:918-921.
related link ortho mcqs bank

Question 66

What would be the most appropriate surgical indication for transferring fascicles of the ulnar nerve to the motor nerve of the biceps and fascicles of the median nerve to the motor nerve of the brachialis?

Explanation

(SBQ12FA.31) A 30-year-old male patient involved in a hang-gliding accident sustains a knee dislocation with multiligamentous knee injury and transection of his peroneal nerve. He undergoes multiple reconstructive surgeries. Two years later, he continues to have a foot drop and dynamic tendon transfer is recommended. This treatment most commonly involves transferring a tendon from which native insertion point to which new insertion point? Review Topic
Plantar distal phalanges to medial navicular
Medial navicular to dorsal lateral cuneiform
Plantar 1st metatarsal to dorsal lateral cuneiform
5th metatarsal base to dorsal medial cuneiform
Plantar distal phalanx of the hallux to dorsal distal phalanx of hallux
Dynamic tendon transfer to restore active dorsiflexion of the foot involves transferring the posterior tibial tendon (PTT) insertion on the medial navicular to the dorsal lateral cuneiform.
Common peroneal nerve (CPN) injuries following traumatic knee dislocation are common, with an incidence of 25-40%. CPN palsy is characterized by foot drop due to loss of ankle dorsiflexors with a steppage gait and eventual development of a supinated equinovarus foot secondary to the unopposed pull of the PTT. Nonsurgical management involves use of an ankle-foot orthosis and physical therapy. Surgical
options include acute primary repair, nerve grafting with either autologous sural nerve or nerve conduits and dynamic tendon transfer. The PTT is harvested from its insertion at the navicular, passed through the interosseous membrane (IOM) and anchored to the lateral cuneiform (see Illustration A). The classic bridle procedure involves concomitant anastamosis of the PTT to the tibialis anterior (TA) and peroneus longus (PL) tendons.
Garozzo et al reported a case series of 62 patients with post-traumatic CPN palsy who underwent a one-stage procedure consisting of nerve repair and PTT transfer. Nerve repair combined with PTT transfer improved postoperative outcomes compared to nerve repair alone. At 2-year follow up, neural regeneration was demonstrated in 90% of patients. The authors hypothesized that poor outcomes following nerve repair alone are due to force imbalance between the functioning flexors and paralyzed extensors, which is somewhat equalized by performing a PTT transfer at time of repair.
Niall et al reviewed 55 patients with traumatic knee dislocation and reported a 41% incidence of CPN injury, exclusively associated with dislocations involving disruption of the posterior cruciate ligament (PCL) and posterolateral corner (PLC). Complete neurologic recovery was found in only 21% of patients. The best prognosis was found with lesions in continuity, less than 7cm of nerve involvement, and short conduction block and muscle activity on nerve conduction and EMG studies.
Vigasio et al described a dynamic tendon transfer technique for traumatic complete CPN injury, involving transfer of the PTT to the TA rerouted to a new origin at the lateral cuneiform to restore ankle dorsiflexion and flexor digitorum longus (FDL) to the extensor digitorum longus (EDL) and extensor hallucis longus (EHL) to restore digit dorsiflexion. Rerouting the TA towards the transferred PTT ensures the PTT harvest length is sufficient. This avoids excessive tensioning of the PTT, which may limit tendon excursion and result in a static tenodesis rather than dynamic function, as well as the need for PTT lengthening which may decrease strength of the transfer
Illustration A is a series of intraoperative photographs demonstrating PTT transfer from Garg et al. An incision is made distal to the medial malleolus and the PTT is harvested subperiosteally (A). The PTT is delivered through a second incision ~15cm proximal to the medial malleolus (B-C). The PTT is then passed through the interosseous membrane and out a third incision over the anterior fibula (D). Lastly, the PTT is passed through a fourth incision over the dorsal midfoot and anchored to the lateral cuneiform (E).
Incorrect Responses:
nerve and therefore would not be functional. Answer 5: Transferring the flexor hallucis longus (FHL; insertion = plantar distal phalanx of the hallux) to the insertion of the EHL (dorsal distal phalanx of hallux) is recommended for correction of claw toe deformity and would not help restore foot dorsiflexion in this patient.

Question 67

What is the most common behavioral effect of anabolic steroid use in athletes?

Explanation

DISCUSSION: Users of anabolic steroids often display increased feelings of hostility and aggression. Although reports of psychotic, depressive, and manic behavior have been reported with the use of steroids, they are rare. Drug dependence, such as seen with narcotics, is not a feature of steroid use.
REFERENCES: Hartgens F, Kuipers H: Effects of androgenic-anabolic steroids in athletes. Sports Med 2004;34:513-554.
Blue JG, Lombardo JA: Steroids and steroid-like compounds. Clin Sports Med
1999;19:667-689.

Question 68

When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?

Explanation

DISCUSSION: As the chance of success of lumbosacral fusion increases with the stiffness and rigidity of the construct, fixation and stiffness improve with fixation into both the upper sacrum and the ilium. In a review of individuals treated with long constructs to the pelvis for adult scoliosis, Islam and associates reported that the rate of pseudarthrosis was significantly lower with sacral and iliac fixation compared with sacral fixation alone or iliac fixation alone. Iliac screws provide significant fixation anterior to the instantaneous axis of rotation for flexion and extension, as well as provides resistance to lateral bending and rotational forces. Numerous biomechanical studies support the concept of increasing biomechanical stabilization with increased fixation from the sacrum to the ilium.
REFERENCES: Islam NC, Wood KB, Transfeldt EE, et al: Extension of fusions to the pelvis in idiopathic scoliosis. Spine 2001;26:166-173.
O’Brien N, et al: Sacral pelvic fixation and spinal deformity, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 601-614.
McCord DH, Cunningham BW, Shono Y, et al: Biomechanical analysis of lumbosacral fixation. Spine 1992;17:S235-S243.

Question 69

A hip compression screw is placed in a test jig and a bending load is applied to the tip of the screw. After the load is released, the screw returns completely to its original shape. What is this type of deformation called?

Explanation

When an implant is loaded below the yield point, by definition, it undergoes elastic deformation, meaning that all of the deformation recovers when the load is removed. If it is loaded above the yield point, then plastic or permanent deformation occurs. Fatigue is the gradual accumulation and progression of cracks in the material, which, after many cycles of loading, can lead to gross failure. Creep is the gradual accumulation of permanent (plastic) deformation over time, which may occur with polymeric materials but is not typical of metals or ceramics. Torsion refers to a torque being applied about the long axis of a bone or an implant. In general, the materials and dimensions of an implant are chosen to avoid plastic deformation or fatigue failure during typical clinical use.

Question 70

A 17-year-old high school football player reports wrist pain after being tackled. Radiographs are shown in Figures 22a through 22c. What is the recommended intervention?

Explanation

DISCUSSION: The patient has an acute fracture of the proximal pole. A 100% healing rate has been reported for open reduction and internal fixation of proximal pole fractures via a dorsal approach. This allows for direct viewing of the fracture line, facilitates reduction, and bone grafting can be done through the same incision if necessary. A vascularized or corticocancellous graft is reserved for nonunions. Proximal fractures are very slow to heal with a cast, if they heal at all. As a small fragment, percutaneous fixation is very difficult and has been reported for waist fractures.
REFERENCES: Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210.
Raskin KB, Parisi D, Baker J, et al: Dorsal open repair of proximal pole scaphoid fractures. Hand Clin 2001;17:601-610.

Question 71

A 48-year-old woman has an open subtrochanteric femur fracture. No other injuries are reported. After thorough evaluation, it is determined that she will need emergent surgical fixation. The patient and family indicate that they are practicing Jehovah's witnesses and desire adherence to the religious standards with respect to blood product usage. The patient signs a valid advanced directive confirming these wishes. Which of the following would be considered acceptable treatment?

Explanation

Jehovah's witnesses beliefs regarding blood products stems from direct interpretation of passages from the bible. The use of crystalloid, starch products such as Hetastarch and colloids are accepted. Typically Jehovah's witnesses will accept most medical treatment but refrain from the use of blood products including whole blood, packed red cells, platelets, white cells, or plasma. Any autologous transfusion, whether from the patient themself or donor directed, is forbidden. The use of cell-saver type processes is a matter of individual choice by the patient. The use of hemoglobin-based oxygen carriers are now accepted by many patients but it is important to respect the wishes of each individual patient. It is very important to discuss preoperatively with the patient and family their wishes and thoughts on what is acceptable to use. Many facilities have adopted bloodless-surgery protocols and committees that definitively outline the measures that can be used and take into consideration the many ethical issues involved in taking care of these patients.

Question 72

A 16-year-old cheerleader reports an ache in the right shoulder and arm that is worse after activity. She denies any history of acute trauma. Examination reveals a positive sulcus sign and an AP glide test with a posterior and anterior apprehension sign. To confirm a diagnosis of multidirectional instability, which of the following imaging studies is most appropriate?

Explanation

DISCUSSION: Multidirectional instability is a common finding in young female athletes. The anatomic structures are all intact but are hypermobile; therefore, CT and bone scans and scapular Y-views are often normal. Obtaining a weighted or AP stress view while applying downward traction on the arm will document instability and hypermobility of the joint. MRI generally is not indicated in this condition. Ultrasound is used primarily for rotator cuff pathology.
REFERENCES: Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908.
Warner JJ, Johnson D, Miller M, Caborn DN: Technique for selecting capsular tightness in repair of anterior-inferior shoulder instability. J Shoulder Elbow Surg 1995;4:352-364.

Question 73

Figure 30 shows the AP radiograph of a 9-month-old girl who has been referred for evaluation of unequal leg lengths. Examination reveals symmetrical abduction of the hips. When the hips are flexed 90°, the right knee height is greater than the left knee. The girth of the right thigh and calf is larger than the contralateral side. There are no cutaneous lesions, and examination of the spine is normal. The infant is moving all extremities equally and spontaneously. Management should consist of

Explanation

DISCUSSION: Hemihypertrophy or hemihypotrophy is usually idiopathic, and either the leg or the entire side of the body may be involved. In the infant or young child, it is often difficult to determine which side is abnormal if the condition is mild. Because of the association of Wilms’ tumor with hemihypertrophy, these patients should undergo a yearly renal ultrasound until at least age 5 years. Other conditions that may exhibit hemihypertrophy include Klippel-Trenaunay-Weber syndrome, Proteus syndrome, and neurofibromatosis. In this patient, the mild hemihypertrophy is idiopathic. Because of the normal spinal examination and absence of neurologic findings, an MRI scan is unnecessary. The absence of clinical and radiographic evidence of hip dysplasia makes both an ultrasound of the hips and application of a Pavlik harness unnecessary.
REFERENCES: Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont Ill, American Academy of Orthopaedic Surgeons, 1996, pp 185-193.
Sponseller PD: Localized disorders of bone and soft tissue, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 305-344.
Beals RK: Hemihypertrophy and hemihypotrophy. Clin Orthop 1982;166:199-203.

Question 74

A 55-year-old male is involved in a motorcycle crash and sustains a closed, right-sided, midshaft femur fracture. This is an isolated injury. He is treated with retrograde femoral nailing, and postoperatively is noted to have 30 degrees of internal rotation of the operative extremity, when compared with his nonsurgical side. Which of the following is the most likely cause of this malrotation deformity?

Explanation

Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing can cause a malrotation deformity.
Postsurgical internal malrotation after treatment for a diaphyseal femur fracture typically occurs either via internal rotation of the distal segment relative to the proximal or external rotation of the proximal segment relative to the distal. These clinical findings are consistent with an iatrogenic increase in femoral anteversion.
Dimitriou et al. performed a study to quantify the side-to-side anatomic variation in the proximal femur and the implications for preoperative planning and leg length discrepancy following hip arthroplasty. CT-based 3D femoral models were reconstructed for 122 paired femurs in 61 young healthy subjects with no history of hip pathology. Significant side-to-side differences were found in femoral anteversion, horizontal offset, and femoral head center location.
They concluded that relying on the anatomic landmarks of the contralateral femur during hip arthroplasty may not necessarily result in restoration of native anatomy and leg-length.
Karaman et al. conducted a study which saught to clarify the influence of a femoral rotational malalignment of ≥10° after intramedullary nailing on daily activities. They evaluated twenty-four femoral shaft fracture patients treated with closed antegrade IMN, and determined the presence of malrotation with post-operative CT scans. Ten of the 24 patients had a CT-detected true rotational malalignment of ≥10° compared with the unaffected side, and were noted to have significantly worse functional outcome scores compared with normally rotated femoral shaft patients.
Espinoza et al. present a technique using intraoperative fluoroscopy and the anteversion inherent to the IM nail for obtaining appropriate femoral rotational alignment during surgery. The authors state that their technique reliably sets the femoral anteversion within a normal physiologic range with minimal additional intraoperative steps and without preoperative measurements.
Illustration A shows a CT evaluation of femoral malrotation. The angle on the uninjured side measures 30°, while the malrotated fractured side measures only 3°, indicating a 27° external rotation deformity.
Incorrect Answers:

OrthoCash 2020

Question 75

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 Review Topic

Explanation

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.

Question 76

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

Explanation

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

Question 77

Contraindications to cervical laminectomy as a treatment for cervical spondylotic myelopathy include which of the following findings?

Explanation

DISCUSSION: Cervical laminectomy is an accepted treatment for multilevel cervical spondylotic myelopathy. When the compression is posterior, laminectomy addresses it directly; when the compression is anterior, it is addressed indirectly (the spinal cord floats posteriorly away from the anterior compression). Preexisting kyphosis is a contraindication to laminectomy because the cord is unable to float posteriorly away from the anterior compression, and the risk for increasing kyphosis is significant. Kyphosis after laminectomy is more likely to develop in younger patients who have fewer degenerative changes to stabilize the spine.
REFERENCES: Malone DG, Benzyl 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 817-825.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 673-680.

Question 78

When the iliac apophysis starts ossifying in the normal adolescent, growth of the sitting height or trunk height is characterized by

Explanation

DISCUSSION: Studies by Anderson and associates have resulted in a growth-remaining chart for sitting height that shows an increase of 3 to 5 cm in girls and an increase of 5 to 8 cm in boys. Future growth of the spine may impact brace longevity and fit.
REFERENCES: Anderson M, Hwang SC, Green WT: Growth of the normal trunk in boys and girls during the second decade of life: Related to age, maturity, and ossification of the iliac epiphyses. J Bone Joint Surg Am 1965;47:1554-1564.
Zaoussis AL, James JIP: The iliac apophysis and the evolution of curves in scoliosis. J Bone Joint Surg Br 1958;40:442-453.

Question 79

Placing a plate too anteriorly against the lateral aspect of the bicipital groove while performing open reduction and internal fixation (ORIF) of a proximal humerus fracture has an increased risk of what complication?

Explanation

There are two major arteries that supply the humeral head. One is the ascending branch of the anterior humeral circumflex artery, which runs up the lateral aspect of the bicipital groove terminating in the arcuate artery. The other is the posterior humeral circumflex artery, which more recently has been demonstrated to supply a significant portion of the blood supply to the humeral head. Capsular arteries also play a role in humeral head perfusion. Care should be taken to preserve all intact arterial supply when performing ORIF, as injury to these arteries may result in avascular necrosis. In general, the most common complications of locked plating include loss of reduction with penetration of the joint by the screws, particularly with initial varus positioning of the humeral head. Placement of the plate in the position described, however, should not have an impact on any of
the other complications noted.

Question 80

-Postsurgically, the patient recovers well and is fully rehabilitated. He demonstrates full motion with no instability or pain and is cleared to return to play 12 months after the surgery. He asks for your advice regarding use of a functional brace for playing basketball following his reconstruction. What is the most appropriate recommendation?

Explanation

DISCUSSION FOR QUESTIONS 89 THROUGH 95
The athlete most likely suffered an acute ACL rupture however the presence of a lipohemarthrosis is concerning for the possibility of an intraarticular fracture. Because of this, the patient should not be allowed full weight bearing until a fracture is ruled out with radiographs. Given the athlete’s inability to perform a straight leg raise, the extensor mechanism is not functioning and a telescoping knee brace locked in extension should be utilized. A neoprene knee sleeve does not have a role in the
treatment of this acute injury.The radiographs reveal a lateral avulsion fracture off of the proximal tibial epiphysis which is known as a Segond fracture. It is indicative of an ACL injury and the fracture fragment seen is the consequence of the lateral capsule injury sustained during the pivot-shift mechanism. There is no radiographic evidence of a medial tibial plateau fracture. A radiographic sign of a chronic MCL injury is known as a Pellegrini-Stieda lesion and this is seen as calcification of the femoral origin of the MCL. A radiographic sign of an acute LCL rupture would be an avulsion fracture of the tip of the fibula.The MRI shows kissing contusions of the posterolateral tibial plateau and the midpoint of the lateral femoral condyle. These “kissing lesions” are seen as a result of a pivot shift mechanism of injury and are diagnostic for an ACL rupture. The most common associated injury in an acute ACL rupture is a lateral meniscus tear. Medial meniscus tears are more common in chronic ACL injuries. PCL rupture and PLC injury are all associated injuries seen in acute ACL rupture; however, these are much less common than meniscal tears. The team physician has a role in encouraging, but
not demanding, the athlete to report the injury andtreatment to the scholarship school’s coaching staff. What the athlete decides to do is his decision; the physician would be violating the athlete’s HIPAA rights as well as their confidence by reporting it directly to the scholarship school. Clearly the physician should not discourage the athlete from reporting the injury. The athlete is 18 years old and, as such, the physician would need the athlete’s permission to discuss any medical issues with the family in keeping with HIPAA.
The athlete’s exam demonstrates incompetence of both bundles of the ACL as demonstrated by the loss of stability with anterior translation of the tibia (Lachman test) as well as with rotation (pivot shift). The external rotation stress with the knee in 30 degrees of flexion tests the competence of the posterolateral corner while rotation at 90 degrees of flexion tests the PCL. Since the athlete’s knee is stable to posterior drawer testing demonstrating an intact PCL and the external rotation at 30 degrees is equivalent to that at 90 degrees, the posterolateral corner in intact.
The ACL has two separate and distinct bundles, the AM and PL. Each bundle takes on tension at varying degrees of knee flexion and therefore each bundle is thought to have a varying contribution to the stability of the knee. The AM bundle takes on tension with the knee in flexion and the PL bundle is tight in extension. Neither bundle is isometric during knee range of motion. Both bundles have contributions to rotational stability of the knee throughout the range of motion.
The success of traditional trans-tibial single-bundle ACL reconstruction has recently been called into question given the demonstration of persistent rotational instability following reconstruction. The persistence of rotational instability in trans-tibial single bundle ACL reconstruction has been attributed to the location of the graft in a vertically malpositioned femoral tunnel. The goal of double-bundle ACL reconstruction is to more accurately reproduce the native ACL and provide grafts that contribute to anteroposterior stability as well as rotational stability by placing the grafts in more anatomic locations not central in the knee axis. There is an increased cost and surgical time associated with double-bundle reconstruction.
The use of functional braces following ACL reconstruction is a surgeon’s preference because there is no difference in retear rate with or without a brace. Some authors recommend brace use for one to two years following ACL reconstruction for all athletic activities, but this is not supported by the literature. No literature exists showing a higher rate of reinjury with a functional brace and off-the shelf and custom braces have been found to be equivalent leading those who advocate for braces to recommend off-theshelf braces given their significantly lower cost.

Question 81

A 32-year-old powerlifter who was performing a dead lift 3 days ago noted a sharp pain in the front of his dominant right arm just after beginning to lower the weight. He now reports pain in the anterior aspect of the arm that worsens when he opens a door. Examination reveals moderate ecchymosis and swelling of the forearm and tenderness in the antecubital fossa. The MRI scans are shown in Figures 15a and 15b. If the injury is left unrepaired, the greatest functional deficit will most likely be the loss of

Explanation

DISCUSSION: A complete tear of the distal biceps brachii most often occurs from a large, rapid eccentric elbow extension load. A pop or tearing sensation usually occurs, and a palpable defect in the antecubital fossa is often present on examination. The treatment of choice is a direct primary repair by a two-incision technique. If left unrepaired, the most disabling consequence is the loss of forearm supination strength. It is unlikely that significant elbow or forearm motion will be lost if the rupture is left unrepaired and early motion exercises are initiated. Elbow flexion strength tends to return with time, but the loss of forearm supination strength remains problematic.
REFERENCES: D’Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. Am J Sports Med 1993;21:114-119.
Agins HJ, Chess JL, Hoekstra DV, Teitge RA: Rupture of the distal insertion of the biceps brachii tendon. Clin Orthop 1988;234:34-38.

Question 82

A 13-year-old girl sustained an isolated midshaft left femoral fracture in a motor vehicle accident. The fracture was treated with a rigid, antegrade intramedullary nail placed through the piriformis fossa. The fracture healed uneventfully, as shown in Figure 46a; however, at 12 months postoperatively she now reports left hip pain. A current AP radiograph and MRI scan are shown in Figures 46b and 46c. What complication occurred in this patient? Review Topic

Explanation

The development of femoral head ischemic necrosis is the iatrogenically created complication in this skeletally immature patient. Placement of a rigid, antegrade intramedullary nail through the piriformis fossa is likely to damage the vascular supply to the femoral head as the vessels ascend the femoral neck on the way to the femoral head. The MRI scan reveals ischemic necrosis with early collapse of the femoral head. The joint space is preserved on the MRI scan, ruling out chondrolysis.

Question 83

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

Explanation

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

Question 84

What muscles are responsible for the most common deformity after antegrade intramedullary nailing for a subtrochanteric femur fracture?

Explanation

DISCUSSION: The most common deformity after antegrade nailing of a subtrochanteric femur fracture is varus and procurvatum (or flexion). This is caused by the hip abductors and iliopsoas pulling the proximal fragment into abduction and flexion, while the distal fragment is pulled into adduction from the adductors.
The reference by French et al is a review on 45 patients with subtrochanteric fractures treated with cephalomedullary interlocked nailing. Based on femoral neck-shaft angle, 61% of the fractures were reduced in at least 5º varus. The authors attributed this malalignment to failure to counteract muscle forces acting on the proximal fragment, combined with the adducted position of the distal femur during portal creation.
The reference by Ricci et al is a report of 403 femoral shaft fractures treated with intramedullary nailing. Patients with proximal femoral shaft fractures were found to have the highest incidence of malalignment. The most common deformity in this group was varus, followed by procurvatum (or flexion).

Question 85

Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints?

Explanation

images with tibial stress fractures.
After activity, pain persists longer with tibial stress fractures.
DISCUSSION: Anterior tibial pain can often be difficult to diagnose. A bone scan showing the tibial cortex in a diffuse, longitudinal orientation is consistent with shin splints compared to a more discreet, localized uptake more commonly seen with a stress fracture. Bone stress injuries are due to cyclical overuse of the bone. They are relatively common in athletes and military recruits but are also seem in otherwise healthy people who have recently started new or intensive physical activity. Diagnosis of bone stress injuries is based on the patient’s history of increased physical activity and on imaging findings.
The general symptom of a bone stress injury is stress-related pain. Bone stress injuries are difficult to diagnose based only on a clinical examination because the clinical symptoms may vary depending on the phase of the pathophysiological spectrum in the bone stress injury. Imaging studies are needed to ensure an early and exact diagnosis. If the diagnosis is made early, most bone stress injuries heal well without complications.
REFERENCES: Mubarak SJ, Gould RN, Lee YF, et al: The medial tibial stress syndrome: A cause of shin splints. Am J Sports Med 1982;10:201-205.
Knobloch K, Yoon U, Vogt PM: Acute and overuse injuries correlated to hours of training in master running athletes. Foot Ankle Int 2008:29:671-676.
Kiuru MJ, Pihlajamaki HK, Ahovuo JA: Bone stress injuries. Acta Radiol 2004;45:317-326.

Question 86

A 14-year-old boy is lifting weights and feels a sudden pain in his back, associated with sciatica bilaterally. The sciatica persists for several weeks. The radiograph shown in Figure 7a is negative, and the CT scan shown in Figure 7b is available for evaluation. An MRI scan is read as a disk bulge. Management should consist of

Explanation

DISCUSSION: A limbus or apophyseal fracture caused by heavy lifting or twisting is commonly seen in older children and adolescents. Patients describe feeling a popping sensation and report radicular symptoms. Radiographs usually are not sufficient to diagnose the injury. MRI or CT should be used to determine the exact location of the fracture. Nonsurgical management is rarely successful. A wide laminectomy with surgical excision of the limbus fragment is recommended if neurologic symptoms are present.
REFERENCE: Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, p 694.
2010 Pediatric Orthopaedic Examination Answer Book • 13

Question 87

Which of the following therapies has a direct anabolic effect on bone?

Explanation

Bisphosphonates are antiresorptive agents that act by targeting osteoclatic bone resorption. Calcitonin also inhibits osteoclastic bone resorption. Excessive cortisol decreases intestinal calcium absorption, increases calcium loss from the kidney, inhibits bone matrix formation, and causes secondary hyperparathyroidism. TNF-a inhibits osteoblastic activity and enhances osteoclastic bone resorption. Intermittent administration of PTH isoforms is anabolic, whereas persistent elevated levels of PTH promotes bone resorption.

Question 88

Figures 45a and 45b show the AP and lateral radiographs of a 15-year old patient who is undergoing surgery to add 3 cm of length to the femur. Based on the radiographic findings, what is the next most appropriate step in management?

Explanation

DISCUSSION: Because the radiographs reveal poor regenerate bone, especially anteriorly and laterally, the first step in management is to slow the distraction rate. If this does not solve the problem, temporary reversal of the distraction, or “accordionization,” can be used to induce a greater healing response. Maintaining the same distraction rate will further impair regenerate formation and delay healing. Bone grafting should be reserved as an option if decreasing the distraction rate or alternating a week of compression with a week of distraction fails to improve the callus formation. Repeat corticotomy is performed in patients with premature consolidation.
REFERENCES: Raney EM: Limb-length discrepancy, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1519-1526.
Ilizarov GA: Pseudarthroses and defects of long tubular bones, in Transosseous Osteosynthesis: Theoretical and Clinical Aspects of the Regeneration and Growth of Tissue. Berlin, Springer-Verlag, 1992, p 453.

Question 89

Which of the following is considered a contraindication to the use of a reverse total shoulder arthroplasty? Review Topic

Explanation

The reverse total shoulder arthroplasty depends on a functional deltoid muscle which is innervated by the axillary nerve to restore elevation for the patient. Pseudoparalysis is an indication for a reverse shoulder arthroplasty. Acromioplasty has not been correlated with poor results with a reverse shoulder arthroplasty. As long as the patient does not have an active infection, prior infections are not a contraindication. Patients can still have pain and pseudoparalysis from a chronic rotator cuff tear, despite having normal cartilage, and they will still benefit from a reverse total shoulder arthroplasty if other treatments have failed.

Question 90

A 75-year-old woman with rheumatoid arthritis and a long history of oral corticosteroid use sustains a comminuted intra-articular distal humerus fracture. What is the best surgical option?

Explanation

TEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial comparing ORIF with TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and more predictable outcomes compared with ORIF. TEA was also likely to result in a lower resurgical rate; one- quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and associates reported a comparative study of TEA versus ORIF in 24 elderly women. TEA outcomes were again
superior to ORIF at a minimum of 2 years of follow-up. TEA was especially useful in patients with comorbidities that compromise bone stock, including osteoporosis and oral corticosteroid use. Closed
reduction and percutaneous pinning studies have not been published on the adult population.

Question 91

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

Explanation

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

Question 92

When compared with reamed intramedullary nailing for an unstable diaphyseal tibia fracture, unreamed nailing is associated with which of the following?

Explanation

The Investigators Randomized Trial of Reamed versus Non-Reamed Intramedullary Nailing of Tibial Shaft Fractures (SPRINT) study, a large, randomized, controlled trial, has shown a benefit of reamed intramedullary (IM) nailing versus unreamed IM nailing for closed tibial shaft fractures with regard to reoperation rates. No such association exists for open tibial fractures; ie, union rates are the same for open fractures. The infection rates are the same, as is functional outcome, and surgical time is potentially shorter for unreamed nails. The potential pulmonary benefits from unreamed nailing have never been clinically proven.

Question 93

What is the most common sequela of turf toe (hyperextension of the first metatarsophalangeal joint)?

Explanation

The reference article Turf Toe by Rodeo et al 1990 looked at 80 professional football players and occurrence of turf toe. This study consisted of a questionnaire and physical exam. In a nut shell, 85% of players with turf toe sustained their initial injury on artificial turf. Although turf toe accounted for 6 cases per year and ankle sprains 24.7 cases per year turf toe accounted for more missed games. The advent of artificial surfaces and lighter, more flexible shoes for use on artificial turf are suspected causes for the increased incidence of turf toe. The most common mechanism is a hyperextension injury to the MTPJ of a foot in a slightly dorsiflexed position. The injury is a sprain to the capsuloligamentous complex.
What they found was a decreased ROM of the first MTPJ in patients with turf toe and stated that it demonstrates the POSSIBILITY of long-term sequelae to the turf toe injury and that hallux rigidus must be considered in the athlete with progressively limited ROM. Other possible
sequelae cited were hallux valgus, production of a dorsal osteophyte, calcification in periarticular soft tissue, and chondromalacia of the head of the first metatarsal. NO MENTION WAS MADE OF THE MOST COMMON SEQUELAE OF TURF TOE!
Clanton & Schon Chapter 27 Mann Foot & Ankle state that it remains unclear whether these sprains (turf toe) will ultimately result in arthritic changes in the affected joint. No mention is made of hallux rigidus. Again in Mann Chapter 14 on hallux rigidus states that the etiology is degenerative arthritis of the first MTPJ and what predisposes the patient to degenerative arthritis is not known. No mention is made of turf toe.

Question 94

The so-called high ankle sprain from an external rotation mechanism of injury typically involves injury to which of the following structures?

Explanation

DISCUSSION: Ankle sprains most commonly involve injury to the lateral collateral ligaments of the ankle (anterior talofibular, posterior talofibular, and calcaneofibular) from an inversion mechanism of injury. A different entity has been more recently described that involves an external rotation mechanism of injury that widens the ankle mortise and disrupts the anterior inferior tibiofibular ligament. Deltoid ligament and extensor retinaculum injuries do occur, although infrequently, and involve eversion and extreme plantar flexion mechanisms, respectively.
REFERENCES: Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, p 182.
Kaye RA: Stabilization of ankle syndesmosis injuries with a syndesmosis screw. Foot Ankle 1989;9:290-293.
Baxter DE: The Foot and Ankle in Sports. St Louis, MO, Mosby-Year Book, 1995, p 30.
Pfeffer GB (ed): Chronic Ankle Pain in the Athlete. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 11.

Question 95

Which of the following changes is seen with age and degeneration in the intervertebral disk? Review Topic

Explanation

The intervertebral disk consists of annulus fibrosus, nucleus pulposus, and endplate. Nucleus cells have a critical need for glucose because they obtain their energy primarily by glycolysis, even in the presence of oxygen. Disk cells do not require oxygen to remain alive, but they die at low glucose levels or acidic pH. Nutrients are supplied from the blood vessels at the margins of the disk and have to traverse the cartilaginous endplate and the fibrous annulus in order to reach the disk cells. The loss of the nutrient supply through the vertebral body will starve the cells in the disk center and may be a major factor in disk degeneration. The gross appearance of the nucleus pulposus is clear watery gelatinous matrix in the very young disk, but with age the nucleus pulposus becomes more opaque, and less hydrated and firm. The cellular composition of the young disk consists of many notochordal cells, but after 10 years of age, notochordal cells are not seen in the disk. Notochordal cells are the remnant of embryonal cells in the nucleus pulposus.

Question 96

A 47-year-old woman has had medial ankle pain and swelling for the past 3 months. She recalls no specific injury, and casting and nonsteroidal anti-inflammatory drugs have failed to provide relief. Examination reveals a pes planus with heel valgus that is passively correctable. Radiographs show no evidence of arthritis. An MRI scan is shown in Figure 16. What is the most appropriate surgical procedure to alleviate her pain?

Explanation

DISCUSSION: The patient has a stage II posterior tibial tendon tear with a supple foot; therefore, the treatment of choice is flexor digitorum longus transfer with medial displacement calcaneal osteotomy. Triple arthrodesis is not indicated, and isolated tendon transfer will stretch out in the face of persistent heel valgus. Direct repair of the posterior tibial tendon or repair of the spring ligament is not sufficient to correct the deformity.
REFERENCES: Myerson MS, Corrigan J: Treatment of posterior tibial tendon dysfunction with flexor digitorum longus tendon transfer and calcaneal osteotomy. Orthopedics 1996;19:383-388.
Mosier-LaClair S, Pomeroy G, Manoli A II: Operative treatment of the difficult stage 2 adult acquired flatfoot deformity. Foot Ankle Clin 2001;6:95-119.

Question 97

A 54-year-old laborer has a 6-month history of lateral elbow pain. An elbow examination reveals full range of motion, tenderness over the lateral epicondyle, and pain with resisted wrist extension with the elbow in extension. Elbow radiograph findings are normal. You perform a steroid injection and the patient's symptoms are decreased 6 weeks later. One year after receiving the injection, this patient—when compared to a patient who did not have a steroid injection—is likely to

Explanation

EXPLANATION:
This patient has signs and symptoms of lateral epicondylitis. Treatments include various forms of physical therapy, iontophoresis, corticosteroid injection, nitroglycerin patch treatment, blood injections, prolotherapy, and surgical intervention. No single treatment is superior to other treatments for this common problem. Several studies have demonstrated a short-term decrease in symptoms following steroid injection (6 weeks) but an increased likelihood of persistent symptoms 1 year after treatment. Steroid injection at this site has not been associated with increased risk for tendon rupture or need for surgical intervention.

Question 98

03 A 13 y/o girl sustains the injury shown in Figures 69a and 69b in a fall. Examination reveals this to be an isolated injury, and the patient’s neurologic and vascular examinations are normal. Based on these findings, management should consist of

Explanation

Type B & C lateral condyle fxs in children are potentially unstable. Mintzer and associates recommended pinning of these fractures in the articular surface is not disrupted. To determine the status of the articular surface, they recommended arthrography. If the articular surface is intact, perc
pinning may be performed. If the articular surface shows that the fx line has extended into the joint and the articular surface is separated, open reduction and pinning are necessary. Once the fx is stabilized, the elbow is immobilized for 4 wks. The pins are then removed & motion is begun.
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Question 99

Which of the following is considered the best cementless acetabular reconstruction method when planning for total hip arthroplasty in a patient with developmental dysplasia of the hip (DDH)?

Explanation

DISCUSSION: Anatomic positioning of the acetabular component has been shown to be the optimal position for reconstruction of the acetabulum in total hip arthroplasty for DDH. The use of medialized component positioning has been shown to be successful at maximizing the host bone coverage and minimizing the use of bone graft to structurally support the acetabular component. A small acetabular component can be used successfully as long as the femoral head is also reduced in size to maintain the thickness of the acetabular polyethylene. High and lateral positioning for the acetabular reconstruction will result in an increase in the joint reaction forces. In addition, a high and lateral placement will not provide adequate bone to stabilize the reconstruction.
REFERENCES: Numair J, Joshi AB, Murphy JC, Porter ML, Hardinge K: Total hip arthroplasty for congenital dysplasia or dislocation of the hip: Survivorship analysis and long-term results. J Bone Joint Surg Am 1997;79:1352-1360.
Dorr LD, Tawakkol S, Moorthy M, Long W, Wan Z: Medial protrusio technique for placement of a porous-coated, hemispherical acetabular component without cement in a total hip arthroplasty in patients who have acetabular dysplasia. J Bone Joint Surg Am 1999;81:83-92.
Jasty M, Anderson MJ, Harris WH: Total hip replacement for developmental dysplasia of the hip. Clin Orthop 1995;311:40-45.

Question 100

Figures 42a and 42b show the sagittal and axial MRI scans of a 24-year-old patient who has sciatia. Which of the following combinations of physical findings is most consistent wit the MRI studies?

Explanation

Figures 42a and 42b show a posterocentral disc herniation between L5 and S1 and will affect the S1 nerve root. This will cause sensory changes in the posterior calf and plantar foot, motor loss in the gastrocnemius/soleus complex, reflex changes in the ankle jerk, and a positive straight leg raise sign. A positive femoral nerve stretch test may indicate L2, L3, or L4 nerve root irritation. EHL function is mainly L5.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Lining up of collagen fibers within the ligaments
Stretching of elastin within the disk and ligaments
Transition between flexion and extension
Reversible elongation of the soft tissues
Traumatic range of motion, resulting in damage to the soft tissues

Correct Answer: Traumatic range of motion, resulting in damage to the soft tissues

Explanation:

Question 2:

Options:

Obtain a menstrual history.
Advise the athlete never to compete in high level endurance sports again.
Obtain serum calcium levels.
Obtain a psychiatric consultation.
Recommend changes in training intensity.

Correct Answer: Obtain a menstrual history.

Explanation:

Question 3:

Which of the following injuries is most likely associated with the fracture seen in Figure A?

Options:

Medial meniscal tear
Lateral meniscal tear
Lateral collateral ligament rupture
Medial collateral ligament rupture
Posterior cruciate ligament rupture

Correct Answer: Medial meniscal tear

Explanation:

Question 4:

Options:

indirect fracture reduction via traction and early mobilization.
volar plate arthroplasty.
open reduction and internal fixation.
closed reduction and percutaneous pin fixation.
cast immobilization.

Correct Answer: indirect fracture reduction via traction and early mobilization.

Explanation:

Question 5:

The anterior portal of a hip arthroscopy places what structure at greatest risk for injury?

Options:

Ascending branch of the lateral circumflex femoral artery
Ascending branch of the medial circumflex femoral artery
Femoral nerve
Lateral femoral cutaneous nerve
Superior gluteal nerve

Correct Answer: Lateral femoral cutaneous nerve

Explanation:

DISCUSSION: The average location of the anterior portal is 6.3 cm distal to the anterior superior iliac spine. The lateral femoral cutaneous nerve typically has divided into three or more branches at the level of the anterior portal. The portal usually passes within several millimeters of the most medial branch. Injury to the nerve can lead to meralgia paresthetica. The femoral nerve lies an average minimum distance of 3.2 cm from the anterior portal. The ascending branch of the lateral circumflex artery lies approximately 3.7 cm inferior to the anterior portal. Neither the ascending branch of the medial circumflex artery nor the superior gluteal nerve are
at risk.
REFERENCES: Byrd JWT: Operative Hip Arthroscopy. New York, NY, Thieme Medical Publishers, 1998, pp 83-91.
Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 281-289.

Question 6:

Options:

Continued semi-rigid immobilization until the extremity surgeries are completed
Halo skeletal fixation prior to the extremity surgery
Definitive clearance of the cervical spine with CT and/or MRI
Removal of the semi-rigid collar and physical examination when the patient is responsive
Soft collar immobilization and local wound care

Correct Answer: Definitive clearance of the cervical spine with CT and/or MRI

Explanation:

Question 7:

03 advancement at age 6 years. What is the most likely diagnosis?

Options:

Osteomyelitis
Lymphoma
Eosinophilic granuloma
Tuberculosis
Ewing’s sarcoma back answer

Correct Answer: Osteomyelitis

Explanation:

Question 8:

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:

Question 9:

With the arm abducted 90 degrees and fully externally rotated, which of the following glenohumeral ligaments resists anterior translation of the humerus?

Options:

Coracohumeral
Superior glenohumeral
Middle glenohumeral
Anterior band of the inferior glenohumeral ligament complex
Posterior band of the inferior glenohumeral ligament complex

Correct Answer: Anterior band of the inferior glenohumeral ligament complex

Explanation:

DISCUSSION: With the arm in the abducted, externally rotated position, the anterior band of the inferior glenohumeral ligament complex moves anteriorly, preventing anterior humeral head translation. Both the coracohumeral ligament and the superior glenohumeral ligament restrain the humeral head to inferior translation of the adducted arm, and to external rotation in the adducted position. The middle glenohumeral ligament is a primary stabilizer to anterior translation with the arm abducted to 45 degrees. The posterior band of the inferior glenohumeral ligament complex resists posterior translation of the humeral head when the arm is internally rotated.
REFERENCES: Harryman DT II, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.
Wang VM, Flatow EL: Pathomechanics of acquired shoulder instability: A basic science perspective. J Shoulder Elbow Surg 2005;14:2S-11S.

Question 10:

Sclerostin and dickkopf-1 (Dkk-1) are direct inhibitors of what pathway related to bone and/or cartilage regulation?

Options:

Bone morphogenetic protein (BMP)/SMAD pathway
Receptor activator of nuclear factor kappa beta (RANK)/RANK ligand (RANKL) pathway
Wnt/Beta-catenin (β-catenin) pathway
Parathyroid hormone (PTH) pathway DISCUSSION.Dkk-1 and sclerostin are proteins that inhibit the binding of the Wnt molecule to receptors LRP5/6. In the absence of sclerostin and Dkk-1, Wnt binds to its receptor, which in turn inhibits phosphorylation of the β-catenin. The unphosphorylated β-catenin then builds up in the cytoplasm of the cell, allowing it to be transported to the nucleus of the cell. Once in the nucleus, β-catenin will lead to upregulation of a series of proteins involved in osteoblast formation differentiation. Knocking out or inhibiting sclerostin or Dkk-1 results in increased bone mass secondary to constitutive activation of the Wnt/β-catenin pathway.The other responses are not directly affected by Dkk-1 or sclerostin. RANKL and RANK are expressed on osteoblasts and osteoclasts, respectively, and are involved in osteoblast-mediated osteoclast activation.BMPs work through SMADs to cause osteoblastic differentiation, and there is reported crosstalk between the Wnt and BMP pathways (but this is an indirect link). Finally, PTH at physiologic levels binds to osteoblasts, causing a series of events that lead to osteoblast-mediated osteoclast activation and subsequent increased bone resorption.

Correct Answer: Wnt/Beta-catenin (β-catenin) pathway

Explanation:

RESPONSES FOR QUESTIONS 3 THROUGH 6
Adhesive wear
Abrasive wear
Fatigue wear
Delamination
For each scenario below, please choose the most likely dominant mechanism of wear from the list
above.

Question 11:

During placement of an external fixator for a distal radius fracture, the most commonly injured nerve is a branch of which of the following nerves? Review Topic

Options:

Ulnar
Median
Superficial radial
Lateral antebrachial cutaneous
Medial antebrachial cutaneous

Correct Answer: Superficial radial

Explanation:

Pin track infections and sensory injuries are among the most common complications of external fixation for distal radius fractures. The proximal pins of most distal radius external fixators are placed in the “bare area” of the distal radius, about four finger-breadths above the radial styloid. This corresponds to the area where the dorsal sensory branch of the radial nerve penetrates the fascia dorsal to the brachioradialis tendon to become a subcutaneous structure. Injury to the superficial radial nerve may produce painful dysesthesias and neuromas.
(SBQ12TR.106) A 67-year-old female sustains the injury shown in Figure A after a trip and fall. When discussing the outcomes of surgery with the patient, which of the following statements is true?
Post-surgical mortality rates are significantly lower after total hip arthroplasty compared to hemiarthroplasty
Internal fixation shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to arthroplasty
Bipolar hemiarthroplasty shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to unipolar hemiarthroplasty
A delay in surgery greater than 48 hours is recommended if the patient has multiple medical comorbiditiesm which are not fully optimized
Dislocation rates are equivalent between total hip arthroplasty and hemiarthroplasty
Moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes. However, patients with significant medical comorbidity should be fully optimized before surgery.
Although several studies have shown a benefit to surgery within 48 hours, no definitive time frame has been elucidated. The majority of literature has shown improved outcomes in regards to pain, complications, and length of stay with early surgery. Patients with significant medical comorbidities have been shown to have the highest mortality rates.
Moran et al. aimed to determine whether a delay in surgery for hip fractures had an affect on postoperative mortality among elderly patients. In an observational study of 2660 patients, they showed that mortality following hip fracture surgery was 9% at 30-days, 19% at 90-days, and 30% at 12-months. Patients with medical comorbidities had 2.5 times the risk of death within 30-days of surgery. In addition, individuals who had surgery delayed beyond 4 days had increased mortality at 90-days and 12-months.
Papakostidis et al. examined the timing of internal fixation of intracapsular fractures of the neck of femur on the development of late complications, particularly osteonecrosis of femoral head (ONFH) and non-union. They showed no benefit of
early surgery on incidence of AVN. However, delay of internal fixation of more than
24 hours showed increased rates of non-union.
Figure A shows a displaced right femoral neck fracture. Incorrect Answers:

Question 12:

A normal functioning posterior tibialis tendon is best confirmed by which of the following physical findings?

Options:

Pronation of the foot during the stance phase of gait
Heel inversion at the beginning of a single limb heel rise
Active inversion of the nonweightbearing foot
Active plantar flexion of the first ray against resistance
Active plantar flexion of the foot during the push-off phase of gait

Correct Answer: Heel inversion at the beginning of a single limb heel rise

Explanation:

Question 13:

A 65-year-old woman has significant neck pain after falling and striking her head. A radiograph and sagittal CT scan are shown in Figures 23a and 23b. What is the most likely diagnosis?

Options:

Degenerative spondylolisthesis
Superior facet fracture
Inferior facet fracture
Perched unilateral facet dislocation
Bilateral facet dislocation

Correct Answer: Perched unilateral facet dislocation

Explanation:

Question 14:

Which modality has the broadest application for the reduction of postsurgical transfusion?

Options:

Regional anesthesia
Tranexamic acid (TXA) administration
Reduced transfusion trigger
Hypotensive anesthesia

Correct Answer: Tranexamic acid (TXA) administration

Explanation:

Question 15:

Reverse total shoulder arthroplasty with a latissimus dorsi transfer would be the most appropriate treatment for which of the following patients? Review Topic

Options:

Previous shoulder arthrodesis and complete brachial plexus injury
Humeral head avascular necrosis with partial thickness infraspinatus tear
Failed hemiarthroplasty with the inability to perform active external rotation with the arm abducted
Primary shoulder osteoarthritis with 10 degree of glenoid retroversion
Primary rotator cuff arthropathy with active forward shoulder flexion >100 degrees and external rotation >50 degrees

Correct Answer: Previous shoulder arthrodesis and complete brachial plexus injury

Explanation:

Question 16:

Figure 12 shows a lateral radiograph of the elbow. What is the most likely diagnosis?

Options:

Osteochondroma
Old fracture fragment
Heterotopic ossification
Normal anatomic variant
Osteosarcoma

Correct Answer: Normal anatomic variant

Explanation:

Question 17:

Options:

measurement for a thoracolumbosacral orthosis.
bed rest with gradual mobilization.
anterior corpectomy and interbody fusion with instrumentation.
kyphoplasty.
posterior fusion with instrumentation.

Correct Answer: posterior fusion with instrumentation.

Explanation:

Question 18:

A 12-year-old girl sustains an acute injury to the right elbow in a fall. An AP radiograph is shown in Figure 5. Nonsurgical management will most likely result in

Options:

a painful nonunion.
asymptomatic nonunion.
chronic elbow instability.
tardy ulnar nerve palsy.
cubitus varus.

Correct Answer: asymptomatic nonunion.

Explanation:

Question 19:

Options:

Greater than 80% of the lamina
Greater than 50% of each facet joint
Interspinous ligament
Facet joint capsules
Ligamentum flavum

Correct Answer: Greater than 50% of each facet joint

Explanation:

Question 20:

What is the most common organism found following a nail puncture wound through tennis shoes in a host without immunocompromise?

Options:

Methicillin-resistant Staphylococcus aureus
Escherichia coli
Enterobacter
Pseudomonas aeruginosa
Klebsiella pneumoniae

Correct Answer: Pseudomonas aeruginosa

Explanation:

Question 21:

- A 16-year-old girl who swims on her high school team reports pain in the shoulder after swimming. History reveals a glenohumeral dislocation at age 14 years while doing the backstroke. Examination shows a positive anterior apprehension sign. Treatment at this time should consist of

Options:

Putti-platt repair
Open Bankart repair
Injection of a subacromial corticosteroid
Arthroscopic transglenoid capsular shift
Rehabilitation of the scapular and rotator cuff muscles

Correct Answer: Rehabilitation of the scapular and rotator cuff muscles

Explanation:

Question 22:

Options:

Chondroblastoma
Osteoid osteoma
Occult instability
Rotator cuff tear
Injury to the proximal humeral physis

Correct Answer: Injury to the proximal humeral physis

Explanation:

Question 23:

Options:

Heart rate
Hematocrit
Base deficit
Urine output
Systolic blood pressure

Correct Answer: Base deficit

Explanation:

Question 24:

What property of titanium alloys accounts for their high corrosion resistance in vivo?

Options:

Self-passivation
Ductility
Hardness
Modulus of elasticity
Conductivity

Correct Answer: Self-passivation

Explanation:

DISCUSSION: In both room temperature air and physiologic fluids, titanium alloys self-passivate or spontaneously form a layer of titanium oxide very rapidly. This layer makes titanium alloys resistant to surface breakdown.
REFERENCES: Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA, Lippincott, 2003, vol 1, pp 269-278.
Lemons JE: Metallic alloys, in Morrey BF (ed): Joint Replacement Arthroplasty, ed 3. Philadelphia, PA, Churchill-Livingstone, 2003, pp 19-27.

Question 25:

What is the most common location of osteosarcoma?

Options:

Shoulder
Spine
Pelvis
Knee
Skull

Correct Answer: Knee

Explanation:

Question 26:

Options:

closed reduction and a short arm cast for 10 weeks.
closed reduction and a long arm cast for 10 weeks.
open reduction and internal fixation.
limited intercarpal fusion.
proximal row carpectomy.

Correct Answer: open reduction and internal fixation.

Explanation:

DISCUSSION: The radiographs reveal a scaphoid fracture with displacement and comminution and an unstable fracture pattern. Treatment should consist of open reduction and internal fixation. In displaced scaphoid fractures and fractures with unstable fracture patterns, closed reduction is ineffective and is likely to lead to nonunion. Limited intercarpal fusion and proximal row carpectomy are used to correct a variety of traumatic and posttraumatic problems of the wrist.
REFERENCES: Amadio PC, Taleisnik J: Fractures of the carpal bone, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 809-823.
Rettig ME, Kozin SH, Cooney WP: Open reduction and internal fixation of acute displaced scaphoid waist fractures. J Hand Surg Am 2001;26:271-276.
Cooney WP, Dobyns JH, Linscheid RL: Fractures of the scaphoid: A rational approach to management. Clin Orthop 1980;149:90-97.
Szabo RM, Manske D: Displaced fractures of the scaphoid. Clin Orthop 1988;230:30-38.

Question 27:

A patient with rheumatoid arthritis with both ankle and subtalar involvement was treated as shown in Figures 11a and 11b. What complication is unique to this type of fixation?

Options:

Late rotatory deformity
Limb-length discrepancy
Talar osteonecrosis
Tibial stress fracture
Hardware failure

Correct Answer: Tibial stress fracture

Explanation:

DISCUSSION: The interlocking screws at the proximal end of the rod can act as a stress riser and lead to fracture. Postoperative pain at this level should prompt inclusion of this diagnosis in the differential. Removing the screws following bone union can decrease the chances of this occurring. A short rod that avoids the diaphyseal area may also be beneficial. Rotatory deformity is controlled by the perpendicularly oriented distal transfixion screws. Talar osteonecrosis would be unusual since the dissection can be minimized with an intramedullary rod. Any type of hardware can fail if the construct does not lead to a solid arthrodesis.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 236-237.
Thordarson DB, Chang D: Stress fractures and tibial cortical hypertrophy after tibiotalocalcaneal arthrodesis with an intramedullary nail. Foot Ankle Int 1999;20:497-500.
Hammett R, Hepple S, Forster B, et al: Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail: The results of 52 procedures. Foot Ankle Int 2005;26:810-815.

Question 28:

Second impact syndrome (SIS) after head injury is characterized by which of the following? Review Topic

Options:

Gradual progression of neurologic symptoms
Preventable by restricting return to play until symptom-free
Excellent prognosis for full recovery
Rarely involves brain stem compromise
CT rarely shows brain edema

Correct Answer: Preventable by restricting return to play until symptom-free

Explanation:

Question 29:

Options:

Splinting, admission, and frequent neurovascular checks
Cylinder cast and discharge
Emergent knee arthroscopy
Four-compartment calf fasciotomy
Non-weight-bearing, a knee immobilizer, and follow-up in 1 week

Correct Answer: Splinting, admission, and frequent neurovascular checks

Explanation:

Question 30:

Options:

Aspiration of joint fluid to obtain a cell count
Revision of the UKA using primary total knee arthroplasty (TKA) components
Revision of the UKA using a revision TKA with augments
Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Correct Answer: Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Explanation:

Question 31:

Options:

glenohumeral arthrodesis.
total shoulder arthroplasty.
humeral arthroplasty.
open synovectomy and rotator cuff repair.
anterior acromioplasty and rotator cuff repair.

Correct Answer: humeral arthroplasty.

Explanation:

Question 32:

Options:

major: 3 positive cultures, gross purulence. Minor: elevated C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR), elevated synovial white blood cell (WBC) count, elevated synovial neutrophil count, elevated systemic WBC count, dr
major: draining sinus and elevated synovial WBC count. Minor: elevated CRP and ESR, positive frozen section, purulence at surgery, elevated systemic WBC count, febrile episodes, and a single positive culture from periprosthetic tissue.
major: gross purulence at surgery and a draining sinus. Minor: 2 positive cultures from periprosthetic tissues, an elevated synovial WBC count, elevated synovial neutrophil percentage, elevated CRP and ESR, febrile episodes, and an elevated systemic
major: a draining sinus communicating with the joint and 2 positive cultures with the same organism. Minor: elevated synovial WBC count, elevated synovial neutrophil percentage, elevated CRP and ESR, increased WBCs per high-power field on frozen sec

Correct Answer: major: a draining sinus communicating with the joint and 2 positive cultures with the same organism. Minor: elevated synovial WBC count, elevated synovial neutrophil percentage, elevated CRP and ESR, increased WBCs per high-power field on frozen sec

Explanation:

Question 33:

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 34:

Which complication is most common after syndesmotic fixation?

Options:

Synostosis of the distal tibiofibular joint
Failure of fixation with subsequent loss of reduction
Malreduction of the distal tibiofibular joint
Posttraumatic ankle arthrosis

Correct Answer: Malreduction of the distal tibiofibular joint

Explanation:

DISCUSSION
The injury radiographs reveal a supination external rotation IV ankle fracture with evidence of medial clear space widening exceeding 4 mm and an increase relative to the superior tibiotalar clear space. This indicates injury to the deltoid ligament and necessitates surgical reduction and fixation to restore and maintain ankle stability. Following stabilization of the fibula, an intraoperative stress examination of the syndesmosis such as an external rotation stress test under fluoroscopy or lateral pull on the fibula (the Cotton test) should be performed to determine the integrity of the syndesmosis. Radiographic evidence of tibiofibular clear space widening, medial clear space widening with external rotation, and lateral displacement of the distal fibula when pulled is consistent with syndesmotic injury. In contrast to the presurgical stress test, once the fibula has been reduced and stabilized lateral talar translation can occur only if the syndesmosis is injured in addition to the deltoid ligament. Failure of the syndesmotic screw without evidence of malalignment of the mortise and a pain-free ankle are not indications for further surgery because these patients have satisfactory outcomes when compared to those who have intact or removed screws. Hardware removal following fibula ORIF is indicated when patients have pain directly related to hardware prominence. Resolution of joint pain or stiffness is not a reliable outcome following hardware removal. Although fibular fracture can occur, this is a rare complication. Malreduction of the syndesmosis is the most common complication following ORIF of the syndesmosis and is improved with direct visualization; however, malreduction still may occur with direct visualization.
RECOMMENDED READINGS
Manjoo A, Sanders DW, Tieszer C, MacLeod MD. Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma. 2010 Jan;24(1):2-6. doi: 10.1097/BOT.0b013e3181a9f7a5. PubMed PMID: 20035170.
View
Abstract at PubMed
Jenkinson RJ, Sanders DW, Macleod MD, Domonkos A, Lydestadt J. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma. 2005 Oct;19(9):604-9. PubMed PMID: 16247304.
View Abstract at PubMed
Stark E, Tornetta P 3rd, Creevy WR. Syndesmotic instability in Weber B ankle fractures: a clinical evaluation. J Orthop Trauma. 2007 Oct;21(9):643-6. PubMed PMID: 17921840.
View
Abstract at PubMed
Brown OL, Dirschl DR, Obremskey WT. Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma. 2001 May;15(4):271-4. PubMed PMID: 11371792.
View Abstract at PubMed

Question 35:

Options:

arthroscopic synovectomy.
humeral arthroplasty.
unconstrained total shoulder arthroplasty.
constrained total shoulder arthroplasty with a fixed-fulcrum prosthesis.
glenohumeral arthrodesis.

Correct Answer: unconstrained total shoulder arthroplasty.

Explanation:

Question 36:

Options:

Repeat radiographs while the patient is weight bearing
Ultrasonography of the lower extremity and calf
Stress radiographs
CT scan

Correct Answer: Stress radiographs

Explanation:

Question 37:

Options:

Serial above-knee casting in extension for 4 weeks.
Serial above-knee casting in flexion for 4 weeks.
Arthroscopic anterior cruciate ligament division, followed by above-knee casting
Percutaneous quadriceps recession, followed by above-knee casting
Open VY quadriceps plasty, followed by above-knee casting

Correct Answer: Serial above-knee casting in extension for 4 weeks.

Explanation:

Question 38:

Options:

Unicompartmental arthroplasty
Total knee arthroplasty
Lateral closing wedge proximal tibial osteotomy
Medial opening wedge proximal tibial osteotomy
Medial closing wedge supracondylar femoral osteotomy

Correct Answer: Medial closing wedge supracondylar femoral osteotomy

Explanation:

DISCUSSION: Patients with a valgus alignment about the knee can have lateral compartment arthritis. Similar to a high tibial osteotomy, a supracondylar femoral osteotomy is indicated in younger patients who have a more active lifestyle and isolated unicompartmental disease. In this young patient who works in a factory and has a valgus knee, a medial closing wedge supracondylar femoral osteotomy is the treatment of choice. The role of arthroplasty is limited in younger patients.
REFERENCES: Mathews J, Cobb AG, Richardson S, et al: Distal femoral osteotomy for lateral compartment osteoarthritis of the knee. Orthopedics 1998;21:437-440.
Cameron HU, Botsford DJ, Park YS: Prognostic factors in the outcome of supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee. Can J Surg 1997;40:114-118.

Question 39:

Options:

observation.
serial casting.
flexion osteotomy of the distal humerus.
posterior soft-tissue elbow release and anterior triceps transfer.
adaptive equipment.

Correct Answer: posterior soft-tissue elbow release and anterior triceps transfer.

Explanation:

Question 40:

What tendon has an intra-articular (instrasynovial) location in the knee joint?

Options:

Patellar
Popliteal
Semitendinosus
Semimembranosus
Biceps femoris

Correct Answer: Popliteal

Explanation:

Question 41:

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 42:

Options:

continued use of a sling for 3 to 4 weeks, followed by repeat radiographs.
open reduction and internal fixation of the greater tuberosity fracture.
repeat reduction and placement of an abduction orthosis.
hemiarthroplasty.
percutaneous pinning.

Correct Answer: open reduction and internal fixation of the greater tuberosity fracture.

Explanation:

Question 43:

Options:

Neutralization
Compression
Bridging
Buttressing

Correct Answer: Neutralization

Explanation:

Discussion:
The patient sustained a comminuted extra-articular distal humeral diaphyseal fracture. In isolation, this fracture would still be amenable to an attempt at closed treatment. His radial nerve palsy alone does not warrant open management, as early exploration has not shown a significant benefit in a closed fracture. In addition, despite the comminution and distal extent of the fracture, it is still amenable to closed treatment, though it may be at higher risk for malunion. However, in this patient with multiple lower extremity injuries, fixation of the humerus can facilitate early mobilization and weight-bearing with his right upper extremity, representing a relative indication for surgical management.
The posterior triceps-reflecting approach described can be extended proximally to the level of the axillary nerve. The radial nerve must be found and protected, but the dissection can be carried well proximal to it and the medial triceps origin. The anatomic neck of the humerus cannot be visualized through this approach.
The plate functions as a neutralization plate, as multiple lag screws are seen placed outside of the plate, suggesting anatomic reduction and fixation of the fracture prior to applying the plate.
The working length of the plate is the distance between the proximal and distal screws closest to the fracture. The length of screw purchase in bone represents the working length of the screw, not the plate. The other answer choices describe dimensions of the plate and the fixation construct, not its working length.

Question 44:

When a structure like a long bone is under a bending load, its maximum stress is most dependent on what factor?

Options:

Length of the bone
Type of structural support
Size of cross-sectional area
Plastic modulus of material used
Area moment of inertia of the cross section

Correct Answer: Area moment of inertia of the cross section

Explanation:

Question 45:

Options:

posterior fusion with instrumentation.
posterior instrumentation without fusion.
anterior fusion with instrumentation.
an orthosis.
bed rest with gradual mobilization.

Correct Answer: posterior fusion with instrumentation.

Explanation:

Question 46:

A number of potential complications are associated with the direct lateral approach to the lumbar spine; which complication is most common?

Options:

Infection
Iliopsoas weakness
Injury to the aorta
Foot drop

Correct Answer: Iliopsoas weakness

Explanation:

DISCUSSION
Sofianos and associates examined the cases of 45 patients who underwent the lateral transpsoas approach and found that 18 of 45 patients (40%) experienced at least 1 complication. The most common complication was postsurgical weakness of the iliopsoas, which was an issue for 10 of 45 patients (22.2%). The second-most-common complication in this series was anterior thigh hypoesthesia. This occurred in 8 of 45 patients (17.8%). A series of 600 patients by Rodgers and associates noted that thigh pain and psoas weakness following a direct lateral approach to the lumbar spine were both "nearly universal" but almost "always transient."
RECOMMENDED READINGS
Sofianos DA, Briseño MR, Abrams J, Patel AA. Complications of the lateral transpsoas approach for lumbar interbody arthrodesis: a case series and literature review. Clin Orthop Relat Res. 2012 Jun;470(6):1621-32. doi: 10.1007/s11999-011-2088-3. Review. PubMed
PMID: 21948287.
View Abstract at PubMed
Lee YP, Regev GJ, Chan J, Zhang B, Taylor W, Kim CW, Garfin SR. Evaluation of hip flexion strength following lateral lumbar interbody fusion. Spine J. 2013 Oct;13(10):1259-62. doi: 10.1016/j.spinee.2013.05.031. Epub 2013 Jul 12. PubMed PMID: 23856656.
View Abstract
at PubMed
Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976). 2011 Jan 1;36(1):26-32. doi: 10.1097/BRS.0b013e3181e1040a. PubMed PMID: 21192221.
View
Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 21 AND 22
Figures 21a through 21c are the preoperative lateral standing radiograph, axial T2-weighted MR image at L4-5, and supine sagittal MR image of a 45-year-old woman who has had back and leg pain for 2 years. Treatment had included nonsteroidal anti-inflammatory drugs, physical therapy, and epidural corticosteroid injections. Her pain limited her activities of daily living; she could walk only 1 to 2 blocks before her pain became intolerable.
21A
B
C

Question 47:

During a posterior cruciate ligament (PCL)-retaining total knee arthroplasty, a critical principle to remember is to

Options:

accurately tension the PCL.
use bony resection to adjust the joint line.
maintain a small amount of residual deformity.
use intraoperative fluoroscopy to ensure femoral roll back.

Correct Answer: accurately tension the PCL.

Explanation:

Question 48:

Options:

debridement of the biceps tendon.
debridement of the rotator cuff tear.
repair of the biceps pulley system.
repair of the rotator cuff tear.
tenodesis of the biceps tendon.

Correct Answer: tenodesis of the biceps tendon.

Explanation:

Question 49:

Options:

Trapezoid ligament
Conoid ligament
Acromioclavicular ligament
Deltoid muscle origin
Trapezius muscle insertion

Correct Answer: Trapezius muscle insertion

Explanation:

Question 50:

Options:

Radiographs, including anterior, lateral, and oblique views
MRI of the lumbar spine and follow-up at the clinic in 1 week
Caudal epidural steroid injection
Reassurance, limited analgesics, and early range of motion as tolerated
Immediate MRI of the lumbar spine and possible urgent surgical decompression

Correct Answer: Reassurance, limited analgesics, and early range of motion as tolerated

Explanation:

Question 51:

Options:

Distal femoral osteotomy
Unicompartmental knee replacement
High tibial osteotomy (HTO), lateral closing wedge
HTO, medial opening wedge with decreased tibial slope

Correct Answer: HTO, medial opening wedge with decreased tibial slope

Explanation:

Question 52:

Options:

Ulnar neuritis
Pronator syndrome
Medial epicondylitis
Medial collateral ligament sprain
Varus extension overload

Correct Answer: Medial collateral ligament sprain

Explanation:

Question 53:

An otherwise healthy 15-year-old wrestler has a 6-cm cutaneous lesion on the posterior aspect of his right elbow that he reports as a spider bite. What is the most likely diagnosis? Review Topic

Options:

Psoriasis
Tinea corporis
Herpes simplex virus
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA)

Correct Answer: Psoriasis

Explanation:

Patients who have skin and soft-tissue infections caused by CA-MRSA often describe the lesion as a spider bite. The cytotoxin Panton-Valentine leukocidin that is produced by many strains of CA-MRSA causes tissue necrosis, resulting in rapid development of an abscess and the appearance of a spider bite. Patients with psoriasis have thick, red skin with flaky, silver-white patches. Tinea corporis is a general term for a cutaneous fungal infection. The lesion appears as a well-demarcated erythematous plaque with a raised border and central hypopigmentation, giving it a ring-like appearance. Primary infection with herpes simplex virus can produce constitutional symptoms with burning, tingling, or stinging at the site. Grouped vesicles with clear fluid 1 to 2 mm in size form on an erythematous base and then rupture, leaving moist ulcers or crusted plaques.
(SBQ07SM.48) Carbohydrate loading is a common practice among endurance athletes that works by what mechanism?
Review Topic
Increasing serum fructose levels
Maximizing stored muscle glycogen for endurance after 90 minutes of exercise
Diuresis
Decreasing serum glucose levels
Maximizing stored liver glycogen for endurance after 60 minutes of exercise
Carbohydrate loading is a strategy that involves changes to training and nutrition which can maximize muscle glycogen stores prior to endurance exercise lasting longer than 90 minutes.
There continues to be varying scientific opinions as to whether athletes should eat low vs. high glycemic index foods, and how this will affect the amount that the serum glucose levels rise. Fructose is able to be converted to glycogen in the liver but not muscle, therefore high-fructose containing foods are suboptimal. This practice is recommended for athletes participating in events that are longer than 90 minutes (after the bodies normal supply of glycogen is depleted).
Coyle et al. analyzed 10 trained cyclists who performed two bicycle ergometer exercise tests 1 wk apart. They found that blood glucose concentration was 20-40% higher during the exercise after carbohydrate ingestion than during the exercise without carbohydrate feeding. The exercise-induced decrease in plasma insulin was prevented by carbohydrate feeding. Ultimately, fatigue was postponed by carbohydrate feeding during exercise in seven out of the ten subjects.
Costill et al. examined the effect of carbohydrates on muscle glycogen resynthesis in trained runners and found that muscle glycogen levels could be normalized with the proper use of carbohydrates after strenuous activity.
Sherman et al. used muscle biopsies to determine the effects of moderate- or high-carbohydrate diets on muscle glycogen and performance in runners and cyclists over 7 consecutive days of training. They found that a high carbohydrate diet restored muscle glycogen to more normal levels than a moderate carbohydrate diet but did not find any difference in the effect on performance.
Illustration A is a graph depicting the typical carbohydrate depletion/loading regimen that endurance athletes utilize to maximize muscle glycogen stores prior to endurance exercise. This typically involves a hard workout followed by three days of a low-carb diet, another hard workout, and another three days of a high-carb diet.
Incorrect

Question 54:

Why is tendon considered an anisotropic material?

Options:

Young’s modulus is greater than that of bone.
Young’s modulus is greater than that of ligament.
Mechanical properties change with preconditioning.
Intrinsic mechanical properties vary depending on the direction of loading.
Intrinsic mechanical properties vary depending on the rate of loading.

Correct Answer: Intrinsic mechanical properties vary depending on the direction of loading.

Explanation:

DISCUSSION: Anisotropic materials have mechanical properties that vary based on the direction of loading. The relative values of Young’s modulus for tendon, ligament, and bone are not relevant to isotropy. The mechanical properties of tendon do change with preconditioning, but this change is related to viscoelasticity. The intrinsic mechanical properties of tendon do vary with the rate of loading, but this variance is related to viscoelasticity.
REFERENCES: Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 134-180.
Lu L, Kaufman KR, Yaszemski MJ: Biomechanics, in Einhorn TA, O’Keefe RJ,
Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, in press.

Question 55:

Options:

Advanced degenerative disk disease with facet arthrosis at L5-S1
Decreased T2 signal in the L5-S1 disk with normal facet joints
Previous laminectomy at L5-S1
Fixed tilt of L5 with severe unilateral facet arthrosis
Spondylolysis bilaterally at L5

Correct Answer: Decreased T2 signal in the L5-S1 disk with normal facet joints

Explanation:

Question 56:

Following total elbow arthroplasty, patients should be instructed to Review Topic

Options:

return to impact activities such as golf or tennis.
permanently limit the load bearing of that arm to 5 pounds or less.
aggressively strengthen the triceps immediately following surgery.
immobilize the wrist and hand for 4 weeks postoperatively to minimize stress on the surgical site.
avoid pronation and supination to reduce torsional stress on the implant.

Correct Answer: permanently limit the load bearing of that arm to 5 pounds or less.

Explanation:

Question 57:

What is the most common presenting sign or symptom in an adult with lumbar pyogenic infection?

Options:

Fever
Night sweats
Unexplained weight loss
Foot drop
Back pain

Correct Answer: Back pain

Explanation:

Question 58:

Sterilization of ultra-high molecular weight polyethylene by gamma irradiation in air will degrade its wear performance because of

Options:

oxidation.
melting.
cross-linking.
corrosion.
creep.

Correct Answer: oxidation.

Explanation:

DISCUSSION: Gamma irradiation has long been used as a sterilization method for polyethylene. Exposure to gamma irradiation causes breakage of the chemical bonds in the polyethylene, and oxidation will occur if the material is subsequently exposed to air. The amount of oxidation and decrease in wear performance is also related to the length of time that the gamma-irradiated polyethylene is exposed to oxygen.
REFERENCES: Collier JP, Sutula LC, Currier BH, et al: Overview of polyethylene as a bearing material: Comparison of sterilization methods. Clin Orthop 1996;333:76-86.
McKellop H, Shen FW, Lu B, et al: Effect of sterilization method and other modifications on the wear resistance of acetabular cups made of ultra-high molecular weight polyethylene: A hip-simulator study. J Bone Joint Surg Am 2000;82:1708-1725.
Sychterz CJ, Young AM, Orishimo K, et al: The relationship between shelf life and in vivo wear for polyethylene acetabular liners. J Arthroplasty 2005;20:168-173.

Question 59:

Options:

Grade III chondrosis of the proximal patella
Caton-Deschamps ratio of 1:1
Tibial tubercle-trochlear groove (TT-TG) distance of 21 mm
Q angle of 17 degrees

Correct Answer: Grade III chondrosis of the proximal patella

Explanation:

DISCUSSION
TTO is a common treatment for patellofemoral instability. The angle of correction must be customized to each patient’s anatomy. For this patient, the orthopaedic surgeon plans an osteotomy that will both anteriorize and medialize the tubercle. This will consistently result in
a change of patellofemoral kinematics and contact pressures. Medialization decreases lateral and increases medial patellofemoral contact pressures, and anteriorization shifts contact pressures from distal to proximal. Significant anteriorization may not be desired in a patient with proximal patellar chondrosis unless a concomitant chondral procedure is performed as well. The patellar height (Caton-Deschamps ratio) is normal, precluding the need for distalization but not medialization. The TT-TG distance, at more than 20 mm, is a strong indication for osteotomy. The Q angle, although a less precise indicator of malalignment, is also elevated and would be considered an indication for osteotomy.
CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 41
A healthy, active 18-year-old man has acute-onset right knee pain and an inability to fully extend his knee following an attempt to stand from a seated position yesterday. He sustained a noncontact injury to his right knee while playing basketball 2 years ago and underwent primary anterior cruciate ligament (ACL) reconstruction with bone-patella-tendon-bone autograft and medial meniscus repair. He sustained another noncontact injury to the same knee 8 months later and underwent a revision ACL reconstruction using soft-tissue allograft and revision medial meniscus repair. He reports multiple episodes of “giving way” of his knee, but no pain prior to yesterday’s acute injury.

Question 60:

Options:

insert a standard humeral prosthesis with cerclage wires at the fracture site and autologous cancellous bone graft.
insert a standard humeral component and apply a humeral orthosis postoperatively.
cement a long-stemmed humeral component to bypass the fracture site and supplement with cerclage wires.
remove all instrumentation, perform an open reduction and internal fixation of the fracture, and delay completion of replacement surgery until the fracture has healed.
discontinue the procedure and return for completion of total shoulder replacement when the fracture has healed.

Correct Answer: cement a long-stemmed humeral component to bypass the fracture site and supplement with cerclage wires.

Explanation:

Question 61:

Options:

open reduction and exchange humeral nailing.
a custom orthosis and an external bone stimulator.
removal of the humeral nail and external fixation.
removal of the humeral nail and plate fixation with bone grafting.
open bone grafting and an internal bone stimulator.

Correct Answer: removal of the humeral nail and plate fixation with bone grafting.

Explanation:

DISCUSSION: The use of locked nailing for the treatment of established nonunion of the humerus has produced poor results. Since humeral nailing has already failed, exchange humeral nailing without bone grafting has an even less change of success. To increase the likelihood of achieving bony union, the treatment of choice is removal of the humeral nail, dynamic compression plating, and bone grafting.
REFERENCES: Zuckerman J, Giordanno C, Rosen H: Treatment of humeral shaft non-unions, in Bigliani L (ed): Complications of shoulder surgery. Baltimore, MD, William & Wilkins, 1993, pp 173-190.
Jupiter JB: Complex non-union of the humeral diaphysis: Treatment with a medial approach,
an anterior plate, and a vascularized fibular graft. J Bone Joint Surg Am 1990;72:701-707.

Question 62:

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

Options:

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

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

Explanation:

Question 63:

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads?

Options:

Nucleus pulposus
Cartilaginous end plate
Anterior longitudinal ligament
Annulus fibrosis
Cellular matrix

Correct Answer: Annulus fibrosis

Explanation:

DISCUSSION: The annulus fibrosis has a multilayer lamellar architecture mode of type I collagen fibers. Each successive layer is oriented at 30 degrees to the horizontal in the opposite direction, leading to a “criss-cross” type pattern. This composition allows the annulus, which has the highest tensile modulus, to resist torsional, axial, and tensile loads.
REFERENCE: Rhee JM, Schaufele M, Abdu WA: Radiculopathy and the herniated lumbar disc: Controversies regarding pathophysiology and management. J Bone Joint Surg Am 2006;88:2070-2080.

Question 64:

Options:

Completion of the tear from the bursal surface and rotator cuff repair
Arthroscopic long head biceps tenotomy
Arthroscopic glenohumeral synovectomy
Arthroscopic tendon debridement and subacromial decompression
Transtendinous rotator cuff repair

Correct Answer: Arthroscopic tendon debridement and subacromial decompression

Explanation:

Question 65:

What radiographic view will best reveal degeneration of the pisotriquetral joint in a patient who is being evaluated for pisotriquetral arthrosis?

Options:

True lateral
Lateral in 30 degrees of pronation
Lateral in 30 degrees of supination
Posteroanterior in 30 degrees of pronation
Carpal tunnel

Correct Answer: Lateral in 30 degrees of supination

Explanation:

Question 66:

Options:

C8 - T1 nerve root avulsion 3 months ago
C5 - C6 nerve root avulsion 2 months ago
Upper brachial plexus palsy 22 months ago
Medial and posterior cord injury from gunshot wound 2 months ago
C6 ASIA A spinal cord injury PREFERRED RESPONSE 2 Transfer of fascicles from (1) ulnar nerve to the nerve to the biceps and (2) median nerve to the motor nerve of the brachialis would be appropriate in the treatment of an acute (<3-6 months) upper brachial plexus palsy. Upper trunk injury (C5, C6) often results from the avulsion of both the C5 and C6 nerve roots. Injuries of this nature usually result from a downward force on the shoulder with lateral bending of the cervical spine in the opposite direction. This results in what is commonly called an Erb-Duchenne palsy. Patients often present with a flail shoulder and loss of elbow flexion. Other common treatments for C5 and C6 root avulsion include neurotization of the musculocutaneous (MSC) nerve by the spinal accessory (SA) or intercostal nerve, and neurotization of the supra-scapular nerve by the SA. Liverneaux et al. looked at short term results of (1) ulnar nerve fascicle transfer to the nerve to the biceps and (2) fascicle of the median nerve to the motor branch to the brachialis in 15 patients with acute C5 - C6 nerve root avulsion injuries. Grade 4 elbow flexion was restored in each of the 10 patients. There was no secondary deficit in grip strength or sensation.They concluded that this double nerve transfer technique will likely reduce the need for secondary procedures to augment elbow flexion. Teboul et al. reviewed thirty-two patients with an upper nerve-root brachial plexus injury that underwent ulnar nerve fascicle transfer to the nerve of biceps to restore elbow flexion. After the nerve transfer, twenty-four patients achieved grade 3 elbow flexion strength or better. They note that this procedure will spare the C5 nerve root and other nerves for grafting or transfer elsewhere. Illustration A shows harvesting of an ulnar nerve fascicle for transfer. Illustration B shows transfer of the fascicle of the ulnar nerve to the motor nerve of the biceps. Incorrect Answers:

Correct Answer: C8 - T1 nerve root avulsion 3 months ago

Explanation:

(SBQ12FA.31) A 30-year-old male patient involved in a hang-gliding accident sustains a knee dislocation with multiligamentous knee injury and transection of his peroneal nerve. He undergoes multiple reconstructive surgeries. Two years later, he continues to have a foot drop and dynamic tendon transfer is recommended. This treatment most commonly involves transferring a tendon from which native insertion point to which new insertion point?
Review
Topic
Plantar distal phalanges to medial navicular
Medial navicular to dorsal lateral cuneiform
Plantar 1st metatarsal to dorsal lateral cuneiform
5th metatarsal base to dorsal medial cuneiform
Plantar distal phalanx of the hallux to dorsal distal phalanx of hallux
Dynamic tendon transfer to restore active dorsiflexion of the foot involves transferring the posterior tibial tendon (PTT) insertion on the medial navicular to the dorsal lateral cuneiform.
Common peroneal nerve (CPN) injuries following traumatic knee dislocation are common, with an incidence of 25-40%. CPN palsy is characterized by foot drop due to loss of ankle dorsiflexors with a steppage gait and eventual development of a supinated equinovarus foot secondary to the unopposed pull of the PTT. Nonsurgical management involves use of an ankle-foot orthosis and physical therapy. Surgical
options include acute primary repair, nerve grafting with either autologous sural nerve or nerve conduits and dynamic tendon transfer. The PTT is harvested from its insertion at the navicular, passed through the interosseous membrane (IOM) and anchored to the lateral cuneiform (see Illustration A). The classic bridle procedure involves concomitant anastamosis of the PTT to the tibialis anterior (TA) and peroneus longus (PL) tendons.
Garozzo et al reported a case series of 62 patients with post-traumatic CPN palsy who underwent a one-stage procedure consisting of nerve repair and PTT transfer. Nerve repair combined with PTT transfer improved postoperative outcomes compared to nerve repair alone. At 2-year follow up, neural regeneration was demonstrated in 90% of patients. The authors hypothesized that poor outcomes following nerve repair alone are due to force imbalance between the functioning flexors and paralyzed extensors, which is somewhat equalized by performing a PTT transfer at time of repair.
Niall et al reviewed 55 patients with traumatic knee dislocation and reported a 41% incidence of CPN injury, exclusively associated with dislocations involving disruption of the posterior cruciate ligament (PCL) and posterolateral corner (PLC). Complete neurologic recovery was found in only 21% of patients. The best prognosis was found with lesions in continuity, less than 7cm of nerve involvement, and short conduction block and muscle activity on nerve conduction and EMG studies.
Vigasio et al described a dynamic tendon transfer technique for traumatic complete CPN injury, involving transfer of the PTT to the TA rerouted to a new origin at the lateral cuneiform to restore ankle dorsiflexion and flexor digitorum longus (FDL) to the extensor digitorum longus (EDL) and extensor hallucis longus (EHL) to restore digit dorsiflexion. Rerouting the TA towards the transferred PTT ensures the PTT harvest length is sufficient. This avoids excessive tensioning of the PTT, which may limit tendon excursion and result in a static tenodesis rather than dynamic function, as well as the need for PTT lengthening which may decrease strength of the transfer
Illustration A is a series of intraoperative photographs demonstrating PTT transfer from Garg et al. An incision is made distal to the medial malleolus and the PTT is harvested subperiosteally (A). The PTT is delivered through a second incision ~15cm proximal to the medial malleolus (B-C). The PTT is then passed through the interosseous membrane and out a third incision over the anterior fibula (D). Lastly, the PTT is passed through a fourth incision over the dorsal midfoot and anchored to the lateral cuneiform (E).
Incorrect Responses:
nerve and therefore would not be functional. Answer 5: Transferring the flexor hallucis longus (FHL; insertion = plantar distal phalanx of the hallux) to the insertion of the EHL (dorsal distal phalanx of hallux) is recommended for correction of claw toe deformity and would not help restore foot dorsiflexion in this patient.

Question 67:

What is the most common behavioral effect of anabolic steroid use in athletes?

Options:

Increased aggression
Psychosis
Drug dependence
Depression
Mania

Correct Answer: Increased aggression

Explanation:

Question 68:

When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?

Options:

Addition of sublaminar wires to the midlumbar spine
Cross-linking of the longitudinal rods
Use of multiple claw hook fixation in the upper thoracic spine
Use of large-diameter rods and pedicle screws
Fixation into both the ilium and the sacrum

Correct Answer: Fixation into both the ilium and the sacrum

Explanation:

Question 69:

Options:

Plastic
Elastic
Fatigue
Creep
Torsion

Correct Answer: Elastic

Explanation:

Question 70:

A 17-year-old high school football player reports wrist pain after being tackled. Radiographs are shown in Figures 22a through 22c. What is the recommended intervention?

Options:

Pedicled vascularized bone graft
Long arm thumb spica cast
Percutaneous screw fixation
Corticocancellous bone grafting via a volar approach (Matti-Russe)
Open reduction and differential pitch screw placement via a dorsal approach

Correct Answer: Open reduction and differential pitch screw placement via a dorsal approach

Explanation:

DISCUSSION: The patient has an acute fracture of the proximal pole. A 100% healing rate has been reported for open reduction and internal fixation of proximal pole fractures via a dorsal approach. This allows for direct viewing of the fracture line, facilitates reduction, and bone grafting can be done through the same incision if necessary. A vascularized or corticocancellous graft is reserved for nonunions. Proximal fractures are very slow to heal with a cast, if they heal at all. As a small fragment, percutaneous fixation is very difficult and has been reported for waist fractures.
REFERENCES: Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210.
Raskin KB, Parisi D, Baker J, et al: Dorsal open repair of proximal pole scaphoid fractures. Hand Clin 2001;17:601-610.

Question 71:

Options:

Whole blood
Platelets
Plasma
Starch product (ie, Hetastarch, Hespan)
Donor-directed blood from a family member who is a practicing Jehovah's witness

Correct Answer: Starch product (ie, Hetastarch, Hespan)

Explanation:

Question 72:

Options:

Ultrasound
CT
Bone scan
Scapular Y-view of the shoulder
Stress views of the shoulder

Correct Answer: Stress views of the shoulder

Explanation:

Question 73:

Options:

assessment of the bone age in the left wrist and hand.
an MRI scan of the spine.
an ultrasound of the hips.
a renal ultrasound.
a Pavlik harness.

Correct Answer: a renal ultrasound.

Explanation:

Question 74:

Options:

External rotation of the distal femoral segment relative to the proximal femoral segment during nailing
Internal rotation of the proximal femoral segment relative to the distal femoral segment during nailing
Iatrogenic decrease in femoral anteversion on the operative leg during nailing
Increased contralateral femoral retroversion during surgery
Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing

Correct Answer: External rotation of the distal femoral segment relative to the proximal femoral segment during nailing

Explanation:

Question 75:

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 76:

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

Options:

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

Correct Answer: Radial nerve injury

Explanation:

Question 77:

Contraindications to cervical laminectomy as a treatment for cervical spondylotic myelopathy include which of the following findings?

Options:

Multilevel disease with spinal cord compression
Anterior spinal cord compression
Posterior spinal cord compression
Cervical kyphosis
Ossification of the posterior longitudinal ligament

Correct Answer: Cervical kyphosis

Explanation:

Question 78:

When the iliac apophysis starts ossifying in the normal adolescent, growth of the sitting height or trunk height is characterized by

Options:

no appreciable change during the remainder of growth for either boys or girls.
an increase of 3 to 5 cm in girls and an increase of 5 to 8 cm in boys.
an increase of 5 to 8 cm in girls and an increase of 3 to 5 cm in boys.
an increase of 8 to 11 cm in girls and an increase of 11 to 13 cm in boys.
an increase of 11 to 13 cm in girls and an increase of 8 to 11 cm in boys.

Correct Answer: an increase of 3 to 5 cm in girls and an increase of 5 to 8 cm in boys.

Explanation:

Question 79:

Options:

Avascular necrosis
Loss of fixation of the fracture
Malunion leading to increased retroversion of the articular surface
Glenoid arthrosis

Correct Answer: Avascular necrosis

Explanation:

Question 80:

Options:

The athlete must wear a functional brace for all athletic activities for 2 years following reconstruction.
The athlete may wear a functional brace for athletic activities; however, no evidence exists to show the brace decreases the rate of ACL retear.
The athlete must wear a functional brace for 2 years following reconstruction for basketball only; other athletic activities such as running and tennis are allowed without the brace.
The athlete must wear a custom-fit functional brace for 2 years following reconstruction because off-the-shelf braces produce inferior results.

Correct Answer: The athlete may wear a functional brace for athletic activities; however, no evidence exists to show the brace decreases the rate of ACL retear.

Explanation:

DISCUSSION FOR QUESTIONS 89 THROUGH 95
The athlete most likely suffered an acute ACL rupture however the presence of a lipohemarthrosis is concerning for the possibility of an intraarticular fracture. Because of this, the patient should not be allowed full weight bearing until a fracture is ruled out with radiographs. Given the athlete’s inability to perform a straight leg raise, the extensor mechanism is not functioning and a telescoping knee brace locked in extension should be utilized. A neoprene knee sleeve does not have a role in the
treatment of this acute injury.The radiographs reveal a lateral avulsion fracture off of the proximal tibial epiphysis which is known as a Segond fracture. It is indicative of an ACL injury and the fracture fragment seen is the consequence of the lateral capsule injury sustained during the pivot-shift mechanism. There is no radiographic evidence of a medial tibial plateau fracture. A radiographic sign of a chronic MCL injury is known as a Pellegrini-Stieda lesion and this is seen as calcification of the femoral origin of the MCL. A radiographic sign of an acute LCL rupture would be an avulsion fracture of the tip of the fibula.The MRI shows kissing contusions of the posterolateral tibial plateau and the midpoint of the lateral femoral condyle. These “kissing lesions” are seen as a result of a pivot shift mechanism of injury and are diagnostic for an ACL rupture. The most common associated injury in an acute ACL rupture is a lateral meniscus tear. Medial meniscus tears are more common in chronic ACL injuries. PCL rupture and PLC injury are all associated injuries seen in acute ACL rupture; however, these are much less common than meniscal tears. The team physician has a role in encouraging, but
not demanding, the athlete to report the injury andtreatment to the scholarship school’s coaching staff. What the athlete decides to do is his decision; the physician would be violating the athlete’s HIPAA rights as well as their confidence by reporting it directly to the scholarship school. Clearly the physician should not discourage the athlete from reporting the injury. The athlete is 18 years old and, as such, the physician would need the athlete’s permission to discuss any medical issues with the family in keeping with HIPAA.
The athlete’s exam demonstrates incompetence of both bundles of the ACL as demonstrated by the loss of stability with anterior translation of the tibia (Lachman test) as well as with rotation (pivot shift). The external rotation stress with the knee in 30 degrees of flexion tests the competence of the posterolateral corner while rotation at 90 degrees of flexion tests the PCL. Since the athlete’s knee is stable to posterior drawer testing demonstrating an intact PCL and the external rotation at 30 degrees is equivalent to that at 90 degrees, the posterolateral corner in intact.
The ACL has two separate and distinct bundles, the AM and PL. Each bundle takes on tension at varying degrees of knee flexion and therefore each bundle is thought to have a varying contribution to the stability of the knee. The AM bundle takes on tension with the knee in flexion and the PL bundle is tight in extension. Neither bundle is isometric during knee range of motion. Both bundles have contributions to rotational stability of the knee throughout the range of motion.
The success of traditional trans-tibial single-bundle ACL reconstruction has recently been called into question given the demonstration of persistent rotational instability following reconstruction. The persistence of rotational instability in trans-tibial single bundle ACL reconstruction has been attributed to the location of the graft in a vertically malpositioned femoral tunnel. The goal of double-bundle ACL reconstruction is to more accurately reproduce the native ACL and provide grafts that contribute to anteroposterior stability as well as rotational stability by placing the grafts in more anatomic locations not central in the knee axis. There is an increased cost and surgical time associated with double-bundle reconstruction.
The use of functional braces following ACL reconstruction is a surgeon’s preference because there is no difference in retear rate with or without a brace. Some authors recommend brace use for one to two years following ACL reconstruction for all athletic activities, but this is not supported by the literature. No literature exists showing a higher rate of reinjury with a functional brace and off-the shelf and custom braces have been found to be equivalent leading those who advocate for braces to recommend off-theshelf braces given their significantly lower cost.

Question 81:

Options:

elbow extension motion.
elbow flexion strength.
forearm supination motion.
forearm pronation strength.
forearm supination strength.

Correct Answer: forearm supination strength.

Explanation:

Question 82:

Options:

Chondrolysis
Ischemic necrosis of the femoral head
Ischemic necrosis of the greater trochanter
Femoral neck fracture
Trochanteric overgrowth

Correct Answer: Ischemic necrosis of the femoral head

Explanation:

Question 83:

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

Options:

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

Correct Answer: Once ankylosis of the forearm or elbow occurs

Explanation:

Question 84:

What muscles are responsible for the most common deformity after antegrade intramedullary nailing for a subtrochanteric femur fracture?

Options:

Hip abductors and iliopsoas muscle
Hip internal rotators and iliopsoas muscle
Quadriceps and iliopsoas muscle
Hamstring and iliopsoas muscle
Quadriceps and hip adductors

Correct Answer: Hip abductors and iliopsoas muscle

Explanation:

Question 85:

Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints?

Options:

With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.
With tibial shin splints, the bone scan is more intense.
A more diffuse area of tenderness is seen in tibial stress fractures.
A three-phase bone scan is positive in all phases with shin splints, but only positive in delayed

Correct Answer: With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.

Explanation:

Question 86:

Options:

resection of the fragment through a microdiskectomy approach.
epidural steroid injections until symptoms improve.
laminectomy with surgical excision of the limbus fragment.
activity restrictions until the symptoms improve.
chiropractic manipulation.

Correct Answer: laminectomy with surgical excision of the limbus fragment.

Explanation:

DISCUSSION: A limbus or apophyseal fracture caused by heavy lifting or twisting is commonly seen in older children and adolescents. Patients describe feeling a popping sensation and report radicular symptoms. Radiographs usually are not sufficient to diagnose the injury. MRI or CT should be used to determine the exact location of the fracture. Nonsurgical management is rarely successful. A wide laminectomy with surgical excision of the limbus fragment is recommended if neurologic symptoms are present.
REFERENCE: Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, p 694.
2010 Pediatric Orthopaedic Examination Answer Book • 13

Question 87:

Which of the following therapies has a direct anabolic effect on bone?

Options:

Bisphosphonates
Tumor necrosis factor-a (TNF-a) inhibitors
Calcitonin
Intermittent PTH
Corticosteroids

Correct Answer: Intermittent PTH

Explanation:

Question 88:

Options:

The distraction rate should be maintained.
The distraction rate should be decreased.
The distraction should be reversed.
The distraction gap should be managed with bone grafting in an open procedure.
A repeat corticotomy should be performed.

Correct Answer: The distraction rate should be decreased.

Explanation:

Question 89:

Which of the following is considered a contraindication to the use of a reverse total shoulder arthroplasty? Review Topic

Options:

Prior shoulder joint infection
Pseudoparalysis
Prior partial acromioplasty
Absent glenohumeral joint space narrowing
Axillary neuropathy

Correct Answer: Axillary neuropathy

Explanation:

Question 90:

A 75-year-old woman with rheumatoid arthritis and a long history of oral corticosteroid use sustains a comminuted intra-articular distal humerus fracture. What is the best surgical option?

Options:

Open reduction internal fixation (ORIF) with parallel plates
ORIF with orthogonal plates and iliac crest bone grafting
Total elbow arthroplasty (TEA)
Closed reduction and percutaneous pinning

Correct Answer: Total elbow arthroplasty (TEA)

Explanation:

Question 91:

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

Options:

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

Correct Answer: lower level of functional return.

Explanation:

Question 92:

When compared with reamed intramedullary nailing for an unstable diaphyseal tibia fracture, unreamed nailing is associated with which of the following?

Options:

Longer surgical times
Higher infection rates
Lower functional outcome scores
Similar union rates in open fractures
Higher incidence of pulmonary complications

Correct Answer: Similar union rates in open fractures

Explanation:

Question 93:

- What is the most common sequela of turf toe (hyperextension of the first metatarsophalangeal joint)?

Options:

Hallux rigidus
Hallux valgus
Neuroma of the first web space
Fracture of the sesamoid
Rupture of the flexor hallucis longus

Correct Answer: Hallux rigidus

Explanation:

Question 94:

The so-called high ankle sprain from an external rotation mechanism of injury typically involves injury to which of the following structures?

Options:

Posterior talofibular ligament
Deltoid ligament
Anterior inferior tibiofibular ligament
Calcaneofibular ligament
Extensor retinaculum

Correct Answer: Anterior inferior tibiofibular ligament

Explanation:

Question 95:

Which of the following changes is seen with age and degeneration in the intervertebral disk? Review Topic

Options:

Increased number of blood vessels in the outer annulus fibrosus
Increased number of notochordal cells in the nucleus pulposus
Increase of diffusion gradient between the annulus fibrosus and the nucleus pulposus
Decreased type 1 collagen
Decreased water content of the nucleus pulposus

Correct Answer: Decreased water content of the nucleus pulposus

Explanation:

Question 96:

Options:

Triple arthrodesis
Isolated flexor digitorum longus transfer
Flexor digitorum longus transfer with medial displacement calcaneal osteotomy
Debridement and direct repair of the posterior tibial tendon
Repair of the spring ligament

Correct Answer: Flexor digitorum longus transfer with medial displacement calcaneal osteotomy

Explanation:

Question 97:

Options:

have no difference in elbow pain.
no longer have elbow pain.
need surgery.
experience tendon rupture.

Correct Answer: have no difference in elbow pain.

Explanation:

Question 98:

Options:

– a long arm cast
– closed reduction in the emergency dept and a long arm cast
– closed reduction under general anesthesia and a long arm cast
– closed reduction and percutaneous pin fixation
– open reduction and internal fixation back answer Question 198.03

Correct Answer: – open reduction and internal fixation back answer Question 198.03

Explanation:

Question 99:

Which of the following is considered the best cementless acetabular reconstruction method when planning for total hip arthroplasty in a patient with developmental dysplasia of the hip (DDH)?

Options:

Cemented reconstruction with the cup in an anatomic position and cement filling the defect
Medialized component positioning with no femoral head graft, leaving up to 20% of the shell uncovered
High and lateral positioning of the acetabular component with a femoral head graft
Anatomic positioning of a small shell with a 28-mm liner and 4 mm of polyethylene
Anatomic positioning of the cup and a femoral head graft covering 70% of the cup

Correct Answer: Medialized component positioning with no femoral head graft, leaving up to 20% of the shell uncovered

Explanation:

Question 100:

- Figures 42a and 42b show the sagittal and axial MRI scans of a 24-year-old patient who has sciatia. Which of the following combinations of physical findings is most consistent wit the MRI studies?

Options:

Decreased ankle jerk and positive femoral nerve stretch test
Decreased knee jerk and positive straight-leg raising sign
Gastrocnemius-soleus complex weakness and positive straight-leg raising sign
Weakness of the extensor hallucis longus and positive straight-leg raising sign
Weakness of the extensor hallucis longus and positive femoral nerve stretch test

Correct Answer: Gastrocnemius-soleus complex weakness and positive straight-leg raising sign

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

OITE & ABOS Orthopedic Board Prep MCQs: Arthroscopy, Trauma, Hip | Part 50

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 50

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index