OITE & ABOS Orthopedic MCQ Exam: Arthroplasty, Trauma & Sports Medicine - Part 52

An otherwise healthy 25-year-old man underwent a right anterior cruciate ligament reconstruction with a bone-patellar tendon-bone allograft. Routine preimplantation cultures of the allograft taken by the surgeon were positive for coagulase-negative Staphylococcus 5 days postoperatively. The patient has exhibited no evidence of clinical infection and his postoperative course has been uncomplicated during this time. What is the ideal management of this patient?

A 72-year-old woman falls onto her left hip after tripping over a curb during her daily 3-mile walk. An injury radiograph is shown in Figure A. What is the best long term solution?

Following an episode of transient quadriplegia in contact sports, an athlete’s return to play is absolutely contraindicated when

Which of the following treatment regimens for thromboembolic prophylaxis meets the American College of Chest Physicians Guidelines for 10-day treatment after total hip arthroplasty and total knee arthroplasty?

What is the incidence and significance of anterior cruciate ligament laxity following tibial eminence fractures in skeletally immature individuals?

What is the neoplastic cell of origin for this tumor?

A 29-year-old female has sustained the acute injury shown in Figure A. Which of the following is an indication for open reduction internal fixation in this patient?

-Figures 3a and 3b are the clinical photographs of a 35-year-old man seen 3 months after repair of an acute Achilles tendon rupture. He has no constitutional symptoms and is unable to perform a single heelrise test. The most appropriate treatment is

Which of the following radiographic findings indicates that the injury to the great toe shown in Figures 60a and 60b should be reducible by closed manipulation?

Closure of the rotator cuff interval results in elimination of which direction of shoulder instability?

What is the main benefit of using metal-backed tibial components in total knee arthroplasty?

A 64-year-old man who underwent an L4-5 decompression approximately 1 year ago reported relief of his claudicatory leg pain initially, but he now has increasing low back pain and recurrent neurogenic claudication despite nonsurgical management. Radiographs show new asymmetric collapse and spondylolisthesis at the decompressed segment, and MRI scans show lateral recess stenosis. The next most appropriate step in management should consist of

A 19-year-old running back lands directly on his anterior knee after being tackled. He has mild anterior knee pain, a trace effusion, a 2+ posterior drawer, a grade 1+ stable Lachman, no valgus laxity, and negative dial tests at 30° and 90°. What is the best treatment strategy at this time?

A 22-year-old volleyball player has atrophy of the infraspinatus muscle. This deficit is the result of entrapment of what nerve?

A patient with a below-the-knee amputation is being evaluated for a new prosthesis. He wants to improve his ability to walk on uneven surfaces. What modification to the prosthesis can be made to accommodate this request?

A Trendelenburg gait is most likely to be seen in association with

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

Figures below show the radiographs, and the CT obtained from a 58-year-old woman who underwent cementless left total hip arthroplasty. Nine months after surgery, she continued to have groin pain when actively flexing her hip. She has trouble walking up stairs and getting out of her car. What is the most likely diagnosis?

A 45-year-old previously healthy woman has experienced weakness and fatigability for 2 months. She states she feels best in the morning, but tires easily with exertion. If she sits and rests her strength improves, but she easily tires with each activity. When her fatigue is most severe, she has double vision. Physical examination is positive for ptosis with upward gaze after 20 seconds. When she holds her arms out straight she shows good initial strength, but rapidly decreasing strength with time. What is the pathologic cause of her muscle weakness? Review Topic

Figures 4a and 4b show the radiographs of a 53-year-old woman who was injured in a fall. After initial closed reduction, what is the preferred treatment for this fracture?

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

All of the following have been shown to negatively affect clinical outcomes in treating displaced acetabular fractures, EXCEPT:

Which of the following has been associated with a decreased rate of glenoid component radiolucent lines?

A 29-year-old woman reports shoulder pain after sustaining a minor fall 6 weeks ago. She has a history of celiac sprue. Radiographs of the forearm and shoulder are shown in Figures 53a and 53b. Which of the following serum abnormalities would be expected?

When performing a bunionectomy with a release of the lateral soft-tissue structures, the surgeon is cautioned against releasing the conjoined tendon that inserts along the lateral base of the proximal phalanx of the great toe. This conjoined tendon is made up of what two muscles?

Figures 31a and 31b are the radiographs of a 5-year-old boy with an elbow injury.

A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with Review Topic

-Six weeks later the boy remains uncomfortable and continues to use crutches for all ambulation. What do the new radiographs seen in Figures 78a and 78b reveal?

An 18-year-old high school football player sustains a thigh injury that results in the findings shown in Figure 1. Initial management should consist of

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

Figure 38 shows the radiograph of a 75-year-old woman who has had right shoulder pain, difficulty sleeping on the affected arm, and difficulties performing activities of daily living for the past 6 weeks. Initial nonsurgical management includes analgesics, a subacromial cortisone injection, and gentle range-of-motion exercises. However, these modalities have failed to provide relief, and the patient reports that she is unable to elevate her arm. Her pain is worse and she would like the most reliable treatment method for pain relief and functional improvement. What is the best surgical treatment?

A 67-year-old female presents with shoulder pain for 3 months after falling down stairs. Imaging demonstrates a large rotator cuff tear involving multiple tendons. You perform an arthroscopic rotator cuff repair and biceps tenodesis. At her 2 month follow up, she reports worsening shoulder pain and decreased range of motion. Examination reveals active forward flexion to 80°. Passive range of motion is full. There is a positive external rotation lag sign. An MRI is performed and is pictured in Figure A. Which is the best treatment for this patient? Review Topic

In a patient with a major head injury and a femoral shaft fracture, intraoperative hypotension during femoral fixation has been associated with which of the following?

A 67-year-old man who underwent humeral head arthroplasty for a four-part fracture 6 months ago reports that he is still unable to actively elevate his arm. Rehabilitation after surgery consisted of a sling with passive range-of-motion exercises for 2 weeks and then progressed to active-assisted and strengthening exercises at 3 weeks. Radiographs are shown in Figures 28a and 28b. What is the primary cause of his inability to elevate the arm?

A 66-year-old woman was a restrained passenger in an automobile accident. She sustained a direct blow to her nondominant left hand as the airbag in her automobile deployed and she now reports pain, swelling, and difficulty moving her fingers. Radiographs are shown in Figures 58a and 58b. Appropriate definitive treatment should consist of

Figures below show the radiographs obtained from an 86-year-old-woman who has had chronic left hip pain for several years. She now uses a walker and a wheelchair for ambulation. She is medically healthy. What is the most appropriate surgical intervention?

A patient has pain 2 years after undergoing a metal-on-metal (MOM) left total hip arthroplasty (THA). Which test(s) best correlate with prognosis in the setting of reaction to metal debris?

A 17-year-old football player is injured during a play and reports abdominal pain that is soon followed by nausea and vomiting. What organ has most likely been injured?

Acral metastases are most commonly seen in what type of carcinoma?

Which of the following best describes heat stroke? Review Topic

A 54-year-old woman undergoes an interposition arthroplasty that fails and requires conversion to a total elbow arthroplasty. She has progressive elbow pain and radiographic loosening. Erythrocyte sedimentation rate and C-reactive protein are normal. Joint aspiration is positive for Staphylococcus epidermidis. What surgical treatment would best optimize function and decrease risk of recurrence?

An 18-year-old girl with quadriplegic cerebral palsy underwent posterior spinal fusion from T2 to the pelvis 3 weeks ago. She now has a low-grade fever and mild midline erythema in a 1-cm area from which there is slight clear yellowish drainage. What is the next most appropriate step in management?

What is the best initial screening test for a patient with a limb-length discrepancy?

A 7-year-old boy sustained a head contusion and small bowel injuries in a motor vehicle accident in which he was wearing a lap belt. He subsequently required a bowel resection. Six weeks after the accident, his parents note a painful mass in his lower back. His neurologic examination is normal. A radiograph and CT scans are shown in Figures 47a through 47c. Definitive management should now consist of

Following spinal cord injury (SCI), methylprednisolone (a bolus of 30 mg/kg plus 5.4 mg/kg per hour over 24 hours) initiated within 8 hours of injury has been associated with which of the following MRI findings? Review Topic

.A patient is unable to actively externally rotate the shoulder when the arm is placed into 90 degrees of abduction and neutral rotation. This finding is most consistent with a tear of the

Which structure(s) is/are most at risk with surgical treatment of displaced clavicle fractures with ORIF?

A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals no other injuries. Radiographs are shown in Figures 35a and 35b. Initial management of this fracture should consist of

In addition to the radiographic features seen in Figures 49a and 49b, this patient will most likely have which of the following findings?

What is the best approach to reduce and stabilize a displaced volar lunate facet fracture of the wrist?

A 26-year-old man with chronic lateral ankle instability underwent a modified Broström procedure 8 months ago. He reports persistent pain and swelling of the lateral ankle. Examination reveals lateral ankle tenderness and swelling and a negative anterior drawer test. Laboratory studies show a WBC count of 6,500/mm 3 and an erythrocyte sedimentation rate of 15 mm/h. Radiographs of the ankle are normal. What is the most likely cause of this problem?

Figures 1 and 2 are the radiographs of a 35-year-old right-hand-dominant man who has had progressive right wrist pain for 1 year. There is no history of trauma, and he has had no treatment to date. He reports some pain at rest with limited motion and substantial pain with use. He is currently out of work on short-term disability because of this wrist problem. An examination reveals mild dorsal wrist swelling, decrease wrist range of motion, and decreased grip strength. Contralateral wrist examination findings are normal. What is the most appropriate course of treatment?

Plate fixation of olecranon fractures is recommended over tension band wire fixation when

A metal-on-metal bearing used for total hip arthroplasty shows which of the following properties?

A 58-year-old man has had increasing midback pain for 8 weeks. Radiographs reveal mild osteopenia and mild disk degeneration but no fractures or lesions. An MRI of the spine reveals diskitis with a small-intensity signal within the spinal canal that is consistent with an epidural abscess at T11-12. The patient is neurologically intact but in significant pain. CT-guided biopsy of the disk space is positive for methicillin-sensitive Staphylococcus aureus. What is the most appropriate treatment?

Figure 36a shows the current radiograph of a 65-year-old woman who slipped and fell. History reveals that prior to the fall she was actively functioning without pain. Figure 36b shows a radiograph obtained 1 year ago. Based on the fracture pattern, the failure is most likely related to

A 44-year-old man sustains the injury shown in Figures 1 through 3. What is the most appropriate treatment?

Figures  below  show  the  radiographs  obtained  from  a  19-year-old  woman  with  a  3-year  history  of progressive hip pain in the left groin with activity, which is unresponsive to activity modification and physical therapy. Examination reveals normal range of motion, with pain on anterior impingement testing. What treatment is associated with the best long-term results?

In patients with displaced radial neck fractures treated with open reduction and internal fixation with a plate and screws, the plate must be limited to what surface of the radius to avoid impingement on the proximal ulna?

A 28-year-old man sustained a shoulder dislocation 2 years ago. It remained dislocated for 3 weeks and required an open reduction. He now reports constant pain and has only 60 degrees of forward elevation and 10 degrees of external rotation. He desires to return to some sporting activities. An AP radiograph and intraoperative photograph (a view of the humeral head through a deltopectoral approach) are shown in Figures 31a and 31b. What is the best treatment option to decrease pain and improve function?

Figures below demonstrate the radiographs obtained from a 56-year-old man with a 3-year history of right groin pain. A comprehensive nonsurgical program has failed, and the patient would like to proceed with total hip arthroplasty. He is seen by a pain management specialist and is currently taking 40 mg of sustained-release morphine twice daily with oxycodone 10 mg 2 to 3 times a day for severe pain. What is the recommended course of action regarding his chronic narcotic use?

When compared to smokers who do not quit, an improvement in the rate of lumbar fusion is seen in patients who cease smoking for at least how many months postoperatively?

A 19-year-old wrestler has numbness along the radial aspect of the forearm after undergoing an open Bankart repair through an anterior deltopectoral approach. Motor weakness would be expected along with what other finding?

When planning pin placement for external fixation of the tibia, what is the maximum extent of the knee capsular reflection from the subchondral joint line?

What is the main biologic effect of aggrecan in cartilage? Review Topic

A 66-year-old female presents to your clinic complaining of back pain, difficulty standing-up straight, weakness in her legs, and neurogenic claudication. On upright thoracolumbar radiographs, there is a 75 degree thoracolumbar curve with the apex at L2, and the C7 plumb line falls 12 cm anterior to the posterosuperior corner of S1. Aside from a decompression of the stenotic levels, which of the following choices will lead to the MOST reliable decrease in overall disability? Review Topic

A radiograph of a 12-year-old boy who has had an insidious onset of pain in the right hip for the past 6 weeks shows diffuse narrowing of the joint space. Examination reveals that he is afrebile, and the range of motion of the hip is less than 50% of normal in all planes. Laboratory studies show an erythrocyte sedimentation rate of 21 mm/hr and a WBC of 11,000/mm3. What is the most likely diagnosis?

A 68-year-old woman undergoes a complicated four-level anterior cervical diskectomy and fusion at C3-7 with iliac crest bone graft and instrumentation for multilevel cervical stenosis. Surgical time was approximately 6 hours and estimated blood loss was 800 mL. Neuromonitoring was stable throughout the procedure. The patient’s history is significant for smoking. The most immediate appropriate postoperative management for this patient should include

Patient outcomes can be improved and early post-injury management errors decreased by adhering to the Advanced Trauma Life Support (ATLS) protocol. This protocol includes criteria for inter-hospital transfer when the patient's needs exceed the resources available. Which of the following would it be acceptable to manage without interfacility transfer to a trauma center?

Figure 37 shows the T2-weighted MRI scan of the hip joint. What structure is labeled A?

A 67-year-old woman has a painful, arthritic proximal interphalangeal (PIP) joint, and nonsurgical measures have failed to improve the pain. What implant and joint replacement approach combination has been demonstrated to have the lowest rate of revision surgery?

What percentage of bone weight is collagen?

Figures below depict the radiographs obtained from a 76-year-old woman with a painful total knee arthroplasty. She describes an uneventful recovery with no wound-healing issues and was pain free for the first 10 years. Although reporting no trauma or inciting event, she now describes pain in the entire knee that is most severe with her first few steps. She has begun to notice night pain and, more recently, constant swelling. What is the most appropriate work-up at this time?

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

The primary purpose of obtaining the radiograph shown in Figure 9 is to assess

Figures 9a and 9b show the radiographs of a 75-year-old man who underwent a revision total knee arthroplasty with a long-stemmed tibial component. In rehabilitation, he reports fullness and tenderness in the proximal medial leg (at the knee). The strategy that would best limit this postoperative problem is use of

Chondrosarcoma The plain radiographs show a purely lytic destructive lesion that is poorly marginated. The technetium bone scan does not show any major uptake. The computerized tomography scan shows purely lytic bone destruction with breakthrough of the cortical bone. Complete destruction of the cortical bone is suggestive of a malignancy. The magnetic resonance image shows a lesion that is homogenously low on T1-weighted images and high on T2-weighted images. Surgeons cannot make a definitive diagnosis based upon the radiographic features. The most common malignancies in this age group are:

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

Figure 24 shows the arthroscopic view of a patient with ankle impingement syndrome. This is commonly seen after high ankle sprains and represents fibrotic granulation thickening of what structure?

Figure 21 shows the tomogram of a 26-year-old woman who sustained an axial load injury to her neck in a fall off a horse. What ligament is injured?

A 13-year-old girl injures her ankle playing soccer. Radiographs reveal a displaced Tillaux fracture. CT scans are shown in Figure 25. What is the most important consideration for appropriate management?

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

A 35-year-old man has a brachial plexus injury affecting the lateral cord. He partially improves with observation and now has complete return of median nerve function and pectoral muscle function. What nerve transfer is most likely to restore the motor function he is lacking?

Which of the following factors has the greatest effect on the pull-out strength of a lumbar pedicle screw?

Figures below show the radiographs, and the MRIs obtained from a 32-year-old man with worsening left knee  pain.  A  3-foot  hip-to-ankle  radiograph  shows  a  13-degree  varus  knee  deformity.  The  patient sustained a major left knee injury 5 years ago and a confirmed complete anterior cruciate ligament (ACL) tear. He managed this injury nonsurgically with a functional brace but experienced worsening pain. He was seen by an orthopaedic surgeon 18 months ago, and a medial meniscus tear was diagnosed; the tear was treated with an arthroscopic partial medial meniscectomy. Since then, his knee has been giving way more often, and he no longer feels safe working on a pitched roof. The patient received 6 months of formal physical therapy and was fitted for a new functional ACL brace, but he still has pain and instability. He believes he has exhausted his nonsurgical options and would like to undergo surgery. What is the most appropriate treatment at this time?

A 14-year-old girl with a right thoracic curve from T4 through L2 measuring 78 degrees is scheduled to undergo posterior spinal fusion for scoliosis. The surgical plan is to fuse from T3 through L2, using pedicle screws at L2 and about the apex at T8. What neural monitoring modality is most likely to identify a reversible neurologic deficit during surgery?

A 17-year-old boy is shot in the left side of the neck at the C5-6 level and sustains an incomplete spinal cord injury that is called a Brown-Sequard syndrome. Which of the following best describes the expected deficits? Review Topic

A 66-year-old man who underwent shoulder arthroplasty 7 years ago reports progressively worsening shoulder pain for the past 4 weeks after hospital discharge for community-acquired pneumonia. He is afebrile and reports no chills or night sweats. Laboratory studies show a white blood cell count of 11,200/mm3 and an erythrocyte sedimentation rate of 25/h. Shoulder radiographs are negative for fracture, dislocation, or signs of implant loosening. What is the most appropriate management? Review Topic

When balancing gaps in the coronal plane, what structure preferentially impacts the flexion space more than the extension space?

Baseball pitchers who have internal impingement will most likely demonstrate what changes in range of motion?

A 13-year-old girl has had increasing left hip pain for the past 4 months. A radiograph, bone scan, MRI scan, and photomicrograph are shown in Figures 1a through 1d. Which of the following immunohistochemistry results would confirm the most likely diagnosis?

Which of the following factors are considered prognostic of survival in patients with soft-tissue sarcomas?

.Figures 59a and 59b are the axial T2 and T1 with contrast MRI scans of a 32-year-old woman who has a 10-year history of pain and a 1-year history of progressive swelling in her right leg. The histopathology is shown in Figure 59c. A radiograph of her leg showed no mineralizations or osseous erosions. The chromosomal abnormality that is associated with this disease is

A 65-year-old woman sustained an axial load on the arm followed by an abduction injury after falling on ice. Treatment in the emergency department consisted of reduction of an anterior dislocation. She now has a positive drop arm sign and a positive lift-off test. An MRI scan is shown in Figure 9. Based on these findings, management should consist of

Which of the following amputations will lead to the greatest oxygen requirement per meter walked following prosthesis fitting?

• Which of the following factors is used to determine torsional rigidity of a long bone fracture under internal or external fixation?

What mechanism is most likely responsible for the initiation of mechanical failure seen at the midstem modular junction of modular revision hip stems?

A 27-year-old woman with Down syndrome has a severe bunion with pain and deformity in the left forefoot. Nonsurgical management has failed to provide relief. She does not use any assistive ambulatory devices. A radiograph is shown in Figure 21. Treatment should now consist of

Figure 7 shows the MRI scan of a 23-year-old competitive rugby player who has anterior ankle pain and swelling. He states that he has been playing for many years and has sprained his ankle several times. Examination will reveal what specific hallmark feature?

Following insertion of a cementless femoral component into the total hip arthroplasty construct, the amount of femoral stress shielding is most associated with