Orthopedic MCQs: Arthroplasty, Deformity & Shoulder

About This Board Review Set

This is Part 58 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.
Exam Mode — All feedback is hidden until you click Submit & See Results. A live timer tracks elapsed time. A percentage score and detailed breakdown are displayed upon submission.

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 58

This module focuses heavily on: Arthroplasty, Deformity, Shoulder.

Sample Questions from This Set

Sample Question 1: Figure 39 shows the radiograph of a 4-month old infant who has been undergoing weekly casting since birth for a congenital equinovarus deformity. Management should now consist of...

Sample Question 2: A 72-year-old woman with diabetes mellitus who underwent a total shoulder arthroplasty for degenerative arthritis 5 years ago now reports the sudden onset of shoulder pain following recent hospitalization for pneumonia. Laboratory values sh...

Sample Question 3: A 66-year-old man has a high-grade angiosarcoma of the right tibia. A radiograph is shown in Figure 43. Treatment should consist of...

Sample Question 4: What condition favors pollicization in hypoplasia of the thumb?...

Sample Question 5: -A 15-year-old dancer who has had brief episodes of back pain over the past 2 years now reports a 3 month history of low back pain and a decreased tolerance for dance. Figure 22a-c show flexion and extension x-rays and CT scan. She reports ...

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

00:00

Start Quiz

Question 1

Figure 39 shows the radiograph of a 4-month old infant who has been undergoing weekly casting since birth for a congenital equinovarus deformity. Management should now consist of

Explanation

DISCUSSION: The radiograph shows the development of a rocker-bottom foot deformity. A rocker-bottom foot occurs in the treatment of clubfoot when casting is continued in the presence of a very tight gastrocnemius-soleus complex and an uncorrected hindfoot. While there are some preliminary reports on using Botox injection and continued casting for the equinus deformity, most authors recommend posterior or posterior medial release. Percutaneous tenotomy has been recently recommended with the resurgence of the Ponsetti technique.
REFERENCES: Lehman WB, Atar D: Complications in the management of talipes equinovarus, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992,

pp 135-136.
Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002,

pp 927-935.
Tachdjian MO: Pediatric Orthopedics, ed 2. Philadelphia, PA, WB Saunders, 1990,

pp 2461-2564.

Question 2

A 72-year-old woman with diabetes mellitus who underwent a total shoulder arthroplasty for degenerative arthritis 5 years ago now reports the sudden onset of shoulder pain following recent hospitalization for pneumonia. Laboratory values show a WBC count of 11,400/mm3 and an erythrocyte sedimentation rate of 52mm/h. What is the most appropriate action?

Explanation

DISCUSSION: The patient has the preliminary diagnosis of an infected shoulder arthroplasty; therefore, shoulder radiographs and joint aspiration for organism identification should be the first steps in the work-up. The patient is at risk for hematogenous spread given the recent history of pneumonia and her history of diabetes mellitus. Although she has stiffness, a stretching program is not indicated with the possibility of infection. Scheduling for revision arthroplasty, or irrigation and debridement will depend on multiple factors including identification of the infecting organism, the organism’s susceptibility to antibiotics, and implant stability. An MRI scan to evaluate for a rotator cuff tear is not indicated at this time.
REFERENCES: Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 953-954.
Stinchfield FE, Bigliani LU, Neu HC, et al: Late hematogenous infection of total joint replacement. J Bone Joint Surg Am 1980;62:1345-1350.

Question 3

A 66-year-old man has a high-grade angiosarcoma of the right tibia. A radiograph is shown in Figure 43. Treatment should consist of

Explanation

DISCUSSION: Angiosarcoma is a locally aggressive sarcoma. The radiograph shows extensive multiple discontinuous lesions throughout the entire tibia. The extent of bone involvement precludes resection; therefore, the treatment of choice is amputation, either above the knee or through the knee. Radiation therapy is not needed after amputation, and chemotherapy remains investigational for soft-tissue sarcoma.
REFERENCE: Simon MA, Springfield DA: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott-Raven, 1998, ch 29.

Question 4

What condition favors pollicization in hypoplasia of the thumb?

Explanation

DISCUSSION
The decision to ablate and pollicize vs preserve and reconstruct is based on the stability of the carpometacarpal joint. A stable thumb is more easily used in prehension activities of grasping and pinching. All other responses are associated with surgical options for reconstruction of the thumb. The carpometacarpal joint is the “keystone” for thumb-to-hand attachment. Without a stable carpometacarpal joint, pollicization may be required. No other response necessitates pollicization.
RECOMMENDED READINGS
McCarroll HR. Congenital anomalies: a 25-year overview. J Hand Surg Am. 2000 Nov;25(6):1007-37. Review. PubMed PMID: 11119659. View Abstract at PubMed
Manske PR, Goldfarb CA. Congenital failure of formation of the upper limb. Hand Clin. 2009 May;25(2):157-70. doi: 10.1016/j.hcl.2008.10.005. Review. PubMed PMID: 19380058.View Abstract at PubMed

Question 5

A 15-year-old dancer who has had brief episodes of back pain over the past 2 years now reports a 3 month history of low back pain and a decreased tolerance for dance. Figure 22a-c show flexion and extension x-rays and CT scan. She reports no leg pain, nor any bowel or bladder difficulties. Management should now consist of

Explanation

rays show a Grade I spondylolisthesis. Studies have shown that pts with grade 3 or 4 spondylolisthesis had a minimal success (8%) with nonoperative treatment, whereas pts with grade 1 or 2 spondylolisthesis had significant relief of pain. Conservative tx included rest, NSAIDs, abdominal strengthening exercises, hamstring stretching exercises, or traction.

Question 6

A 22-year-old female collegiate javelin thrower has shoulder pain. She notes that her pain is primarily located in the posterior aspect of her shoulder, is exacerbated with throwing, and she experiences maximal tenderness in the extreme cocking phase of the throwing cycle. On examination, she reports deep posterior shoulder pain when the arm is abducted 90 degrees and maximally externally rotated to 110 degrees. This reproduces her symptoms precisely. Shoulder radiographs are normal. What is the most likely diagnosis? Review Topic

Explanation

The patient has internal impingement. Internal impingement is commonly seen in overhead throwing athletes. When positioned in the extreme cocking phase of the throwing cycle, the posterior glenoid impacts the articular surface of the infraspinatus and posterior fibers of the supraspinatus tendon. This impact can cause partial-thickness rotator cuff tearing and posterosuperior labral lesions. She has no evidence of anterior shoulder instability, and her range of motion is excellent which rules out adhesive capsulitis. Subacromial impingement is identified with anterolateral shoulder pain with internal rotation in the abducted position. A full-thickness rotator cuff tear in a 22-year-old individual would require significant trauma and would likely result in pain at rest and with lifting.

Question 7

A 42-year-old woman underwent an instrumented posterior spinal fusion at L3-S1 with transforaminal lumbar interbody fusion. She had an excellent

Explanation

The MRI scans reveal a postoperative infection. Observation and antibiotics are not appropriate choices. There is a large fluid collection and this requires decompression because the patient has neurologic changes. There is considerable debate regarding the removal of hardware. Many contend that biofilm on the implants can harbor the infection. However, these complications usually can be treated with serial irrigations, debridements, and IV antibiotics. The incidence of infection has been widely studied with varying rates in fusions with instrumentation. Rates appear to be increased with instrumentation, yet these infections usually can be managed without hardware removal.

Question 8

Figures 25a through 25c show the radiographs, including a stress radiograph, of a 58-year-old woman who twisted her ankle on a step. She has no history of diabetes or vascular disease. Examination reveals a closed injury with moderate swelling about the ankle. Her neurologic examination is normal. She has a strong dorsalis pedis pulse and tenderness over the lateral malleolus and the medial side of her ankle. What is the most appropriate management? Review Topic

Explanation

The patient has a lateral malleolus fracture with an ankle mortise that is stable to a stress examination; therefore, surgical treatment is not indicated. In a stable lateral malleolus fracture, strict non-weight-bearing is not necessary, and a removable walking boot or walking cast can be used along with progressive weight bearing. The presence of tenderness or swelling medially at the ankle has been shown to be a poor indicator of medial-sided injury. The clinical utility of MRI scans in ankle fractures is controversial. Studies have used MRI scans to evaluate the competence of the deltoid ligament and have shown that the ligament may remain intact even with an increased medial clear space on a stress examination. In the patient, the stress examination does not show talar subluxation so the deltoid ligament is not incompetent.

Question 9

An otherwise healthy 25-year-old man sustained a wound with a 1-cm by 1.5-cm soft-tissue loss over the volar aspect of the middle phalanx of his middle finger. After appropriate debridement and irrigation, the flexor digitorum profundus tendon and neurovascular bundles are visible. The wound should be treated with a

Explanation

DISCUSSION: The wound described indicates loss of soft tissue directly to the level of the tendon, precluding use of skin grafts if excursion of the tendon is desired. A cross-finger

flap is ideal for small wounds on the volar aspect of digits. A thenar flap is suitable for tip injuries. A lateral arm flap will not reach the fingers. A Moberg flap is limited to distal injuries of the thumb.

REFERENCES: Kappel DA, Burech JG: The cross-finger flap: An established reconstructive procedure. Hand Clin 1985;1:677-683.
Lister GD: Skin flaps, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1741.

Question 10

A 54-year-old woman underwent prophylactic intramedullary fixation for an impending fracture of her right femur secondary to metastatic breast cancer. A bone scan revealed a second lesion in her inferior pubic ramus. Her oncologist has recommended that she receive the intravenous bisphosphonate, zoledronic acid, because the medication would

Explanation

DISCUSSION: Bisphosphonates have been reported to reduce the incidence of new osseous lesions and prevent an increase in size of existing lesions. Zoledronic acid has been reported in clinical trials to decrease the skeletal complications of patients with multiple myeloma and with bone metastases from solid tumors. Results also have demonstrated that zoledronic acid delays the initial onset of bone complications by more than 2 months in patients with non-small-cell lung cancer and other solid tumors. In two placebo-controlled clinical studies of zoledronic acid conducted in patients with bone metastases from prostate cancer or other solid tumors, there was a decrease in the number of patients with skeletal-related events compared to placebo, and the time to the first skeletal-related event was delayed.
REFERENCES: Mundy GR, Yoneda T: Bisphosphonates as anticancer drugs. N Engl J Med 1998;339:398-400.
Rosen LS, Gordon D, Kaminski M, et al: Zoledronic acid versus pamidronate in the treatment of skeletal metastases in patients with breast cancer or osteolytic lesions of multiple myeloma: A phase III, double-blind, comparative trial. Cancer J 2001;7:377-387.

Question 11

1 and 2 show the radiograph and CT obtained from a year-old woman who underwent right total hip replacement in She initially did well with no pain. She was last seen 7 years ago and was having mild hip pain at that time. She was found to have a supra-acetabular cyst on radiographs. She has had severe right hip pain for the past 9 months while using a walker for ambulation. The initial blood work reveals an estimated erythrocyte sedimentation rate of 32 mm/hr, a C-reactive protein level of 5 mg/L, a serum cobalt level of 4 µg/L, and a serum chromium level of 6 µg/L. Right hip aspiration is performed, revealing a white blood cell count of 139, 52% neutrophils, and a negative leukocyte esterase test. What is the best next step?

Explanation

DISCUSSION:
The hip replacement was performed in 1995, during the period when the previous generation of polyethylene was utilized. This polyethylene was subjected to irradiation in air, with subsequent oxidation and consequent osteolysis after implantation. The mechanism of osteolysis begins with the uptake of polyethylene particles by macrophages, which then initiate an inflammatory cascade and the release of osteolytic factors. This cycle continues, with eventual implant loosening and failure. The imaging shows significant osteolysis and raises concern for pelvic discontinuity and acetabular implant failure. The surgical treatment consists of acetabular reconstruction. In this patient, concern exists for discontinuity based on the substantial amount of bone loss and nonsupportive anterior and posterior columns. This scenario requires complex acetabular revision using a custom triflange device, distraction with a jumbo acetabular component, or placement of a porous metal cup/cage construct with augmentation. The laboratory values are not consistent with infection or failure due to metal debris.

Question 12

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

Explanation

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

Question 13

-A 37-year-old woman has a 2-month history of weakness in thumb and finger extension, but has normal radial deviation during extension of the wrist. An MRI scan of her forearm shows no abnormality. She does not recall any traumatic event. Needle electromyography findings show fibrillations and reduced

Explanation

Question 14

A 40-year-old female recreational basketball player notes pain deep within her shoulder that occurs with activity. Pain began insidiously 6 months previously. She has completed a physical therapy program, and an intra-articular corticosteroid injection provided excellent temporary relief. Physical examination shows symmetric range of motion of her shoulder. She has a positive O'Brien’s active compression test. There is no pain with cross-arm adduction or tenderness to palpation over the acromioclavicular joint. Resisted abduction is nonpainful and strong. MRI shows increased signal in the substance of the superior labrum, low-grade bursal surface fraying of the supraspinatus, and mild degenerative changes within the acromioclavicular joint. What is the best treatment option?

Explanation

A 50-year-old man sustained an external rotation traction injury to his right arm. He felt a pop in the anterior aspect of his shoulder associated with immediate pain and swelling. The MRI scan shows a tear of the subscapularis tendon, as shown in Figures 1 and 2. The arrow points to what anatomic structure?

Question 15

Up to what time frame are the risks minimized in anterior revision disk replacement surgery?

Explanation

DISCUSSION: Revision anterior exposure within 2 weeks of total disk replacement incurs relatively little additional morbidity because adhesion formation is minimal. Surgeons should have a low threshold for revising implants that are clearly dangerously malpositioned or show early migration within this 2-week window. Beyond this time period, a revision strategy must be individualized to the particular clinical situation. A posterior fusion with instrumentation with or without a laminectomy is currently the most effective salvage procedure.
REFERENCE: Tortolani JP, McAfee PC, Saiedy S: Failures of lumbar disc replacement. Sem Spine Surg 2006;18:78-86.

Question 16

Which of the following is considered the cause of Milwaukee shoulder, a joint disease similar to rotator cuff arthropathy?

Explanation

DISCUSSION: Neer and associates focused on mechanical and nutritional factors as the etiology of rotator cuff arthropathy. McCarty and associates, in describing a similar syndrome known as Milwaukee shoulder, focused on an inflammatory cause in proposing the pathogenic role of hydroxyapatite, a basic calcium phosphate.
REFERENCES: Neer CS II, Craig EV, Fukuda H: Cuff-tear arthropathy. J Bone Joint Surg Am 1983;65:1232-1244.
McCarty DJ, Halverson PB, Carrera GF, Brewer BJ, Kozin F: Milwaukee shoulder: Association of microspheroids containing hydroxyapatite crystals, active collagenase, and neutral protease with rotator cuff defects. I: Clinical aspects. Arthritis Rheum 1981;24:464-473.

Question 17

Which gene correlates with severity of disease in spinal muscular atrophy (SMA)? Review Topic

Explanation

SMA is caused by a deficiency in SMN protein. Deficiency of SMN protein leads to progressive loss of anterior horn cells and progressive muscle weakness. The severity of disease is directly related to the amount of reduction in circulating levels of SMN proteins, which are encoded by 2 alleles of the SMN1 gene and multiple copies of the SMN2 genes on chromosome 5. Affected patients with all types of SMA will have functional loss of both SMN1 genes, so this does not differentiate disease severity. Disease severity depends on the number of functional copies of SMN2 that remain. Patients with SMA1 have only 1 functioning SMN2 gene, whereas the milder forms, SMA types 2 and 3, have multiple copies that produce higher levels of SMN protein. The other choices are not associated with spinal muscular atrophy. Defects in PMP22 are the cause of 70% to 80% of cases of Charcot-Marie-Tooth disease. Mutations in the dystrophin gene cause Duchenne muscular dystrophy.

Question 18

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

Explanation

DISCUSSION: Plexiform neurofibromas are lesions found in patients with NF1. Clinical reports show the prevalence of plexiform neurofibroma to be 20% to 30% but increases to 40% when imaging studies are routinely obtained. The lesions are characterized by diffuse hypertrophy of the involved nerves but with preservation of the nerves’ fascicular organization. The lesions may involve the dermis or may arise in the deeper structures. Palpation of a dermal lesion provokes an image of a “bag of worms.” Plexiform neurofibromas may cause disfigurement and hyperpigmentation of the overlying skin. The lesions also can cause diffuse hypertrophy of the soft tissue and bone, with resultant changes ranging from a relatively minor limb-length discrepancy to gigantism of the entire extremity. Dural ectasia is frequently found in patients with NF1. Therefore, MRI should be obtained prior to planning spinal procedures in these patients; however, dural ectasia is not the cause of limb overgrowth. Lisch nodules are benign hamartomas of the iris. The lesions are uncommon during early childhood but are found in all adults with NF1. Juvenile xanthogranuloma has a low occurrence rate in patients with NF1; its presence is associated with juvenile chronic myeloid leukemia. Malignant peripheral nerve sheath tumors, formally called neurofibrosarcoma, result from malignant degeneration of a plexiform neurofibroma. This condition occurs in up to 4% of patients with NF1. Localized pain, an enlarging mass, or progressive neurologic symptoms suggest a malignant peripheral nerve sheath tumor in a patient with NF1. However, progressive neurologic symptoms also may occur with benign growth of a plexiform neurofibroma.
REFERENCES: Alman BA, Goldberg MJ: Syndromes of orthopaedic importance, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 287-338.
Greene WB: Neurofibromatosis type I, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1584-1588.

Question 19

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 20

When an acute infection of a total elbow arthroplasty is managed with irrigation and debridement, which of the following organisms is associated with the highest risk of persistent infection?

Explanation

DISCUSSION: Salvage of a total elbow arthroplasty is possible with early aggressive management of acute infection (symptoms for less than 30 days) with serial irrigation and debridement and antibiotic bead placement. This form of treatment is indicated when there are no radiographic or intraoperative signs of loosening. However, successful treatment is largely dependent on the organism. Staphylococcus epidermidis is associated with persistent infection because it is an encapsulating organism, and it is best treated with implant removal and

IV antibiotics.
REFERENCES: Yamaguchi K, Adams RA, Morrey BF: Infection after total elbow arthroplasty. J Bone Joint Surg Am 1998;80:481-491.
Schoifet SD, Morrey BF: Treatment of infection after total knee arthroplasty by debridement with retention of the components. J Bone Joint Surg Am 1990;72:1383-1390.

Question 21

A 39-year-old male with chronic renal disease and type 2 diabetes mellitus fell 1 week ago after slipping on ice. He is unable to bear weight on the right lower extremity or perform active knee extension. He reports no prior history of knee pain or instability. Lachman, posterior drawer, posterolateral recurvatum testing are deferred secondary to patient's pain. He has a palpable dorsalis pedis pulse but does have neuropathy as determined by Semmes-Weinstein filament testing. His radiograph is shown in Figure A and MR images in Figures B and C. What is the most appropriate initial plan for management? Review Topic

Explanation

The clinical presentation, exam, and images are consistent with an acute patellar tendon rupture.
Primary surgical repair within 2 weeks of injury is recommended to prevent extensor mechanism contracture. Patellar tendon ruptures typically occur in patients younger than 40 years old. Most ruptures occur at the junction of the tendon and distal pole of the patella.
Matava et al. presents a level 5 review on patellar tendon ruptures and states that active knee extension is permitted at 3 weeks postoperatively. Non-weightbearing movement exercises like heel slides are encouraged. This can incorporate active knee flexion with passive extension. Alternatively, active knee flexion in the prone position with passive knee extension can be performed. Open chain strengthening exercises such as leg extensions are started later, as are weight bearing resistance exercises like squats, lunges and leg presses.
Volk et al. discuss potential complications and pitfalls of patients with the management of extensor mechanism injuries. They warn that complications can consist of misdiagnosis, delayed surgery, failed repair due to poor surgical planning of injury site, or wound infection.
Figure A demonstrates patella alta which in this case is indicative of complete patellar tendon rupture. Patella alta can be quantified by using the Insall-Salvati ratio (patellar tendon length / patellar bone length): PTL/PBL normal =1, >1.2 is patella alta, <0.8 is patella baja) with the knee flexed to 30 degrees. Figure B and C are sagittal T1 and T2 images showing complete patellar tendon rupture.
Incorrect answers:

Question 22

A 52-year-old woman with a 2-year history of a flexible (stage II) adult-acquired flatfoot deformity has failed to respond to nonsurgical management consisting of immobilization, custom orthotics, nonsteroidal anti-inflammatory drugs, and physical therapy. The patient is unable to perform a single limb heel rise. Weight-bearing radiographs are shown in Figures 30a through 30c. What is the most appropriate surgical correction?

Explanation

DISCUSSION: The patient has an atypical adult flatfoot deformity. The radiographs reveal forefoot abduction, mild loss of calcaneal pitch, and marked plantar flexion sag through the naviculocuneiform joint. The inability to perform a single limb heel rise indicates that the posterior tibial tendon is nonfunctional; however, the deformity remains flexible. In this patient, surgical treatment should include a tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening. Because a substantial portion of the deformity stems from the naviculocuneiform joint in this instance, tendon transfer and lateral column lengthening alone provide insufficient deformity correction. Triple arthrodesis and heel cord lengthening is best reserved for fixed flatfoot deformities. Soft-tissue procedures alone are associated with a high failure rate, as are attempted tendon repairs.
REFERENCES: Greisberg J, Assal M, Hansen ST Jr, et al: Isolated medial column stabilization improves alignment in adult-acquired flatfoot. Clin Orthop Relat Res 2005;435:197-202.
Greisberg J, Hansen ST Jr, Sangeorzan BJ: Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot. Foot Ankle Int 2003;24:530-534.

Question 23

Figure below depicts the radiograph obtained from a 52-year-old woman who has leg-length inequality and chronic, activity-related buttock discomfort. This problem has been lifelong, but it is getting worse and increasingly causing back pain. What is the best current technique for total hip arthroplasty?

Explanation

DISCUSSION:
A high hip center is not recommended for Crowe type IV hips because of the lack of acetabular bone and altered hip biomechanics. An anatomic center is a better option but necessitates a technique to address the tight soft-tissue envelope. A trochanteric osteotomy with progressive femoral shortening has been described but can be prone to trochanter nonunion. Iliofemoral lengthening prior to surgery has been described but may not be tolerated by all patients. A shortening subtrochanteric osteotomy avoids trochanter nonunion and allows adjustment of femoral anteversion. Fixation of the osteotomy can include a stem with distal rotational control, plate fixation, a step versus oblique cut, or strut grafts.

Question 24

Figure 1 is the MR image of a high school soccer player who sustained a right knee injury during a game while making a cut toward the ball. He felt a pop and his leg gave way. During physical examination, as the knee is moved from full extension into flexion with an internal rotation and valgus force, you notice a "clunk" within the knee. What is the most likely biomechanical basis for the "clunk"?

Explanation

This patient sustained an isolated anterior cruciate ligament (ACL) injury based upon the mechanism described and examination findings. The finding that produces the “clunk” is the pivot-shift maneuver, which is positive in a knee with an incompetent ACL. With an ACL-deficient knee in full extension and internal rotation, the lateral tibial plateau subluxates anteriorly. As the knee is flexed, the lateral tibial plateau slides posteriorly into a reduced position, causing an audible clunk. Response D correctly describes the pathomechanics that result in the audible clunk heard during the pivot-shift maneuver. Responses A and B are incorrect because they describe the medial tibial plateau, which is not part of the pathomechanics of the pivot shift. Response C is incorrect because in extension, the lateral tibial plateau is subluxated, not reduced.

Question 25

Type I collagen fibers in peripheral nerves are primarily responsible for which of the following?

Explanation

Type I collagen fibers are most responsible for the tensile strength of a peripheral nerve. Type I collagen is the most abundant collagen of the human body which forms large, eosinophilic fibers known as collagen fibers. It is present in scar tissue, the end product when tissue heals by repair, as well as tendons, ligaments, the endomysium of myofibrils, the organic part of bone, the dermis, the dentin and organ capsules.
The COL1A1 gene produces a component of type I collagen, called the pro-alpha1(I) chain. This chain combines with another pro-alpha1(I) chain and also with a pro-alpha2(I) chain (produced by the COL1A2 gene) to make a molecule of type I procollagen. These triple-stranded, rope-like procollagen molecules must be processed by enzymes outside the cell. Once these molecules are processed, they arrange themselves into long, thin fibrils that cross-link to one another in the spaces around cells. The cross-links result in the formation of very strong mature type I collagen fibers.
Wong et al. provide a review of the basic science behind nerve healing and the recovery after nerve repair. They note the importance of minimizing additional surgical insult and careful handling of nerve tissue during repair to optimize outcomes.
Pertici et al. noted that autologous nerve implantation to bridge a long nerve gap presents the greatest regenerative performance in spite of substantial drawbacks. They were able to show improved nerve guided regrowth with a type I collagen matrix conduit as compared to a conduit made of a mix of type I and type III collagen.
Illustration A shows a diagram of type I collagen, showing the rope-like characteristics behind the tensile strength.
Incorrect Answers:

Question 26

Kinematic testing of patellofemoral motion demonstrates that malalignment that produces increased Q angle causes a shift of the patella laterally in the trochlear groove and is most pronounced during what phase of the flexion arc? Review Topic

Explanation

Dynamic patellofemoral joint contact measurements on cadaveric knees with simulated increased Q angle demonstrated that forces shifted to the lateral facet. The lateral shift in the patella was most pronounced from 40 to 90 degrees of flexion. At lower degrees of flexion, the lateral shift was significantly less. At higher degrees of flexion, the continued shift of the patella was not as pronounced.

Question 27

82 • American Academy of Orthopaedic Surgeons A 12-year-old girl is seen for left ankle pain. Radiographs reveal osteochondritis dissecans (OCD) involving the talus. What should the parents be told regarding management?

Explanation

DISCUSSION: Nonsurgical management of OCD of the talus in skeletally immature individuals frequently results in a fairly rapid decrease in symptoms, but radiographic abnormalities can frequently be found even 6 months after treatment. Spontaneous resolution of this condition is rare. Hyperbaric oxygen treatment has not been shown to be beneficial for this condition. Progression of the condition to the point of requiring ankle fusion is rare.
REFERENCES: Perumal V, Wall E, Babekir N: Juvenile osteochondritis dissecans of the talus. J Pediat Orthop 2007;27:821-825.
Letts M, Davidson D, Ahmer A: Osteochondritis dissecans of the talus in children. J Pediatr Orthop 2003;23:617-625.

Question 28

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

Explanation

DISCUSSION: The CT scans show a fracture of the anterior process of the calcaneus that involves less than 25% of the joint surface with minimal to no displacement. The preferred treatment is external immobilization in either a walking cast or, more typically, a removable cast boot. For larger fractures that involve more than 25% of the articular surface with joint incongruity, open reduction and internal fixation may be indicated. Primary calcaneocuboid joint arthrodesis is not warranted because symptoms are rare in most patients. Delayed excision of the fragment is a late reconstructive option if painful nonunion develops. Percutaneous pin fixation is not indicated beceause there tends to be inherent stability in this fracture.
REFERENCES: Heckman JD: Fractures and dislocations in the foot, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 2267-2405.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.

Question 29

A 14-year-old boy has medial ankle pain, progressive unilateral flatfoot deformity, and pain with most activities of daily living. He denies any recent injury. His parents recall that at age 7 years he sustained an injury that was treated as a sprain. Examination reveals valgus deformity with painless, unrestricted passive motion of the ankle. He has grossly equal limb lengths. A radiograph of the affected ankle is shown in Figure 48a, and the contralateral ankle is shown in Figure 48b. Management should consist of

Explanation

DISCUSSION: Angular deformities of the ankle can occur following physeal injury. While an orthosis may be beneficial, the deformity is at the level of the ankle rather than the hindfoot. An epiphysiodesis or physeal bar resection would not be indicated as the growth plates are closed. Correction of the angular deformity should level the ankle joint and normalize the weight-bearing stresses on the ankle. This is most easily achieved with a closing wedge distal tibial osteotomy with or without concomitant osteotomy of the fibula.
REFERENCES: Thompson DM, Calhoun JH: Advanced techniques in foot and ankle reconstruction. Foot Ankle Clin 2000;5:417-442.
Ting AJ, Tarr RR, Sarmiento A, Wagner K, Resnick C: The role of subtalar motion and ankle contact pressure changes from angular deformities of the tibia. Foot Ankle 1987;7:290-299.
Tarr RR, Resnick CT, Wagner KS, Sarmiento A: Changes in tibiotalar joint contact areas following experimentally induced tibial angular deformities. Clin Orthop 1985;199:72-80.

Question 30

A research study is initiated on 500 patients undergoing total hip arthroplasty. The patients are followed and outcome is assessed according to body mass index (BMI). The effects of BMI on outcome should be reported as which of the following?

Explanation

The study describes an example of a cohort study. Cohort studies follow a group of individuals over time and are optimal for studying the incidence, course, and risk factors of a disease. The effects in a cohort study are frequently reported in terms of relative risk (RR). Odds ratios are used to report effects in a case-control study. Incidence and prevalence rates are descriptors of a given characteristic either developed over time (incidence) or at one given time (prevalence). Confidence intervals are used to convey the significance of findings and are often used in lieu of or in conjunction with P values.

Question 31

They found statistically significant decreases in need for secondary intervention, hardware failure, and infection as well as faster wound healing and faster time to fracture union.

Explanation

OrthoCash 2020
A 32-year-old male is involved in a motor vehicle collision and sustains the injury seen in Figure A. What is the most common urological injury associated with this injury pattern?

Testicular torsion
Posterior urethral tear
Bladder denervation
Testicular rupture
Renal hematoma
The figure shows an anteroposterior pelvic ring injury. The most common urological injury with pelvic ring injuries remains the posterior urethral tear, followed by bladder rupture.
Watnik et al notes lower urinary tract (bladder to end of urethra) injuries in up to 25% of patients with this injury. He reports that when contaminated urine communicates with the anterior arch, the possibility of infection exists, and early repair of bladder disruptions with simultaneous anterior arch plating minimizes this risk.
Routt et al notes that even with simultaneous treatment of these injuries, complications are common (late stricture in 44%, impotence in 16%, delayed incontinence in 20% of females, anterior deep pelvic infection in 4%). Despite this, they report that early urological repairs are easily performed at the time of anterior pelvic open reduction and internal fixation.
OrthoCash 2020
A 26-year-old women, 31-weeks pregnant, presents to the emergency department with the injury shown in Figure A. She states the injury occurred while lifting a heavy vacuum five days ago. She suffers from chronic headaches and sleep disturbances. On inspection, there are multiple dorsal and volar bruising over her wrist and upper arm. She is neurologically intact. After closed reduction and immobilizing the arm, what would be the next best step in management of this patient?

Diagnostic wrist arthroscopy
Urgent MRI wrist
Skeletal survey radiographs
Request a consultation with social worker in the hospital
Urgent open reduction internal fixation Corrent answer: 4
This patient presents with classic features of domestic violence. The most appropriate next step would be consultation with a social worker at the hospital, assess for child and patient safety, and encouraging the patient to seek self-protection.
Factors suggestive of domestic violence in the patient include pregnancy, delayed presentation after injury, inconsistent history, multiple bruises and complaints of chronic headache/sleep disturbances. Victims frequently miss days of work and as a result are at risk for losing their jobs. Victims are also more likely to engage in high-risk behavior with sex, drugs, alcohol, smoking, and eating.
The AAOS published a document outlining the Orthopaedic Surgeon’s responsibilities in domestic and family violence. Musculoskeletal injuries that should raise a suspicion of a problem include (1) Multiple injuries/fractures; (2) Unusual patterns of injury/fracture; (3) Injuries/fractures of varying ages; (4)
Injuries/fractures inconsistent with or disproportional to the history; (5) Multiple injuries treated in different hospital emergency departments or by different providers.
Incorrect Answers:
OrthoCash 2020
A 45-year-old man undergoes open reduction and internal fixation for a comminuted intra-articular humerus fracture . An olecranon osteotomy is performed and subsequently fixed with an intramedullary cancellous screw. Which of the following options in the table shown in Figure A best describes the characteristics of this osteotomy?

Question 32

A patient with Charcot-Marie-Tooth disease has a progressively rigid cavovarus foot deformity. The patient states that the pain is restricted to the forefoot, where rigid claw toe deformities have developed. Which of the following structures is primarily involved in creation of a claw toe deformity?

Explanation

DISCUSSION: Diseases such as Charcot-Marie-Tooth result in spasticity to the extrinsic flexor tendons. This results in hyperflexion of the proximal and distal interphalangeal joints of the involved toe, as well as hyperextension at the metatarsophalangeal joint. The tendon often becomes contracted with progressive equinus of the ankle. Correction of ankle equinus exaggerates the claw toe deformity. The interosseous tendon plays no role in the etiology of a claw toe but may become contracted in later stages of the disease. Laxity of the volar plate may precipitate a claw toe deformity in a nonspastic situation. In patients with a head injury, claw toe deformities are generally the result of overactivity of the extensor tendons.
REFERENCES: Keenan MA, Gorai AP, Smith CW, Garland DE: Intrinsic toe flexion deformity following correction of spastic equinovarus deformity in adults. Foot Ankle 1987;7:333-337.
Pichney GA, Derner R, Lauf E: Digital “V” arthrodesis. J Foot Ankle Surg 1993;32:473-479.
Mizel MS, Michelson JD: Nonsurgical treatment of monarticular nontraumatic synovitis of the second metatarsophalangeal joint. Foot Ankle Int 1997;18:424-426.

Question 33

A 34-year-old woman reports constant midlateral arm pain after sustaining minimal trauma to the shoulder. Radiographs and a biopsy specimen are shown in Figures 29a and 29b. What is the most likely diagnosis?

Explanation

DISCUSSION: Eighty percent of giant cell tumors occur in patients older than age 20 years, with the peak incidence in the third decade of life. Most of these tumors are eccentrically located and epiphyseal in location. They are lytic in nature as in this patient. Although named for the hallmarked multinucleated giant cells seen in the lesion, the basic cell type is the spindle-shaped stromal cell. Chondroblastoma is highly cellular and contains large multinucleated giant cells with intercellular chondroid material, some of which is calcified. Chondromyxoid fibroma has chondroid tissue separated by strands of more cellular tissue with occasional multinucleated giant cells. Desmoplastic fibroma is characterized by poorly cellular fibrous tissue, and lymphoma is highly cellular with characteristic round cells.
REFERENCES: Campanacci M, Baldini N, Boriani S, et al: Giant cell tumor of bone. J Bone Joint Surg Am 1987;69:106-114.
Goldenberg RR, Campbell CJ, Bonfiglio M: Giant cell tumor of bone: An analysis of two hundred and eighteen cases. J Bone Joint Surg Am 1970;52:619-664.

Question 34

During a retroperitoneal approach to the L4-5 disk, what structure must be ligated to safely mobilize the common iliac vessels toward the midline from laterally and gain exposure?

Explanation

DISCUSSION: To mobilize the common iliac vessels across the midline, the iliolumbar vein must be ligated. It has a short trunk and can be torn if mobilization is attempted without ligation. It is the only branch off the common iliacs (there are no arterial branches) prior to the terminal branches, the internal (hypogastric) and external iliacs. The middle sacral vessels run distally from the axilla of the bifurcation and are a factor when accessing the L5-S1 disk.
REFERENCES: Baker JK, Reardon PR, Reardon MJ, et al: Vascular injury in anterior lumbar surgery. Spine 1993;18:2227-2230.
Lewis WH: Gray’s Anatomy of the Human Body: The Veins of the Lower Extremity, Abdomen, and Pelvis, ed 20. Philadelphia, PA, Lea & Febiger, 2000.

Question 35

A 55-year-old man who works as a carpenter reports chronic right anterior shoulder pain and weakness. Examination reveals 90 degrees of external rotation (with the arm at the side) compared to 45 degrees on the left side. His lift-off examination is positive, along with a positive belly press finding. An MRI scan reveals a chronic, retracted atrophied subscapularis tendon. What is the most appropriate management of his shoulder pain and weakness? Review Topic

Explanation

Chronic subscapularis tendon ruptures preclude primary repair. In such instances, subcoracoid pectoralis major tendon transfers may improve function and diminish pain. The subcoracoid position of the transfer allows redirection of the pectoralis major in a direction recreating the vector of the subscapularis tendon. Shoulder fusion is a salvage procedure, and corticosteroid injection may reduce pain but will not improve function.

Question 36

A 61-year-old woman with a long-standing history of rheumatoid arthritis reports progressive elbow pain for the past 12 months. She denies any recent trauma to the elbow; however, she notes increasing pain and decreased joint motion that are now compromising her function. Radiographs are shown in Figures 57a and 57b. What is the most appropriate treatment at this time? Review Topic

Explanation

The patient has end-stage arthritis of the elbow with advanced joint destruction. At this point, nonsurgical management is unlikely to provide much relief of symptoms. Arthroscopic procedures can provide relief, but it is likely to be incomplete and unpredictable. The most reliable surgical option is total elbow arthroplasty. Currently, semiconstrained components are generally preferred because constrained components have been associated with a high rate of early prosthetic loosening.

Question 37

A farmer is seen in the emergency department after falling out of a hay loft onto the barn floor below. He is unable to bear weight. Exploration of a 0.5 cm laceration over the anterior tibia reveals bone. Radiographs reveal oblique displaced midshaft tibial and fibular fractures. Based on these findings, what is the most appropriate antibiotic prophylaxis?

Explanation

DISCUSSION: A farm injury is automatically considered a grade III (Gustillo classification) injury regardless of size, energy, or additional soft-tissue injury due to the likelihood of substantial contamination. Antibiotic recommendations for grade III injuries include a first- or second-generation cephalosporin with an aminoglycoside or fluoroquinolone within 3 hours of injury, with penicillin added for farm injuries.
REFERENCES: Okike K, Bhattacharyya T: Trends in the management of open fractures: A critical analysis. J Bone Joint Surg Am 2006;88:2739-2748.
Holtom PD: Antibiotic prophylaxis: Current recommendations. J Am Acad Orthop Surg 2006:14:S98-S100.

Question 38

A 38-year-old man who is an avid runner reports a several month history of right hip pain. Based on the radiograph and cross-sectional CT scan shown in Figures 33a and 33b, what is the most likely diagnosis for the lesions seen on the femoral neck?

Explanation

DISCUSSION: Synovial herniation pits or Pitt’s pits are tumor simulators and are incidentally identified on radiographs obtained for either pain or trauma. The main diagnostic pitfall with this lesion is mistakenly identifying it as an osteoid osteoma. Accurate diagnosis is achieved by knowledge of the location and the characteristic imaging appearance. These are common lesions in individuals with femoroacetabular impingement.
REFERENCES: Pitt MJ, Graham AR, Shipman JH, et al: Herniation pit of the femoral neck. Am J Roentgenol 1982;138:1115-1121.
Daenen B, Preidler KW, Padmanabhan S, et al: Symptomatic herniation pits of the femoral neck: Anatomic and clinical study. Am J Roentgenol 1997;168:149-153.

Question 39

A 7-year-old boy has had low back pain for the past 3 weeks. Radiographs reveal apparent disk space narrowing at L4-5. The patient is afebrile. Laboratory studies show a WBC count of 9,000/mm P 3 P and a C-reactive protein level of 10 mg/L. A lumbar MRI scan confirms the loss of disk height at L4-5 and reveals a small perivertebral abscess at that level. To achieve the most rapid improvement and to lessen the chances of recurrence, management should consist of

Explanation

DISCUSSION: The patient has diskitis. Administration of IV antibiotics speeds resolution and minimizes recurrence. Bed rest and cast immobilization have been successfully used to treat this disorder but can be associated with prolonged recovery and frequent recurrence, even when oral antibiotics are administered. A perivertebral abscess seen in association with this condition usually resolves without surgery.
REFERENCES: Ring D, Johnston CE II, Wenger DR: Pyogenic infectious spondylitis in children: The convergence of discitis and vertebral osteomyelitis. J Pediatr Orthop

1995;15:652-660.
Crawford AH, Kucharzyk DW, Ruda R, et al: Diskitis in children. Clin Orthop 1991;266:70-79.

Question 40

A 13-year-old boy has a radiographically mild, clinically stable slipped capital femoral epiphysis (SCFE). What is the most appropriate treatment? Review Topic

Explanation

The accepted treatment of a stable SCFE lesion involves fixation of the epiphysis in situ with a single screw that is perpendicular to the epiphysis and central in both the AP and lateral planes. Constructs such as the three-screw inverted triangle configuration have increased rates of penetration of the femoral head as well as femoral head osteonecrosis. Spica casting was once a popular treatment modality but is associated with a high incidence of chondrolysis and is no longer recommended. Closed reduction attempts increase the risk of osteonecrosis.
(SBQ13PE.46) What developmental milestones are likely to be present in a 30-month-old child? Review Topic
Hand dominance established
Hops on one foot
Heel-to-toe walk
Puts shoes on correct feet
Manages buttons
Hand dominance is usually established in the third year of life.
Normally, children younger than 2 years of age are ambidextrous. In some normal cases this persists after 2 years. Although there is some variability in this timing, strong hand preference in a younger child may be the result of a neurologic deficit.
Frankenburg et al. used the Denver Developmental Screening Test (DDST) to evaluate 1036 Denver area children from 2 to 6.4 years. The ages at which 25, 50, 75 and 90 percent of children could perform tasks were calculated to establish norms for the sample. The authors stress that the DDST is not an intelligence test, but rather a screening test to be used in clinical practice to determine whether a child's development is within the normal range.
Illustration
A
shows
the
DDST.
Incorrect
2:
Normal
for

Question 41

Work-related injuries to the lower back are most often related to which of the following risk factors?

Explanation

The strongest variable for predicting subsequent low back pain is current or prior low back pain, defined at time loss for back pain during the previous 6 months or at the time of initial examination; relative risk 60%. Smoking was associated with a 40% increased risk of reporting back pain.

Question 42

A 6-year-old sustains the injury shown in Figures A and B. The nerve most commonly affected by this fracture pattern innervates which of the following motor groups?

Explanation

This patient has sustained a displaced extension-type supracondylar fracture. The most commonly affected nerve in this setting is the anterior interosseous nerve (AIN). This will affect thumb IP flexion.
The most common neurapraxia after pediatric extension-type supracondylar fractures involve the AIN. It supplies the FPL (thumb IP flexion), the pronator quadratus, and the FDP of the index/long fingers. Subsequently, patients are often unable to make an “a-ok” sign. Most of these neuropraxias resolve without complication. The ulnar nerve is most commonly implicated with flexion-type supracondylar fractures.
Abzug et al. review management of supracondylar fractures. They note that the AIN
is most commonly injured nerve in extension type supracondylar fractures. They note that nerve injuries often resolve within 6-12 weeks.
Babal et al. completed a meta-analysis to determine the risk of neurapraxia associated with pediatric supracondylar fractures. The rate of traumatic neurapraxia was 11.4% amongst 5000 patients. The AIN was affected 34.1% of the time. AIN neurapraxia was most common in extension type injuries.
Figures A and B show an AP and lateral radiographs of a displaced pediatric supracondylar fracture
Incorrect Answers

Question 43

A patient who sustained a cerebrovascular accident (CVA) 18 months ago has a long-standing spastic adduction contracture of the shoulder with a rigid block to passive external rotation. Significant hygiene problems exist with maceration and continued skin breakdown. Management should consist of

Explanation

DISCUSSION: Following a CVA, the muscular imbalance often leads to a fixed contracture of the shoulder in adduction, internal rotation, and flexion. The responsible muscles include the pectoralis major, subscapularis, teres major, and latissimus dorsi. If stretching cannot produce enough improvement for axillary hygiene, then surgery is an option. If the shoulder resists external rotation during examination with the arm at the side, as in this patient, then the subscapularis is spastic and contributing to the deformity as well and needs to be released along with the pectoralis. Phenol nerve blocks are most effective and best given within 6 months of the initial CVA to be effective. Lidocaine blocks may be helpful in determining whether a deformity is caused by a fixed soft-tissue contracture or by spasticity but play no role once the contracture is present. The modified L’Episcopo procedure is indicated in patients with contracture secondary to brachial plexus birth palsies.
REFERENCES: Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65.
McCollough NC III: Orthopaedic evaluation and treatment of the stroke patient. Instr Course Lect 1975;24:45-55.

Question 44

Clinical evidence suggests that grafts for replacing a torn anterior cruciate ligament often stretch after surgery. What is the most probable mechanism for this behavior?

Explanation

DISCUSSION: The stretching of the graft occurs over time as the graft is loaded. Time-dependent deformation under load is called creep and is common in viscoelastic materials such as ligament tissue. Creep can occur under both static and cyclic load conditions; time-dependent deformation will occur as long as load is applied to the tissue. Similarly, when a graft is initially tensioned to a given deformation at surgery, the load generated in the graft will decrease over time; this behavior is called stress relaxation and also is indicative of a viscoelastic material. Water content may affect the viscoelastic properties by changing the friction between collagen fibers, but studies have shown little difference in water content between grafts and normal ligaments. Fatigue failures may manifest themselves through damage to the ligament tissue, but this would require higher loads than are routinely experienced by grafts. Elastic stretch is recoverable and, therefore, does not contribute to a permanent stretch. Similarly, gross failure at the attachment would not cause a stretch, but rather a catastrophic instantaneous instability.
REFERENCES: Boorman RS, Thornton GM, Shrive NG, et al: Ligament grafts become more susceptible to creep within days after surgery. Acta Orthop Scand 2002;73:568-574.
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 596-609.
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 45

A 40-year-old unrestrained passenger reports chest wall pain after a motor vehicle accident. Which of the following structures is most important in preventing the injury shown in Figure 33?

Explanation

DISCUSSION: Through cadaveric study, Spencer and associates measured anterior and posterior translation of the sternoclavicular joint. The study demonstrated that the posterior sternoclavicular joint capsule is the most important structure for preventing both anterior and posterior translation of the sternoclavicular joint.
REFERENCES: Gilot GJ, Wirth MA, Rockwood CA: Injuries to the sternoclavicular joint, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott, Williams and Wilkins, 2006, vol 2, pp 1373-1374.
Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.

Question 46

Figure 1 shows the radiograph and Figure 2 shows the MRI scan obtained from a 37-year-old woman with a 2-month history of left hip pain. Which combination of a single symptom and examination finding is most likely in this scenario?

Explanation

MRI reveals an anterior labral tear, and the radiograph shows minimal arthritis with possible dysplasia. The most common location of pain in patients with a labral tear is the groin, and the most common physical finding is a positive impingement test result. Pain during sitting, clicking, and buttock pain are frequently described by patients with a labral tear, but these symptoms are less common than groin pain. A positive posterior impingement test finding is more common in patients with a posterior labral tear. Although age over 40 years and a body mass index higher than 30 can adversely affect clinical outcomes after joint preservation procedures such as PAO, hip arthroscopy, and femoral acetabular impingement surgery, the presence of hip arthritis on presurgical radiographs is the most commonly mentioned cause of failed hip joint preservation surgery. Tönnis grade is a radiographic measure of hip arthritis. A higher Outerbridge score is associated with more frequent poor outcomes after hip arthroscopy; however, the Outerbridge cartilage score is determined by direct visualization at the time of surgery. The Outerbridge score cannot be determined presurgically.

Question 47

During a posterior approach to the right Achilles tendon, the surgeon encounters a nerve running with the small saphenous vein as shown in Figure 22. This nerve innervates what part of the foot?

Explanation

DISCUSSION: The sural nerve runs with the small saphenous vein on the posterior leg just lateral to the Achilles tendon. It is formed by contributions from both the tibial and common peroneal nerves and provides sensation on the dorso-lateral aspect of the foot.
REFERENCES: Aktan Ikiz ZA, Ucerler H, Bilge O: The anatomic features of the sural nerve with an emphasis on its clinical importance. Foot Ankle Int 2005;26:560-567.
Lawrence SJ, Botte MJ: The sural nerve in the foot and ankle: An anatomic study with clinical and surgical implications. Foot Ankle Int 1994;15:490-494.

Question 48

A 38-year-old woman fell from a ladder onto her right hip. The radiographs and CT scan are shown in Figures 52a through 52d. What is the best surgical approach for this fracture?

Explanation

DISCUSSION: The fracture is an associated both column fracture. The best approach for this fracture is the ilioinguinal. The Kocher-Langenbeck is best for posterior injuries to the acetabulum and some transverse fractures. The iliofemoral alone is limited to high anterior column injuries. The extended iliofemoral and triradiate approaches although useful for this fracture, have a higher rate of complications.
REFERENCES: Letournel E: The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat Res 1993;292:62-76.
Matta JM: Operative treatment of acetabular fractures through the ilioinguinal approach:

A 10-year perspective. Clin Orthop Relat Res 1994;305:10-19.

Question 49

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

Explanation

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

Question 50

During the early swing phase of the normal gait cycle, what lower extremity muscle is primarily contracting?

Explanation

DISCUSSION: Electromyography during walking reveals the tibialis anterior muscle is active during early swing, allowing the foot to clear the ground. All of the other muscles are quiet, as the limb moves forward through space with minimal muscular effort. The other muscles are primarily active during weight acceptance or push-off.
REFERENCES: Gage JR: An overview of normal walking. Instr Course Lect 1990;39:291-303.
Wootten ME, Kadaba MP, Cochran GV: Dynamic electromyography II: Normal patterns during gait. J Orthop Res 1990;8:259-265.

Question 51

What pathology is most likely to result in failure of an arthroscopic Bankart repair?

Explanation

DISCUSSION: Recent studies have documented that an arthroscopic Bankart repair performed with good technique can produce success rates similar to an open repair. However, the results of an arthroscopic repair deteriorate significantly if there is a 25% or greater anterior-inferior glenoid rim defect (inverted pear configuration) or an engaging Hill-Sachs lesion in which the humeral head defect keys onto the glenoid rim in abduction and external rotation. If either of these entities exist or there is multidirectional instability with pathologic hyperextensible tissue laxity, an open repair is recommended. An associated SLAP lesion would not significantly affect the result of the Bankart procedure. Not infrequently, the anterior glenoid labrum is partially or completely disrupted and, in itself, is not a contraindication to arthroscopic Bankart repair. In almost all patients with predominantly unidirectional instability, some degree of capsular/anterior-inferior glenohumeral ligament attenuation is present and can be addressed during the arthroscopic repair.
REFERENCES: Burkhart SS, De Beer JF: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677-694.
Cole BJ, Romeo AA: Arthroscopic shoulder stabilization with suture anchors: Technique, technology, and pitfalls. Clin Orthop 2001;390:17-30.

Question 52

A 43-year-old man sustained a closed, intra-articular pilon fracture. It has now been 1 year since he underwent open reduction and internal fixation. Which of the following statements most accurately describes his perceived outcome?

Explanation

DISCUSSION: Marsh and associates retrospectively reviewed 56 tibial plafond fractures and found that the patients perceived improvement in their function and pain for an average of 2.4 years. They demonstrated some limitations in recreational activities but not marked limitations. Patients were unlikely to need a late arthrodesis (13%), and their outcomes did not correlate well with assessments of reduction or arthritis scores.
REFERENCE: Marsh JL, Weigel DP, Dirschl DR: Tibial plafond fractures: How do these ankles function over time? J Bone Joint Surg Am 2003;85:287-295.

Question 53

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?

Explanation

The most reliable surgical option in this case for eradicating a deep infection following a total elbow arthroplasty is a two-stage revision. One study, however, reported that staged reimplantation of an infected total elbow replacement could be successful in the setting of organisms other than S epidermidis. Arthroscopic debridement is not a viable option with poorly fixed or loose components. A single-stage revision, while considered an option in hip and knee arthroplasty, has not been definitively proven to be an option for revision total elbow arthroplasty. Single-stage revision has shown moderate success in the setting of Staphylococcus aureus infections, although with only short-term follow-up. A resection arthroplasty would likely be successful in managing the deep infection but would not optimize the functional result. Resection arthroplasty
is best reserved for low-demand or infirm patients.

Question 54

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

Explanation

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

Question 55

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

Explanation

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

Question 56

A 10-year-boy has had thigh pain for the past several months. He denies any history of trauma. Examination reveals no soft-tissue mass, and mild tenderness. Figures 33a and 33b show the plain radiograph and MRI scan, and the biopsy specimens are shown in Figures 33c and 33d. What is the most likely diagnosis?

Explanation

DISCUSSION: The diagnosis is eosinophilic granuloma. The plain radiograph and MRI scan show a lesion in the midshaft of the femur. There is no soft-tissue mass. There is reactive bone about the lesion that suggests a less aggressive tumor. The histology reveals eosinophils in an otherwise bland cellular background with no evidence of mitotic figures or malignant cells to suggest sarcoma. The diagnostic elements are the amphophilic (ie, pale purple) histiocytes with cigar-shaped nuclei, some of which have linear longitudinal grooves. There is no histologic evidence of infection. Lymphoma of bone would be an unusual occurrence in this age group, and the histology is not consistent with that diagnosis.
REFERENCE: Simon MA, Springfield DS, et al: Common Benign Bone Tumors: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 194-200.

Question 57

Figure 37 shows the clinical photograph of a 1-day-old infant who weighed 10.25 lb at birth. Examination reveals an absent right Moro reflex and limited active motion of the right shoulder, elbow, and wrist, but flexion of the fingers. Passive range of motion of the shoulder and elbow is normal. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient’s right upper extremity is held in the “head waiter’s” posture with the shoulder internally rotated, the elbow extended, and the wrist in flexion. The Erb type of obstetrical brachial plexus palsy involves the C5 and C6 nerve root, and occasionally, as in this child, the C7 nerve root. Obstetrical palsy is a traction injury, and is associated with a high birth weight, shoulder dystocia, cephalopelvic disproportion, or the use of forceps. Erb palsy is four times more common than injury to the entire plexus or injury to the C8 and T1 nerve roots. It results from the shoulder being depressed while the head and neck are laterally rotated, extended, and tilted in the opposite direction. Most patients recover wrist extension and elbow flexion. Patients with residual weakness of shoulder external rotation and abduction will benefit from release of the pectoralis major, latissimus dorsi, and teres major, with transfer of the latissimus dorsi and the teres major to the posterosuperior aspect of the rotator cuff. Recent studies using arthrograms and CT scans have shown a higher incidence of posterior glenoid deficiency and posterior subluxation than that observed with plain radiographs. The posterior subluxation or dislocation can be effectively reduced by tendon release and transfer procedures.
REFERENCES: Hoffer MM, Phipps GJ: Closed reduction and tendon transfer for treatment of dislocation of the glenohumeral joint secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:997-1001.
Pearl ML, Edgerton BW: Glenoid deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:659-667.
Waters PM, Smith GR, Jaramillo D: Glenohumeral deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:668-677.

Question 58

A 45-year-old woman with stage II posterior tibial tendinitis has failed to respond to nonsurgical management. Recommended treatment now includes posterior tibial tendon debridement and medial calcaneal displacement osteotomy along with transfer of what tendon?

Explanation

DISCUSSION: The flexor digitorium longus is the commonly accepted tendon transfer for posterior tibial tendon insufficiency. The flexor hallucis longus has to be carefully rerouted to avoid crossing the neurovascular bundle and has not been shown clinically to provide superior results to flexor digitorum longus transfer. Use of the peroneus longus results in loss of plantar flexion strength of the first metatarsal, contributing to the flatfoot deformity. The anterior tibial tendon is in the anterior compartment and fires out of phase with the posterior tibial tendon.
REFERENCES: Sitler DF, Bell SJ: Soft tissue procedures. Foot Ankle Clin 2003;8:503-520.
Guyton GP, Jeng C, Krieger LE, et al: Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for posterior tibial tendon dysfunction: A middle-term clinical follow-up. Foot Ankle Int 2001;22:627-632.

Question 59

A 58-year-old man presents to the clinic with 9 months of progressive right lower extremity pain. Over the past 4 months, he also notes a decreased ability to walk long distances due to pain, which is relieved by sitting down. Figure A and B

Explanation

The clinical presentation is consistent with lumbar stenosis. At 4 years, surgical management is expected to result in more improvement in pain, function, satisfaction than nonoperative management.
Surgical management of lumbar stenosis typically consists of wide pedicle to pedicle decompression at the affected levels. Instrumention and fusion may be indicated if there is evidence of instability. Nonsurgical management typically involves oral medications, physical therapy, and corticosteroid injections
Weinstein et al. (2010, 2008), as part of the SPORT trial, found that surgical management of symptomatic lumbar stenosis with decompressive laminectomy resulted in greater improvement in pain, function, and satisfaction as compared to nonsurgical management. These advantages were maintained at both two and four years of follow up.
Figure A is a T2 sagittal MRI showing lumbar spinal stenosis from L1-L5, most prominent from L3-L5. Figure B is a T2 axial MRI showing severe stenosis at L4-L5 secondary to ligamentum flavum hypertrophy and facet arthropathy. Illustration A is an example of a one-level decompressive laminectomy.
Incorrect Answers:
mortality.

Question 60

Figure 20 shows the MRI scan of a 20-year-old athlete who has a painful shoulder. This pathology is most commonly seen in

Explanation

DISCUSSION: The MRI scan reveals a posterior labral detachment. This injury is the result of a posteriorly directed force and is common to football players in blocking positions. Although this injury can occur with trauma in all types of athletes, it is seen with relative frequency in football. Treatment is aimed at labral repair with posterior capsulorrhaphy. Both open and arthroscopic techniques can be used.
REFERENCES: Misamore GW, Facibene WA: Posterior capsulorrhaphy for the treatment of traumatic recurrent posterior subluxations of the shoulder in athletes. J Shoulder Elbow Surg 2000;9:403-408.
Mair SD, Zarzour RH, Speer KP: Posterior labral injury in contact athletes. Am J Sports Med 1998;26:753-758.

Question 61

The thickest bone in the occiput is located

Explanation

DISCUSSION: Anatomic studies have shown that the thickest bone of the occiput is at the level of the external occipital protuberance. It ranges from 11.5 mm to 15.1 mm in men and from 9.7 mm to 12 mm in women. In general, the bone thins as it extends distally from the external occipital protuberance and it also moves laterally from the midline. The structures at risk during screw placement include the venous sinuses.
REFERENCES: Nadim Y, Lu J, Sabry FF, et al: Occipital screws in occipitocervical fusion and their relation to the venous sinuses: An anatomic and radiographic study. Orthopedics 2000;23:717-719.
Ebraheim N, Lu J, Biyani A, et al: An anatomic study of the thickness of the occipital bone: Implications for occipitocervical instrumentation. Spine 1996;21:1725-1729.

Question 62

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

Explanation

DISCUSSION
This clinical scenario describes a patient with an isolated injury affecting the infraspinatus muscle. The anatomic location of such a lesion would be at the spinoglenoid notch, at which the suprascapular nerve may be compressed distal to its innervation of the supraspinatus but proximal to the infraspinatus innervation. A calcified transverse scapular ligament would also affect the suprascapular nerve but is proximal to the innervation of both muscles. Quadrilateral space syndrome would affect innervation of the deltoid (and teres minor). Parsonage-Turner syndrome is a more diffuse, and often severely painful, brachial plexus neuropathy.

Question 63

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

Explanation

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

Question 64

A young, healthy male undergoes a distal biceps repair and sustains an iatrogenic nerve injury during the procedure. Which of the following clinical findings are most likely to be seen in this circumstance? Review Topic

Explanation

The most commonly injured nerve during a distal biceps repair is the lateral antebrachial cutaneous nerve (LABCN). Injury to this nerve would result in lateral volar forearm numbness.
Distal biceps avulsions can be partial or complete. Indications for surgical management include young, healthy patients who do not wish to sacrifice function, as well as partial biceps avulsions that do not respond to conservative management. Repair of a distal biceps avulsion can be approached through either an anterior one-incision technique or a two-incision technique (Boyd-Anderson). The one-incision technique uses the interval between the brachioradialis (radial nerve) and pronator teres (median nerve), while the two-incision technique uses this same interval in addition to a second posterolateral elbow incision. The lateral antebrachial cutaneous nerve is the most common nerve injured during either approach.
Kelly et al. retrospectively reviewed 74 distal biceps tendon repairs, and found five sensory nerve paresthesias. The lateral antebrachial cutaneous nerve was most commonly injured, followed by the superficial radial nerve.
Cain et al. retrospectively reviewed 198 distal biceps tendon repairs, and found a 36% complication rate. Lateral antebrachial cutaneous nerve paresthesias were found in 26%, while radial sensory nerve paresthesias were found in 6%, and posterior interosseous nerve (PIN) injury in 4%.
Illustration A shows the close relationship between the lateral antebrachial cutaneous nerve (LABCN) and the distal biceps. Illustration B shows the sensory nerves of the upper extremity and their respective areas of innervation.
Incorrect Answers:

Question 65

Up to what time frame are the risks minimized in anterior revision disk replacement surgery? Review Topic

Explanation

Revision anterior exposure within 2 weeks of total disk replacement incurs relatively little additional morbidity because adhesion formation is minimal. Surgeons should have a low threshold for revising implants that are clearly dangerously malpositioned or show early migration within this 2-week window. Beyond this time period, a revision strategy must be individualized to the particular clinical situation. A posterior fusion with instrumentation with or without a laminectomy is currently the most effective salvage procedure.

Question 66

A 15-year-old diver has had persistent, activity-related low back pain for the past 2 months. He denies any history of trauma. Examination reveals that the pain is localized to the lumbosacral junction, and there are no radicular symptoms. The pain is worse with back extension. Neurologic examination is normal, as are AP, lateral, and oblique radiographs of the lumbosacral spine. Further evaluation should include

Explanation

DISCUSSION: Spondylolysis may develop as a stress fracture resulting from repetitive hyperextension during athletic activities. In young people, the pars interarticularis is thin, the neural arch has not yet reached maximum strength, and the intravertebral disk is less resistant to shear. While clinical symptoms may lead to the suspicion of spondylolysis, radiographic confirmation may be difficult in early cases. Plain radiographs may be negative initially, and the plain MRI scan may not offer good visualization of the pars. A bone scan with SPECT is very sensitive initially. CT scans with regular axial and reverse-gantry angled cuts may help determine the type of fracture and the course of treatment.
REFERENCES: Congeni J, McCulloch J, Swanson K: Lumbar spondylolysis: A study of natural progression in athletes. Am J Sports Med 1997;25:248-253.
Harvey CJ, Richenberg JL, Saifuddin A, Wolman RL: The radiological investigation of lumbar spondylolysis. Clin Radiol 1998;53:723-728.

Question 67

Figure 53 is a coronal-cut CT scan of a 63-year-old woman who has a longstanding pes planus. She is seen for lateral ankle discomfort. Upon examination she is tender over the sinus tarsi and distal to the fibula. She has painless passive hindfoot eversion with 5/5 eversion strength. The most appropriate diagnosis is

Explanation

DISCUSSION
With the use of CT scans, adults with symptomatic flatfoot deformity have been noted to develop subluxation of the talocalcaneal joint with resulting lateral hindfoot pain. Impingement of the talus and calcaneus in the sinus tarsi and/or between the tip of the fibula and the calcaneus may occur. This impingement is known as lateral impaction syndrome. Hindfoot motion is painless; therefore, this patient does not have symptomatic subtalar arthritis. Middle facet and calcaneonavicular coalitions are not present (hindfoot motion is present).
RECOMMENDED READINGS
Malicky ES, Crary JL, Houghton MJ, Agel J, Hansen ST Jr, Sangeorzan BJ. Talocalcaneal and subfibular impingement in symptomatic flatfoot in adults. J Bone Joint Surg Am. 2002 Nov;84-A(11):2005-9. PubMed PMID: 12429762. ? View Abstract at PubMed
Ananthakrisnan D, Ching R, Tencer A, Hansen ST Jr, Sangeorzan BJ. Subluxation of the talocalcaneal joint in adults who have symptomatic flatfoot. J Bone Joint Surg Am. 1999 Aug;81(8):1147-54. PubMed PMID: 10466647. ?View Abstract at PubMed

Question 68

A 73-year-old man stepped off a street curb and felt a crack in his left hip. He is now unable to bear weight. A radiograph is shown in Figure 54a. Biopsy specimens are shown in Figures 54b and 54c. What is the most likely diagnosis?

Explanation

DISCUSSION: The biopsy specimens reveal a high-grade spindle cell lesion adjacent to an area of benign cartilage. This is consistent with a dedifferentiated chondrosarcoma. The radiograph shows a pathologic fracture through a lesion characterized by calcification within the left greater trochanter. Distal to the area of calcification, there is a more osteolytic, destructive appearance. Synovial sarcoma has a biphasic appearance histologically with areas of glandular differentiation that stain positive with keratin. Metastatic prostate cancer, although osteoblastic in appearance, would have a glandular histologic appearance. There is no cartilage in these lesions. Classic low-grade chondrosarcoma does not have an area of high-grade pleomorphic spindle cells within the lesion. A periosteal osteosarcoma is a surface-based lesion with a sunburst radiographic pattern. Although there may be cartilage in the lesion histologically, there are also malignant cells producing osteoid. Dedifferentiated chondrosarcoma is an aggressive, high-grade variant of chondrosarcoma.
REFERENCES: Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 269.
Mercuri M, Picci P, Campanacci L, et al: Dedifferentiated chondrosarcoma. Skeletal Radiol 1995;24:409-416.

Question 69

Figure 40 shows the radiograph of a 16-year-old wrestler who injured his elbow when he was thrown to the mat by his opponent. Closed reduction is readily accomplished, and the elbow seems stable. Management should now consist of application of a splint for

Explanation

DISCUSSION: Flexion contractures are the most common complication of elbow dislocations. About 15% of patients lose more than 30 degrees of flexion. The risk of contracture is proportional to the duration of immobilization. Elbows should be moved within the first few days after reduction. The splinting is for comfort and protection only while the pain subsides.
REFERENCES: Mehlhoff TL, Noble PC, Bennett JB, Tullos HS: Simple dislocation of the elbow in the adult: Results after closed treatment. J Bone Joint Surg Am 1988;70:244-249.
Linscheid RL, O’Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, pp 441-452.
O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF: The unstable elbow. Instr Course Lect 2001;50:89-102.
Ross G, McDevitt ER, Chronister R, Ove PN: Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med 1999;27:308-311.

Question 70

-A 15-year-old boy underwent open reduction and internal fixation for a tibial tubercle fracture. The next morning he had dramatically increased pain, hypotension, ascending rash, and fever to 103°F. What is the most appropriate course of action?

Explanation

Question 71

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

Explanation

DISCUSSION: The arterial supply to the hand is abundant and normally duplicated. The deep palmar arch as shown in this arteriogram typically receives its primary contribution from the radial artery which travels deep to the first dorsal compartment tendons and then returns to the volar aspect of the palm through the first web space. The superficial palmar arch receives its supply from the ulnar artery and is not visualized in this patient.
REFERENCE: Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist: Diagnosis and Operative Treatment. Philadephia, PA, Mosby-Year Book, 1998, p 110.

Question 72

-What leads to muscle hypertrophy?

Explanation

Question 73

A 36-year-old professional baseball player reports the acute onset of severe right groin pain while attempting to avoid being hit by a baseball while at bat. Examination reveals tenderness, soft-tissue swelling, and ecchymosis in the right groin extending over the medial thigh. MRI scans are shown in Figures 8a and 8b. Management should consist of

Explanation

DISCUSSION: The MRI scans reveal a severe avulsion injury of the adductor muscle from the pubic ramus with muscle edema and hemorrhage. Injury to the adductor muscle group, a “pulled groin,” is caused by forceful external rotation of an abducted leg. Pain is immediate and severe in the groin region. Tenderness is at the site of injury along the subcutaneous border of the pubic ramus. Treatment is dictated by the severity of the symptoms but generally consists of rest, ice, and protected weight bearing, followed by a rehabilitation program that begins with gentle stretching and progresses to resistance exercise with a gradual return to sports. Immobilization should be avoided because this promotes muscle tightness and scarring. No data exist to suggest that open repair yields a better outcome than nonsurgical management. Tenotomy has been performed in high-level athletes with chronic groin pain following injury.
REFERENCES: Gilmore J: Groin pain in the soccer athlete: Fact, fiction, and treatment. Clin Sports Med 1998;17:787-793.
Irshad K, Feldman LS, Lavoie C, et al: Operative management of “hockey groin syndrome”:
12 years of experience in National Hockey League players. Surgery 2001;130:759-766.

Question 74

A 32-year-old man presents to the emergency department with a humeral shaft fracture. He has wrist drop as well as impaired finger and thumb extension. Which motor function would be expected to recover last?

Explanation

DISCUSSION: The patient is presenting with radial nerve palsy secondary to his humerus fracture. Motor recovery proceeds in a proximal to distal direction.
Abrams et al detailed the order of innervation of the radial nerve and found the following order (proximal to distal): brachioradialis, extensor carpi radialis longus, supinator, extensor carpi radialis brevis, extensor digitorum communis, extensor carpi ulnaris, extensor digiti quinti, abductor policis longus, extensor policis longus, extensor policis brevis, and extensor indicis proprius.
Branovacki et al found a slightly different pattern: brachioradialis, extensor carpi radialis longus, superficial sensory, extensor carpi radialis brevis, supinator, extensor digitorum/extensor carpi ulnaris, extensor digiti minimi, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus and extensor indicis proprius.
While both extensor digitorum and extensor indicis proprius extend the index finger MCP joint, only extensor indicis proprius hyperextends the index finger past neutral

Question 75

A 28-year-old hockey player has a shoulder deformity after being checked into the boards. Examination reveals that swelling has improved, but there is tenderness along the distal clavicle. Radiographs reveal a grade II acromioclavicular joint separation. Initial management should consist of

Explanation

DISCUSSION: The most common shoulder injury in hockey players is to the acromioclavicular joint. Early rest and control of pain and inflammation is the preferred management. Surgery is reserved for patients with significant coracoclavicular disruption that has failed to respond to nonsurgical management. Cross-chest stretches and overhead exercises may increase symptoms. A cortisone injection within the glenohumeral joint will have little effect.
REFERENCES: Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:11-18.
Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU: Surgical treatment of complete acromioclavicular dislocation. Am J Sports Med 1995;23:324-331.

Question 76

Which study is most useful for diagnosis of exertional compartment syndrome?

Explanation

CLINICAL SITUATION FOR QUESTIONS 48 THROUGH 50
Figures 48a through 48f reveal the radiographs and MR images of a 30-year-old man who has a 1-year history of atraumatic medial-sided left knee pain refractory to nonsurgical measures.

Question 77

Which of the following factors is associated with improved outcomes following surgery for hip fractures?

Explanation

Many studies have looked at patient outcomes following hip fracture surgery. While early surgery in these patients is recommended, medical optimization prior to surgical intervention is warranted in all cases. Anesthetic type and discharge status have not been proven to alter patient outcomes. Total hip arthroplasty has improved function at 1 year compared with hemiarthroplasty; no changes in mortality have been reported.

Question 78

Figures 55a through 55c are the clinical photograph and radiographs of a 5-year-old boy who fell and injured his right elbow. His radial pulse is thready. Which neurologic deficit most commonly is associated with this injury?

Explanation

DISCUSSION
This injury is a type III supracondylar humerus fracture with posterolateral displacement. The area of ecchymosis is anteromedial, corresponding to the proximal spike of the humeral metaphysis. The brachial artery is likely tented over this spike, leading to diminished perfusion. The median nerve also resides in this area, and any neurological deficit is likely in its most vulnerable fibers, those of the anterior interosseous nerve (AIN). The AIN contains no sensory fibers, and its motor function involves flexion of both the thumb IP joint and the index distal IP joint.
First dorsal web space anesthesia and an inability to extend the fingers would indicate radial nerve neuropraxia, which would be more likely with posteromedially displaced fractures and lead to anterolateral ecchymosis. Finger abduction is controlled by the ulnar nerve, which most often is injured in flexion injuries and iatrogenically by medially placed pins.

Question 79

A 2-year-old boy has been referred for musculoskeletal evaluation. Examination reveals shortened proximal limbs, hip and knee flexion contractures, an abducted thumb, and ear abnormalities. His parents are concerned about his deformed feet. What is the most common foot deformity associated with this patient’s diagnosis?

Explanation

DISCUSSION: The patient has diastrophic dysplasia. Affected individuals have rhizomelic short stature, cauliflower ears, severe joint contractures (especially knees and hips), hitchhiker’s thumb, and a cleft palate. The most common foot abnormality is a rigid equinovarus deformity. Surgical results are poorer than those for idiopathic clubfeet and often require bony procedures or talectomy.
REFERENCES: Ryoppy S, Poussa M, Merikanto J, Marttinen E, Kaitila I: Foot deformities in diastrophic dysplasia: An analysis of 102 patients. J Bone Joint Surg Br 1992;74:441-444.
Bussett GS: The osteochondrodysplasias, in Morrissy RT, Weinstein S (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, p 219.

Question 80

The patient undergoes further testing and it is discovered that the lesion encompasses 70% of the joint. What is the best next treatment option?

Explanation

DISCUSSION
A tarsal coalition is an abnormal connection of 2 or more bones in the foot. Although tarsal coalitions are present at birth, children and adults typically do not show signs of the disorder until early adolescence or later. The exact incidence of the disorder is hard to determine; however, it is caused by a gene mutation that affects cells that produce the tarsal bones. The 2 most common locations for tarsal coalitions are between the calcaneus and the navicular or between the talus and the calcaneus. It is estimated that 1 out of every 100 people may have a tarsal coalition. In 50% of cases, both feet are affected. Tarsal coalitions are rarely discovered until symptoms arise. Symptoms may include stiff and painful feet, a rigid flatfoot, or increased pain or a limp with high-level activities. Upon examination, symptoms may include tenderness in the area of the coalition, loss of motion, rigid flat feet, and arthritic changes of the joint. Imaging studies begin with radiographs. A CT scan can provide bony detail for imaging tarsal coalitions and determining the extent of the coalition and any accompanying degenerative change. MRI can provide details of the soft tissues. Treatment includes nonsurgical care including rest, orthotics, a temporary boot or cast, and injections. Surgical options include resection with interposition of muscle or fatty tissue from another area of the body or fusions when large (exceeding 50% of the joint), more severe coalitions are encountered.
RECOMMENDED READINGS
Lemley F, Berlet G, Hill K, Philbin T, Isaac B, Lee T. Current concepts review: Tarsal coalition. Foot Ankle Int. 2006 Dec;27(12):1163-9. Review. PubMed PMID: 17207452. View Abstract at PubMed
Badgley CE. Coalition of the calcaneus and the navicular. Arch Surg. 1927;15:75-88. Conway JJ, Cowell HR. Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology. 1969 Mar;92(4):799-811. PubMed PMID: 5767760. View Abstract at PubMed
Herzenberg JE, Goldner JL, Martinez S, Silverman PM. Computerized tomography of talocalcaneal tarsal coalition: a clinical and anatomic study. Foot Ankle. 1986 Jun;6(6):273-

Question 81

Figure 13 is the photograph of 18-month-old triplets with a lower-limb condition. What is the best initial treatment? Review Topic

Explanation

Brodie's Abscess
Osteomyelitis of the humeral metaphysis
Subperiosteal abscess of the humerus
Presence of subcutaneous air
High risk of proximal humeral growth arrest
This patient has osteomyelitis of the humerus with a large subperiosteal abscess. The presence of subperiosteal abscess necessitates surgical intervention for irrigation and debridement (I&D).
The diagnosis of acute osteomyelitis in children is made based upon a constellation of findings including pain, systemic signs of infection, elevated serum inflammatory markers, and imaging studies demonstrative of osseous infection. It is most commonly hematogenously spread to the metaphysis of immature bone, which is highly vascular prior to skeletal maturity. Treatment involves obtaining specimen for culture, empiric antibiotic treatment, and surgical irrigation and debridement of known abscesses. The end-point of treatment is return of pain-free functionality and the resolution of local/systemic signs of infection.
Conrad reviewed the management of acute hematogenous osteomyelitis and emphasized that surgical intervention in the presence of abscess can be both therapeutic and diagnostic: I&D can obtain culture and narrow the antibiotic plan.
Jones et. al. reviewed chronic pediatric osteomyelitis and report that surgery is the mainstay of treatment because removal of dead bone is essential for resolution of infection. This may be performed with sequestrectomy and curettage, with an emphasis on prevention of pathologic fracture, growth disturbances, bone loss, joint involvement, and permanent loss of function.
Figure A is a coronal STIR MRI image of the humerus demonstrating osteomyelitis
with extensive subperiosteal abscess.
Incorrect Answers:
Brodie's abscess is a type of subacute osteomyelitis which remains indolent and creates a focal intra-osseous abscess. This is not demonstrated in the clinical image.
The patient does have osteomyelitis of the humeral metaphysis, but this alone is not the indication for surgery. Uncomplicated osteomyelitis may be treated effectively with antibiotics alone.
Presence of subcutaneous air is suggestive of necrotizing fasciitis, which is a surgical emergency. The MRI however does not demonstrate this finding.
The infection and its surgical management both increase risk of injury to the proximal humeral physis and has the potential for growth arrest or angular deformity.
(SBQ13PE.3) Figure A demonstrates a physical examination maneuver in a 1 month old infant. What is this maneuver? Review Topic

Ortolani Test
Barlow Test
Galeazzi Sign
Patrick test
Teratologic Sign
Figure A shows a schematic image of the Ortalani test.
The Ortolani test, or Ortolani maneuver, is part of the physical examination for developmental dysplasia of the hip. It is used alongside the Barlow test to detect subluxated hips that are either reducible or irreducible. A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral head relocates anteriorly into the acetabulum.
Guille et al. showed that the use of Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step before they are able to stand.
Video V is a lecture discussing the hip examination of the infant. Incorrect Answers:
pressure on the knee, directing the force the femoral head posteriorly. A positive Barlow test would result in posterior subluxation/dislocation of the hip. Answer 3: Galeazzi test is performed by flexing an infant's knees in the supine position so that the ankles touch the buttocks. If the knees are not level then the test is positive, which indicates a potential congenital hip issue (e.g. DDH). Answer 4: Patrick or Faber test (flexion, abduction, external rotation) has been described both for stressing the SI joint and for isolating symptoms to the hip Answer 5: Teratologic dislocation of the hip is a term used to imply that the hip joint did not develop normally in utero, thus the hip is in a fixed dislocated position at birth.

Question 82

Figures 51a and 51b show the AP and lateral radiographs of the elbow of a 26-year-old man who fell. Closed reduction was performed in the emergency department, and management consisted of immobilization for 3 weeks prior to the initiation of motion. At 12 weeks after injury, he reports continued feelings of instability and catching in his elbow when using his arms to rise from a chair. Which of the following procedures needs to be performed, at a minimum, to reestablish stability of the elbow? Review Topic

Explanation

The patient has chronic posterolateral instability of the elbow following dislocation. The lateral collateral ligament complex is responsible for maintaining stability of the elbow. Because of the chronicity of the injury, the ligamentous tissues are frequently attenuated and not amenable to simple repair; while the native ligament can be imbricated, reconstruction with allograft or autograft is recommended. Medial collateral ligament reconstruction or hinged external fixation is needed only if restoration of the lateral ligamentous complex does not restore elbow stability; however, these procedures are rarely required. Lateral elbow pain when rising from a chair is equivalent to a positive pivot shift test.

Question 83

Which of the following statements describing chordomas is false?

Explanation

DISCUSSION: Casali and associates provided a recent review of the treatment options for chordomas. These tumors are not radiosensitive; however, modern intensity modulated radiosurgery techniques may be of value. The combination of surgery and radiotherapy compared to surgery alone results in the same disease-free survival time. Complete surgical resection of the chondroma with clean margins offers the best survival; however, its location may make total removal impossible. Thus subtotal resection followed by radiotherapy results in better survival despite the tumor’s lack of radiosensitivity.
REFERENCE: Casali PG, Stacchiotti S, Sangalli C, et al: Chordoma. Curr Opin Oncol 2007;19:367-370.

Question 84

Which of the following best describes a Bonferroni correction? Review Topic

Explanation

A Bonferroni correction is a post-hoc statistical correction made to P values when several dependent or independent statistical tests are being performed simultaneously on a single data set.
To perform a Bonferroni correction, divide the critical P value (alpha level) by the number of comparisons being made. For example, if 10 hypotheses are being tested, the new critical P value would be (alpha level)/10. The statistical power of the study is then calculated based on this modified P value.
Guyatt et al. discusses hypothesis testing and the role of alpha levels and P values. They report that the Bonferroni correction is derived from testing a dependent or independent hypotheses on a set of data and finding that the probability of a type I error is offset by testing each hypothesis at a statistical significance level divided by the number of times what it would be if only one hypothesis were tested.
Incorrect
1:
This
describes
Bayesian
analysis.
2:
This
describes
Hawthorne
effect.
3:
This
describes
Pearson
correlation.

Question 85

Figures 27a through 27c show the radiographs and CT scan of a 27-year-old man who sustained a low-velocity gunshot wound to the neck. He is quadriplegic (ASIA A), hemodynamically stable, and does not have drainage from his wound. After initial resuscitation and stabilization, the cervical spine and spinal cord injuries are best managed by

Explanation

DISCUSSION: Although the spinal canal has been penetrated, the lateral masses are intact bilaterally with only partial destruction of the vertebral body and penetration of the lamina on one side, thus the cervical spine is not unstable and surgical stabilization is not indicated. Dural repair is not indicated since there is no external cerebrospinal fluid leakage. Surgical treatment should be based on the need to treat extraspinal pathology only.
REFERENCES: Bono CM, Heary RF: Gunshot wounds to the spine. Spine J 2004;4:230-240.
Punjabi MM, Jue JJ, Dvorak J, et al: Cervical spine kinematics and clinical instability, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,

pp 55-87.

Question 86

A 42-year-old woman sustained a closed, displaced talar neck fracture in a motor vehicle accident. Which of the following is an avoidable complication of surgical treatment?

Explanation

DISCUSSION: Malunion of the talus is a devastating complication that leads to malpositioning of the foot and subsequent arthrosis of the subtalar joint complex. This is considered an avoidable complication in that accurate surgical reduction will minimize its development. Posttraumatic arthritis of the subtalar joint, osteonecrosis of the talus, posttraumatic arthritis of the ankle joint, and complex regional pain syndrome all may develop as a result of the initial traumatic event and may not be avoidable despite anatomic reduction.
REFERENCES: Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott, Williams and Wilkins, 2001, pp 2091-2132.
Daniels TR, Smith JW, Ross TI: Varus malalignment of the talar neck: Its affects on the position of the foot and on subtalar motion. J Bone Joint Surg Am 1996;78:1559-1567.

Question 87

A 16-year-old female dancer has persistent posterior ankle pain, particularly after a vigorous dancing schedule. Examination reveals tenderness both posteromedially and posterolaterally. MRI scans are seen in Figures 44a and 44b. What is the most likely diagnosis?

Explanation

DISCUSSION: Posterior ankle impingement or os trigonum syndrome is well described in dancers, and it is often associated with flexor hallucis longus tendinitis. High-quality MRI imaging will reveal the inflammation about the os trigonum and flexor hallucis longus tendinitis.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont IL, American Academy of Orthopaedic Surgeons, 1998, pp 315-332.
Hamilton WG, Hamilton LH: Foot and ankle injuries in dancers, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1225-1256.

Question 88

A 9-year-old boy falls from a scooter and sustains the injury shown in the radiographs in Figure 26. After closed reduction and cast immobilization, what is the most likely complication that can result?

Explanation

DISCUSSION: The radiographs show a fracture of the distal radius and ulna physis. The most likely complication is growth arrest of the distal ulna. In contradistinction to physis fractures of the radius (growth arrest incidence of less than 5%), the incidence of growth arrest in the ulna is between 30% and 40%. Entrapment of the EPL tendon and cross union between the two bones is extremely rare.
REFERENCES: Vanheest A: Wrist deformities after fracture. Hand Clin 2006;22:113-120.
Cannata G, De Maio F, Mancini F, et al: Physeal fractures of the distal radius and ulna: Long-term prognosis. J Orthop Trauma 2003;17:172-179.
Ray TD, Tessler RH, Dell PC: Traumatic ulnar physeal arrest after distal forearm fractures in children. J Pediatr Orthop 1996;16:195-200.
Aminian A, Schoenecker PL: Premature closure of the distal radial physis after fracture of the distal radial metaphysis. J Pediatr Orthop 1995;15:495-498.

Question 89

Which of the following plain radiographic views of the shoulder best reveals a Hill-Sachs lesion of the humeral head?

Explanation

Hill-Sachs lesion is an impression fracture of the posterosuperior aspect of the humeral head, produced by contact with the anteroinferior glenoid when dislocated. Hill-Sachs lesion is demonstrated on plain AP radiograph in internal rotation.

Question 90

A 16-year-old boy with osteochondritis dissecans of the capitellum has intermittent symptoms of catching and locking. Examination is unremarkable. Radiographs reveal a loose body anteriorly with a diameter of 10 mm. To remove the loose body, elbow arthroscopy is being considered. Which of the following procedures would minimize the risk of neurovascular complication during the procedure?

Explanation

DISCUSSION: Complications of elbow arthroscopy are usually minor or temporary. However, serious complications include nerve injuries. The deep radial nerve is the closest to any of the portals, resting as close as 1 mm away from the scope inserted in the anterolateral portal. The capsule can be displaced anteriorly by distending the joint with about 25 mL of saline solution, thus moving the deep radial nerve approximately 1 cm anteriorly and decreasing the risk of injuring it while establishing the anterolateral portal. Keeping plastic cannulae in the portals may help to diminish fluid extravasation and swelling, which is more of an impediment than a serious complication. The image intensifier has no documented role in guiding loose body removal. While the proximal anteromedial portal is probably the safest anterior portal to establish, it is actually easier to remove a large loose body from this portal while viewing it from an anterolateral position. There is less tendon and muscle bulk to pass through at the site of the proximal anteromedial portal than at the anterolateral portal, making it less likely for the loose body to get stuck in the soft tissues. Techniques have been developed to permit removal of loose bodies as large as 2 cm in diameter without breaking them up into pieces. If it is possible to remove a large loose body intact, doing so greatly simplifies and shortens the procedure.
REFERENCES: Lynch GJ, Meyers JF, Whipple TL, Caspari RB: Neurovascular anatomy and elbow arthroscopy: Inherent risks. Arthroscopy 1986;2:190-197.
O’Driscoll S: Loose bodies and synovial conditions, in Green D, Hotchkiss R, Pederson W (eds): Green’s Operative Hand Surgery. New York, NY, Churchill Livingstone, 1999, pp 235-249.

Question 91

For a patient with a type II odontoid fracture, which of the following factors best predicts the development of a nonunion with nonsurgical management? Review Topic

Explanation

All five factors have been found to be associated with nonunion for type II odontoid fractures. Of these, initial fracture displacement of greater than 6 mm has the greatest association with the development of fracture nonunion.

Question 92

During a dual incision fasciotomy of the leg, the soleus is elevated from the tibia to allow access to which of the following compartments?

Explanation

DISCUSSION: The soleus is elevated/released from the posterior tibia during the medial approach to allow access to the deep posterior compartment. Release of this compartment cannot be done without proper elevation of the soleus. The superficial posterior compartment mass is primarily located in the proximal half of the leg, while the deep posterior musculature is located in the distal 2/3 of the leg.

Question 93

A 62-year-old man complains of shoulder pain for 2 years. He has had 1 course of intra-articular sodium hyaluronate and 6 weeks of physical therapy with little relief. Examination reveals diminished arm flexion and abduction secondary to pain. Radiographs of his shoulder are shown in Figures A and B. According to the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines, what is the next best step? Review Topic

Explanation

This patient has end-stage glenohumeral osteoarthritis (GH OA). According to the AAOS CPG, total shoulder arthroplasty (TSA) is recommended using an all-polyethylene cemented glenoid component.
TSA is indicated for cases of end-stage GH OA. It is preferred to hemiarthroplasty. It is contraindicated in cases with insufficient glenoid bone stock (glenoid wear to the level of the coracoid), rotator cuff arthropathy or irreparable cuff tears and deltoid dysfunction. It provides good pain relief and has good survival at 10 years (>90%).
Radnay et al. performed a systematic review involving 1952 patients comparing TSA with humeral head replacement (HHR). They found that TSR provided greater pain relief, range of motion, patient satisfaction, and had lower revision rates. They recommend TSA over HHR for GH OA.
Izquierdo et al. described the AAOS Clinical Practice Guidelines (CPG) regarding treatment of GH OA. This is summarized in Illustration A.
Figures A and B show end-stage GH OA with large osteophytes and subchondral sclerosis. There is significant glenoid wear and posterior subluxation (Walch B glenoid deformity). Illustration A is a table summarizing the AAOS CPG on treatment of GH OA. Illustration B shows a CTA humeral component. It is not paired with a glenoid component.
Incorrect Answers:

Question 94

A 14-year-old girl reports bilateral patellofemoral symptoms. Based on the radiograph and MRI scans shown in Figures 23a through 23d, what is the next most appropriate step in management of the lesion?

Explanation

DISCUSSION: A periosteal desmoid lesion is a tumor simulator. It is characterized by a bone irregularity along the posteromedial aspect of the distal femur at the insertion of the adductor magnus or the origin of the gastrocnemius muscle. It most commonly occurs in patients who are age 10 to 15 years. The lesions are asymptomatic, with no palpable mass, pain, or swelling. They are frequently an incidental finding when radiographs are obtained for nonspecific symptoms or trauma about the knee. Following recognition of the characteristic imaging findings, observation is the management of choice.
REFERENCES: Dunham WK, Marcus NW, Enneking WF, et al: Developmental defects of the distal femoral metaphysis. J Bone Joint Surg Am 1980;62:801-806.
Verdonk PC, Verstraete K, Verdonk R: Distal femoral cortical irregularity in a 13-year old boy: A case report. Acta Orthop Belg 2003;69:377-381.

Question 95

Which of the following statements best describes the instantaneous axis of rotation (IAR) for the functional spinal unit? Review Topic

Explanation

The instantaneous axis of rotation is the axis about which each vertebral segment rotates, but is theoretical depending on how it is defined, and varies depending on multiple factors. It is not a fixed point but can move depending on the position of the spine, and it is affected by degenerative conditions, fractures, injuries, and other anatomic changes of the spine. There are three axes of movement with 6 degrees of freedom (rotation and translation movements about each axis).

Question 96

Which of the following statements best describes the kinematic behavior of the knee during motion from full extension to flexion?

Explanation

DISCUSSION: During normal knee flexion, knee kinematic analysis reveals that the medial tibiofemoral contact point moves very little (translates) in the anterior-posterior direction, whereas the lateral contact point moves much
greater in the anterior-posterior direction (translates), resulting in more lateral translation, rollback, and medial pivoting.
REFERENCE: Churchill DL, Incavo SJ, Johnson CC, et al: The transepicondylar axis approximates the optimal flexion axis of the knee. Clin Orthop Relat Res 1998;356:111-118.
Figure 98c Question 98
A 71-year-old businessman reports medial knee pain recalcitrant to nonsurgical management.
Examination reveals that his body mass index (BMI) is 28 and he has a mild varus deformity with a range of
motion from 5 degrees to 130 degrees of flexion. Anterior drawer and Lachman’s test are negative. Radiographs are shown in Figures 98a through 98c. For cultural and religious reasons, he is concerned about maintaining his range of motion and kneeling ability. Which of the following options is best?
High tibial osteotomy
Unicompartmental knee arthroplasty
Cruciate-retaining total knee arthroplasty with a fixed bearing design
Posterior stabilized total knee arthroplasty with a fixed bearing design
Cruciate-sacrificing total knee arthroplasty with a rotating platform design PREFERRED RESPONSE: 2
DISCUSSION: Unicompartmental arthroplasty of the knee is associated with better range of motion than either total knee arthroplasty or high tibial osteotomy. In a prospective randomized trial of unicompartmental and total knee arthroplasty for patients with medial compartment osteoarthritis, patients with the unicompartmental prosthesis had better range of motion. The literature that compares range of motion in cruciate-retaining as opposed to posterior stabilized and fixed bearing as opposed to mobile- bearing total knees suggests relatively equivalent range of motion between these designs.
REFERENCES: Newman JH, Ackroyd CE, Shah NE: Unicompartmental or total knee replacement? Five- year results of a prospective randomized trial of 102 osteoarthritic knees with unicompartmental arthritis.
J Bone Joint Surg Br 1998;80:862-865.
Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 59-69.

Question 97

A 26-year-old woman sustained a nondisplaced femoral neck fracture and treatment consisted of use of percutaneous cannulated screws. At her 3-month follow-up visit, she reports hip pain and is unable to ambulate. A radiograph is shown in Figure 1. What is the next most appropriate treatment?

Explanation

DISCUSSION: Femoral neck fracture nonunion is a challenging problem for orthopaedic surgeons. Vertical fractures are more prone to nonunion due to shear stress rather than compressive forces across the fracture site. Several authors have suggested these fractures are more common in young adults due to injury type and bone composition. It is widely regarded that an effort should be made to salvage the femoral head if vascularity remains. The most common method to treat this complication is valgus intertrochanteric osteotomy of the femur. This functionally makes a vertical fracture more horizontal, converting shear into compressive forces. It also helps correct the varus position of the fracture nonunion.
REFERENCES: Hartford JM, Patel A, Powell J: Intertrochanteric osteotomy using a dynamic hip screw for femoral neck nonunion. J Orthop Trauma 2005;19:329-333.
Mathews V, Cabanela ME: Femoral neck nonunion treatment. Clin Orthop Relat Res 2004;419:57-64.

Question 98

Figures 1 through 5 are the MR images of a 12-year-old boy with left lateral-sided knee pain following a football injury. He has a several-year history of recurrent knee pain that improves with rest. An examination reveals a moderate effusion. Range of motion is 0° to 90° and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted. Treatment should include

Explanation

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatment of a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.

Question 99

A 4-month-old infant is referred for evaluation of congenital scoliosis. The child has no congenital heart anomalies, and a renal ultrasound shows that he has one kidney. Examination reveals mild scoliosis and a large hairy patch on the child’s back. Neurologic evaluation is normal for his age. A clinical photograph and radiograph are shown in Figures 19a and 19b. Initial management should consist of Review Topic

Explanation

Congenital anomalies of the spine, including failure of formation and failure of segmentation, are associated with other anomalies in other organ systems that develop at the same time. These include anomalies in the genitourinary system, cardiac anomalies, Sprengel’s deformity, radial hypoplasia, and gastrointestinal anomalies including imperforate anus and trachealesophageal fistula. Spinal dysraphism is the most common associated abnormality. McMaster found an 18% incidence before the common use of MRI. Bradford and associates reported on 16 of 42 patients with congenital spinal anomalies and spinal dysraphism using MRI. Neural axis lesions may be associated with visible midline abnormalities such as a hairy patch or nevus. The child has already had a cardiac and renal work-up, and based on the findings of the hairy patch and congenital vertebral anomalies, MRI of the entire spine is prudent at this time. Spinal fusion is indicated for progressive congenital scoliosis or kyphosis. Physical therapy does not affect the natural history of congenital scoliosis.

Question 100

Which of the following is true regarding changes in the vascularity of the adult intervertebral disc with age? Review Topic

Explanation

As a person ages through adulthood, neovascularization of the intervertebral disc originates from the outer annulus.
The intervertebral disc is composed of an outer structure called the annulus fibrosis and an inner structure called the nucleus pulposus. The annulus fibrosis is composed
of type 1 collagen, water, and proteoglycans. The inner nucleus pulposus is composed of type 2 collagen, water, and proteoglycans. Intervertebral discs are avascular with capillaries terminating at the end plates. The nucleus pulposus receives nutrition primarily through diffusion through blood vessels within the endplate.
Roberts et al. review the histology and pathology of the intervertebral disc. They note that at birth, the cartilagenous end plates have large vascular channels through them as well as vascular channels through the annulus. Soon after birth, these vascular channels close with none remaining at the end of the first decade of life. However, with age, more blood vessels grow into the disc from the outer annulus fibrosis in response to degenerative changes.
Illustration A is a diagram of the vascular supply in an adult intervertebral disc. Incorrect Answers:

Full Question & Answer Text (for Search Engines)

Question 1:

Figure 39 shows the radiograph of a 4-month old infant who has been undergoing weekly casting since birth for a congenital equinovarus deformity. Management should now consist of

Options:

surgical correction.
continued casting.
botulinum toxin injection into the gastrocnemius-soleus complex.
an ankle-foot orthosis.
observation with no further treatment.

Correct Answer: surgical correction.

Explanation:

DISCUSSION: The radiograph shows the development of a rocker-bottom foot deformity. A rocker-bottom foot occurs in the treatment of clubfoot when casting is continued in the presence of a very tight gastrocnemius-soleus complex and an uncorrected hindfoot. While there are some preliminary reports on using Botox injection and continued casting for the equinus deformity, most authors recommend posterior or posterior medial release. Percutaneous tenotomy has been recently recommended with the resurgence of the Ponsetti technique.
REFERENCES: Lehman WB, Atar D: Complications in the management of talipes equinovarus, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992,
pp 135-136.
Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002,
pp 927-935.
Tachdjian MO: Pediatric Orthopedics, ed 2. Philadelphia, PA, WB Saunders, 1990,
pp 2461-2564.

Question 2:

Options:

Begin a stretching program.
Obtain shoulder radiographs and aspirate the shoulder joint.
Obtain an MRI scan to evaluate for a rotator cuff tear.
Schedule for irrigation and debridement.
Schedule for revision shoulder arthroplasty.

Correct Answer: Obtain shoulder radiographs and aspirate the shoulder joint.

Explanation:

DISCUSSION: The patient has the preliminary diagnosis of an infected shoulder arthroplasty; therefore, shoulder radiographs and joint aspiration for organism identification should be the first steps in the work-up. The patient is at risk for hematogenous spread given the recent history of pneumonia and her history of diabetes mellitus. Although she has stiffness, a stretching program is not indicated with the possibility of infection. Scheduling for revision arthroplasty, or irrigation and debridement will depend on multiple factors including identification of the infecting organism, the organism’s susceptibility to antibiotics, and implant stability. An MRI scan to evaluate for a rotator cuff tear is not indicated at this time.
REFERENCES: Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 953-954.
Stinchfield FE, Bigliani LU, Neu HC, et al: Late hematogenous infection of total joint replacement. J Bone Joint Surg Am 1980;62:1345-1350.

Question 3:

A 66-year-old man has a high-grade angiosarcoma of the right tibia. A radiograph is shown in Figure 43. Treatment should consist of

Options:

amputation.
wide resection.
radical resection.
radiation therapy.
chemotherapy.

Correct Answer: amputation.

Explanation:

Question 4:

What condition favors pollicization in hypoplasia of the thumb?

Options:

Extrinsic tendon abnormalities involving the flexor and extensor
Narrowing of the first web space
Insufficiency of the ulnar collateral ligament of the metaphalangeal joint
Unstable carpometacarpal joint

Correct Answer: Unstable carpometacarpal joint

Explanation:

DISCUSSION
The decision to ablate and pollicize vs preserve and reconstruct is based on the stability of the carpometacarpal joint. A stable thumb is more easily used in prehension activities of grasping and pinching. All other responses are associated with surgical options for reconstruction of the thumb. The carpometacarpal joint is the “keystone” for thumb-to-hand attachment. Without a stable carpometacarpal joint, pollicization may be required. No other response necessitates pollicization.
RECOMMENDED READINGS
McCarroll HR. Congenital anomalies: a 25-year overview. J Hand Surg Am. 2000 Nov;25(6):1007-37. Review. PubMed PMID: 11119659.
View Abstract at PubMed
Manske PR, Goldfarb CA. Congenital failure of formation of the upper limb. Hand Clin. 2009 May;25(2):157-70. doi: 10.1016/j.hcl.2008.10.005. Review. PubMed PMID: 19380058.
View Abstract at PubMed

Question 5:

- A 15-year-old dancer who has had brief episodes of back pain over the past 2 years now reports a 3 month history of low back pain and a decreased tolerance for dance. Figure 22a-c show flexion and extension x-rays and CT scan. She reports no leg pain, nor any bowel or bladder difficulties. Management should now consist of

Options:

Post spinal fusion from L5to S1
Primary repair with an iliac bone graft
Post spinal fusion of L4-5
A pantaloon body cast and 6 weeks of bed rest
Rest, NSAIDS, and limited dancing

Correct Answer: Rest, NSAIDS, and limited dancing

Explanation:

Question 6:

Options:

Anterior shoulder instability
Early adhesive capsulitis
Internal impingement
Subacromial impingement
Full-thickness rotator cuff tear

Correct Answer: Internal impingement

Explanation:

Question 7:

A 42-year-old woman underwent an instrumented posterior spinal fusion at L3-S1 with transforaminal lumbar interbody fusion. She had an excellent

Options:

Observation
Oral antibiotics only
IV antibiotics only
Irrigation and debridement of the surgical site
Irrigation and debridement of the surgical site with hardware removal

Correct Answer: Irrigation and debridement of the surgical site

Explanation:

Question 8:

Options:

MRI scan of the ankle
Non-weight-bearing cast for 6 weeks
Removable walking boot and progressive weight bearing
Open reduction and internal fixation of the fibula
Open reduction and internal fixation of the fibula with medial ligament repair

Correct Answer: Removable walking boot and progressive weight bearing

Explanation:

Question 9:

Options:

split-thickness skin graft.
thenar flap.
cross-finger flap.
lateral arm flap.
Moberg (volar advancement) flap.

Correct Answer: cross-finger flap.

Explanation:

DISCUSSION: The wound described indicates loss of soft tissue directly to the level of the tendon, precluding use of skin grafts if excursion of the tendon is desired. A cross-finger
flap is ideal for small wounds on the volar aspect of digits. A thenar flap is suitable for tip injuries. A lateral arm flap will not reach the fingers. A Moberg flap is limited to distal injuries of the thumb.
REFERENCES: Kappel DA, Burech JG: The cross-finger flap: An established reconstructive procedure. Hand Clin 1985;1:677-683.
Lister GD: Skin flaps, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1741.

Question 10:

Options:

result in increased bone density.
accelerate healing of the femoral fracture.
lower the serum phosphate level.
reduce processing of future bone metastases.
heal other impending fractures.

Correct Answer: reduce processing of future bone metastases.

Explanation:

Question 11:

Options:

Acetabular revision, with placement of a custom triflange acetabular component and femoral head exchange
Removal of the femoral and acetabular components and placement of an antibiotic spacer, with 6 weeks of intravenous antibiotics
Head and liner exchange and retention of the femoral and acetabular implants with acetabular bone grafting
Nonsurgical management with the initiation of bisphosphonates and referral to pain management

Correct Answer: Acetabular revision, with placement of a custom triflange acetabular component and femoral head exchange

Explanation:

Question 12:

Options:

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

Correct Answer: cervical MRI followed by reduction.

Explanation:

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

Question 13:

Options:

recruitment in the extensor pollicis longus, abductor pollicis longus, extensor digitorum communis, and extensor carpi ulnaris muscles. Which nerve is most likely compressed?
Median
Radial
Anterior interosseous
Posterior interosseous
Lateral antebrachial cutaneous

Correct Answer: Anterior interosseous

Question 14:

Options:

Biceps tenodesis
Superior labrum anterior to posterior (SLAP) repair
Rotator cuff repair
Distal clavicle excision The patient has a clinical history and physical examination consistent with degenerative superior labral pathology, which is supported by the MRI scan. She has failed appropriate nonoperative treatment, and surgical intervention would be indicated. In a middle-aged patient with a degenerative superior labral tear, biceps tenodesis has been shown to have better outcomes and return to sport than SLAP repair. In a young patient with a traumatic superior labral tear, repair would be indicated. The other MRI findings noted are incidental and asymptomatic in this patient. As a result, rotator cuff repair or distal clavicle excision is not indicated.

Correct Answer: Biceps tenodesis

Explanation:

Question 15:

Up to what time frame are the risks minimized in anterior revision disk replacement surgery?

Options:

3 days
1 week
10 days
2 weeks
6 weeks

Correct Answer: 2 weeks

Explanation:

DISCUSSION: Revision anterior exposure within 2 weeks of total disk replacement incurs relatively little additional morbidity because adhesion formation is minimal. Surgeons should have a low threshold for revising implants that are clearly dangerously malpositioned or show early migration within this 2-week window. Beyond this time period, a revision strategy must be individualized to the particular clinical situation. A posterior fusion with instrumentation with or without a laminectomy is currently the most effective salvage procedure.
REFERENCE: Tortolani JP, McAfee PC, Saiedy S: Failures of lumbar disc replacement. Sem Spine Surg 2006;18:78-86.

Question 16:

Which of the following is considered the cause of Milwaukee shoulder, a joint disease similar to rotator cuff arthropathy?

Options:

Abundance of basic calcium phosphate crystals
Abundance of calcium pyrophosphate crystals
Gout
Rheumatoid arthritis
Osteonecrosis

Correct Answer: Abundance of basic calcium phosphate crystals

Explanation:

Question 17:

Which gene correlates with severity of disease in spinal muscular atrophy (SMA)? Review Topic

Options:

Peripheral myelin protein 22 (PMP22)
Survival motor neuron I (SMN1)
Survival motor neuron II (SMN2)
Dystrophin

Correct Answer: Survival motor neuron II (SMN2)

Explanation:

Question 18:

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

Options:

dural ectasia.
Lisch nodules.
juvenile xanthogranuloma.
malignant peripheral nerve sheath tumor.
plexiform neurofibroma.

Correct Answer: plexiform neurofibroma.

Explanation:

Question 19:

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 20:

When an acute infection of a total elbow arthroplasty is managed with irrigation and debridement, which of the following organisms is associated with the highest risk of persistent infection?

Options:

Enterococcus cloacae
Klebsiella
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus

Correct Answer: Staphylococcus epidermidis

Explanation:

DISCUSSION: Salvage of a total elbow arthroplasty is possible with early aggressive management of acute infection (symptoms for less than 30 days) with serial irrigation and debridement and antibiotic bead placement. This form of treatment is indicated when there are no radiographic or intraoperative signs of loosening. However, successful treatment is largely dependent on the organism. Staphylococcus epidermidis is associated with persistent infection because it is an encapsulating organism, and it is best treated with implant removal and
IV antibiotics.
REFERENCES: Yamaguchi K, Adams RA, Morrey BF: Infection after total elbow arthroplasty. J Bone Joint Surg Am 1998;80:481-491.
Schoifet SD, Morrey BF: Treatment of infection after total knee arthroplasty by debridement with retention of the components. J Bone Joint Surg Am 1990;72:1383-1390.

Question 21:

Options:

Primary repair of injured structure
Primary repair of injured structure combined with anterior and medial tibial tubercle transfer
Immobilization of knee in full extension with a progressive weight-bearing exercise program
Semitendinosus or gracilis tendon autograft reconstruction of the injured structure
CT angiography followed by primary repair of injured structure if the limb has vascular stability

Correct Answer: CT angiography followed by primary repair of injured structure if the limb has vascular stability

Explanation:

Question 22:

Options:

Tendon transfer, lateral column lengthening, and heel cord lengthening
Triple arthrodesis and heel cord lengthening
Tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening
Tendon transfer, spring ligament repair, and heel cord lengthening
Tendon repair, medial displacement calcaneal osteotomy, and heel cord lengthening

Correct Answer: Tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening

Explanation:

DISCUSSION: The patient has an atypical adult flatfoot deformity. The radiographs reveal forefoot abduction, mild loss of calcaneal pitch, and marked plantar flexion sag through the naviculocuneiform joint. The inability to perform a single limb heel rise indicates that the posterior tibial tendon is nonfunctional; however, the deformity remains flexible. In this patient, surgical treatment should include a tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening. Because a substantial portion of the deformity stems from the naviculocuneiform joint in this instance, tendon transfer and lateral column lengthening alone provide insufficient deformity correction. Triple arthrodesis and heel cord lengthening is best reserved for fixed flatfoot deformities. Soft-tissue procedures alone are associated with a high failure rate, as are attempted tendon repairs.
REFERENCES: Greisberg J, Assal M, Hansen ST Jr, et al: Isolated medial column stabilization improves alignment in adult-acquired flatfoot. Clin Orthop Relat Res 2005;435:197-202.
Greisberg J, Hansen ST Jr, Sangeorzan BJ: Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot. Foot Ankle Int 2003;24:530-534.

Question 23:

Options:

High hip center
Anatomic hip center with trochanteric osteotomy and progressive femoral shortening
Anatomic hip center with subtrochanteric shortening osteotomy
Iliofemoral lengthening followed by an anatomic hip center

Correct Answer: Anatomic hip center with subtrochanteric shortening osteotomy

Explanation:

Question 24:

Options:

In extension with internal rotation/valgus force, the medial tibial plateau is subluxated; with flexion, the medial tibial plateau reduces.
In extension with internal rotation/valgus force, the medial tibial plateau is reduced; with flexion, the medial tibial plateau subluxates.
In extension with internal rotation/valgus force, the lateral tibial plateau is reduced; with flexion, the lateral plateau subluxates.
In extension with internal rotation/valgus force, the lateral tibial plateau is subluxated; with flexion, the lateral plateau reduces.

Correct Answer: In extension with internal rotation/valgus force, the lateral tibial plateau is subluxated; with flexion, the lateral plateau reduces.

Explanation:

Question 25:

Type I collagen fibers in peripheral nerves are primarily responsible for which of the following?

Options:

Conduction strength
Tensile strength
Conduction velocity
Compressive strength
Cross-linkage

Correct Answer: Conduction velocity

Explanation:

Question 26:

Options:

0 to 15 degrees
20 to 30 degrees
40 to 90 degrees
100 to 120 degrees
130 to 140 degrees

Correct Answer: 40 to 90 degrees

Explanation:

Question 27:

Options:

No treatment is required because spontaneous healing is common.
Nonsurgical management typically relieves pain and results in radiographic healing in less than 12 weeks.
Nonsurgical management frequently relieves pain but often may not result in radiographic healing even 6 months after treatment.
Hyperbaric oxygen treatment is helpful.
Ankle fusion is frequently necessary.

Correct Answer: Nonsurgical management frequently relieves pain but often may not result in radiographic healing even 6 months after treatment.

Explanation:

Question 28:

Options:

open reduction and internal fixation.
percutaneous pin fixation.
excision of the fracture fragment.
primary calcaneocuboid joint arthrodesis.
a walking cast or removable cast boot.

Correct Answer: a walking cast or removable cast boot.

Explanation:

Question 29:

Options:

a University of California Biomechanics Laboratory (UCBL) orthosis.
subtalar arthrodesis.
physeal bar resection.
tibial epiphysiodesis.
closing wedge distal tibial osteotomy.

Correct Answer: closing wedge distal tibial osteotomy.

Explanation:

Question 30:

Options:

Odds ratio
Incidence rates
Prevalence rates
Relative risk
Confidence intervals

Correct Answer: Relative risk

Explanation:

Question 31:

They found statistically significant decreases in need for secondary intervention, hardware failure, and infection as well as faster wound healing and faster time to fracture union.

Options:

Wei et al. provide a meta analysis regarding use of rhBMP-2 in open tibia fractures. Due to decreased rates of secondary interventions they estimated a net savings of $6,000 per case when rh-BMP2 was used. They found no significant difference in rates of infection, postoperative pain, hardware failure, or fracture healing at 20 weeks.
Incorrect answers:

Correct Answer: Wei et al. provide a meta analysis regarding use of rhBMP-2 in open tibia fractures. Due to decreased rates of secondary interventions they estimated a net savings of $6,000 per case when rh-BMP2 was used. They found no significant difference in rates of infection, postoperative pain, hardware failure, or fracture healing at 20 weeks.

Explanation:

OrthoCash 2020
A 76-year old patient underwent partial foot amputation through the talonavicular and calcaneocuboid joints. Besides Achilles tendon lengthening, what additional procedure(s) may be required to prevent the most common post-operative deformity?
Posterior capsule release
Anterior tibialis transfer to the talar neck
Anterior tibialis transfer to cuboid
Flexor hallucis longus transfer to calcaneus
Peroneus brevis transfer to calcaneus
Corrent answer: 2
Achilles tendon lengthening AND anterior tibialis transfer to the talar neck would be required to prevent equinovarus deformity.
Partial foot amputation through the talonavicular and calcaneocuboid joints is also known as the Chopart amputation. Chopart amputation alone is known to result in significant equinovarus deformity. This deformity results in excessive pressure on the anterior wound during gait, causing pain and wound complications. Transfer of the tibialis anterior tendon to talar neck will provide force, and muscle tone, that promotes ankle dorsiflexion. Lengthening of the Achilles tendon will also reduce the equinus moment force across the ankle joint.
Dillion et al. examined the gait patterns of partial foot amputees. They found that amputations proximal to the metatarsal heads compromised the normal propulsive function of the foot and ankle. The ideal level of amputation to maintain normal propulsive function was distal to the metatarsal heads (i.e., disarticulating the metatarsophalangeal (MTP) joint).
Illustration A is a lateral radiograph showing a Chopart amputation. Incorrect Answers:
prevent the equinovarus deformity.
OrthoCash 2020
A 32-year-old male is involved in a motor vehicle collision and sustains the injury seen in Figure A. What is the most common urological injury associated with this injury pattern?
Testicular torsion
Posterior urethral tear
Bladder denervation
Testicular rupture
Renal hematoma
The figure shows an anteroposterior pelvic ring injury. The most common urological injury with pelvic ring injuries remains the posterior urethral tear, followed by bladder rupture.
Watnik et al notes lower urinary tract (bladder to end of urethra) injuries in up to 25% of patients with this injury. He reports that when contaminated urine communicates with the anterior arch, the possibility of infection exists, and early repair of bladder disruptions with simultaneous anterior arch plating minimizes this risk.
Routt et al notes that even with simultaneous treatment of these injuries, complications are common (late stricture in 44%, impotence in 16%, delayed incontinence in 20% of females, anterior deep pelvic infection in 4%). Despite this, they report that early urological repairs are easily performed at the time of anterior pelvic open reduction and internal fixation.
OrthoCash 2020
A 26-year-old women, 31-weeks pregnant, presents to the emergency department with the injury shown in Figure A. She states the injury occurred while lifting a heavy vacuum five days ago. She suffers from chronic headaches and sleep disturbances. On inspection, there are multiple dorsal and volar bruising over her wrist and upper arm. She is neurologically intact. After closed reduction and immobilizing the arm, what would be the next best step in management of this patient?
Diagnostic wrist arthroscopy
Urgent MRI wrist
Skeletal survey radiographs
Request a consultation with social worker in the hospital
Urgent open reduction internal fixation
Corrent answer: 4
This patient presents with classic features of domestic violence. The most appropriate next step would be consultation with a social worker at the hospital, assess for child and patient safety, and encouraging the patient to seek self-protection.
Factors suggestive of domestic violence in the patient include pregnancy, delayed presentation after injury, inconsistent history, multiple bruises and complaints of chronic headache/sleep disturbances. Victims frequently miss days of work and as a result are at risk for losing their jobs. Victims are also more likely to engage in high-risk behavior with sex, drugs, alcohol, smoking, and eating.
The AAOS published a document outlining the Orthopaedic Surgeon’s responsibilities in domestic and family violence. Musculoskeletal injuries that should raise a suspicion of a problem include (1) Multiple injuries/fractures; (2) Unusual patterns of injury/fracture; (3) Injuries/fractures of varying ages; (4)
Injuries/fractures inconsistent with or disproportional to the history; (5) Multiple injuries treated in different hospital emergency departments or by different providers.
Incorrect Answers:
OrthoCash 2020
A 45-year-old man undergoes open reduction and internal fixation for a comminuted intra-articular humerus fracture . An olecranon osteotomy is performed and subsequently fixed with an intramedullary cancellous screw. Which of the following options in the table shown in Figure A best describes the characteristics of this osteotomy?

Question 32:

Options:

Laxity of the volar plate
Intraosseous tendon
Extensor digitorum longus tendon
Extensor digitorum brevis tendon
Flexor digitorum longus tendon

Correct Answer: Flexor digitorum longus tendon

Explanation:

Question 33:

Options:

Chondroblastoma
Lymphoma
Giant cell tumor
Chondromyxoid fibroma
Desmoplastic fibroma

Correct Answer: Giant cell tumor

Explanation:

Question 34:

During a retroperitoneal approach to the L4-5 disk, what structure must be ligated to safely mobilize the common iliac vessels toward the midline from laterally and gain exposure?

Options:

Obturator vein
Iliolumbar vein
External iliac vein
Middle sacral artery
Hypogastric artery

Correct Answer: Iliolumbar vein

Explanation:

DISCUSSION: To mobilize the common iliac vessels across the midline, the iliolumbar vein must be ligated. It has a short trunk and can be torn if mobilization is attempted without ligation. It is the only branch off the common iliacs (there are no arterial branches) prior to the terminal branches, the internal (hypogastric) and external iliacs. The middle sacral vessels run distally from the axilla of the bifurcation and are a factor when accessing the L5-S1 disk.
REFERENCES: Baker JK, Reardon PR, Reardon MJ, et al: Vascular injury in anterior lumbar surgery. Spine 1993;18:2227-2230.
Lewis WH: Gray’s Anatomy of the Human Body: The Veins of the Lower Extremity, Abdomen, and Pelvis, ed 20. Philadelphia, PA, Lea & Febiger, 2000.

Question 35:

Options:

Shoulder fusion
Arthroscopic subscapularis repair
Intra-articular corticosteroid injection
Open subscapularis repair
Pectoralis major transfer

Correct Answer: Pectoralis major transfer

Explanation:

Question 36:

Options:

Physical therapy for restoration of motion
Elbow arthroscopy, removal of loose bodies, excision of osteophytes, and capsular release (osteocapsulectomy)
Elbow arthroscopy and synovectomy
Constrained total elbow arthroplasty
Semiconstrained total elbow arthroplasty

Correct Answer: Semiconstrained total elbow arthroplasty

Explanation:

Question 37:

Options:

Cephalosporin
Cephalosporin and aminoglycoside
Cephalosporin and penicillin
Cephalosporin and vancomyacin
Cephalosporin, aminoglycoside, and penicillin

Correct Answer: Cephalosporin, aminoglycoside, and penicillin

Explanation:

DISCUSSION: A farm injury is automatically considered a grade III (Gustillo classification) injury regardless of size, energy, or additional soft-tissue injury due to the likelihood of substantial contamination. Antibiotic recommendations for grade III injuries include a first- or second-generation cephalosporin with an aminoglycoside or fluoroquinolone within 3 hours of injury, with penicillin added for farm injuries.
REFERENCES: Okike K, Bhattacharyya T: Trends in the management of open fractures: A critical analysis. J Bone Joint Surg Am 2006;88:2739-2748.
Holtom PD: Antibiotic prophylaxis: Current recommendations. J Am Acad Orthop Surg 2006:14:S98-S100.

Question 38:

Options:

Synovial herniation pits
Osteoid osteoma
Fibrous dysplasia
Metastatic bone disease
Multiple enchondromas

Correct Answer: Synovial herniation pits

Explanation:

DISCUSSION: Synovial herniation pits or Pitt’s pits are tumor simulators and are incidentally identified on radiographs obtained for either pain or trauma. The main diagnostic pitfall with this lesion is mistakenly identifying it as an osteoid osteoma. Accurate diagnosis is achieved by knowledge of the location and the characteristic imaging appearance. These are common lesions in individuals with femoroacetabular impingement.
REFERENCES: Pitt MJ, Graham AR, Shipman JH, et al: Herniation pit of the femoral neck. Am J Roentgenol 1982;138:1115-1121.
Daenen B, Preidler KW, Padmanabhan S, et al: Symptomatic herniation pits of the femoral neck: Anatomic and clinical study. Am J Roentgenol 1997;168:149-153.

Question 39:

Options:

oral antibiotics.
IV antibiotics.
surgical drainage of the perivertebral abscess and IV antibiotics.
bed rest.
cast immobilization.

Correct Answer: IV antibiotics.

Explanation:

DISCUSSION: The patient has diskitis. Administration of IV antibiotics speeds resolution and minimizes recurrence. Bed rest and cast immobilization have been successfully used to treat this disorder but can be associated with prolonged recovery and frequent recurrence, even when oral antibiotics are administered. A perivertebral abscess seen in association with this condition usually resolves without surgery.
REFERENCES: Ring D, Johnston CE II, Wenger DR: Pyogenic infectious spondylitis in children: The convergence of discitis and vertebral osteomyelitis. J Pediatr Orthop
1995;15:652-660.
Crawford AH, Kucharzyk DW, Ruda R, et al: Diskitis in children. Clin Orthop 1991;266:70-79.

Question 40:

A 13-year-old boy has a radiographically mild, clinically stable slipped capital femoral epiphysis (SCFE). What is the most appropriate treatment? Review Topic

Options:

Spica casting
Open reduction and internal fixation
Single screw in situ fixation of the epiphysis
Two-screw in situ fixation of the epiphysis
Crutches and no weight bearing for 6 weeks

Correct Answer: Spica casting

Explanation:

The accepted treatment of a stable SCFE lesion involves fixation of the epiphysis in situ with a single screw that is perpendicular to the epiphysis and central in both the AP and lateral planes. Constructs such as the three-screw inverted triangle configuration have increased rates of penetration of the femoral head as well as femoral head osteonecrosis. Spica casting was once a popular treatment modality but is associated with a high incidence of chondrolysis and is no longer recommended. Closed reduction attempts increase the risk of osteonecrosis.
(SBQ13PE.46) What developmental milestones are likely to be present in a 30-month-old child?
Review Topic
Hand dominance established
Hops on one foot
Heel-to-toe walk
Puts shoes on correct feet
Manages buttons
Hand dominance is usually established in the third year of life.
Normally, children younger than 2 years of age are ambidextrous. In some normal cases this persists after 2 years. Although there is some variability in this timing, strong hand preference in a younger child may be the result of a neurologic deficit.
Frankenburg et al. used the Denver Developmental Screening Test (DDST) to evaluate 1036 Denver area children from 2 to 6.4 years. The ages at which 25, 50, 75 and 90 percent of children could perform tasks were calculated to establish norms for the sample. The authors stress that the DDST is not an intelligence test, but rather a screening test to be used in clinical practice to determine whether a child's development is within the normal range.
Illustration
A
shows
the
DDST.
Incorrect
2:
Normal
for

Question 41:

- Work-related injuries to the lower back are most often related to which of the following risk factors?

Options:

Female gender
History of cigarette smoking
L5-S1 spondylolisthesis on pre-employment radiography
Decreased strength of the lower extremities on pre-employment testing
Decreased flexibility of the lumbar spine on pre-employment testing

Correct Answer: History of cigarette smoking

Explanation:

Question 42:

A 6-year-old sustains the injury shown in Figures A and B. The nerve most commonly affected by this fracture pattern innervates which of the following motor groups?

Options:

Intrinsics of the hand
Wrist extensor
Thumb extensor
Thumb IP flexor
Digital extensor

Correct Answer: Intrinsics of the hand

Explanation:

Question 43:

Options:

a percutaneous pectoralis tenotomy.
a modified L’Episcopo procedure.
serial lidocaine nerve blocks.
pectoralis tenotomy and subscapularis tendon lengthening.
phenol nerve blocks.

Correct Answer: pectoralis tenotomy and subscapularis tendon lengthening.

Explanation:

Question 44:

Clinical evidence suggests that grafts for replacing a torn anterior cruciate ligament often stretch after surgery. What is the most probable mechanism for this behavior?

Options:

Gross failure at the attachment sites
Fatigue failure of the ligament tissue
Creep of the graft material
Water absorption by the graft material
Elastic stretch of collagen fibers

Correct Answer: Creep of the graft material

Explanation:

DISCUSSION: The stretching of the graft occurs over time as the graft is loaded. Time-dependent deformation under load is called creep and is common in viscoelastic materials such as ligament tissue. Creep can occur under both static and cyclic load conditions; time-dependent deformation will occur as long as load is applied to the tissue. Similarly, when a graft is initially tensioned to a given deformation at surgery, the load generated in the graft will decrease over time; this behavior is called stress relaxation and also is indicative of a viscoelastic material. Water content may affect the viscoelastic properties by changing the friction between collagen fibers, but studies have shown little difference in water content between grafts and normal ligaments. Fatigue failures may manifest themselves through damage to the ligament tissue, but this would require higher loads than are routinely experienced by grafts. Elastic stretch is recoverable and, therefore, does not contribute to a permanent stretch. Similarly, gross failure at the attachment would not cause a stretch, but rather a catastrophic instantaneous instability.
REFERENCES: Boorman RS, Thornton GM, Shrive NG, et al: Ligament grafts become more susceptible to creep within days after surgery. Acta Orthop Scand 2002;73:568-574.
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 596-609.
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 45:

A 40-year-old unrestrained passenger reports chest wall pain after a motor vehicle accident. Which of the following structures is most important in preventing the injury shown in Figure 33?

Options:

First rib
Intra-articular disk ligament
Costoclavicular ligament
Interclavicular ligament
Posterior sternoclavicular joint capsule

Correct Answer: Posterior sternoclavicular joint capsule

Explanation:

DISCUSSION: Through cadaveric study, Spencer and associates measured anterior and posterior translation of the sternoclavicular joint. The study demonstrated that the posterior sternoclavicular joint capsule is the most important structure for preventing both anterior and posterior translation of the sternoclavicular joint.
REFERENCES: Gilot GJ, Wirth MA, Rockwood CA: Injuries to the sternoclavicular joint, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott, Williams and Wilkins, 2006, vol 2, pp 1373-1374.
Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.

Question 46:

Options:

Buttock pain; pain with hip extension, adduction, and external rotation while prone
Pain during sitting; flexion abduction and external rotation of the hip
Groin pain; pain with internal rotation and adduction while supine with the hip and knee flexed 90°
Clicking; abductor lurch

Correct Answer: Pain during sitting; flexion abduction and external rotation of the hip

Explanation:

Question 47:

During a posterior approach to the right Achilles tendon, the surgeon encounters a nerve running with the small saphenous vein as shown in Figure 22. This nerve innervates what part of the foot?

Options:

Posterior heel
Plantar-lateral foot
Plantar-medial foot
Dorso-lateral foot
Dorso-medial foot

Correct Answer: Dorso-lateral foot

Explanation:

DISCUSSION: The sural nerve runs with the small saphenous vein on the posterior leg just lateral to the Achilles tendon. It is formed by contributions from both the tibial and common peroneal nerves and provides sensation on the dorso-lateral aspect of the foot.
REFERENCES: Aktan Ikiz ZA, Ucerler H, Bilge O: The anatomic features of the sural nerve with an emphasis on its clinical importance. Foot Ankle Int 2005;26:560-567.
Lawrence SJ, Botte MJ: The sural nerve in the foot and ankle: An anatomic study with clinical and surgical implications. Foot Ankle Int 1994;15:490-494.

Question 48:

A 38-year-old woman fell from a ladder onto her right hip. The radiographs and CT scan are shown in Figures 52a through 52d. What is the best surgical approach for this fracture?

Options:

Kocher-Langenbeck
Iliofemoral
Ilioinguinal
Extended iliofemoral
Triradiate approach

Correct Answer: Ilioinguinal

Explanation:

DISCUSSION: The fracture is an associated both column fracture. The best approach for this fracture is the ilioinguinal. The Kocher-Langenbeck is best for posterior injuries to the acetabulum and some transverse fractures. The iliofemoral alone is limited to high anterior column injuries. The extended iliofemoral and triradiate approaches although useful for this fracture, have a higher rate of complications.
REFERENCES: Letournel E: The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat Res 1993;292:62-76.
Matta JM: Operative treatment of acetabular fractures through the ilioinguinal approach:
A 10-year perspective. Clin Orthop Relat Res 1994;305:10-19.

Question 49:

Options:

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

Correct Answer: Poor because it is a late infection

Explanation:

Question 50:

During the early swing phase of the normal gait cycle, what lower extremity muscle is primarily contracting?

Options:

Tibialis posterior
Tibialis anterior
Vastus medialis
Adductor longus
Gastrocnemius

Correct Answer: Tibialis anterior

Explanation:

DISCUSSION: Electromyography during walking reveals the tibialis anterior muscle is active during early swing, allowing the foot to clear the ground. All of the other muscles are quiet, as the limb moves forward through space with minimal muscular effort. The other muscles are primarily active during weight acceptance or push-off.
REFERENCES: Gage JR: An overview of normal walking. Instr Course Lect 1990;39:291-303.
Wootten ME, Kadaba MP, Cochran GV: Dynamic electromyography II: Normal patterns during gait. J Orthop Res 1990;8:259-265.

Question 51:

What pathology is most likely to result in failure of an arthroscopic Bankart repair?

Options:

A 25% or greater anterior-inferior glenoid rim defect
Nonengaging moderate Hill-Sachs defect
Associated type IV superior labrum anterior and posterior (SLAP) lesion
Absence of an intact cartilaginous labrum
Atttenuated anterior-inferior capsule and glenohumeral ligament complex

Correct Answer: A 25% or greater anterior-inferior glenoid rim defect

Explanation:

Question 52:

Options:

His clinical outcome will correlate closely with his initial reduction.
His outcome will correlate with his radiographic score on the Ankle Osteoarthritis Score.
He will likely require a late ankle arthrodesis.
He will demonstrate marked limitations with regard to recreational activities.
He will perceive improvements for a period of over 2 years.

Correct Answer: He will perceive improvements for a period of over 2 years.

Explanation:

DISCUSSION: Marsh and associates retrospectively reviewed 56 tibial plafond fractures and found that the patients perceived improvement in their function and pain for an average of 2.4 years. They demonstrated some limitations in recreational activities but not marked limitations. Patients were unlikely to need a late arthrodesis (13%), and their outcomes did not correlate well with assessments of reduction or arthritis scores.
REFERENCE: Marsh JL, Weigel DP, Dirschl DR: Tibial plafond fractures: How do these ankles function over time? J Bone Joint Surg Am 2003;85:287-295.

Question 53:

Options:

Resection arthroplasty
Single-stage revision total elbow arthroplasty
Two-stage revision elbow arthroplasty
Aggressive arthroscopic debridement and retention of components

Correct Answer: Two-stage revision elbow arthroplasty

Explanation:

Question 54:

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

Options:

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

Correct Answer: Milking maneuver

Explanation:

Question 55:

Options:

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

Correct Answer: immediate subscapularis repair.

Explanation:

Question 56:

Options:

Osteomyelitis
Eosinophilic granuloma
Osteosarcoma
Ewing’s sarcoma
Lymphoma of bone

Correct Answer: Eosinophilic granuloma

Explanation:

Question 57:

Options:

Pseudoparalysis secondary to fracture of the proximal humerus
Cervical myelomeningocele
Erb palsy
Arthrogryposis
Cerebral palsy and spastic hemiplegia

Correct Answer: Erb palsy

Explanation:

Question 58:

Options:

Flexor hallucis longus
Flexor digitorum longus
Flexor digitorum brevis
Peroneus longus
Split anterior tibial tendon

Correct Answer: Flexor digitorum longus

Explanation:

Question 59:

Options:

Surgical management will lead to more improvement in pain but not function
Surgical management will have higher 4-year mortality
Surgical management will lead to more improvement in pain, function, and satisfaction
Nonsurgical management will lead to more improvement in pain but not function
Surgical management will lead more improvement in function, but less improvement in pain

Correct Answer: Nonsurgical management will lead to more improvement in pain but not function

Explanation:

Question 60:

Figure 20 shows the MRI scan of a 20-year-old athlete who has a painful shoulder. This pathology is most commonly seen in

Options:

baseball pitchers.
downhill skiers.
football linemen.
volleyball players.
tennis players.

Correct Answer: football linemen.

Explanation:

Question 61:

The thickest bone in the occiput is located

Options:

in no predictable pattern.
at the level of the foramen magnum.
at the level of the external occipital protuberance.
4 cm below the external occipital protuberance.
4 cm lateral to the external occipital protuberance.

Correct Answer: at the level of the external occipital protuberance.

Explanation:

Question 62:

Options:

Calcified transverse scapular ligament
Parsonage-Turner syndrome
Spinoglenoid notch cyst
Quadrilateral space syndrome

Correct Answer: Spinoglenoid notch cyst

Explanation:

Question 63:

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 64:

Options:

Inability to extend the thumb
Lateral volar forearm numbness
Inability to flex the middle finger
Medial volar forearm numbness
Dorsal thumb numbness

Correct Answer: Medial volar forearm numbness

Explanation:

Question 65:

Up to what time frame are the risks minimized in anterior revision disk replacement surgery? Review Topic

Options:

3 days
1 week
10 days
2 weeks
6 weeks

Correct Answer: 2 weeks

Explanation:

Question 66:

Options:

flexion and extension radiographs of the lumbosacral spine.
diskography.
an MRI scan of the lumbosacral spine.
a bone scan with single proton emission computed tomography (SPECT).
a renal ultrasound.

Correct Answer: a bone scan with single proton emission computed tomography (SPECT).

Explanation:

Question 67:

Options:

subtalar arthritis.
middle-facet coalition.
lateral impaction syndrome.
calcaneonavicular coalition.

Correct Answer: lateral impaction syndrome.

Explanation:

DISCUSSION
With the use of CT scans, adults with symptomatic flatfoot deformity have been noted to develop subluxation of the talocalcaneal joint with resulting lateral hindfoot pain. Impingement of the talus and calcaneus in the sinus tarsi and/or between the tip of the fibula and the calcaneus may occur. This impingement is known as lateral impaction syndrome. Hindfoot motion is painless; therefore, this patient does not have symptomatic subtalar arthritis. Middle facet and calcaneonavicular coalitions are not present (hindfoot motion is present).
RECOMMENDED READINGS
Malicky ES, Crary JL, Houghton MJ, Agel J, Hansen ST Jr, Sangeorzan BJ. Talocalcaneal and subfibular impingement in symptomatic flatfoot in adults. J Bone Joint Surg Am. 2002 Nov;84-A(11):2005-9. PubMed PMID: 12429762. ?
View Abstract at PubMed
Ananthakrisnan D, Ching R, Tencer A, Hansen ST Jr, Sangeorzan BJ. Subluxation of the talocalcaneal joint in adults who have symptomatic flatfoot. J Bone Joint Surg Am. 1999 Aug;81(8):1147-54. PubMed PMID: 10466647. ?
View Abstract at PubMed

Question 68:

Options:

Synovial sarcoma
Adamantinoma - metastatic prostate cancer
Chondrosarcoma
Dedifferentiated chondrosarcoma
Periosteal osteosarcoma

Correct Answer: Dedifferentiated chondrosarcoma

Explanation:

DISCUSSION: The biopsy specimens reveal a high-grade spindle cell lesion adjacent to an area of benign cartilage. This is consistent with a dedifferentiated chondrosarcoma. The radiograph shows a pathologic fracture through a lesion characterized by calcification within the left greater trochanter. Distal to the area of calcification, there is a more osteolytic, destructive appearance. Synovial sarcoma has a biphasic appearance histologically with areas of glandular differentiation that stain positive with keratin. Metastatic prostate cancer, although osteoblastic in appearance, would have a glandular histologic appearance. There is no cartilage in these lesions. Classic low-grade chondrosarcoma does not have an area of high-grade pleomorphic spindle cells within the lesion. A periosteal osteosarcoma is a surface-based lesion with a sunburst radiographic pattern. Although there may be cartilage in the lesion histologically, there are also malignant cells producing osteoid. Dedifferentiated chondrosarcoma is an aggressive, high-grade variant of chondrosarcoma.
REFERENCES: Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 269.
Mercuri M, Picci P, Campanacci L, et al: Dedifferentiated chondrosarcoma. Skeletal Radiol 1995;24:409-416.

Question 69:

Options:

2 to 5 days, followed by initiation of assisted motion.
14 to 21 days, followed by initiation of assisted motion.
4 weeks, followed by active motion.
6 weeks, followed by physical therapy.
8 weeks, followed by active motion of the elbow.

Correct Answer: 2 to 5 days, followed by initiation of assisted motion.

Explanation:

Question 70:

Options:

Close follow-up
Begin a steroid dose pack
Blood cultures followed by antibiotics only if the cultures are positive
Order a CT scan (because of the metal implants) and follow up later that day
Start antibiotics immediately and schedule a biopsy and debridement

Correct Answer: Start antibiotics immediately and schedule a biopsy and debridement

Question 71:

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

Options:

A patent ulnar artery and deep palmar arch
A patent ulnar artery and superficial palmar arch
A patent radial artery and deep palmar arch
A patent radial artery and superficial palmar arch
A patent radial artery and an ulnar artery aneurysm

Correct Answer: A patent radial artery and deep palmar arch

Explanation:

DISCUSSION: The arterial supply to the hand is abundant and normally duplicated. The deep palmar arch as shown in this arteriogram typically receives its primary contribution from the radial artery which travels deep to the first dorsal compartment tendons and then returns to the volar aspect of the palm through the first web space. The superficial palmar arch receives its supply from the ulnar artery and is not visualized in this patient.
REFERENCE: Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist: Diagnosis and Operative Treatment. Philadephia, PA, Mosby-Year Book, 1998, p 110.

Question 72:

-What leads to muscle hypertrophy?

Options:

Neural recruitment
Active stretching
Passive stretching
Proprioceptive training
Progressive overloading

Correct Answer: Progressive overloading

Question 73:

Options:

open repair.
immobilization.
aspiration and steroid injection.
rest, ice, and rehabilitation.
tenotomy.

Correct Answer: rest, ice, and rehabilitation.

Explanation:

Question 74:

Options:

Elbow extension
Forearm supination
Wrist extension in radial deviation
Middle finger MCP extension
Index finger MCP hyperextension

Correct Answer: Elbow extension

Explanation:

Question 75:

Options:

a sling, ice, and isometric exercises.
a glenohumeral cortisone injection.
surgical repair of the coracoclavicular ligaments.
chin-ups and latissimus pull-down exercises.
cross-chest stretches.

Correct Answer: a sling, ice, and isometric exercises.

Explanation:

Question 76:

Which study is most useful for diagnosis of exertional compartment syndrome?

Options:

MRI
Arterial Doppler
Static compartment pressures
Exertional compartment pressures

Correct Answer: Exertional compartment pressures

Explanation:

DISCUSSION
The most sensitive study in the diagnosis of exertional compartment syndrome is intracompartmental pressures taken at rest (compared to pressures taken immediately after exercise). MRI often can reveal nonspecific muscle edema in exertional compartment syndrome, but this is usually not diagnostic. Arterial Doppler studies are usually unremarkable unless they are taken after exercise, in which case these findings may be abnormal.
CLINICAL SITUATION FOR QUESTIONS 48 THROUGH 50
Figures 48a through 48f reveal the radiographs and MR images of a 30-year-old man who has a 1-year history of atraumatic medial-sided left knee pain refractory to nonsurgical measures.

Question 77:

Which of the following factors is associated with improved outcomes following surgery for hip fractures?

Options:

Immediate surgical intervention
Early discharge to a skilled nursing facility
Choosing spinal versus general anesthesia for surgery
Choosing total hip arthroplasty instead of hemiarthroplasty for a displaced femoral neck fracture
Correction of metabolic abnormalities prior to surgical intervention

Correct Answer: Correction of metabolic abnormalities prior to surgical intervention

Explanation:

Question 78:

Options:

Anesthesia in the first dorsal web space
Inability to extend the fingers
Inability to abduct the fingers
Inability to flex the thumb interphalangeal (IP) joint

Correct Answer: Inability to flex the thumb interphalangeal (IP) joint

Explanation:

Question 79:

Options:

Pes calcaneovalgus
Fixed pes planovalgus
Rigid equinovarus
Metatarsus adductus
Skewfoot (forefoot adduction and heel valgus)

Correct Answer: Rigid equinovarus

Explanation:

Question 80:

The patient undergoes further testing and it is discovered that the lesion encompasses 70% of the joint. What is the best next treatment option?

Options:

Arthroscopic debridement
Subtalar arthroereisis
Subtalar fusion
Lesion resection

Correct Answer: Subtalar fusion

Explanation:

DISCUSSION
A tarsal coalition is an abnormal connection of 2 or more bones in the foot. Although tarsal coalitions are present at birth, children and adults typically do not show signs of the disorder until early adolescence or later. The exact incidence of the disorder is hard to determine; however, it is caused by a gene mutation that affects cells that produce the tarsal bones. The 2 most common locations for tarsal coalitions are between the calcaneus and the navicular or between the talus and the calcaneus. It is estimated that 1 out of every 100 people may have a tarsal coalition. In 50% of cases, both feet are affected. Tarsal coalitions are rarely discovered until symptoms arise. Symptoms may include stiff and painful feet, a rigid flatfoot, or increased pain or a limp with high-level activities. Upon examination, symptoms may include tenderness in the area of the coalition, loss of motion, rigid flat feet, and arthritic changes of the joint. Imaging studies begin with radiographs. A CT scan can provide bony detail for imaging tarsal coalitions and determining the extent of the coalition and any accompanying degenerative change. MRI can provide details of the soft tissues. Treatment includes nonsurgical care including rest, orthotics, a temporary boot or cast, and injections. Surgical options include resection with interposition of muscle or fatty tissue from another area of the body or fusions when large (exceeding 50% of the joint), more severe coalitions are encountered.
RECOMMENDED READINGS
Lemley F, Berlet G, Hill K, Philbin T, Isaac B, Lee T. Current concepts review: Tarsal coalition. Foot Ankle Int. 2006 Dec;27(12):1163-9. Review. PubMed PMID: 17207452.
View Abstract
at PubMed
Badgley CE. Coalition of the calcaneus and the navicular. Arch Surg. 1927;15:75-88. Conway JJ, Cowell HR. Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology. 1969 Mar;92(4):799-811. PubMed PMID: 5767760.
View Abstract
at PubMed
Herzenberg JE, Goldner JL, Martinez S, Silverman PM. Computerized tomography of talocalcaneal tarsal coalition: a clinical and anatomic study. Foot Ankle. 1986 Jun;6(6):273-

Question 81:

Figure 13 is the photograph of 18-month-old triplets with a lower-limb condition. What is the best initial treatment? Review Topic

Options:

Vitamin D supplementation and serum level monitoring
Mechanical axis alignment measurements on serial standing knee radiographs
Genetic testing and counseling for short-stature syndrome
Observation and clinical follow-up.

Correct Answer: Mechanical axis alignment measurements on serial standing knee radiographs

Explanation:

These triplets exhibit genu varum and internal tibial torsion that can be part of normal development. Fetal packing is the likely major contributing cause for these triplets, however. Observation and follow-up will be sufficient. Bowing and torsion can be clinical features of vitamin D deficiency, Blount disease, and short-stature syndromes, but these are not the most likely diagnoses. Radiographic diagnosis of Blount disease may not be accurate at this age.
(SBQ13PE.56) A 22-month-old female is hospitalized with a fever and malaise. She is found to be bacteremic, and blood cultures grow methicillin-sensitive Staphylococcus aureus (MSSA). During her hospitalization, the pediatrician notices her arm is slightly swollen and appears painful to use. MRI is obtained and demonstrated in figure A. Which feature of the MRI suggests the need for surgical management?
Review Topic
Brodie's Abscess
Osteomyelitis of the humeral metaphysis
Subperiosteal abscess of the humerus
Presence of subcutaneous air
High risk of proximal humeral growth arrest
This patient has osteomyelitis of the humerus with a large subperiosteal abscess. The presence of subperiosteal abscess necessitates surgical intervention for irrigation and debridement (I&D).
The diagnosis of acute osteomyelitis in children is made based upon a constellation of findings including pain, systemic signs of infection, elevated serum inflammatory markers, and imaging studies demonstrative of osseous infection. It is most commonly hematogenously spread to the metaphysis of immature bone, which is highly vascular prior to skeletal maturity. Treatment involves obtaining specimen for culture, empiric antibiotic treatment, and surgical irrigation and debridement of known abscesses. The end-point of treatment is return of pain-free functionality and the resolution of local/systemic signs of infection.
Conrad reviewed the management of acute hematogenous osteomyelitis and emphasized that surgical intervention in the presence of abscess can be both therapeutic and diagnostic: I&D can obtain culture and narrow the antibiotic plan.
Jones et. al. reviewed chronic pediatric osteomyelitis and report that surgery is the mainstay of treatment because removal of dead bone is essential for resolution of infection. This may be performed with sequestrectomy and curettage, with an emphasis on prevention of pathologic fracture, growth disturbances, bone loss, joint involvement, and permanent loss of function.
Figure A is a coronal STIR MRI image of the humerus demonstrating osteomyelitis
with extensive subperiosteal abscess.
Incorrect Answers:
Brodie's abscess is a type of subacute osteomyelitis which remains indolent and creates a focal intra-osseous abscess. This is not demonstrated in the clinical image.
The patient does have osteomyelitis of the humeral metaphysis, but this alone is not the indication for surgery. Uncomplicated osteomyelitis may be treated effectively with antibiotics alone.
Presence of subcutaneous air is suggestive of necrotizing fasciitis, which is a surgical emergency. The MRI however does not demonstrate this finding.
The infection and its surgical management both increase risk of injury to the proximal humeral physis and has the potential for growth arrest or angular deformity.
(SBQ13PE.3) Figure A demonstrates a physical examination maneuver in a 1 month old infant. What is this maneuver?
Review Topic
Ortolani Test
Barlow Test
Galeazzi Sign
Patrick test
Teratologic Sign
Figure A shows a schematic image of the Ortalani test.
The Ortolani test, or Ortolani maneuver, is part of the physical examination for developmental dysplasia of the hip. It is used alongside the Barlow test to detect subluxated hips that are either reducible or irreducible. A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral head relocates anteriorly into the acetabulum.
Guille et al. showed that the use of Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step before they are able to stand.
Video V is a lecture discussing the hip examination of the infant. Incorrect Answers:
pressure on the knee, directing the force the femoral head posteriorly. A positive Barlow test would result in posterior subluxation/dislocation of the hip. Answer 3: Galeazzi test is performed by flexing an infant's knees in the supine position so that the ankles touch the buttocks. If the knees are not level then the test is positive, which indicates a potential congenital hip issue (e.g. DDH). Answer 4: Patrick or Faber test (flexion, abduction, external rotation) has been described both for stressing the SI joint and for isolating symptoms to the hip Answer 5: Teratologic dislocation of the hip is a term used to imply that the hip joint did not develop normally in utero, thus the hip is in a fixed dislocated position at birth.

Question 82:

Options:

Medial collateral ligament repair
Medial collateral ligament reconstruction
Hinged external fixation
Lateral collateral ligament repair
Lateral collateral ligament reconstruction

Correct Answer: Lateral collateral ligament reconstruction

Explanation:

Question 83:

Which of the following statements describing chordomas is false?

Options:

Treatment consisting of complete surgical resection with clean margins offers the best survival.
They occur in the clivus and sacrum and occur only 15% of the time in the rest of the spine.
They are locally aggressive and invasive tumors.
They are highly radiosensitive.
They have the ability to become malignant.

Correct Answer: They are highly radiosensitive.

Explanation:

DISCUSSION: Casali and associates provided a recent review of the treatment options for chordomas. These tumors are not radiosensitive; however, modern intensity modulated radiosurgery techniques may be of value. The combination of surgery and radiotherapy compared to surgery alone results in the same disease-free survival time. Complete surgical resection of the chondroma with clean margins offers the best survival; however, its location may make total removal impossible. Thus subtotal resection followed by radiotherapy results in better survival despite the tumor’s lack of radiosensitivity.
REFERENCE: Casali PG, Stacchiotti S, Sangalli C, et al: Chordoma. Curr Opin Oncol 2007;19:367-370.

Question 84:

Which of the following best describes a Bonferroni correction? Review Topic

Options:

An analysis that starts with a particular probability of an event (the prior probability) and incorporates new information to generate a revised probability (a posterior probability)
Human behavior that is changed when participants are aware that their behavior is being observed.
Used to assess the relationship between two normally distributed continuous variables
A post-hoc statistical correction made to P values when several dependent or independent statistical tests are being performed simultaneously on a single data set
The ability of a study to detect the difference between two interventions if one in fact exists

Correct Answer: The ability of a study to detect the difference between two interventions if one in fact exists

Explanation:

Question 85:

Options:

wound debridement, anterior corpectomy, spinal cord decompression, dural repair, and anterior fusion with strut graft and anterior plating.
wound debridement, anterior corpectomy, spinal cord decompression, dural repair, anterior fusion with strut graft and anterior plating followed by posterior laminectomy, and spinal cord decompression and dural repair with excision of the bullet fragment.
wound debridement, anterior corpectomy, spinal cord decompression, dural repair, anterior fusion with strut graft and anterior plating followed by laminectomy and posterior fusion, and spinal cord decompression and dural repair with excision of the bullet fragment.
laminectomy and posterior fusion, and spinal cord decompression and dural repair with excision of the bullet fragment.
surgical treatment based on extraspinal pathology with orthotic treatment of the spinal fractures.

Correct Answer: surgical treatment based on extraspinal pathology with orthotic treatment of the spinal fractures.

Explanation:

DISCUSSION: Although the spinal canal has been penetrated, the lateral masses are intact bilaterally with only partial destruction of the vertebral body and penetration of the lamina on one side, thus the cervical spine is not unstable and surgical stabilization is not indicated. Dural repair is not indicated since there is no external cerebrospinal fluid leakage. Surgical treatment should be based on the need to treat extraspinal pathology only.
REFERENCES: Bono CM, Heary RF: Gunshot wounds to the spine. Spine J 2004;4:230-240.
Punjabi MM, Jue JJ, Dvorak J, et al: Cervical spine kinematics and clinical instability, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,
pp 55-87.

Question 86:

A 42-year-old woman sustained a closed, displaced talar neck fracture in a motor vehicle accident. Which of the following is an avoidable complication of surgical treatment?

Options:

Posttraumatic arthritis of the subtalar joint
Posttraumatic arthritis of the ankle joint
Malunion of the talus
Osteonecrosis of the talus
Complex regional pain syndrome

Correct Answer: Malunion of the talus

Explanation:

Question 87:

Options:

Posterior tibial tendinitis
Tarsal tunnel syndrome
Os trigonum impingement syndrome
Insertional tendinitis of the Achilles tendon
Osteochondritis dissecans of the talus

Correct Answer: Os trigonum impingement syndrome

Explanation:

Question 88:

Options:

Growth arrest of the distal ulna
Growth arrest of the distal radius
Compartment syndrome
Radioulnar synostosis
Entrapment of the extensor pollicis longus (EPL) tendon

Correct Answer: Growth arrest of the distal ulna

Explanation:

DISCUSSION: The radiographs show a fracture of the distal radius and ulna physis. The most likely complication is growth arrest of the distal ulna. In contradistinction to physis fractures of the radius (growth arrest incidence of less than 5%), the incidence of growth arrest in the ulna is between 30% and 40%. Entrapment of the EPL tendon and cross union between the two bones is extremely rare.
REFERENCES: Vanheest A: Wrist deformities after fracture. Hand Clin 2006;22:113-120.
Cannata G, De Maio F, Mancini F, et al: Physeal fractures of the distal radius and ulna: Long-term prognosis. J Orthop Trauma 2003;17:172-179.
Ray TD, Tessler RH, Dell PC: Traumatic ulnar physeal arrest after distal forearm fractures in children. J Pediatr Orthop 1996;16:195-200.
Aminian A, Schoenecker PL: Premature closure of the distal radial physis after fracture of the distal radial metaphysis. J Pediatr Orthop 1995;15:495-498.

Question 89:

Which of the following plain radiographic views of the shoulder best reveals a Hill-Sachs lesion of the humeral head?

Options:

Lateral Y
Scapular AP
Neutral rotation AP
Internal rotation AP
External rotation AP

Correct Answer: Internal rotation AP

Explanation:

Question 90:

Options:

Keeping a smooth plastic cannula in each portal after it is established
Using an image intensifier to localize the loose body
Distending the elbow joint capsule prior to establishing the anterolateral portal
Placing the scope in the proximal anteromedial portal and then enlarging the anterolateral portal so that it is bigger than the maximum diameter of the loose body
Breaking up the loose body into several pieces prior to extracting it

Correct Answer: Distending the elbow joint capsule prior to establishing the anterolateral portal

Explanation:

Question 91:

For a patient with a type II odontoid fracture, which of the following factors best predicts the development of a nonunion with nonsurgical management? Review Topic

Options:

Frontal oblique pattern
Magnitude of fracture displacement
Degree of posterior angulation
Age
Patient history of diabetes mellitus

Correct Answer: Magnitude of fracture displacement

Explanation:

Question 92:

During a dual incision fasciotomy of the leg, the soleus is elevated from the tibia to allow access to which of the following compartments?

Options:

Superficial posterior
Deep posterior
Lateral
Anterior
Mobile wad

Correct Answer: Superficial posterior

Explanation:

Question 93:

Options:

Humeral head replacement arthroplasty
Hemiarthroplasty and ream-and-run glenoid procedure
Cuff tear arthropathy (CTA) prosthesis
Total shoulder arthroplasty with a metal-backed cemented glenoid component
Total shoulder arthroplasty with an all-polyethylene cemented glenoid component

Correct Answer: Hemiarthroplasty and ream-and-run glenoid procedure

Explanation:

Question 94:

Options:

Open biopsy
Observation
Cortisone injection
Oncology referral
CT of the chest

Correct Answer: Observation

Explanation:

DISCUSSION: A periosteal desmoid lesion is a tumor simulator. It is characterized by a bone irregularity along the posteromedial aspect of the distal femur at the insertion of the adductor magnus or the origin of the gastrocnemius muscle. It most commonly occurs in patients who are age 10 to 15 years. The lesions are asymptomatic, with no palpable mass, pain, or swelling. They are frequently an incidental finding when radiographs are obtained for nonspecific symptoms or trauma about the knee. Following recognition of the characteristic imaging findings, observation is the management of choice.
REFERENCES: Dunham WK, Marcus NW, Enneking WF, et al: Developmental defects of the distal femoral metaphysis. J Bone Joint Surg Am 1980;62:801-806.
Verdonk PC, Verstraete K, Verdonk R: Distal femoral cortical irregularity in a 13-year old boy: A case report. Acta Orthop Belg 2003;69:377-381.

Question 95:

Which of the following statements best describes the instantaneous axis of rotation (IAR) for the functional spinal unit? Review Topic

Options:

The IAR is calculated by movement around six different axes.
The IAR consists of potential movements or 12 degrees of freedom.
The IAR is fixed and consistent and is the axis about which each vertebral segment rotates.
The IAR can be derived from AP and lateral radiographs.
Degenerative disease, fractures, and ligamentous injuries can affect the IAR.

Correct Answer: Degenerative disease, fractures, and ligamentous injuries can affect the IAR.

Explanation:

Question 96:

Which of the following statements best describes the kinematic behavior of the knee during motion from full extension to flexion?

Options:

Both the medial and lateral knee tibiofemoral contact points rotate and translate equally with increasing knee flexion.
The medial femoral condyle translates much less than the lateral femoral condyle with knee flexion.
The lateral femoral condyle translates much less than the medial femoral condyle with knee flexion.
The medial compartment rotates internally whereas the lateral compartment rotates externally.
The lateral compartment rotates internally whereas the medial compartment rotates externally.

Correct Answer: The medial femoral condyle translates much less than the lateral femoral condyle with knee flexion.

Explanation:

Question 97:

Options:

Bone grafting and revision open reduction and internal fixation
Hemiarthroplasty
Dynamic hip screw without angular correction
Valgus intertrochanteric osteotomy
Core decompression

Correct Answer: Valgus intertrochanteric osteotomy

Explanation:

DISCUSSION: Femoral neck fracture nonunion is a challenging problem for orthopaedic surgeons. Vertical fractures are more prone to nonunion due to shear stress rather than compressive forces across the fracture site. Several authors have suggested these fractures are more common in young adults due to injury type and bone composition. It is widely regarded that an effort should be made to salvage the femoral head if vascularity remains. The most common method to treat this complication is valgus intertrochanteric osteotomy of the femur. This functionally makes a vertical fracture more horizontal, converting shear into compressive forces. It also helps correct the varus position of the fracture nonunion.
REFERENCES: Hartford JM, Patel A, Powell J: Intertrochanteric osteotomy using a dynamic hip screw for femoral neck nonunion. J Orthop Trauma 2005;19:329-333.
Mathews V, Cabanela ME: Femoral neck nonunion treatment. Clin Orthop Relat Res 2004;419:57-64.

Question 98:

Options:

anterior cruciate ligament reconstruction with lateral meniscus repair.
partial lateral meniscectomy with saucerization.
lateral meniscus transplant.
protected weight bearing with referral for genetic testing.

Correct Answer: partial lateral meniscectomy with saucerization.

Explanation:

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatment
of a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.

Question 99:

Options:

referral to a plastic surgeon to remove the hairy patch.
MRI of the entire spine.
physical therapy and repeat evaluation and radiographs in 1 year.
anterior and posterior fusion of the anomalous regions of the spine to prevent deformity.
voiding cystourethrography.

Correct Answer: MRI of the entire spine.

Explanation:

Question 100:

Which of the following is true regarding changes in the vascularity of the adult intervertebral disc with age? Review Topic

Options:

Neovascularization occurs from the nucleus pulposus
Neovascularization occurs from the outer annulus
Neovascularization occurs from the endplates
There is no change in vascularity
There is a decrease in vascularity

Correct Answer: Neovascularization occurs from the nucleus pulposus

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

Orthopedic Board Prep MCQs: Arthroplasty, Deformity & Shoulder | Part 58

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 58

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index