100 OITE & ABOS Orthopedic Board Prep MCQs: Part 6

About This Board Review Set

This is Part 6 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

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

Topics Covered in Part 6

This module focuses heavily on: Deformity, Fracture, Hip, Knee, Ligament, Wrist.

Sample Questions from This Set

Sample Question 1: What allograft has the highest antigenicity when used for ligament reconstruction about the knee?...

Sample Question 2: A patient has a displaced complex intra-articular distal humeral fracture. What factor is considered most important when deciding on what surgical approach to use?...

Sample Question 3: A 75-year-old man has persistent radial sided hand and wrist pain. Radiographs demonstrate severe scaphotrapezial trapezoidal arthritis. His basal joint is unaffected. His pain has failed to improve with bracing, activity modification, and ...

Sample Question 4: What clinical finding is associated with the least favorable prognosis in an adolescent patient who has been diagnosed with a high-grade osteosarcoma of the distal femur?...

Sample Question 5: A 2-year-old child has refused to bear weight on his leg for the past 2 days. His parents report that he will crawl, has no fever, and has painless full range of motion of his hip and knee. Examination reveals no deformity or bruising, but ...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

What allograft has the highest antigenicity when used for ligament reconstruction about the knee?

Explanation

Although theoretically the intra-articular environment is slightly more immune privileged, the role of immunogenicity is related more to bone than soft tissue. Therefore, the bone-patellar tendon-bone used for ACL reconstruction would have the highest risk of immunogenicity if storage techniques and harvest techniques were similar. This also is true for bone plugs associated with meniscal allografts.

Question 2

A patient has a displaced complex intra-articular distal humeral fracture. What factor is considered most important when deciding on what surgical approach to use?

Explanation

DISCUSSION: When managing a complex intra-articular fracture, it is imperative that there is adequate visualization of the joint; this usually means an extensile approach. At the elbow, this is usually through a transolecranon osteotomy. The recent addition of a muscle-sparing approach as described by Bryan and Morrey has gained popularity, but it is difficult to maintain soft-tissue viability and it may put the ulnar nerve at risk. A triceps-splitting approach, which can be used for simple single articular splits into the joint where extra-articular reduction is available, is possible and good results have been reported. To date, there is minimal data on these alternative approaches for comminuted intra-articular distal humeral fractures.
REFERENCES: McKee MD, Mehne DK, Jupiter JP: Fractures of the distal humerus: Part II, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1483-1522
McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR: Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82:1701-1707.
Patterson SD, Bain GI, Mehta JA: Surgical approaches to the elbow. Clin Orthop

2000;370:19-33.
Bryan RS, Morrey BF: Extensive posterior exposure of the elbow: A triceps-sparing approach. Clin Orthop 1982;166:188-192.

Question 3

A 75-year-old man has persistent radial sided hand and wrist pain. Radiographs demonstrate severe scaphotrapezial trapezoidal arthritis. His basal joint is unaffected. His pain has failed to improve with bracing, activity modification, and image-guided corticosteroid injection. He has elected surgical treatment. What longterm complication can arise from a distal scaphoid resection?

Explanation

EXPLANATION:
Resection of the distal pole of the scaphoid eliminates the arthritic contact at the scaphotrapeziotrapezoid joint; however, it functionally shortens the scaphoid. Theoretically, the lunate is at equilibrium between the extension moment of the capitate and the triquetrum and the flexion moment of the scaphoid. Shortening the scaphoid allows the extension moment of the triquetrum to predominate, pulling the lunate into extension and creating a DISI deformity. Concomitant capsulodesis or interposition is recommended by some authors to prevent this complication.

Question 4

What clinical finding is associated with the least favorable prognosis in an adolescent patient who has been diagnosed with a high-grade osteosarcoma of the distal femur?

Explanation

DISCUSSION: The presence of synchronous bone disease in young patients carries a dismal prognosis, one that is even worse than the presence of resectable pulmonary metastasis. Many osteosarcomas cross the physis; therefore, this has not been shown to be of prognostic importance. Similarly, the presence of the soft-tissue mass has less prognostic significance.
REFERENCE: Mirra JM: Bone Tumors: Clinical, Radiologic, and Pathologic Correlation. Philadelphia, PA, Lea and Febiger, 1989, pp 344-350.

Question 5

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

Explanation

DISCUSSION: Despite the negative radiographic findings, the child’s age and presentation are most consistent with a toddler’s fracture. There is often not a witnessed injury. The differential diagnosis of infection is unlikely given that the child is afebrile and shows no signs of illness. Immobilization will make the child more comfortable and will often allow weight bearing. Repeat radiographs at the end of treatment will show a healing fracture and confirm the diagnosis. Aspiration of the tibial metaphysis would be indicated to obtain material for culture. The bone scan and MRI would show abnormalities, but these studies are nonspecific, costly, and time-consuming. Occasionally, oblique radiographs will show the fracture.
REFERENCES: Halsey MF, Finzel KC, Carrion WV, Haralabatos SS, et al: Toddler’s fracture: Presumptive diagnosis and treatment. J Pediatr Orthop 2001;21:152-156.
Oudjihane K, Newman B, Oh KS, et al: Occult fractures in preschool children. Trauma 1988;28:858-860.

Question 6

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

Explanation

DISCUSSION:
Proximal tibial osteotomy is the most appropriate intervention to correct varus malalignment and to reduce stress on the ACL. In some cases, proximal tibial osteotomy alone may address both pain and instability, but if instability persists, particularly in the setting in which instability can be dangerous, subsequent ACL reconstruction can further stabilize the knee with less stress on the graft after the correction of malalignment. Varus alignment places increased stress on the native or reconstructed ACL. ACL reconstruction should be performed only at the same time as or following proximal tibial osteotomy to correct alignment in the setting of varus malalignment. It is not appropriate to perform ACL reconstruction prior to proximal tibial osteotomy in this setting. Distal femoral osteotomy is not indicated to correct varus malalignment. Varus alignment places increased stress on the native or reconstructed ACL, and ACL
reconstruction alone is not indicated for this patient.

Question 7

A 13-year-old boy who has a history of a pituitary adenoma has an unstable unilateral slipped capital femoral epiphysis. What is the indication for prophylactic pinning of the contralateral, unslipped side? Review Topic

Explanation

Endocrine disorders post the highest risk for bilateral involvement, and prophylactic pinning of the uninvolved side is most often recommended. Risk of contralateral slippage is highest in the youngest patients. In a study by Riad and associates, all girls younger than age 10 and all boys younger than age 12 presenting with a unilateral slipped capital femoral epiphysis subsequently developed a contralateral slip. Initial presentation of an unstable slip has not been shown to be an independent risk factor for later contralateral slippage.

Question 8

Figures below show the radiograph and the MRI scan obtained from a 37-year-old woman with a 2-month history of left hip pain. Which presurgical factor is most commonly associated with a poor outcome after a hip joint salvage procedure?

Explanation

DISCUSSION:
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 9

What is the plasma half-life of warfarin?

Explanation

Warfarin, which is dosed daily, can take 72 to 96 hours to reach therapeutic levels. It has a plasma half-life of 36 to 42 hours. Low-molecular heparins have a plasma half-life of 4 to 5 hours, and fondaparinux has a half-life of 17 to 21 hours. Warfarin will not affect the International Normalized Ratio (INR) until 2 to 3 days after it is given. Patients on chronic warfarin therapy should have treatment stopped 3 to 5 days before elective surgery to allow the INR to normalize.

Question 10

The blood supply to the anterior cruciate ligament is primarily derived from what artery?

Explanation

DISCUSSION: Microvascular studies have shown that the majority of the blood supply to the cruciate ligaments comes from the middle geniculate artery, although there is collateral flow through the other geniculates and from bone.
REFERENCES: Arnoczky SP: Blood supply to the anterior cruciate ligament and supporting structures. Orthop Clin North Am 1985;16:15-28.
Arnoczky SP, Rubin RM, Marshall JL: Microvasculature of the cruciate ligaments and its response to injury. J Bone Joint Surg Am 1979;61:1221-1229.

Question 11

A 68-year-old woman underwent an uncemented medial/lateral tapered femoral placement during a total hip arthroplasty. The orthopaedic surgeon noticed a nondisplaced vertical fracture in the calcar region of the femoral neck during final implant insertion. What is the most appropriate treatment?

Explanation

DISCUSSION:
The recognized treatment for a proximal periprosthetic fracture is to first identify the extent and then optimize the correction of the fracture. Several studies indicate that proximal cerclage wiring is adequate to create "barrel hoop" stability of the proximal femur. Braided cables offer superior stability compared with twisted wires or Luque wires. Finally, the appropriate postoperative treatment is protected
weight bearing for 6 weeks, with periodic radiographs taken at 2-week intervals. Other options such as cementing the femoral stem and using a revision arthroplasty device are indicated for unstable fractures.

Question 12

An adult with a distal humeral fracture underwent open reduction and internal fixation. What is the most common postoperative complication?

Explanation

DISCUSSION: Most patients lose elbow range of motion after open reduction and internal fixation of a distal humeral fracture. Ulnar nerve dysfunction, nonunion, and infection all occur less commonly.
REFERENCES: Webb LX: Distal humerus fractures in adults. J Am Acad Orthop Surg 1996;4:336-344.
McKee MD, Wilson TL, Winston L, et al: Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82:1701-1707.

Question 13

When compared to patients with a body mass index (BMI) lower than 35, patients with a BMI above 40 who undergo primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) are likely to have

Explanation

CLINICAL SITUATION FOR QUESTIONS 96 THROUGH 99
Figures 96a through 96c are the anteroposterior and lateral radiographs of a 64-year-old man with long-standing right knee osteoarthritis and pain unresponsive to nonsurgical treatment. This patient is scheduled for navigated cruciate-retaining right total knee arthroplasty. His range of motion is 20 to 120 degrees before surgery. Following bone resections and release of the posterolateral capsule and iliotibial band the knee is stable and extends fully, but during knee flexion there is lift-off of the anterior portion of the trial insert. Alignment is neutral to the mechanical axis. A distal femoral medial resection involved 9 mm of bone with a 9-mm-thick implant. An appropriate tibial resection was perpendicular to the long axis, and the posterior tibial slope was 7 degrees.

Question 14

Which radiographic abnormality most accurately serves as a predictor of ankle syndesmosis disruption?

Explanation

DISCUSSION
Normal syndesmotic relationships include a tibiofibular clear space smaller than 6 mm on both AP and mortise views. In a 1989 cadaveric study by Harper and Keller, a tibiofibular clear space exceeding 6 mm on both the AP and mortise views was the most reliable predictor of early syndesmotic widening. Tibiofibular overlap is measured 1 cm proximal to the plafond. Normal values exceed 6 mm or 42% of the width of the fibula on the AP view, or 1 mm on the mortise view. Proximal fibula fracture can occur in isolation without syndesmotic injury, frequently after direct trauma. The medial clear space is the distance between the lateral border of the medial malleolus and the medial border of the talus and is measured at the level of the talar dome. In the mortise view with the ankle in neutral dorsiflexion, the medial clear space should be equal to or smaller than the superior clear space between the talar dome and the tibial plafond. ?A normal medial clear space may be present with syndesmotic injury and consequently lacks sensitivity and specificity.
RECOMMENDED READINGS
Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg. 2007 Jun;15(6):330-9. Review. PubMed PMID: 17548882. View Abstract at PubMed
Wuest TK. Injuries to the Distal Lower Extremity Syndesmosis. J Am Acad Orthop Surg. 1997 May;5(3):172-181. PubMed PMID: 10797219. View Abstract at PubMed
Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989 Dec;10(3):156-60. PubMed PMID: 2613128. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 40
A 41-year-old man sustained a twisting injury while running up stairs 4 weeks ago. He was treated in an ankle brace and has been bearing weight since the injury occurred. He has no history of ankle problems, but he now has ankle pain, swelling, and instability. The pain is aggravated by stairs, and the instability is worse on unlevel ground. Radiographs do not show a fracture.

Question 15

A 17-year-old high school soccer player sustains an anterior cruciate ligament (ACL) tear at the beginning of the season. An MRI scan confirms a complete ACL tear with no meniscal injuries. The patient plans an early return to play and would like to avoid surgery. Therefore, the patient and family should be advised that nonsurgical management consisting of rehabilitative exercises and the use of a functional knee brace will most likely result in

Explanation

DISCUSSION: While there are athletes who can function at a full level with an ACL tear, they are in the minority. As yet, there is no reliable way to predict the patients who will be able to compensate for the loss of the ACL. Studies have confirmed the risk of recurrent instability and meniscal injury in athletes with an ACL-deficient knee who participate in cutting sports. One study showed that only 12 of 43 patients who attempted rehabilitation and bracing were able to return successfully for the season. Another study showed that 17 of 31 athletes who were able to return to their sport sustained 23 meniscal tears because of recurrent instability.
REFERENCES: Shelton WR, Barrett GR, Dukes A: Early season anterior cruciate ligament tears: A treatment dilemma. Am J Sports Med 1997;25:656-658.
Snyder-Mackler L, Fitzgerald GK, Bartolozzi AR III, Ciccotti MG: The relationship between passive joint laxity and functional outcome after anterior cruciate ligament injury. Am J Sports Med 1997;25:191-195.

Question 16

What is the prognosis for ambulation, from best to worst, for patients with an incomplete spinal cord injury?

Explanation

DISCUSSION: Of the incomplete spinal cord injuries, Brown-Sequard syndrome has the best prognosis for ambulation. Central cord syndrome has a variable recovery. Anterior cord syndrome has the worst prognosis, with motor recovery rare below the level of the injury.
REFERENCES: Apple DF: Spinal cord injury rehabilitation, in Herkowitz HN, Garfin SR, Balderston RA, Eismont FJ, Bell GR, Wiesel SW (eds): Rothman-Simeone The Spine, ed 4. Philadelphia, PA, WB Saunders, 1999, pp 1130-1131.
Northrup BE: Evaluation and early treatment of acute injuries to the spine and spinal cord, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 544-545.

Question 17

9A 9B 9C 9D Figures 9a through 9d are the radiographs of a 21-year-old woman who is involved in a high-speed motor vehicle collision and sustains an isolated right closed-foot injury. Before surgery, the patient is advised about the relatively poor long-term outcomes associated with this injury. What is the most common reason for functional limitations after surgical treatment in this scenario?

Explanation

DISCUSSION
When a displaced talar neck fracture occurs, the rate of osteonecrosis is high; however, many revascularize the talus without collapse. A nonunion can occur but is less common than osteonecrosis and arthritis. A varus malunion can be debilitating and lead to subtalar arthritis. In a fracture with the talar body dislocated posteromedially (such as in this example) neurologic deficits in the tibial nerve distribution are common but typically improve with urgent
reduction. Studies show that posttraumatic subtalar arthritis is common after this injury and is the most likely cause of long-term functional impairment.
RECOMMENDED READINGS
Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone Joint Surg Am. 2004 Aug;86-A(8):1616-24. PubMed PMID: 15292407. View Abstract at PubMed
Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am. 2004 Oct;86-A(10):2229-34. PubMed PMID: 15466732. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 10 THROUGH 12

10A

10B

10C
Figure 10a is the radiograph of a 30-year-old man who sustained an injury in a motor vehicle collision.

Question 18

A 20-year-old man is brought to the emergency department after a high-speed motor vehicle accident. His initial blood pressure is 70/40 mm Hg. He is currently receiving intravenous fluids as well as blood. His Focused Assessment with Sonography for Trauma examination did not show any free fluid in his abdomen and his chest radiograph is unremarkable. An AP pelvis radiograph is shown in Figure 15. What is the next most appropriate step in the management of his pelvic injury? Review Topic

Explanation

This hypotensive patient has an obvious open book injury of the pelvic ring on the AP pelvis radiograph and further radiographs are not needed prior to the initiation of treatment. Although angiography may be indicated if he does not respond to stabilization of his pelvis and fluid/blood administration, temporary stabilization of the pelvis with a sheet or binder should be performed first because it is simple, quick, and has been shown to be effective. This patient does not need a laparotomy at this point since the FAST examination did not show any free intra-abdominal fluid and his chest radiograph was unremarkable, leaving the most likely source of bleeding the pelvic fracture. Open reduction with internal fixation of a pelvic injury is not indicated in an acutely ill patient.

Question 19

A 40-year-old man with a history of Legg-Calve-Perthes disease underwent a right hip resurfacing 3 years ago with no perioperative complications. Hip pain has developed gradually during the last 4 months. Radiographs show no evidence of fixation loosening or any adverse changes at the femoral neck. No periarticular osteolysis is evident. What is the most appropriate management of this condition?

Explanation

DISCUSSION:
Controversy persists over what exactly is the best approach to managing patients with metal-on-metal (MOM) hip arthroplasties. All patients with painful MOM hip arthroplasties should be examined for fixation loosening, wear/osteolysis, and infection—no differently than patients without MOM hip arthroplasties. It is recommended to obtain serum trace element levels. If the levels are high, cross- sectional imaging should be obtained to determine whether any pseudotumor or tissue necrosis is present around the hip arthroplasty. Hip aspiration should be considered if concern for infection exists. Adverse tissue reaction has been identified to occur around MOM hip arthroplasties. The predominant histologic feature is tissue necrosis with infiltration of lymphocytes and plasma cells.

Question 20

A 23-year-old male is involved in a motor vehicle accident and sustains a left open femur fracture, right open humeral shaft fracture, and an LC-II pelvic ring injury. Which of the following best describes the radiographic findings associated with this pelvic injury pattern using the Young-Burgess Classification system?

Explanation

DISCUSSION: Lateral compression type II fractures (as described by the Young-Burgess Classification System) are associated with a crescent fracture of the iliac wing located on the side of impact. A representative CT scan image and illustration of this injury are shown in Illustration A and B respectively. A table describing each pelvic injury and their associated complications is shown in Illustration C. Illustration D shows each Young-Burgess pelvic injury type.
Burgess et al discuss the effectiveness of a treatment protocol as determined by their pelvic injury classification and hemodynamic status. The injury classification system was based on lateral compression, anteroposterior compression, vertical shear, and combined mechanical injury types. They found that their classification-based treatment protocols reduce the morbidity and mortality related to pelvic ring disruption.
Tile discusses acute pelvic trauma and his classification system for pelvic injuries (ie. Types A, B, and C). He states that any classification system must be seen only as a general guide to treatment, and that the management of each patient requires careful, individualized decision making.
Incorrect
2:
This
describes
an
APC-II
injury
3:
This
describes
an
APC-III
injury
4:
This
describes
and
LC-I
injury

Question 21

A distal radius fracture in an elderly man is strongly predictive for what subsequent injury?

Explanation

DISCUSSION: Fractures of the distal radius increase the relative risk of a subsequent hip fracture significantly more in men than in women. A previous spinal fracture has an equally important impact on the risk of a subsequent hip fracture in both genders.
REFERENCE: Haentjens P, Autier P, Collins J, et al: Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women: A meta-analysis. J Bone Joint Surg Am 2003;85:1936-1943.

Question 22

A 45-year-old man has severe pain in both feet after his boots become wet while hunting. Examination 3 hours after the onset of symptoms reveals that his feet are cold to touch and the skin appears blanched. Management should consist of

Explanation

DISCUSSION: The patient has frostbite involving both feet. Rapid rewarming in a protected environment is the initial treatment. A footbath with water at 104.0 degrees F to 107.6 degrees F (40 degrees C to 42 degrees C) is ideal. This facilitates a uniform rewarming of the involved tissue. The other choices are less than ideal. Appliances such as heating pads provide uneven heating and may actually burn the skin.
REFERENCES: Pinzur MS: Frostbite: Prevention and treatment. Biomechanics 1997;4:14-21.
Fritz RL, Perrin DH: Cold exposure injuries: Prevention and treatment. Clin Sports Med 1989;8:111-128.

Question 23

Which of the following methods of meniscal repair has the highest load to failure strength?

Explanation

DISCUSSION: Numerous experimental studies have shown that vertical suture techniques are superior to all of the other noted methods. In fact, vertical sutures have been shown to be twice as strong as several of these techniques.
REFERENCES: DeHaven KE: Meniscus repair. Am J Sports Med 1999;27:242-250.
Dervin GF, Downing KJ, Keene GC, McBride DG: Failure strengths of suture versus biodegradable arrow for meniscal repair: An in vitro study. Arthroscopy 1997;13:296-300.
Barber FA: Endoscopic meniscal repair: The T-fix technique. Sports Med Arthroscopy Rev 1999;7:28-33.

Question 24

A surgeon decides to report outcomes for a new surgical procedure that he has performed on 10 patients who have a rare type of arthritis. He provides data on the functional and subjective patient outcomes. This type of study design is best described as a

Explanation

The type of study design in which a series of cases is presented with outcomes (without a control population or comparison group) is known as a case series. This type of study design, although frequently seen in orthopaedic literature, provides the lowest level of evidence. There is no control group and the population is usually poorly defined. This type of study can be helpful as a starting point for further analysis. A randomized trial provides the highest level of evidence in medical research, featuring a comparison group and randomized (and usually blinded) placement of subjects into study groups. In case-control studies, cases are compared to a control group. The control group has not been randomized, but may be a naturally occurring group of subjects who have not had the same exposure or intervention as the case group. A cohort study can be retrospective or prospective and usually looks at a large group of people over time to assess exposures and incidence of disease.

Question 25

Examination of a 25-year-old man who was injured in a motor vehicle accident reveals a fracture-dislocation of C5-6 with a Frankel B spinal cord injury. He also has a closed right femoral shaft fracture and a grade II open ipsilateral midshaft tibial fracture. Assessment of his vital signs reveals a pulse rate of 45/min, a blood pressure of 80/45 mm Hg, and respirations of 25/min. A general surgeon has assessed the abdomen, and a peritoneal lavage is negative. His clinical presentation is most consistent with what type of shock?

Explanation

DISCUSSION: Assessment of the acutely injured patient follows the Advanced Trauma Life Support protocol. Cervical cord injury is often associated with a disruption in sympathetic outflow. Absent sympathetic input to the lower extremities leads to vasodilatation, decreased venous return to the heart, and subsequent hypotension. With hypotension, the physiologic response of tachycardia is not possible because of the unopposed vagal tone. This results in bradycardia. Patient positioning, fluid support, pressor agents, and atropine are used to treat neurogenic shock.
REFERENCE: Sutton DC, Siveri CP, Cotler JM: Initial evaluation and management of the spinal injured patient, in Cotler JM, Simpson JM, An HS, et al (eds): Surgery of Spinal Trauma. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 113-126.

Question 26

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

Explanation

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

Question 27

A 19-year-old collegiate middistance runner has a 4-year history of bilateral leg pain. Pain begins within 10 minutes after starting to run and is described as a “tightness and cramping in the front of the legs.” Symptoms resolve within 15 to 20 minutes of running cessation. A presumptive diagnosis of exercise-induced compartment syndrome (EICS) is made, and the patient elects to undergo compartmental pressure testing. What is the strongest indication for elective fasciotomy of the anterior compartment?

Explanation

DISCUSSION
This clinical scenario describes a patient with EICS, marked by a nonphysiologic rise in muscle compartment pressure during exercise. Pressure testing is the best currently accepted method of diagnosis. Most physicians use the following criteria for diagnosis: resting pressure higher than 15 mm Hg, 1-minute postexercise pressure higher than 30 mm Hg, or 5-minute postexercise pressure higher than 20 mm Hg. Only 1-minute postexercise anterior compartment pressure of 42 mm Hg meets these criteria. Neurologic symptoms in the plantar foot would imply involvement of the posterior compartments and would not support the diagnosis of anterior compartment involvement.

Question 28

With respect to femoral component design, stress relief osteopenia in the proximal femur following noncemented total hip arthroplasty appears to be most strongly influenced by the

Explanation

Stress relief changes seem to be most strongly related to component stiffness. However, stress relief changes are probably multifactoral and involve stiffness, location and extent of porous coating and the presence or absence of a collar. Host factors also influence stress relief.

Question 29

In patient selection for meniscal allograft transplantation, which of the following variables has the greatest influence on outcome?

Explanation

DISCUSSION: Many clinical studies to date show that the extent of arthritis is the most common variable that has the greatest influence on outcome. The success rate of allograft transplantation is significantly diminished in patients who have grade IV chondromalacia of the knee or notable flattening and general joint incongruity.
REFERENCES: Carter TR: Meniscal allograft transplantation. Sports Med Arthroscopy Rev 1999;7:51-63.
Garrett JC: Meniscal transplantation: A review of 43 cases with two- to seven-year follow-up. Sports Med Arthroscopy Rev 1993;2:164-167.
van Arkel ER, de Boer HH: Human meniscal transplantation: Preliminary results at 2- to 5-year follow-up. J Bone Joint Surg Br 1995;77:589-595.

Question 30

Thoracic disk herniations are most frequently found in what area of the spine?

Explanation

DISCUSSION: Although thoracic disk herniations have been reported at all levels of the thoracic spine, more than two thirds are found at T9-T12, which is the more mobile lower third of the thoracic region.
REFERENCES: Belanger TA, Emery SE: Thoracic disc disease and myelopathy, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 855-864.
Bohlman HH, Zdeblick TA: Anterior excision of herniated thoracic discs. J Bone Joint Surg Am 1988;70:70-77.

Question 31

A 29-year-old woman who underwent an anterior cruciate ligament (ACL) reconstruction 6 months ago now reports difficulty achieving full knee extension, and physical therapy fails to provide relief. The knee is stable on ligament testing. Figure 3 shows the findings at a repeat arthroscopy. Treatment should now include

Explanation

DISCUSSION: The patient has a cyclops lesion. This is a nodule of fibroproliferative tissue that originates from either drilling debris from the tibial tunnel or remnants of the ACL stump; more rarely it is the result of broken graft fibers. The treatment of choice is excision of the nodule and, if needed, additional notchplasty. Marked improvements in function and symptoms have been noted after removal of the extension block and resumption of a rehabilitation program.

REFERENCES: Delince P, Krallis P, Descamps PY, et al: Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: A multifactorial etiopathogenesis. Arthroscopy 1998;14:869-876.
Fisher SE, Shelbourne KD: Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction. Am J Sports Med 1993;4:558-564.

Question 32

The axial stability of a 4-pin uniplanar external fixator used to treat a patient who has a transverse midthird fracture of the tibia with a 5-mm fracture gap can be most greatly increased by

Explanation

The mechanical behavior of an externally fixed fracture can be evaluated in axial, bending and torsion loads. The axial stiffness is increased most by the load sharing effect of cortical contact and compression, 94% of intact bone. Sidebar to bone spacing is proportional to the distance cubed. The pin diameter is proportional to the diameter to the 4th power.
Bone contact allows load sharing between bone and fixator for compressive, torsional, and certain bending loads. Without bone contact, the external fixator must support the full load. It is also possible to apply compression across a fracture gap using an external fixator. With transverse fractures, application of compression across the fracture site can greatly increase the stiffness of the framebone system.

Question 33

Figures 1 and 2 are the MRI scans of a 35-year-old right-hand dominant man who has right elbow pain after trying to lift a large television at home. An examination reveals ecchymosis, an abnormal hook test, and altered biceps muscle contour. What treatment is most likely to result in a satisfactory and predictable outcome?

Explanation

Figures 1 and 2 show a full thickness distal biceps tendon rupture with proximal retraction. Edema is seen along the course of the distal biceps tendon, and the axial cut demonstrates the absence of tendon at the radial tuberosity. The sagittal cut demonstrates the stump of the proximally retracted biceps tendon. The biceps muscle contour is abnormal in appearance, demonstrating the classic “popeye” deformity. Nonsurgical treatment options result in predictable loss of supination and elbow flexion strength that is not desirable. A local corticosteroid injection would not improve strength, and there is no evidence to support the use of a PRP injection.

Question 34

Figure 23 shows the radiograph of a 55-year-old man who underwent a total hip arthroplasty 5 years ago. Management should now consist of

Explanation

DISCUSSION: Because the radiograph shows that the femoral stem is loose within the femoral canal and there is a fracture in the distal cement mantle, the stem should be revised. The Ogden-type plate and the allograft bone plates will reconstruct the femur but will not restore stability to the stem. Similarly, traction may allow the femur to heal but will not restore stability to the femoral stem within the femur. Resection arthroplasty is considered a salvage option following failure of the other procedures.
REFERENCES: Lewallen DG, Berry DJ: Periprosthetic fracture of the femur after total hip arthroplasty: Treatment and results to date, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 243-249.
Bethea JS, DeAndrade JR, Fleming LL, Lindenbaum SD, Welch RB: Proximal femoral fractures following total hip arthroplasty. Clin Orthop 1982;170:95-106.

Question 35

Chronic flatfoot deformity is most commonly associated with a contracture of the

Explanation

According to Mann a contracted Achilles tendon that limits dorsiflexion is the underlying pathology behind symptomatic (rigid) flatfoot. Due to chronic Achilles contracture there is over time attenuation of the spring ligament with progressive rocker bottom deformity.
Deltoid ligament, plantar fascia, or intrinsic tendon contracture would not cause this deformity.

Question 36

04 Which of the following laboratory studies is predictive of wound healing prior to performing a lower extremity amputation?

Explanation

A serum albumin level of below 3.5 g/dl indicates malnourished patient. An absolute lymphocyte count below 1500/mm3 is a sign of immune deficiency. If possible, amputation surgery should be delayed in such patients. An absolute Doppler pressure of 70 mm Hg is the minimum inflow level. The ischemic index is the ratio of the Doppler pressure at the level being tested to the brachial systolic pressure. Genreally accepted to require an ischemic index of 0.5 or greater. Transcutaneous partial pressure of oxygen (TcpO2) is the present gold standard of vascular inflow. TcpO2 values of 40 mm Hg correlate with acceptable wound healing
(eliminates false positive predictions with using area under the Doppler waveform). Pressures less than 20 mm Hg are predictive of poor healing. Miller 505-6
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Question 37

What is the most common associated pathology in patients who have suprascapular nerve entrapment secondary to ganglion cysts?

Explanation

DISCUSSION: It is well known that suprascapular nerve entrapment can be secondary to many entities, and its association with ganglion cysts and SLAP lesions has been well documented. Because of a superior labral tear, synovial fluid will leak out of the joint underneath the labrum, causing the cyst and secondary compression of the nerve.
REFERENCES: Fehrman DA, Orwin JF, Jennings RM: Suprascapular nerve entrapment by ganglion cysts: A report of six cases with arthroscopic findings and review of the literature. Arthroscopy 1995;11:727-734.
Iannotti JP, Ramesey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression. Arthroscopy 1996;12:739-745.
Moore TP, Fritts HM, Quick DC, Buss DD: Suprascapular nerve entrapment caused by supraglenoid cyst compression. J Shoulder Elbow Surg 1997;6:455-462.

Question 38

A 25-year-old male sustains the isolated injury shown in Figure A. Antegrade intramedullary nailing is planned for definite fixation within the next 12 hours. After obtaining lateral radiographs of the injury site, what would be the next best step in management of this patient?

Explanation

This patient has sustained a femoral shaft fracture. The next best step in management would be to CT scan the hip to assess for an associated femoral neck fracture.
Femoral neck fractures are seen less than 10% of the time with femoral shaft fractures, but they are frequently missed on initial evaluation. The neck fracture line is almost vertical and nondisplaced, or minimally displaced. Therefore fine (2-mm) cut CT scan through the femoral neck should be ordered in the preoperative workup of these patients.
Tornetta et al. reported that they reduced the delay in diagnosis of concomitant femoral neck fractures by 91% by instituting a protocol that included: dedicated AP internal rotation plain radiograph, a fine (2-mm) cut CT scan through the femoral neck, an intraoperative fluoroscopic lateral radiograph prior to fixation, as well as postoperative AP and lateral radiographs of the hip in the operating room prior to awakening the patient.
Figure A shows a trauma view lower extremity radiograph with an isolated left midshaft femur fracture.
Incorrect Answers:
setting of fracture. Answer 5: The age, injury and fracture pattern are not consistent with a pathologic femur fracture.

Question 39

The major blood supply to the cruciate ligaments arises from which of the following structures?

Explanation

DISCUSSION: The major blood supply to the cruciate ligaments arises from the ligamentous branches of the middle genicular artery. Few terminal branches of the inferior genicular artery contribute to the blood supply. The synovial plexus and sheath covering the cruciate ligaments are also supplied by branches of the middle genicular artery. The blood supply to the cruciate ligaments is predominately of soft-tissue origin. There is no significant osseous vascular contribution to the ligaments.
REFERENCES: Arnoczky SP: Anatomy of the anterior cruciate ligament. Clin Orthop 1983;172:19-25.
Arnoczsky SP: Blood supply to the anterior cruciate ligament and supporting structures. Orthop Clin North Am 1985;16:15-28.

Question 40

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

Explanation

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

Question 41

A 35-year-old man has had a mass on the bottom of his foot for the past 6 months. He reports that initially the mass was exquisitely painful but now is minimally tender. Examination reveals a 2.5- x 2.0-cm firm, noncompressible, nonmobile mass contiguous with the plantar fascia in the distal arch. The mass is particularly prominent with passive dorsiflexion of the ankle and toes. What is the best course of action?

Explanation

DISCUSSION: The history is most consistent with a plantar fibroma. The nodules typically are located within the substance of the plantar aponeurosis. The clinical appearance is usually diagnostic without the need for advanced imaging studies. While the lesion may be prominent and painful to direct palpation, the anatomic location is usually off of the weight-bearing surface. Observation with or without an accommodative orthotic is the treatment of choice. Recurrence is common following attempted excision.
REFERENCES: Sammarco GJ, Mangone PG: Classification and treatment of plantar fibromatosis. Foot Ankle Int 2000;21:563-569.
Durr HR, Krodel A, Trouillier H, Lienemann A, Refior HJ: Fibromatosis of the plantar fascia: Diagnosis and indications for surgical treatment. Foot Ankle Int 1999;20:13-17.

Question 42

Demyelination diseases as multiple sclerosis and Guillain-Barre $ create neurologic symptoms by

Explanation

These diseases cause demyelinated regions of the axon and thus have a higher capacitance and lower membrane resistance (opposite of normal) and thus affects an action potential’s saltatory propagation. When an action potential is propagate down a myelinated axon and reaches a demyelinated region its conduction becomes slowed or may even stop. This loss of conduction had effects on behavior.

Question 43

Based on the injury shown on the axial MRI scan of the shoulder in Figure 1, what other pathology should be closely examined for during surgery?

Explanation

The axial MRI scan reveals a subluxated biceps tendon. In the study by Koh and associates, 85% of patients with a biceps subluxation on MRI were found to have a subscapularis tear at the time of arthroscopy. These are not always obvious on the MRI, and close inspection of the leading edge/upper border of the subscapularis tendon at the time of arthroscopy is necessary. Although supraspinatus tears, SLAP tears, and Bankart tears can all occur in conjunction with a biceps subluxation, none have been shown to be strongly correlated with this pathology, nor as
specific to this pathology.

Question 44

The best candidate for a reverse total shoulder arthroplasty is a patient with rotator cuff tear arthropathy with Review Topic

Explanation

Reverse total shoulder arthroplasty is relatively contraindicated in patients with acromial stress fractures and rheumatoid arthritis. A patient with active forward elevation to 130 degrees is better treated with a hemiarthroplasty because the motion already exceeds the average forward elevation attained in most studies using the reverse prosthesis. A centered case of rotator cuff tear arthropathy is also better treated with a hemiarthroplasty, especially in patients with a large external rotation lag sign because the reverse prosthesis has been shown to decrease active external rotation. However, hemiarthroplasties have not performed well in patients with anterior superior escape and in this group of patients, the reverse prosthesis is best.

Question 45

Figure 23 shows the radiograph of an elderly man who fell on his right arm. What is the most important determinate of a good outcome following this injury?

Explanation

DISCUSSION: Minimally displaced fractures of the proximal humerus have a good outcome if physical therapy is initiated within 2 weeks of the injury. Results are not affected by age, open reduction and internal fixation, or involvement of the greater tuberosity. Immobilization for longer than 3 weeks will often result in stiffness.
REFERENCES: Koval KJ, Gallagher MA, Marsicano JG, et al: Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am 1997;79:203-207.
Hodgson SA, Mawson SJ, Stanley D: Rehabilitation after two-part fractures of the neck of the humerus. J Bone Joint Surg Br 2003;85:419-422.

Question 46

A complication unique to computer navigation of total knee arthroplasty (TKA) is

Explanation

CLINICAL SITUATION FOR QUESTIONS 111 THROUGH 113
Figure 111 is the anteroposterior radiograph of a 79-year-old woman with a presurgical diagnosis of osteonecrosis who sustained a periprosthetic tibia fracture following her total knee arthroplasty (TKA).

Question 47

A patient has had a locked posterior dislocation of the shoulder for the past 6 months. After undergoing total shoulder arthroplasty that includes adequate anterior releases and posterior capsulorrhaphy, the patient still exhibits posterior instability intraoperatively. The postoperative rehabilitation regimen should include

Explanation

DISCUSSION: Achieving stability in chronic locked posterior dislocations of the shoulder remains a difficult challenge. Intraoperative measures include decreased humeral retroversion, anterior releases, and posterior capsular tightening. Postoperative rehabilitation is of equal importance. Immobilization in an external rotation brace (10 degrees to 15 degrees) with the arm at the side for 4 to 6 weeks is recommended to decrease tension in the posterior capsule. When passive range-of-motion exercises are instituted, they should be performed in the plane of the scapula to avoid stress posteriorly. Internal rotation and supine elevation should be avoided for similar reasons.
REFERENCES: Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
Loebenberg MI, Cuomo F: The treatment of chronic anterior and posterior dislocations of the glenohumeral joint and associated articular surface defects. Orthop Clin North Am 2000;31:23-24.

Question 48

At what age does the lateral epicondyle normally ossify in males?

Explanation

The lateral epicondylar epiphysis is the last to ossify in the elbow at age 12 to 14 years in males. The first secondary ossification center to ossify is the capitellum, which ossifies during the first 6 months of life. Next is the radial head, ossifying between age 3 and 6 years. The medial epicondyle appears between 5 and 7 years; the trochlea and olecranon at 8 and 10 years, respectively. In females, the appearance of ossification centers is about a year earlier than males.

Question 49

The biopsy specimens seen in Figures 55a and 55b are from a lytic lesion in the sacrum of a 58-year-old man. What is the most likely diagnosis?

Explanation

DISCUSSION: The lesion is a chordoma and the other listed choices can be eliminated based on the histology. Many tumors can occur in the sacrum including chordoma, multiple myeloma, giant cell tumor, aneurysmal bone cyst, and metastatic disease. The histology in this patient shows a lobulated lesion on low power with fibrous septae separating the lobules. At higher magnification, the cells have eosinophilic vacuolated cytoplasm and are called physaliferous cells. Chordoma is a low-grade neoplasm that most commonly occurs in the sacrum and rarely in the base of the skull. The diagnosis is often delayed. Chordoma is thought to originate from notochordal remnants. Chordoma typically occurs in the midline and has an associated soft-tissue mass.
REFERENCES: Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 372.
Fuchs B, Dickey ID, Yaszemski MJ, et al: Operative management of sacral chordoma. J Bone Joint Surg Am 2005;87:2211-2216.
Fourney DR, Rhines LD, Hentschel SJ, et al: En bloc resection of primary sacral tumors: Classification of surgical approaches and outcome. J Neurosurg Spine 2005;3:111-122.

Question 50

Which of the following best characterizes the antigenicity of allograft bone?

Explanation

DISCUSSION: Cell surface glycoproteins present in the heterogeneous population of the cells within the graft are primarily responsible for the antigenicity. Macromolocules of the matrix have also been implicated. Cryopreserved grafts have less antigenicity than fresh. Freezing, freeze-drying, or chemical sterilization and antigen extraction of the bone allograft have all been shown to reduce the antigenicity of the graft. Freeze-drying of retroviral-infected cortical bone and tendon does not inactivate retrovirus. Immunosuppression has been shown to decrease response. Hematopoietic elements along with osteogenic, chondrogenic, fibrous, and vascular cells have been shown to be antigenic.
REFERENCES: Crawford MJ, Swenson CL, Arnoczky SP, et al: Lyophilization does not inactivate infectious retrovirus in systemically infected bone and tendon allografts. Am J Sports Med 2004;32:580-586.
Stevenson S, Li XQ, Davy DT, et al: Critical biological determinants of incorporation of non-vascularized cortical bone grafts: Quantification of a complex process and structure. J Bone Joint Surg Am 1997;79:1-16.
Simon SR (eds): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 277-320.

Question 51

A previously healthy 13-year-old girl has had thigh pain for the past 3 weeks. The radiograph shown in Figure 47a reveals a lesion in the right femur. A bone scan and CT scan of the chest show no evidence of other lesions. A biopsy specimen is shown in Figure 47b. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has Langerhans cell histiocytosis that may be solitary (eosinophilic granuloma) or associated with systemic illness (Hand-Schuller-Christian disease and Letterer-Siwe disease). The solitary form of the disease, eosinophilic granuloma, typically affects patients in the first three decades of life. Radiographically, it is characterized as a well-defined, lytic, “punched out” intramedullary lesion. Histologically, two cell types, eosinophils and Langerhans cells, are seen. The Langerhans cells are seen as mononuclear histiocyte-like cells with oval nuclei with well-defined round or oval cytoplasm. A prominent nuclear groove can be seen in most of the nuclei (coffee bean nuclei). A mixture of inflammatory cells and lipid-laden foam cells with nuclear debris may be present as well. The lack of nuclear atypia and atypical mitoses excludes malignant conditions such as Ewing’s sarcoma, lymphoma of bone, and metastatic neuroblastoma. The lack of acute inflammatory cells excludes the diagnosis of osteomyelitis. The eosinophils have bi-lobed nuclei and granular eosinophilic cytoplasm.
REFERENCES: Dorfman H, Czerniak B: Bone Tumors. St Louis, MO, Mosby, 1988.
Mirra, JM: Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia, PA, Lea & Febiger, 1989.

Question 52

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

Explanation

DISCUSSION: In a study of over 400 patients with displaced supracondylar fractures, 3.2% of the fractures were associated with the absence of the radial pulse with an otherwise well-perfused hand. Based on this study, a period of close observation with frequent neurovascular checks should be completed before attempting invasive correction of the problem. Because of the satisfactory results with expectant management, angiography, exploration, removal of fixation and exploration, and thrombectomy are contraindicated.
REFERENCE: Sabharwal S, Tredwell SJ, Beauchamp RD, Mackenzie WG, Jakubec DM, Cairns R: Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop 1997;17:303-310.

Question 53

The natural history of cervical spondylolytic myelopathy is best described as

Explanation

DISCUSSION: The natural history of cervical myelopathy has been described by Lees and Turner as exacerbations of symptoms followed by often long periods of static or deteriorating function (or very rarely improvement). This stepwise pattern of decreasing function has been corroborated by Clarke and Robinson. These authors described long periods of stable neurologic function, sometimes lasting for years, in about 75% of their patients. In the majority of the patients, however, the condition deteriorated between quiescent streaks. About 20% of their patients showed a slow, steady progression of symptoms and signs without a stable period, and 5% had rapid deterioration of neurologic function.
REFERENCES: Emery SF: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Lees F, Turner JA: The natural history and prognosis of cervical spondylosis. Brit Med J 1963;2:1607-1610.
Clarke E, Robinson PK: Cervical myelopathy: A complication of cervical spondylosis. Brain 1956;79:486-510.

Question 54

Arthrodesis

Explanation

Long term prospective study involving 67 humeral head replacements for OA &RA. "Based on this experience, we would recommend that humeral head replacement alone be used sparingly in patients
with OA or RA. Certainly in patients who have glenoid bone deficiency precluding placement of a glenoid component…" as is apparent in this radiograph.

Question 55

What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window?

Explanation

DISCUSSION: Care must be taken when placing a retractor on the anterior aspect of the sacrum, as the L4 and L5 nerve roots are both at risk. The first referenced article by Atlihan et al reported on the anatomy of the anterior sacroiliac joint and reported that the L4 nerve root is within 1 cm of the joint at its inferior margin. The second article by Ebraheim et al found that the L4 and L5 nerve roots are 10 mm medial to the sacroiliac joint at the pelvic brim

Question 56

-An infant was born with complex syndactyly involving all 4 fingers of both hands, short and deformed thumbs, and similar syndactyly involving both feet. In addition, an altered facial appearance was noted with protruding eyes, a towered cranium, and midface hypoplasia. This appearance is characteristic of which syndrome?

Explanation

Question 57

A 2-year-old child is brought in by his parents for evaluation of intoeing. The child has a normal neuromuscular examination, but the heel bisector line is in the fourth web space, indicating a severe flexible metatarsus adductus deformity. The remainder of the lower extremity examination is unremarkable. What is the most appropriate treatment?

Explanation

DISCUSSION: Weinstein reported on 31 patients (45 feet) with congenital metatarsus adductus followed for an average of 33 years. Twenty-nine feet had moderate to severe deformities treated with manipulation and casting with a 90% success rate. In a young child, surgery is not indicated until nonsurgical management has failed. In patients 2 to 4 years of age, tarsometatarsal capsulotomies are indicated, whereas multiple metatarsal osteotomies are reserved for recalcitrant deformities in children older than 4 years of age. Mild or moderate metatarsus adductus that is passively correctable will resolve without treatment.
REFERENCES: Beaty J: Congenital anomalies of the lower extremity, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 10. Philadelphia PA, Mosby, 2003, pp 983-988.
Katz K, David R, Soudry M: Below-knee plaster cast for the treatment of metatarsus adductus.

J Pediatr Orthop 1999;19:49-50.
Weinstein SL: Bristol-Myers Squibb/Zimmer award for distinguished achievement in orthopaedic research. Long-term follow-up of pediatric orthopaedic conditions: Natural history and outcomes

of treatment. J Bone Joint Surg Am 2000;82:980-990.

Question 58

What is the most important preoperative factor predicting conversion to total hip arthroplasty after arthroscopic surgery of the hip?

Explanation

DISCUSSION:
The authors cited in the references examined large databases to determine the risk factors for conversion to total hip arthroplasty after arthroscopic surgery of the hip. In the study by Kester and associates, obesity had an odds ratio (OR) of 5.6 for conversion to hip arthroplasty, whereas age over 60 years had an OR of

Question 59

Two major pharmacologic classes of bisphosphonates exist: nitrogen-containing and non-nitrogen-containing compounds. The nitrogen-containing compounds work by which of the following actions?

Explanation

Bisphosphonates represent the most clinically important class of antiresorptive agents available to treat diseases characterized by osteoclast-mediated bone resorption. Two classes of bisphosphonates exist: nitrogen-containing and non-nitrogen-containing compounds. The non-nitrogen-containing bisphosphonates work by metabolizing into cytotoxic ATP analogs. The nitrogen-containing bisphosphonates work via the mevalonate pathway by inhibiting GTPase formation, leading to loss of GTP prenylation and eventual induction of osteoclast apoptosis.

Question 60

A 66-year-old woman who requires a cane for ambulation now notes increasing difficulty in using the cane after undergoing total elbow arthroplasty 3 months ago. AP and lateral radiographs are shown in Figures 15a and 15b. What is the most likely diagnosis?

Explanation

DISCUSSION: The lateral radiograph reveals a triceps avulsion with a small portion of bone. Triceps weakness and insufficiency can be a symptomatic problem after total elbow arthroplasty and is probably underreported. Ulnar nerve neuritis, aseptic loosening, instability, and infection are all complications of total elbow arthroplasty but would not account for the radiographic findings.
REFERENCES: Koval K (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orhthopaedic Surgeons, 2002, pp 323-327.
Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000,

pp 598-601.

Question 61

Figure below depicts the radiograph obtained from a 30-year-old woman who began having more right than left hip pain during a recent pregnancy. Physical examination reveals increased range of motion with positive flexion abduction and external rotation and flexion adduction and internal rotation as well as pain with external logroll. Assessment of Figure below reveals

Explanation

DISCUSSION:
Studies have demonstrated that pelvic inclination can dramatically affect the interpretation of radiographs in the dysplastic hip, with 9° of increased pelvic inclination leading to the presence of crossover signs and posterior wall signs. A distance of 30 mm to 50 mm from the sacrococcygeal junction to the pubis is often used to assess the adequacy of pelvic inclination on radiographs, although Siebenrock and associates determined the mean difference to be 32 mm in men and 47 mm in women. In this patient, the pelvic inclination is dramatically increased, leading to overestimation of acetabular retroversion.

Question 62

Which of the following is considered the best method to measure limb-length discrepancy in a patient with a knee flexion contracture?

Explanation

DISCUSSION: The most effective way to measure a limb-length discrepancy in a patient with a knee flexion contracture is a lateral CT scanogram. All the other methods listed provide inaccurate results with a knee flexion contracture because the measurements are made in the coronal plane.
REFERENCES: Aaron A, Weinstein D, Thickman D, et al: Comparison of orthoroentgenography and computed tomography in the measurement of limb-length discrepancy. J Bone Joint Surg Am 1992;74:897-902.
Tachdjian MO: Clinical Pediatric Orthopaedics: The Art of Diagnosis and Principles of Management. Stamford, CT, Appleton and Lange, 1997, pp 237-240.

Question 63

Which of the following factors is most critical to the success of a meniscal allograft transplantation?

Explanation

Success of a meniscal allograft transplantation is strongly dependent on accurate graft sizing, typically within 5% of the native meniscus. Previous studies have established that donor cell viability is not mandatory for the survival of these grafts since they are replaced by the recipient’s cells (at least peripherally) within several weeks. Thus,
cryopreservation of the graft to ensure cell viability is not necessary. There is a limited immune response to musculoskeletal allografts; therefore, immunosuppression, as is required for visceral organ transplantation, is not indicated.

Question 64

A 20-year-old collegiate pitcher sustains a medial collateral ligament (MCL) rupture of his throwing elbow for which surgical reconstruction is necessary. The goal of surgery is anatomic restoration of the MCL. Which statement best describes the kinematics of the native MCL?

Explanation

The anterior bundle is the most important portion of the complex when treating valgus instability of the elbow. The ligament originates from the anteroinferior surface of the medial epicondyle. The anterior bundle inserts on the medial border of the coronoid at the sublime tubercle. The anterior bundle of the medial collateral ligament (MCL) is the primary restraint to valgus stress, and the radial head is a secondary restraint. With anterior bundle sectioning, the resultant instability is most substantial between 60° and 70° and is lowest at
full extension and full flexion. True lateral radiographs reveal that the flexion-extension axis, or center of rotation, of the elbow lies in the center of the trochlea and capitellum. The origin of the anterior bundle of the MCL lies slightly posterior to the rotational center of the elbow. The anterior bundle is further divided into an anterior band and a posterior band. The eccentric origin of these anterior bundle components in relation to the rotational center through the trochlea creates a CAM effect during flexion and extension. The anterior band tightens during extension, and the posterior band tightens during flexion. This reciprocal tightening of the two functional components of the anterior bundle allows the ligament to remain taut throughout the full range of flexion. Cadaver dissection studies have identified the origin and insertion of both the medial and lateral stabilizing elbow ligaments. The anterior bundle of the MCL is isometric throughout the flexion/extension arc of motion, making Response C incorrect. The posterior bundle of the MCL elongates with elbow flexion, so Responses B and D are incorrect. The posterior bundle of the MCL also demonstrates the most change in
length from extension to flexion of all the elbow ligaments.

Question 65

Figure 3 is the clinical photograph of a 20-year-old college soccer player who has a 7-day history of worsening left ankle pain and swelling after being slide-tackled in a game. Radiograph findings of his ankle and foot are normal. He complains of malaise. His history includes a severe ankle sprain 3 months ago. The sprain caused him to miss half the season, but he was able to play in the last 2 games. What is the most appropriate treatment? Review Topic

Explanation

The clinical photograph shows a skin infection with an appearance consistent with methicillin-resistant Staphylococcus aureus. This infection should be clinically incised and allowed to drain and a course of antibiotics should follow. If this infection is not promptly treated with debridement, it likely will worsen and potentially spread to other teammates. Antibiotics are secondary to surgical debridement but are a necessary adjunct. Although this patient has a history of severe sprain, his malaise and skin appearance do not correlate with a ligament injury or fracture. Debridement in the training room is not appropriate and would likely not fully decompress the fluid collection.

Question 66

A 35-year-old carpenter sustained an injury to his dominant shoulder in a fall. He reports that he felt a sharp tearing sensation as he held on to a scaffold to keep from falling. Examination reveals swelling and ecchymosis down the upper arm, weakness to internal rotation, and deformity of the anterior axilla. He has good strength in external rotation and no apprehension with instability testing. Radiographs are normal. Management should consist of

Explanation

DISCUSSION: The findings are classic for a pectoralis major tendon avulsion. Deformity of the anterior axillary fold is a classic finding, and ecchymosis down the arm suggests that the injury is at the humeral attachment rather than at the musculotendinous junction. Good external rotation strength indicates that function in the supraspinatus and infraspinatus has been preserved. The treatment of choice for a tendon avulsion in a young individual is early surgical repair. Conversely, if the injury is within the muscle or at the musculotendinous junction, initial nonsurgical management is recommended. If the location of the injury cannot be determined by physical examination, then MRI of the pectoralis major can be helpful.
REFERENCES: Hanna CM, Glenny AB, Stanley SN, et al: Pectoralis major tears: Comparison of surgical and conservative treatment. Br J Sports Med 2001;35:202-206.
Connell DA, Potter HG, Sherman MF, et al: Injuries of the pectoralis major muscle: Evaluation with MR imaging. Radiology 1999;210:785-791.

Question 67

extensor tendons, 3) flexor tendons, 4) arteries, 5) nerves, 6) veins (can be done prior to nerve repair) , 7) skin.

Explanation

outcomes than above the elbow replantations.
A 45-year-old carpenter sustained a table saw injury to his right hand while at work earlier today. Evaluation in the Emergency Department reveals the defect depicted in Figure A. An island volar advancement flap was selected for wound closure. What is the largest defect that could be covered with this technique?

less than 1 cm
1.5 cm

Question 68

What is the primary indication for performing a total wrist arthroplasty in a patient with painful rheumatoid arthritis?

Explanation

The most conservative indications for a total wrist arthroplasty are to spare motion on one side and to improve activities of daily living. Component loosening, dislocation, and wound problems are frequent. Suitable patients can be of various ages, wrist motion, and radiographic stages of arthritis. Ipsilateral total elbow arthroplasty, type III degenerative changes of the wrist, age older than 55, and limited range of motion are neither primary indications nor contraindications to a total wrist arthroplasty.

Question 69

-A 15-year-old boy with mild type I osteogenesis imperfecta (OI) has a midshaft radius/ulna fracture that is in bayonet apposition with loss of the radial bow and 40-degree apex volar and ulnar angulation. Closed reduction improves the angulation to 20 degrees; the bayonet apposition and loss of radial bow remains.His contralateral forearm has a normal appearance upon examination. What is the best treatment for this fracture?

Explanation

Question 70

When polyethylene is exposed to radiation and subsequently heated, certain chemical changes occur in the material. Which of the following statements best describes these changes?

Explanation

DISCUSSION: Exposure of polyethylene to radiation and then heating it to quench the free radicals leads to a cross-linked material. It converts a high molecular weight polyethylene macromolecule to an interpenetrating network structure of polymer chains. The ductility of the material is decreased, hence the greater risk of fracture. While the wear rate (measured as fewer and smaller particles) against a smooth counterface is markedly reduced, cross-linked polyethylene has shown a larger increase in wear rate when a rougher counterface is used compared to noncross-linked material. Due to reduced mechanical strength, highly cross-linked polyethylene is less resistant to abrasive wear.
REFERENCE: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 32-33.

Question 71

Which of the following provides the most stable fixation for comminuted fractures of the posterior acetabular wall?

Explanation

According to the first sited article (Goulet et al, JBJS, 1994) “…comminuted fractures so close to posterior rim (i.e. comminuted fractures)… are amendable only to stabilization with a plate…a buttress plate enhances stability of fixation for comminuted fxs of the poster wall of the acetabulum.” “Fixation requires rigid fixation to prevent loss of fixation resulting in incongruity and instability.”
According to Rockwood & Green and Browner & Jupiter the key to fixing these fractures is to re-establish a congruent articular surface. The other four distracters (i.e. cable, methylmethacrylate, multiple lag screws, and multiple K-wires) may achieve initial stability, but reduction will not be maintained. In addition, further studies show a higher incidence of mortality and complications with the use of lag screws and K-wires alone (Browner & Jupiter, Skeletal trauma, 1998)

Question 72

What is the most common bacteria cultured from dog and cat bites to the upper extremity?

Explanation

DISCUSSION: To define bacteria responsible for dog and cat bite infections, a prospective study yielded a median of five bacterial isolates per culture. Pasteurella is most common from both dog bites (50%) and cat bites (75%). Pasteurella canis was the most frequent pathogen of dog bites, and Pasteurella multocida was the most common isolate of cat bites. Other common aerobes included streptococci, staphylococci, moraxella, and neisseria.
REFERENCE: Talan DA, Citron DM, Abrahamian FM, et al: Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med 1999;340:85-92.

Question 73

Figure 10 is an anteroposterior pelvis radiograph of an 82-year-old man who had right hip pain that began 2 weeks ago but has since resolved with use of over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs). Currently he has no pain. Examination of his hip shows decreased internal rotation and minimal pain at the extremes of motion. What is the most appropriate treatment at this point?

Explanation

DISCUSSION
The radiograph shown is consistent with Paget disease of the bone. It demonstrates classic findings of widened lamellae and disorganized sclerotic and lytic areas. The cause is not clearly defined, but may be linked to a viral infection and subsequent alterations of osteoblastic and osteoclastic activity. Most patients are asymptomatic, and Paget disease is often found incidentally on radiographs. In this case, the patient’s symptoms likely were caused by hip arthritis, but Paget disease can cause diffuse bone pain in some cases. Considering the patient’s mild and short-term symptoms, observation and NSAID use is most appropriate. An MRI scan or biopsy is indicated if sarcomatous transformation is suspected, but this condition is rare and is associated with a substantial, unrelenting increase in pain. SPEP and UPEP are tests for multiple myeloma, of which the radiographs show no signs.
RECOMMENDED READINGS
Ralston SH. Pathogenesis of Paget's disease of bone. Bone. 2008 Nov;43(5):819-25. doi: 10.1016/j.bone.2008.06.015. Epub 2008 Jul 11. Review. PubMed PMID: 18672105.View Abstract at PubMed
Bonenberger E, Einhorn T. Metabolic bone diseases. In: Callaghan JJ, Rosenberg
AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams 14
& Wilkins; 2007:514-533.

Question 74

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Explanation

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.

The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 75

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

Explanation

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

Question 76

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

Explanation

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

Question 77

An 8-year-old girl was treated for a Salter-Harris type I fracture of the right distal femur 2 years ago. Examination reveals symmetric knee flexion, extension, and frontal alignment compared to the contralateral knee. She has 1-cm of shortening of the right femur. History reveals that she has always been in the 50th percentile for height, and her skeletal age matches her chronologic age. Radiographs are shown in Figure 9. What is the expected consequence at maturity?

Explanation

DISCUSSION: The child has a near complete central physeal arrest of the distal femur and worsening limb-length discrepancy will develop. She is growing at the average rate for the population. The distal femoral physis grows at a rate of roughly 9 mm per year. Girls finish their growth at approximately age 14 years. Thus, at maturity the left leg will be 6.4 cm longer than the right. An angular deformity has not developed at this point and her arrest is central; therefore, angular deformity is unlikely to develop in any plane.
REFERENCES: Little DG, Nigo L, Aiona MD: Deficiencies of current methods for the timing of epiphysiodesis. J Pediatr Orthop 1996;16:173-179.
Moseley CF: Assessment and prediction in leg-length discrepancy. Instr Course Lect 1989;38:325-330.

Question 78

A 12-year-old boy is emergently transported to the emergency department following a motor vehicle accident. He was restrained in the back seat with a lap belt. On a physical exam bruising is noted across his abdomen as shown in Figure A. Lateral radiographs are shown in Figure B. Which of the following injuries are most frequently associated with this injury pattern? Review Topic

Explanation

Soft cervical orthosis because his gender puts him at a low risk of nonunion.
Halo vest immobilization because the degree of fracture displacement puts him at a low risk of nonunion.
Anterior screw fixation because his delayed time to treatment puts him at an high risk of nonunion.
Posterior C1-C2 fusion with rigid instrumentation because his age puts him at a high risk of nonunion.
Posterior C1-C2 fusion with sublaminar wiring because the degree of fracture angulation puts him at a high risk of nonunion.
The patient has a type II odontoid fracture and should be managed with halo vest immobilization as he has minimal fracture displacement (< 5mm) and no other risk factors for nonunion.
Type II odontoid fractures comprise 35% of all C2 fractures and have the highest nonunion rate. Commonly cited risk factors for nonunion include posterior displacement, posterior angulation, delayed initiation of treatment, fracture comminution and advanced age. Patients without these risk factors can often be successfully managed with halo vest immobilization. Elderly patients are frequently unable to tolerate halo vest immobilization and can be placed in a rigid cervical orthosis. Patients at high risk for nonunion are generally managed surgically with either anterior screw fixation, posterior rigid fixation (C1-C2 transarticular screw construct versus C1 lateral mass screw + C2 pedicle screw construct), or posterior C1-C2 sublaminar wiring.
Greene et al found that type II odonotoid fractures that were displaced >/= 6mm had a nonunion rate of 86% compared to 18% in patients with < 6mm displacement. This was statistically significant regardless of direction of displacement. Age was not significantly associated with nonunion.
Koivikko et al performed a retrospective review of conservatively treated type II odontoid fractures and identified risk factors for nonunion. Fracture gap > 1mm, posterior displacement > 5mm, posterior angulation > 20°, delayed start of treatment
> 4 days and posterior redisplacement > 2mm were all correlated with nonunion. In this study, anterior displacement, gender and age were unrelated to nonunion.
Figures A and B are coronal and sagittal CT scans of the cervical spine, respectively, demonstrating a noncomminuted type II odontoid fracture with minimal posterior displacement and angulation.
Incorrect
Responses:

Question 79

A 35-year-old active woman with rheumatoid arthritis experiences right shoulder pain following an extended course of corticosteroids (Figures 96a and 96b).

Explanation

DISCUSSION
The indication for anatomic TSA is end-stage glenohumeral arthritis with an intact rotator cuff. For the 62-year-old man, his radiographs reveal osteoarthritis, and his MR image shows an intact rotator cuff. Although humeral head replacement has historically been employed for this disorder, pain relief is not as reliable as with TSA, and the revision rate is higher. rTSA is generally reserved for patients with a nonfunctional rotator cuff.
For this 58-year-old patient with a full-thickness rotator cuff tear, preserved motion, and weakness in forward elevation, a rotator cuff repair is the most appropriate treatment. In the absence of degenerative changes, shoulder hemiarthroplasty or anatomic TSA is not indicated. Although indications for rTSA continue to evolve, well-compensated range of motion and a medium-sized rotator cuff tear in a younger patient are not among them.
rTSA is an emerging treatment for comminuted proximal humerus fractures in elderly patients. Although hemiarthroplasty has been a traditional treatment, current evidence suggests rTSA more reliably restores range of motion, and this 78-year-old patient's CT scan shows a small and comminuted greater tuberosity fragment that is unlikely to heal. ORIF is another option, but the CT scan also shows a small humeral head fragment that suggests osteopenia, making fixation more tenuous and likely less reliable.
A common problem associated with hemiarthroplasty for glenohumeral osteoarthritis is symptomatic glenoid degeneration that necessitates revision. This 55-year-old patient’s images reveal this is the case, although his infection workup is negative. His examination findings suggest an intact subscapularis repair. With a functioning rotator cuff and symptomatic glenoid arthritis, a conversion to anatomic TSA is indicated. In the absence of a functioning rotator cuff in an older patient, an rTSA is a better option.
This 72-year-old patient has classic symptoms and radiographs of cuff tear arthropathy. For patients with massive rotator cuff tear and glenohumeral arthritis, neither anatomic TSA nor rotator cuff repair is indicated. Hemiarthroplasty has historically been indicated for cuff tear arthropathy, but rTSA outcomes for this disorder have been superior and are now the preferred option.
Comminuted proximal humerus fractures in young, active patients are treated primarily with ORIF. The absence of glenohumeral arthritis removes anatomic TSA as a possibility, and concerns about implant longevity in younger, active patients such as this 40-year-old laborer contraindicate rTSA. Hemiarthroplasty is still employed in 3- and 4-part fractures but is generally reserved for subacute presentations or dislocations in which the humeral head is dysvascular and unlikely to survive. In this acute setting, a fixation procedure is preferred.
The 71-year-old patient who has had 2 failed rotator cuff repairs has an MR image that reveals another recurrent tear that is retracted to the glenoid. Her examination findings reveal classic signs
of a decompensated rotator cuff tear with pseudoparalysis and weakness in forward elevation. Although infection is a concern in the setting of multiply failed rotator cuff repair, the workup is negative in this scenario. Because this patient has a dysfunctional rotator cuff and has failed previous attempts at repair, a conversion to rTSA is the better option. In the absence of degenerative changes, hemiarthroplasty and anatomic TSA are not indicated.
The indications for hemiarthroplasty continue to narrow, but it is still a consideration for young patients with unipolar shoulder degeneration. In this 35-year-old patient, her MR image shows avascular necrosis in the humeral head, and her arthroscopy suggests arthritic change only on the humeral side with an uncompromised glenoid. To best treat young and active patients, a hemiarthroplasty that articulates with healthy glenoid cartilage can provide good pain relief and functional outcomes. Anatomic TSA is also reasonable but not an optimal option considering the normal glenoid condition. rTSA is not a consideration when a young patient’s MR images reveal an intact rotator cuff.
RECOMMENDED READINGS
Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with the Neer prosthesis: longterm results. J Shoulder Elbow Surg. 1997 Nov-Dec;6(6):495-505. PubMed PMID: 9437598. View Abstract at PubMed
Chalmers PN, Slikker W 3rd, Mall NA, Gupta AK, Rahman Z, Enriquez D, Nicholson GP. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg. 2014 Feb;23(2):197-204. doi: 10.1016/j.jse.2013.07.044. Epub 2013 Sep 27. PubMed PMID: 24076000. View Abstract at PubMed
Groh GI, Wirth MA. Results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular component systems. J Shoulder Elbow Surg. 2011 Jul;20(5):778-82. doi: 10.1016/j.jse.2010.09.014. Epub 2011 Jan 13. PubMed PMID: 21232989. View Abstract at PubMed
Orfaly RM, Rockwood CA Jr, Esenyel CZ, Wirth MA. Shoulder arthroplasty in cases with avascular necrosis of the humeral head. J Shoulder Elbow Surg. 2007 May-Jun;16(3 Suppl):S27-32. Epub 2006 Nov 16. PubMed PMID: 17113317. View Abstract at PubMed
Sershon RA, Van Thiel GS, Lin EC, McGill KC, Cole BJ, Verma NN, Romeo AA, Nicholson GP. Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years. J Shoulder Elbow Surg. 2014 Mar;23(3):395-400. doi: 10.1016/j.jse.2013.07.047. Epub 2013 Oct 12. PubMed PMID: 24129052. View Abstract at PubMed

Question 80

All of the following techniques can help to prevent valgus angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT:

Explanation

DISCUSSION: Proximal tibial shaft fractures treated with intramedullary nails are most commonly malreduced with apex anterior and valgus deformities. Several techniques are available to overcome this malalignment: proximal and lateral nail starting point, usage of a femoral distractor or temporary plating, suprapatellar nailing, and lateral parapatellar approaches. Suprapatellar nailing portals do not affect coronal angulation - they only affect the apex anterior deformity.
A final technical trick is the usage of blocking (Poller) screws - the referenced article by Ricci et al had 100% correction and maintenance of reduction with usage of blocking screws without other adjunct techniques. These should be placed in the lateral aspect of the proximal and distal fragments when needed.
The referenced study by Krettek et al is a biomechanical evaluation of blocking screws in a tibial model that showed significantly increased strength when they were utilized.

Question 81

What three structures are considered the primary constraints necessary for elbow stability?

Explanation

DISCUSSION: The three primary constraints necessary for elbow stability in all directions are the ulnar part of the lateral collateral ligament (also called the lateral ulnar collateral ligament), the anterior band of the medial collateral ligament, and the coronoid. The radial head and capsule are secondary constraints to elbow instability.
REFERENCES: Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354.

Question 82

A patient who underwent primary total hip arthroplasty 7 years ago that resulted in excellent pain relief and a normal gait now reports pain and a limp. Postoperative and current AP radiographs are shown in Figures 2a and 2b. What is the most likely cause of the pathology seen?

Explanation

DISCUSSION: Osteolysis in the trochanteric bed can result in weakening of the bone and fracture. Nonsurgical management will provide reasonable clinical and radiographic results in patients with limited fracture displacement.
REFERENCES: Claus MC, Hopper RH, Engh CA: Fractures of the greater trochanter induced by osteolysis with the anatomic medullary locking prosthesis. J Arthroplasty 2002;17:706-712.
Heekin RD, Engh CA, Herzwurm MF: Fractures through cystic lesions of the greater trochanter: A cause of late pain after cementless total hip arthroplasty. J Arthroplasty 1996;11:757-760.

Question 83

Which of the following is the most relevant clinical factor in the maturation assessment of an adolescent female athlete contemplating anterior cruciate ligament (ACL) reconstruction?

Explanation

DISCUSSION: Age of menarche is the most accurate clinical factor to assess the degree of skeletal maturity in the female athlete. Such an assessment is necessary prior to ACL reconstruction in a skeletally immature female because of the risk of damage to the distal femoral and proximal tibial physes. Height of an older male sibling is not relevant to the female athlete. Parental height and recent change in shoe size are only moderately useful in predicting final growth, and hence, skeletal maturity. The presence of breast buds occurs early in adolescent development; therefore, its presence suggests a high likelihood of future growth.
REFERENCES: Micheli LJ, Foster TE: Acute knee injuries in the immature athlete. Instr Course Lect 1993;42:473-481.
Stanitski CL: Anterior cruciate ligament injury in the skeletally immature patient: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:146-158.
Fowler PJ: Anterior cruciate ligament injuries in the child, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2067-2074.

Question 84

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 85

During an anterior retroperitoneal approach to the low lumbar spine, the iliac vessels are mobilized along the lateral side, allowing them to be retracted toward the midline. To gain adequate mobility of the common iliac vein for exposure of L5, it is important to identify which of the following structures?

Explanation

DISCUSSION: The iliolumbar vein is a large tributary that sits along the lateral surface of the common iliac vein. It can be quite substantial in size and must be identified prior to mobilizing the common iliac vein toward the midline. The other structures are not of surgical significance in performing this exposure.
REFERENCE: Gray H: Anatomy of the Human Body. Philadelphia, PA, Lea & Febiger,

1918, 2000.

Question 86

When comparing the failure load of an evenly tensioned four-stranded hamstring tendon anterior cruciate ligament autograft to a 10-mm bone-patellar tendon-bone autograft, the hamstring graft will fail at a tension

Explanation

DISCUSSION: The failure load of an evenly tensioned four-stranded hamstring tendon autograft has been reported to be 4,500 Newtons. The failure load of a 10-mm patellar tendon autograft has been estimated at 2,600 Newtons. The intact anterior cruciate ligament failure load has been calculated at 1,725 Newtons.
REFERENCES: Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA: Arthroscopic reconstruction of the anterior cruciate ligament: A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med 1999;27:448-454.
Hamner DL, Brown CH Jr, Steiner ME, et al: Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 1999;81:549-557.
Noyes FR, Butler DL, Grood ES, et al: Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am 1984;66:344-352.

Question 87

What term best describes the process involved when a growth factor produced by an osteoblast stimulates the differentiation of an adjacent undifferentiated mesenchymal cell during fracture repair?

Explanation

DISCUSSION: Growth factors are proteins secreted by cells that can act on target cells to produce certain biologic actions. These actions can be described as autocrine, paracrine, and endocrine. Autocrine actions are those in which the growth factor influences an adjacent cell of its origin or identical phenotype. Paracrine actions are those in which the protein influences an adjacent cell that is different in its origin or phenotype. Endocrine actions are those in which the factor influences a cell located at a distant anatomic site.
REFERENCES: Lieberman J, Daluiski A, Einhorn TA: The role of growth factors in the repair of bone: Biology and clinical applications. J Bone Joint Surg Am 2002;84:1032-1044.
Zuscik MJ, Drissi MH, Reynolds PR, et al: Molecular and cell biology in orthopaedics, 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 88

Figure 53 shows the radiograph of a 48-year-old man who has a left side periprosthetic femoral fracture around the femoral stem of a previous revision hip arthroplasty. What is the most appropriate treatment?

Explanation

DISCUSSION: In type B3 fractures, the proximal femur is so deficient that it cannot be treated with open reduction and internal fixation or support a new femoral component. In younger patients, the femur can be reconstructed with allograft prosthesis composite to restore bone stock. Removal of the distal stem with trephines would compromise fixation with cement. Elderly and low-demand patients can be treated more simply with a cemented segmental replacement prosthesis, such as that used for tumor reconstruction.
REFERENCES: Parvizi J, Tarity TD, Slenker N, et al: Proximal femoral replacement in patients with non-neoplastic conditions. J Bone Joint Surg Am 2007;89:1036-1043.
Harkess JW, Crockarell JR: Arthroplasty of the hip, in Canale ST, Beaty JH (eds): Campbell’s Operative Orthopaedics, ed 11. Philadelphia, PA, Mosby Elsevier, 2008, vol 1, pp 314-483.

Lee SR, Bostrom MP: Periprosthetic fractures of the femur after total hip arthroplasty. Instr Course Lect 2004;53:111-118.

Question 89

When planning scoliosis surgery for a patient with a 50-degree thoracolumbar curve and spinal muscular atrophy, it is most important to include

Explanation

DISCUSSION: Typically, posterior spinal fusion to the pelvis is recommended for patients with spinal muscular atrophy and advanced scoliosis. Examination for lower extremity muscle contractures is important because the contractures may interfere with good sitting balance. Anterior release and fusion usually are not advised. Diaphragmatic pacing is not indicated because diaphragm function usually is not affected. Patients with spinal muscular atrophy usually are not ambulatory or only marginally ambulatory at the time of scoliosis surgery; therefore, gait analysis usually is not relevant. While a muscle biopsy may have a role in the diagnosis of this disorder, it plays no subsequent role in determining life expectancy or the value of spinal surgery.
REFERENCES: Daher YH, Lonstein JE, Winter RB, Bradford DS: Spinal surgery in spinal muscular atrophy. J Pediatr Orthop 1985;5:391-395.
Aprin H, Bowen JR, MacEwen GD, et al: Spinal arthrodesis in patients with spinal muscle atrophy. J Bone Joint Surg Am 1982;64:1179-1187.

Question 90

What are the proposed biomechanical advantages of the Grammont reverse total shoulder arthroplasty when compared to a standard shoulder arthroplasty?

Explanation

DISCUSSION: The Grammont reverse total shoulder arthroplasty is designed to medialize the center of rotation, thereby increasing the deltoid moment arm and lengthening the deltoid.
REFERENCES: Werner CM, Steinmann PA, Gilbert M: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005;87:1476-1486.
Rittmeister M, Kerschbaumer M: Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg 2001;10:17-22.

Question 91

The third plantar intrinsic muscle layer of the foot consists of which of the following structures?

Explanation

DISCUSSION: The plantar intrinsic muscles are divided into four layers with respect to depth from the plantar fascia. They are (from superficial to deep): 1) abductor hallucis, flexor digitorum brevis, abductor digiti minimi; 2) quadratus plantae, lumbricals; 3) flexor digiti minimi, flexor hallucis brevis, adductor hallucis brevis; and 4) dorsal and plantar interosseous muscles. The flexor hallucis brevis and adductor hallucis brevis originate from the midtarsal bones, encompass the sesamoids, and insert into the base of the proximal phalanx. The adductor hallucis brevis consists of two muscle bellies forming a conjoined tendon and inserting into the lateral portion of the proximal phalanx and the lateral sesamoid. The adductor hallucis brevis is stronger than the abductor hallucis brevis, which may contribute to hallux valgus. The flexor digitorum minimi travels under the fifth metatarsal, arising at the base and inserting into the lateral base of the fifth proximal phalanx.
REFERENCE: Resch S: Functional anatomy and topography of the foot and ankle, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 32-33.

Question 92

Figures 111a and 111b show axial MRI scans of a 24-year-old man who injured his right shoulder several years ago and now reports continued difficulty with the shoulder and has pain with activity. He reports that when the injury occurred, he felt that his shoulder "popped" but he never required closed reduction. He wore a

Explanation

Performing a bench press with large amounts of weight is most likely to cause pain for a patient with a posterior labral tear. A patient who sustains a first-time posterior dislocation is less likely to have recurrent dislocations compared with first-time anterior dislocations. Patients often do have problems with loading the shoulder in a forward flexed position, such as during a bench press. The other activities listed here might be difficult, but are not as likely to be problematic. A biceps curl might bother a person with a SLAP tear. The late cocking/early acceleration phase of throwing, the overhead portion of a tennis serve, and spiking a volleyball places the shoulder in an abduction/external rotation position, which is likely to be problematic for a person with anterior instability.

Question 93

An 18-year-old gymnast has had a 1-year history of foot pain. Examination reveals medial midfoot tenderness without swelling. Non-weight-bearing in a cast for 6 weeks has failed to provide relief. An axial CT scan of the midfoot is shown in Figure 20. What is the optimal treatment for this condition?

Explanation

DISCUSSION: Stress fractures of the navicular are often seen in running and jumping sports. Whereas most individuals heal with nonsurgical management consisting of 6 weeks of casting, this gymnast has had pain for 1 year and nonsurgical management has failed. Open reduction with bone grafting is the preferred treatment.
REFERENCES: Quirk RM: Stress fractures of the navicular. Foot Ankle Int 1998;19:494-496.
Saxena A, Fullem B, Hannaford D: Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. J Foot Ankle Surg 2000;39:96-103.

Question 94

A 74-year-old woman with rheumatoid arthritis has pain in the shoulder that has failed to respond to nonsurgical management. AP and axillary radiographs are shown in Figures 24a and 24b. Active forward elevation is 120 degrees and external rotation is 30 degrees. At the time of surgery, a 1-cm rotator cuff tear is found, which is repairable. Which of the following treatment options will result in the most predictable pain relief and function? Review Topic

Explanation

Most studies have shown that total shoulder arthroplasties yield better pain relief and improved forward elevation when compared with hemiarthroplasty in patients with rheumatoid arthritis. Patients with repairable rotator cuff tears should undergo repair at the time of surgery because good results have been shown. Reverse arthroplasties are not indicated with rotator cuff tears that are repairable, and interpositional arthroplasties are not indicated for elderly patients.

Question 95

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

Explanation

DISCUSSION: Internal impingement of the shoulder is a leading cause of shoulder pain in the throwing athlete. The primary lesion in pathologic internal impingement is excessive tightening of the posterior band of the inferior glenohumeral ligament complex. To obtain an accurate assessment of true glenohumeral rotation, the scapula is stabilized during examination. A loss of 20 degrees or more of internal rotation, as measured with the shoulder positioned in 90 degrees of abduction, indicates excessive tightness of the posterior band of the inferior glenohumeral ligament complex.
REFERENCES: Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part I: Pathoanatomy and biomechanics. Arthroscopy 2003;19:404-420.
Meister K: Injuries to the shoulder in the throwing athlete. Part one: Biomechanics, pathophysiology, classification of injury. Am J Sports Med 2000;28:265-275.

Question 96

The vessel seen in the clinical photographs shown in Figures 50a and 50b (1,2 intercompartmental supraretinacular artery) is being dissected to be used as a source of vascularized bone graft for a patient who is scheduled to undergo internal fixation of a scaphoid nonunion. This vessel is a branch of what artery?

Explanation

DISCUSSION: The 1,2 intercompartmental supraretinacular artery is a branch of the radial artery. The vessel provides a reliable source of vascularized bone graft with an adequate pedicle length for use in scaphoid nonunions.
REFERENCES: Sheetz KK, Bishop AT, Berger RA: The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts. J Hand Surg 1995;20:902-914.
Steinmann SP, Bishop AT, Berger RA: Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg

2002;27:391-401.

Question 97

A 65-year-old man has a painful mass of the middle finger. A clinical photograph, lateral radiograph, coronal MRI scan, and biopsy specimen are seen in Figures 20a through 20d. What is the most likely diagnosis?

Explanation

DISCUSSION: Although the degeneration of an isolated benign cartilaginous lesion into a chondrosarcoma is rare, it occurs in roughly 10% of patients with Ollier’s disease. Pain is the most common symptom of chondrosarcoma. The treatment of low-grade chondrosarcoma ranges from intralesional excision to wide amputation. The intent of the surgery is to remove all the disease to decrease the chance of local recurrence.
REFERENCES: Lee FY, Mankin HJ, Fondren G, et al: Chondrosarcoma of bone: An assessment of outcome. J Bone Joint Surg Am 1999;81:326-338.
Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 181-193.

Question 98

Figure 10 shows the radiograph of a 9-year-old girl who injured her left lower leg after being thrown from a horse. Examination reveals no other injuries. Which of the following forms of management will provide the lowest rate of complications and the earliest return to function?

Explanation

DISCUSSION: Because the patient has a transverse midshaft fracture with no evidence of comminution, the treatment of choice is closed reduction and stabilization with flexible intramedullary nails. Transverse fractures treated with an external fixator heal with poor callus and have a high refracture rate. In addition, the pin tracks produce undesirable and excessive scarring. Femoral pin traction is safe and effective but results in considerable muscle wasting and a slow return to function. Interlocking nails run the risk of greater trochanteric growth disturbance and/or osteonecrosis of the femoral head in this age group. Plate fixation, while effective, requires considerable tissue dissection with large scar formation. It also requires a rather extensive dissection for later plate removal.
REFERENCES: Ligier JN, Metaizeau JP, Prevot J, Lascombes P: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-77.
Heinrich SD, Drvaric D, Darr K, MacEwen GD: Stabilization of pediatric diaphyseal femoral fractures with flexible intramedullary nails (a technique paper). J Orthop Trauma 1992;6:452-459.

Question 99

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

Explanation

DISCUSSION: Asymptomatic spondylolysis in a child or adolescent should be observed for the possible development of spondylolisthesis, but no other active intervention is needed. The initial treatment of choice for symptomatic spondylolysis includes rest and activity modifications, nonsteroidal anti-inflammatory drugs, physical therapy, bracing, and casting. Immobilization with a TLSO or pantaloon spica cast may permit healing of an acute pars fracture. Rarely, surgical treatment may be necessary. Surgical options include posterolateral L5-S1 fusion or direct repair of the pars defect.
REFERENCES: Pizzutillo PD, Hummer CD III: Nonoperative treatment for painful adolescent spondylolysis or spondylolisthesis. J Pediatr Orthop 1989;9:538-540.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1996, pp 129-137.

Question 100

Figures 1 and 2 are the radiographs of a 24-year-old male wrestler who underwent surgery for recurrent shoulder dislocations using coracoid autograft. At his first postoperative visit, the patient complains of decreased sensation on the lateral aspect of his forearm. The patient’s symptoms are most likely due to injury of the

Explanation

The patient has undergone a Latarjet procedure as shown in the radiographs. After harvesting the coracoid graft, care must be taken to not place too much tension on or dissect excessively near the musculocutaneous nerve. The nerve is encountered 5 cm distal to the coracoid as it enters the conjoint tendon. The lateral antebrachial cutaneous nerve is the terminal branch of the musculocutaneous nerve and; therefore, injury can cause decreased sensation in the lateral forearm.

Full Question & Answer Text (for Search Engines)

Question 1:

What allograft has the highest antigenicity when used for ligament reconstruction about the knee?

Options:

Tibialis anterior used for anterior cruciate ligament (ACL) reconstruction
Tibialis anterior used for posterolateral reconstruction
Bone-patellar tendon-bone used for ACL reconstruction
Semitendinosus used for posterior cruciate ligament reconstruction
Semitendinosus used for medial collateral ligament reconstruction

Correct Answer: Bone-patellar tendon-bone used for ACL reconstruction

Explanation:

Question 2:

A patient has a displaced complex intra-articular distal humeral fracture. What factor is considered most important when deciding on what surgical approach to use?

Options:

Visualization of the articular surface
Avoidance of an olecranon osteotomy
A muscle-sparing approach
The likelihood a total elbow arthroplasty will be performed
The likelihood that reconstruction of the anterior elbow joint will be performed

Correct Answer: Visualization of the articular surface

Explanation:

DISCUSSION: When managing a complex intra-articular fracture, it is imperative that there is adequate visualization of the joint; this usually means an extensile approach. At the elbow, this is usually through a transolecranon osteotomy. The recent addition of a muscle-sparing approach as described by Bryan and Morrey has gained popularity, but it is difficult to maintain soft-tissue viability and it may put the ulnar nerve at risk. A triceps-splitting approach, which can be used for simple single articular splits into the joint where extra-articular reduction is available, is possible and good results have been reported. To date, there is minimal data on these alternative approaches for comminuted intra-articular distal humeral fractures.
REFERENCES: McKee MD, Mehne DK, Jupiter JP: Fractures of the distal humerus: Part II, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1483-1522
McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR: Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82:1701-1707.
Patterson SD, Bain GI, Mehta JA: Surgical approaches to the elbow. Clin Orthop
2000;370:19-33.
Bryan RS, Morrey BF: Extensive posterior exposure of the elbow: A triceps-sparing approach. Clin Orthop 1982;166:188-192.

Question 3:

Options:

Avascular necrosis of the proximal pole of the scaphoid
Dorsal intercalated segment instability (DISI)
Volar intercalated segment instability
Thumb metacarpophalangeal joint hyperextension

Correct Answer: Dorsal intercalated segment instability (DISI)

Explanation:

Question 4:

What clinical finding is associated with the least favorable prognosis in an adolescent patient who has been diagnosed with a high-grade osteosarcoma of the distal femur?

Options:

A solitary peripheral lung metastasis
Tumor crossing the physis
Extracompartmental extension
Skeletal metastasis
Tumor necrosis of 99% after chemotherapy

Correct Answer: Skeletal metastasis

Explanation:

Question 5:

Options:

Application of a long leg cast
Aspiration of the tibial metaphysis
Bone scan
MRI
Observation

Correct Answer: Application of a long leg cast

Explanation:

Question 6:

Options:

ACL reconstruction and subsequent proximal tibial osteotomy
ACL reconstruction alone
Distal femoral osteotomy with simultaneous ACL reconstruction
Proximal tibial osteotomy with subsequent ACL reconstruction

Correct Answer: Proximal tibial osteotomy with subsequent ACL reconstruction

Explanation:

Question 7:

Options:

Patient gender
Patient age
Presentation with an unstable slipped epiphysis
Coexisting endocrine disorder

Correct Answer: Coexisting endocrine disorder

Explanation:

Question 8:

Options:

Age older than 40 years
Body mass index higher than 30
Tönnis grade of 2 or higher
Outer bridge grade of III or IV

Correct Answer: Tönnis grade of 2 or higher

Explanation:

Question 9:

What is the plasma half-life of warfarin?

Options:

1 to 2 hours
4 to 6 hours
12 to 18 hours
36 to 42 hours

Correct Answer: 36 to 42 hours

Explanation:

Question 10:

The blood supply to the anterior cruciate ligament is primarily derived from what artery?

Options:

Anterior tibial artery
Superolateral geniculate
Middle geniculate
Inferolateral geniculate
Inferomedial geniculate

Correct Answer: Middle geniculate

Explanation:

Question 11:

Options:

Removal of the press-fit implant and cementing of the same femoral stem
Removal of the uncemented femoral component and placement of a revision modular taper-fluted femoral stem
Removal of the implant, placement of a cerclage wire around the femoral neck above the lesser trochanter, and reinsertion of the implant
Final seating of the uncemented femoral component without additional measures

Correct Answer: Removal of the implant, placement of a cerclage wire around the femoral neck above the lesser trochanter, and reinsertion of the implant

Explanation:

Question 12:

An adult with a distal humeral fracture underwent open reduction and internal fixation. What is the most common postoperative complication?

Options:

Loss of elbow range of motion
Nonunion
Malunion
Infection
Ulnar nerve dysfunction

Correct Answer: Loss of elbow range of motion

Explanation:

Question 13:

Options:

smaller incisions.
increased wound complications.
fewer 30- and 90-day readmissions.
lower rates of patient satisfaction.

Correct Answer: increased wound complications.

Explanation:

DISCUSSION
The obesity epidemic is increasing, and the number of patients with a BMI higher than 35 undergoing THA and TKA is increasing. Controversy exists regarding the optimal BMI cutoff and the ability to perform joint replacements safely in patients who are morbidly obese. Several clinical series as well as national database analyses have shown that morbidly obese patients undergoing THA/TKA are at increased risk for wound complications and 30- and 90-day readmissions. These patients’ incisions are typically larger because of the size of the soft-tissue envelope; although their clinical scores following successful THA/TKA often are lower than scores for controls, the overall change in clinical function and satisfaction is equivalent among nonobese and obese patients.
CLINICAL SITUATION FOR QUESTIONS 96 THROUGH 99
Figures 96a through 96c are the anteroposterior and lateral radiographs of a 64-year-old man with long-standing right knee osteoarthritis and pain unresponsive to nonsurgical treatment. This patient is scheduled for navigated cruciate-retaining right total knee arthroplasty. His range of motion is 20 to 120 degrees before surgery. Following bone resections and release of the posterolateral capsule and iliotibial band the knee is stable and extends fully, but during knee flexion there is lift-off of the anterior portion of the trial insert. Alignment is neutral to the mechanical axis. A distal femoral medial resection involved 9 mm of bone with a 9-mm-thick implant. An appropriate tibial resection was perpendicular to the long axis, and the posterior tibial slope was 7 degrees.

Question 14:

Which radiographic abnormality most accurately serves as a predictor of ankle syndesmosis disruption?

Options:

Medial clear space equal to the superior clear space on the anteroposterior (AP) view
Tibiofibular overlap exceeding 6 mm on the AP view
Tibiofibular clear space exceeding 6 mm on AP view
Talocrural angle symmetric to the opposite side

Correct Answer: Tibiofibular clear space exceeding 6 mm on AP view

Explanation:

DISCUSSION
Normal syndesmotic relationships include a tibiofibular clear space smaller than 6 mm on both AP and mortise views. In a 1989 cadaveric study by Harper and Keller, a tibiofibular clear space exceeding 6 mm on both the AP and mortise views was the most reliable predictor of early syndesmotic widening. Tibiofibular overlap is measured 1 cm proximal to the plafond. Normal values exceed 6 mm or 42% of the width of the fibula on the AP view, or 1 mm on the mortise view. Proximal fibula fracture can occur in isolation without syndesmotic injury, frequently after direct trauma. The medial clear space is the distance between the lateral border of the medial malleolus and the medial border of the talus and is measured at the level of the talar dome. In the mortise view with the ankle in neutral dorsiflexion, the medial clear space should be equal to or smaller than the superior clear space between the talar dome and the tibial plafond. ?A normal medial clear space may be present with syndesmotic injury and consequently lacks sensitivity and specificity.
RECOMMENDED READINGS
Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg. 2007 Jun;15(6):330-9. Review. PubMed PMID: 17548882.
View Abstract at PubMed
Wuest TK. Injuries to the Distal Lower Extremity Syndesmosis. J Am Acad Orthop Surg. 1997 May;5(3):172-181. PubMed PMID: 10797219.
View Abstract at PubMed
Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989 Dec;10(3):156-60. PubMed PMID: 2613128.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 40
A 41-year-old man sustained a twisting injury while running up stairs 4 weeks ago. He was treated in an ankle brace and has been bearing weight since the injury occurred. He has no history of ankle problems, but he now has ankle pain, swelling, and instability. The pain is aggravated by stairs, and the instability is worse on unlevel ground. Radiographs do not show a fracture.

Question 15:

Options:

recurrent buckling with a probable meniscal tear.
limitation of motion with a delay in recovery.
a full return to activity with no limitations.
an improvement in overall performance.
an uneventful completion of the soccer season.

Correct Answer: recurrent buckling with a probable meniscal tear.

Explanation:

Question 16:

What is the prognosis for ambulation, from best to worst, for patients with an incomplete spinal cord injury?

Options:

Central cord syndrome, anterior cord syndrome, Brown-Sequard syndrome
Central cord syndrome, Brown-Sequard syndrome, anterior cord syndrome
Brown-Sequard syndrome, anterior cord syndrome, central cord syndrome
Brown-Sequard syndrome, central cord syndrome, anterior cord syndrome
Anterior cord syndrome, central cord syndrome, Brown-Sequard syndrome

Correct Answer: Brown-Sequard syndrome, central cord syndrome, anterior cord syndrome

Explanation:

Question 17:

Options:

- Subtalar arthritis
- Osteonecrosis
- Nonunion
- Varus malunion

Correct Answer: - Subtalar arthritis

Explanation:

DISCUSSION
When a displaced talar neck fracture occurs, the rate of osteonecrosis is high; however, many revascularize the talus without collapse. A nonunion can occur but is less common than osteonecrosis and arthritis. A varus malunion can be debilitating and lead to subtalar arthritis. In a fracture with the talar body dislocated posteromedially (such as in this example) neurologic deficits in the tibial nerve distribution are common but typically improve with urgent
reduction. Studies show that posttraumatic subtalar arthritis is common after this injury and is the most likely cause of long-term functional impairment.
RECOMMENDED READINGS
Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone Joint Surg Am. 2004 Aug;86-A(8):1616-24. PubMed PMID: 15292407.
View Abstract at PubMed
Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am. 2004 Oct;86-A(10):2229-34. PubMed PMID: 15466732.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 10 THROUGH 12
10A
10B
10C
Figure 10a is the radiograph of a 30-year-old man who sustained an injury in a motor vehicle collision.

Question 18:

Options:

Inlet and outlet views of the pelvis to better delineate the injury
Angiography
Laparotomy
Open reduction and internal fixation of the pelvis
Placement of a pelvic binder around the patient

Correct Answer: Placement of a pelvic binder around the patient

Explanation:

Question 19:

Options:

Continue to observe with repeat radiographs in 6 months B. Fluoroscopic-guided iliopsoas tendon cortisone injection C. Hip aspiration
Serum cobalt and chromium levels and metal-reduction MRI scan

Correct Answer: Continue to observe with repeat radiographs in 6 months B. Fluoroscopic-guided iliopsoas tendon cortisone injection C. Hip aspiration

Explanation:

Question 20:

Options:

Crescent fracture located on the side of impact
Widened anterior SI joint, disrupted sacrotuberous and sacrospinous ligaments with intact posterior SI ligaments
Complete SI disruption with lateral displacement
Sacral compression fracture on side of impact with transverse pubic rami fractures
Open-book injury with contralateral sacral compression fracture

Correct Answer: Open-book injury with contralateral sacral compression fracture

Explanation:

Question 21:

A distal radius fracture in an elderly man is strongly predictive for what subsequent injury?

Options:

Another distal radius fracture
Insufficiency fracture of the spine
Insufficiency fracture of the pelvis
Hip fracture
Proximal humerus fracture

Correct Answer: Hip fracture

Explanation:

Question 22:

Options:

slow rewarming in cool 77 degrees F (25 degrees C) water.
rapid rewarming in a footbath at 104.0 degrees F to 107.6 degrees F (40 degrees C to 42 degrees C).
rewarming in 98.6 degrees F (37 degrees C) water.
heated blankets at 100.4 degrees F (38 degrees C).
a heating pad at 104.0 degrees F (40 degrees C).

Correct Answer: rapid rewarming in a footbath at 104.0 degrees F to 107.6 degrees F (40 degrees C to 42 degrees C).

Explanation:

Question 23:

Which of the following methods of meniscal repair has the highest load to failure strength?

Options:

Horizontal suture
Vertical suture
Mulberry knot
T-fix suture
Meniscal arrow

Correct Answer: Vertical suture

Explanation:

Question 24:

Options:

case series.
case-control study.
cohort study.
randomized clinical trial.

Correct Answer: case series.

Explanation:

Question 25:

Options:

Neurogenic
Hemorrhagic
Spinal
Septic
Hypovolemic

Correct Answer: Neurogenic

Explanation:

Question 26:

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

Options:

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

Correct Answer: accurately tension the PCL.

Explanation:

Question 27:

Options:

Resting anterior compartment pressure of 13 mm Hg
Numbness/tingling of the plantar foot during the exercise portion of the test
minute postexercise anterior compartment pressure of 42 mm Hg
minute postexercise anterior compartment pressure of 19 mm Hg

Correct Answer: minute postexercise anterior compartment pressure of 42 mm Hg

Explanation:

Question 28:

With respect to femoral component design, stress relief osteopenia in the proximal femur following noncemented total hip arthroplasty appears to be most strongly influenced by the

Options:

stiffness of the femoral component.
head offset of the femoral component.
femoral component material modulus of elasticity.
extent of the femoral component porous coating.
Presence of a femoral component collar.

Correct Answer: stiffness of the femoral component.

Explanation:

Question 29:

In patient selection for meniscal allograft transplantation, which of the following variables has the greatest influence on outcome?

Options:

Grade of chondromalacia
Limb alignment
Patient age
Patient weight
Postoperative level of activity

Correct Answer: Grade of chondromalacia

Explanation:

Question 30:

Thoracic disk herniations are most frequently found in what area of the spine?

Options:

C7-T2
T2-T5
T5-T8
T9-T12
T12-L1

Correct Answer: T9-T12

Explanation:

Question 31:

Options:

revision of the failing ACL reconstruction.
arthroscopic lysis of adhesions and manipulation of the knee.
surgical removal of hypertrophic fibrous tissue.
excision of the torn medial meniscus.
continued aggressive physical therapy.

Correct Answer: surgical removal of hypertrophic fibrous tissue.

Explanation:

DISCUSSION: The patient has a cyclops lesion. This is a nodule of fibroproliferative tissue that originates from either drilling debris from the tibial tunnel or remnants of the ACL stump; more rarely it is the result of broken graft fibers. The treatment of choice is excision of the nodule and, if needed, additional notchplasty. Marked improvements in function and symptoms have been noted after removal of the extension block and resumption of a rehabilitation program.
REFERENCES: Delince P, Krallis P, Descamps PY, et al: Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: A multifactorial etiopathogenesis. Arthroscopy 1998;14:869-876.
Fisher SE, Shelbourne KD: Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction. Am J Sports Med 1993;4:558-564.

Question 32:

The axial stability of a 4-pin uniplanar external fixator used to treat a patient who has a transverse midthird fracture of the tibia with a 5-mm fracture gap can be most greatly increased by

Options:

Allowing the ends of the fracture to touch
Adding a second connecting bar
Adding one pin to each fracture fragment
Increasing the pin diameter from 4 mm to 6 mm
Decreasing the connecting bar-to-bone distance from 6 cm to 4 cm

Correct Answer: Allowing the ends of the fracture to touch

Explanation:

Question 33:

Options:

Period of immobilization followed by physical therapy
Local corticosteroid injection
Surgical repair
Platelet-rich plasma (PRP)

Correct Answer: Surgical repair

Explanation:

Question 34:

Figure 23 shows the radiograph of a 55-year-old man who underwent a total hip arthroplasty 5 years ago. Management should now consist of

Options:

an Ogden-type plate with screws and cerclage bands or cables.
allograft bone plates fixed with cerclage cables and wires.
skeletal traction for 8 weeks.
revision of the femoral stem.
resection arthroplasty.

Correct Answer: revision of the femoral stem.

Explanation:

Question 35:

- Chronic flatfoot deformity is most commonly associated with a contracture of the

Options:

Plantar fascia
Spring ligament
Deltoid ligament
Intrinsic tendons
Gastorcnemius-solelus complex

Correct Answer: Gastorcnemius-solelus complex

Explanation:

Question 36:

04 Which of the following laboratory studies is predictive of wound healing prior to performing a lower extremity amputation?

Options:

Total protein level
Calcium level
Serum albumin level
Platelet count
ESR back answer Question 11.04

Correct Answer: Serum albumin level

Explanation:

Question 37:

What is the most common associated pathology in patients who have suprascapular nerve entrapment secondary to ganglion cysts?

Options:

Glenohumeral arthritis
Fracture of the clavicle
Tear of the rotator cuff
Rupture of the long head of the biceps tendon
Superior labrum anterior and posterior (SLAP) lesion

Correct Answer: Superior labrum anterior and posterior (SLAP) lesion

Explanation:

Question 38:

Options:

Convert to skeletal leg traction
Radiograph/CT scan hip
MRI scan hip
Frog leg lateral hip radiograph
Oncology consultation

Correct Answer: Convert to skeletal leg traction

Explanation:

Question 39:

The major blood supply to the cruciate ligaments arises from which of the following structures?

Options:

Superior genicular artery
Middle genicular artery
Inferior genicular artery
Infrapatellar fat pad
Intramedullary vessels

Correct Answer: Middle genicular artery

Explanation:

Question 40:

Options:

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

Correct Answer: Total elbow arthroplasty

Explanation:

Question 41:

Options:

Observation
Incisional biopsy
Excisional biopsy
MRI
Ultrasound

Correct Answer: Observation

Explanation:

Question 42:

- Demyelination diseases as multiple sclerosis and Guillain-Barre $ create neurologic symptoms by

Options:

decreasing initiation of action potentials.
increasing action potential amplitude.
blocking the opening of gated sodium channels.
decreasing the number of functional motor units.
slowing or stopping action potential propagation through the axon.

Correct Answer: slowing or stopping action potential propagation through the axon.

Explanation:

Question 43:

Based on the injury shown on the axial MRI scan of the shoulder in Figure 1, what other pathology should be closely examined for during surgery?

Options:

Subscapularis tear
Supraspinatus tear
Superior labral anterior-posterior (SLAP) tear
Bankart tear

Correct Answer: Subscapularis tear

Explanation:

Question 44:

The best candidate for a reverse total shoulder arthroplasty is a patient with rotator cuff tear arthropathy with Review Topic

Options:

anterior superior escape.
rheumatoid arthritis.
an acromial stress fracture.
a centered head and an external rotation lag sign of 50 degrees.
active forward elevation of 130 degrees.

Correct Answer: anterior superior escape.

Explanation:

Question 45:

Figure 23 shows the radiograph of an elderly man who fell on his right arm. What is the most important determinate of a good outcome following this injury?

Options:

Early open reduction and internal fixation
Initiation of physical therapy and passive motion within 2 weeks of the injury
Fracture involvement of the greater tuberosity
Immobilization with a sling and swathe for 4 weeks
Age of younger than 70 years

Correct Answer: Initiation of physical therapy and passive motion within 2 weeks of the injury

Explanation:

Question 46:

A complication unique to computer navigation of total knee arthroplasty (TKA) is

Options:

femoral shaft fracture.
intercondylar femur fracture.
ligament disruption.
nerve palsy.

Correct Answer: femoral shaft fracture.

Explanation:

DISCUSSION
Threaded pins are frequently inserted into the femoral shaft and tibial shafts or proximal tibia to attach arrays for tracking devices. There have been case reports of fractures propagating through the pin tracks, which is a complication unique to computer navigation. Intercondylar fractures can occur following posterior stabilized TKA. Vascular injury, ligament disruption, and nerve palsy are rare complications following TKA performed with or without computer navigation.
CLINICAL SITUATION FOR QUESTIONS 111 THROUGH 113
Figure 111 is the anteroposterior radiograph of a 79-year-old woman with a presurgical diagnosis of osteonecrosis who sustained a periprosthetic tibia fracture following her total knee arthroplasty (TKA).

Question 47:

Options:

use of a sling with no range-of-motion exercises until the condition is stable.
use of a sling and passive range-of-motion exercises within the limits of the repair.
no sling and supine passive range-of-motion exercises.
an internal rotation brace holding the arm at the side.
an external rotation brace holding the arm at the side.

Correct Answer: an external rotation brace holding the arm at the side.

Explanation:

Question 48:

At what age does the lateral epicondyle normally ossify in males?

Options:

2 to 4 years
5 to 6 years
7 to 8 years
9 to 11 years
12 to 14 years

Correct Answer: 12 to 14 years

Explanation:

Question 49:

The biopsy specimens seen in Figures 55a and 55b are from a lytic lesion in the sacrum of a 58-year-old man. What is the most likely diagnosis?

Options:

Chondrosarcoma
Metastatic renal cell carcinoma
Chondromyxoid fibroma
Chordoma
Giant cell tumor

Correct Answer: Chordoma

Explanation:

DISCUSSION: The lesion is a chordoma and the other listed choices can be eliminated based on the histology. Many tumors can occur in the sacrum including chordoma, multiple myeloma, giant cell tumor, aneurysmal bone cyst, and metastatic disease. The histology in this patient shows a lobulated lesion on low power with fibrous septae separating the lobules. At higher magnification, the cells have eosinophilic vacuolated cytoplasm and are called physaliferous cells. Chordoma is a low-grade neoplasm that most commonly occurs in the sacrum and rarely in the base of the skull. The diagnosis is often delayed. Chordoma is thought to originate from notochordal remnants. Chordoma typically occurs in the midline and has an associated soft-tissue mass.
REFERENCES: Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 372.
Fuchs B, Dickey ID, Yaszemski MJ, et al: Operative management of sacral chordoma. J Bone Joint Surg Am 2005;87:2211-2216.
Fourney DR, Rhines LD, Hentschel SJ, et al: En bloc resection of primary sacral tumors: Classification of surgical approaches and outcome. J Neurosurg Spine 2005;3:111-122.

Question 50:

Which of the following best characterizes the antigenicity of allograft bone?

Options:

Cell surface glycoproteins are primarily responsible for the antigenicity of the graft.
Fresh grafts have less antigenicity than cryopreserved grafts.
Immunosupression provides little difference in response to allogenic bone.
Hematopoietic elements are the primary cells causing antigenic response.
Lyophilization (freeze-drying) or chemical sterilization does not change the antigenicity of the graft.

Correct Answer: Cell surface glycoproteins are primarily responsible for the antigenicity of the graft.

Explanation:

Question 51:

Options:

Ewing’s sarcoma
Lymphoma of bone
Metastatic neuroblastoma
Langerhans cell histiocytosis
Osteomyelitis

Correct Answer: Langerhans cell histiocytosis

Explanation:

Question 52:

Options:

close observation with frequent neurovascular checks.
emergency angiography.
emergency exploration of the brachial artery.
removal of pin fixation and exploration of the brachial artery.
thrombectomy.

Correct Answer: close observation with frequent neurovascular checks.

Explanation:

Question 53:

The natural history of cervical spondylolytic myelopathy is best described as

Options:

slow, steady deterioration.
rapid deterioration.
stable over time.
stable for long periods with stepwise deterioration.
significant improvement after an initial episode of severe symptoms.

Correct Answer: stable for long periods with stepwise deterioration.

Explanation:

Question 54:

Arthrodesis

Options:

Repair of the rotator cuff
Replacement of the humeral head
Resection arthroplasty
Total shoulder arthroplasty

Correct Answer: Resection arthroplasty

Explanation:

Question 55:

What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window?

Options:

External iliac artery
Obturator nerve
Corona mortis
L5 nerve root
Ilioinguinal nerve

Correct Answer: External iliac artery

Explanation:

Question 56:

Options:

Apert
Poland
Holt-Oram
VACTERRL
Thrombocytopenia-absent radius (TAR)

Correct Answer: Apert

Question 57:

Options:

Observation as the deformity should resolve in time
Wearing of straight last shoes
Serial stretching and casting for the next 6 to 12 weeks
Heyman, Herndon, and Strong capsular release at the tarsometatarsal and intermetatarsal joints
Berman and Gartland dome-shaped osteotomies of the metatarsal bases

Correct Answer: Serial stretching and casting for the next 6 to 12 weeks

Explanation:

DISCUSSION: Weinstein reported on 31 patients (45 feet) with congenital metatarsus adductus followed for an average of 33 years. Twenty-nine feet had moderate to severe deformities treated with manipulation and casting with a 90% success rate. In a young child, surgery is not indicated until nonsurgical management has failed. In patients 2 to 4 years of age, tarsometatarsal capsulotomies are indicated, whereas multiple metatarsal osteotomies are reserved for recalcitrant deformities in children older than 4 years of age. Mild or moderate metatarsus adductus that is passively correctable will resolve without treatment.
REFERENCES: Beaty J: Congenital anomalies of the lower extremity, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 10. Philadelphia PA, Mosby, 2003, pp 983-988.
Katz K, David R, Soudry M: Below-knee plaster cast for the treatment of metatarsus adductus.
J Pediatr Orthop 1999;19:49-50.
Weinstein SL: Bristol-Myers Squibb/Zimmer award for distinguished achievement in orthopaedic research. Long-term follow-up of pediatric orthopaedic conditions: Natural history and outcomes
of treatment. J Bone Joint Surg Am 2000;82:980-990.

Question 58:

What is the most important preoperative factor predicting conversion to total hip arthroplasty after arthroscopic surgery of the hip?

Options:

Age over 60 years
Morbid obesity
Diagnosis of osteoarthritis
Tobacco use

Correct Answer: Morbid obesity

Explanation:

Question 59:

Two major pharmacologic classes of bisphosphonates exist: nitrogen-containing and non-nitrogen-containing compounds. The nitrogen-containing compounds work by which of the following actions?

Options:

COX inhibition
ATPase formation
GTPase inhibition
DNA gyrase inhibition
RNA polymerase inhibition

Correct Answer: GTPase inhibition

Explanation:

Question 60:

Options:

Ulnar nerve neuritis
Triceps insufficiency
Aseptic loosening
Instability
Infection

Correct Answer: Triceps insufficiency

Explanation:

Question 61:

Options:

classic dysplasia with volume deficient acetabula.
acetabular retroversion with positive crossover signs and ischial spine signs.
no substantial dysplasia, with normal acetabular volume and anteversion.
inadequate radiographic evidence to assess for hip dysplasia.

Correct Answer: inadequate radiographic evidence to assess for hip dysplasia.

Explanation:

Question 62:

Which of the following is considered the best method to measure limb-length discrepancy in a patient with a knee flexion contracture?

Options:

Obtain a standard scanogram
Obtain a lateral CT scanogram
Measure the distance from the anterior superior iliac spine to the medial malleolus
Measure the distance from the umbilicus to the medial malleolus
Stand the patient on blocks to measure the difference in the heights of the iliac wings

Correct Answer: Obtain a lateral CT scanogram

Explanation:

DISCUSSION: The most effective way to measure a limb-length discrepancy in a patient with a knee flexion contracture is a lateral CT scanogram. All the other methods listed provide inaccurate results with a knee flexion contracture because the measurements are made in the coronal plane.
REFERENCES: Aaron A, Weinstein D, Thickman D, et al: Comparison of orthoroentgenography and computed tomography in the measurement of limb-length discrepancy. J Bone Joint Surg Am 1992;74:897-902.
Tachdjian MO: Clinical Pediatric Orthopaedics: The Art of Diagnosis and Principles of Management. Stamford, CT, Appleton and Lange, 1997, pp 237-240.

Question 63:

Which of the following factors is most critical to the success of a meniscal allograft transplantation?

Options:

Accurate graft size
Donor cell viability
Reestablishment of the central meniscal blood supply
Suppression of the immune response
Cryopreservation of the donor graft

Correct Answer: Accurate graft size

Explanation:

Question 64:

Options:

The posterior bundle demonstrates the greatest change in tension from flexion to extension.
The posterior bundle is isometric.
The anterior bundle becomes tight in flexion and lax in extension.
The anterior and posterior bundles are isometric.

Correct Answer: The posterior bundle demonstrates the greatest change in tension from flexion to extension.

Explanation:

Question 65:

Options:

Incision and drainage
Ice the ankle but don't let him play.
Topical antibiotics for 7 days with an occlusive dressing
Debridement in the training room followed by 5 days of oral antibiotics

Correct Answer: Incision and drainage

Explanation:

The clinical photograph shows a skin infection with an appearance consistent with methicillin-resistant
Staphylococcus aureus
. This infection should be clinically incised and allowed to drain and a course of antibiotics should follow. If this infection is not promptly treated with debridement, it likely will worsen and potentially spread to other teammates. Antibiotics are secondary to surgical debridement but are a necessary adjunct. Although this patient has a history of severe sprain, his malaise and skin appearance do not correlate with a ligament injury or fracture. Debridement in the training room is not appropriate and would likely not fully decompress the fluid collection.

Question 66:

Options:

physical therapy for range of motion and strengthening following a decrease in pain and swelling.
shoulder arthroscopy for diagnosis and treatment of a possible labral tear.
open exploration and repair of a pectoralis major tendon avulsion.
MRI of the rotator cuff.
immobilization in a sling and swathe for 3 to 6 weeks, followed by mobilization and strengthening.

Correct Answer: open exploration and repair of a pectoralis major tendon avulsion.

Explanation:

Question 67:

extensor tendons, 3) flexor tendons, 4) arteries, 5) nerves, 6) veins (can be done prior to nerve repair) , 7) skin.

Options:

Sabapathy et al. review replantation surgery in the upper extremity. They discuss that a “functional extremity” could be reconstructed at the upper-arm level in 22% to 34%, at the proximal forearm level in 30% to 41%, and at the distal forearm level in 56% to 80% of cases.
Hanel et al. review wrist level and proximal amputations in the upper extremity. Among other things, they state that wrist-proximal amputations should be performed before 12 hours of cold ischemia time or 6 hours of warm ischemia time have elapsed.
Figure A shows a sharp transcarpal amputation. Incorrect Answers:

Correct Answer: Sabapathy et al. review replantation surgery in the upper extremity. They discuss that a “functional extremity” could be reconstructed at the upper-arm level in 22% to 34%, at the proximal forearm level in 30% to 41%, and at the distal forearm level in 56% to 80% of cases.

Explanation:

Question 68:

What is the primary indication for performing a total wrist arthroplasty in a patient with painful rheumatoid arthritis?

Options:

Ipsilateral total elbow arthroplasty
Contralateral wrist arthrodesis
Type III degenerative changes of the wrist
Age older than 55 years
Less than 30 degrees of wrist flexion/extension

Correct Answer: Contralateral wrist arthrodesis

Explanation:

Question 69:

Options:

Open reduction and plate fixation
Open reduction and intramedullary rod fixation with casting
Cast immobilization with expected remodeling of the fracture and near-full motion
Cast immobilization, accepting malunion and some dysfunction because surgical treatment has a high rate of nonunion in OI DISCUSSION-Teenagers with displaced midshaft forearm fractures do not remodel fully if the angulation is beyond 10 degrees after reduction. Excellent outcomes have been shown with intramedullary rodding as well as plate fixation. In patients with bone fragility, plate fixation poses higher risks for fracture attributable to stress shielding. Load sharing with intramedullary rodding is preferred in surgical management of fractures whenever possible. This patient is 15 years old with unacceptable reduction, so remodeling of this fracture would not be expected with closed management. Patients with OI are not at higher risk for nonunion with surgery; there is no reason to withhold surgery for this patient.

Correct Answer: Open reduction and intramedullary rod fixation with casting

Question 70:

When polyethylene is exposed to radiation and subsequently heated, certain chemical changes occur in the material. Which of the following statements best describes these changes?

Options:

The process converts an otherwise interpenetrating networking structure of polymer chains into a linear, high molecular weight polyethylene macromolecule.
The process increases the ductility of the material.
The process leads to fewer particles that are larger in size than the untreated material.
The process improves (lowers) the wear rate but may increase the risk of fracture.
The process decreases the wear rate of the material, compared to untreated polyethylene, when tested against a rough counterface.

Correct Answer: The process improves (lowers) the wear rate but may increase the risk of fracture.

Explanation:

DISCUSSION: Exposure of polyethylene to radiation and then heating it to quench the free radicals leads to a cross-linked material. It converts a high molecular weight polyethylene macromolecule to an interpenetrating network structure of polymer chains. The ductility of the material is decreased, hence the greater risk of fracture. While the wear rate (measured as fewer and smaller particles) against a smooth counterface is markedly reduced, cross-linked polyethylene has shown a larger increase in wear rate when a rougher counterface is used compared to noncross-linked material. Due to reduced mechanical strength, highly cross-linked polyethylene is less resistant to abrasive wear.
REFERENCE: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 32-33.

Question 71:

- Which of the following provides the most stable fixation for comminuted fractures of the posterior acetabular wall?

Options:

Cable
Buttress plate
Methylmethacrylate
Multiple lag screws
Multiple Kirschner wires

Correct Answer: Buttress plate

Explanation:

Question 72:

What is the most common bacteria cultured from dog and cat bites to the upper extremity?

Options:

Pasteurella
Streptococcus
Staphylococcus
Bacteroides
Moraxella

Correct Answer: Pasteurella

Explanation:

DISCUSSION: To define bacteria responsible for dog and cat bite infections, a prospective study yielded a median of five bacterial isolates per culture. Pasteurella is most common from both dog bites (50%) and cat bites (75%). Pasteurella canis was the most frequent pathogen of dog bites, and Pasteurella multocida was the most common isolate of cat bites. Other common aerobes included streptococci, staphylococci, moraxella, and neisseria.
REFERENCE: Talan DA, Citron DM, Abrahamian FM, et al: Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med 1999;340:85-92.

Question 73:

Options:

Observation and NSAID use as needed
MRI scan
Bone biopsy
Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP).

Correct Answer: Observation and NSAID use as needed

Explanation:

DISCUSSION
The radiograph shown is consistent with Paget disease of the bone. It demonstrates classic findings of widened lamellae and disorganized sclerotic and lytic areas. The cause is not clearly defined, but may be linked to a viral infection and subsequent alterations of osteoblastic and osteoclastic activity. Most patients are asymptomatic, and Paget disease is often found incidentally on radiographs. In this case, the patient’s symptoms likely were caused by hip arthritis, but Paget disease can cause diffuse bone pain in some cases. Considering the patient’s mild and short-term symptoms, observation and NSAID use is most appropriate. An MRI scan or biopsy is indicated if sarcomatous transformation is suspected, but this condition is rare and is associated with a substantial, unrelenting increase in pain. SPEP and UPEP are tests for multiple myeloma, of which the radiographs show no signs.
RECOMMENDED READINGS
Ralston SH. Pathogenesis of Paget's disease of bone. Bone. 2008 Nov;43(5):819-25. doi: 10.1016/j.bone.2008.06.015. Epub 2008 Jul 11. Review. PubMed PMID: 18672105.
View Abstract at PubMed
Bonenberger E, Einhorn T. Metabolic bone diseases. In: Callaghan JJ, Rosenberg
AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams
14
& Wilkins; 2007:514-533.

Question 74:

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Options:

within 1 standard deviation of aged-matched normals.
within 1 and 2.5 standard deviations below aged-matched normals.
within 1 standard deviation of young normals.
within 1 and 2.5 standard deviations below young normals.
more than 2.5 standard deviations below aged-matched normals.

Correct Answer: within 1 and 2.5 standard deviations below young normals.

Explanation:

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.
The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 75:

Options:

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

Correct Answer: Nonfunctional left vocal cord

Explanation:

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

Question 76:

Options:

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

Correct Answer: Continued dressing changes

Explanation:

Question 77:

Options:

cm limb-length discrepancy with the right femur longer
cm limb-length discrepancy with the left femur longer
degree varus deformity
degree valgus deformity
degree recurvatum deformity

Correct Answer: cm limb-length discrepancy with the left femur longer

Explanation:

DISCUSSION: The child has a near complete central physeal arrest of the distal femur and worsening limb-length discrepancy will develop. She is growing at the average rate for the population. The distal femoral physis grows at a rate of roughly 9 mm per year. Girls finish their growth at approximately age 14 years. Thus, at maturity the left leg will be 6.4 cm longer than the right. An angular deformity has not developed at this point and her arrest is central; therefore, angular deformity is unlikely to develop in any plane.
REFERENCES: Little DG, Nigo L, Aiona MD: Deficiencies of current methods for the timing of epiphysiodesis. J Pediatr Orthop 1996;16:173-179.
Moseley CF: Assessment and prediction in leg-length discrepancy. Instr Course Lect 1989;38:325-330.

Question 78:

Options:

Cardiac tamponade
Pulmonary contusion
Colonic rupture
Bladder rupture
Acute cholecystitis

Correct Answer: Acute cholecystitis

Explanation:

The clinical presentation is consistent with a Chance fracture of the spine. These fractures are often associated with concomitant bowel injury.
A Chance fracture injury is a flexion-distraction injury of the spine. The anterior column (vertebral body) collapses under compression and the posterior elements fail under tension (rupture of the interspinous ligaments or avulsion fracture of the spinous process). A common mechanism is a MVA where the child is wearing a seatbelt, leading to a "seatbelt sign". In the presence of a "seatbelt" sign, on should have a high suspicion for a bowel injury.
Reid et al. reported seven cases of pediatric patients with Chance fractures. All had associated intraabdominal bowel injury.
Holland et al. retrospectively reviewed 28 pediatric patients with Chance fractures, 71% sustained following road trauma. Eleven percent had associated small bowel injury, but all patients had abnormal abdominal CT scans.
Figure A is a clinical photo of a 'seatbelt sign' following a motor vehicle accident. Figure B exhibits a "bony" Chance fracture where the spinous process has been avulsed. Illustration A depict the failure of the anterior column under compression and failure of the posterior column under tension.
Incorrect answers:
(SBQ12SP.32) A 48-year-old man is involved in a motor vehicle accident and is taken to an outside hospital where he undergoes CT imaging, displayed in Figures A-B. Approximately 36 hours later he is transferred to your hospital for further evaluation and management. On exam, he has tenderness over his upper cervical spine and is neurologically intact with no myelopathic signs. What is the most appropriate treatment method for this patient and why?
Review
Topic
Soft cervical orthosis because his gender puts him at a low risk of nonunion.
Halo vest immobilization because the degree of fracture displacement puts him at a low risk of nonunion.
Anterior screw fixation because his delayed time to treatment puts him at an high risk of nonunion.
Posterior C1-C2 fusion with rigid instrumentation because his age puts him at a high risk of nonunion.
Posterior C1-C2 fusion with sublaminar wiring because the degree of fracture angulation puts him at a high risk of nonunion.
The patient has a type II odontoid fracture and should be managed with halo vest immobilization as he has minimal fracture displacement (< 5mm) and no other risk factors for nonunion.
Type II odontoid fractures comprise 35% of all C2 fractures and have the highest nonunion rate. Commonly cited risk factors for nonunion include posterior displacement, posterior angulation, delayed initiation of treatment, fracture comminution and advanced age. Patients without these risk factors can often be successfully managed with halo vest immobilization. Elderly patients are frequently unable to tolerate halo vest immobilization and can be placed in a rigid cervical orthosis. Patients at high risk for nonunion are generally managed surgically with either anterior screw fixation, posterior rigid fixation (C1-C2 transarticular screw construct versus C1 lateral mass screw + C2 pedicle screw construct), or posterior C1-C2 sublaminar wiring.
Greene et al found that type II odonotoid fractures that were displaced >/= 6mm had a nonunion rate of 86% compared to 18% in patients with < 6mm displacement. This was statistically significant regardless of direction of displacement. Age was not significantly associated with nonunion.
Koivikko et al performed a retrospective review of conservatively treated type II odontoid fractures and identified risk factors for nonunion. Fracture gap > 1mm, posterior displacement > 5mm, posterior angulation > 20°, delayed start of treatment
> 4 days and posterior redisplacement > 2mm were all correlated with nonunion. In this study, anterior displacement, gender and age were unrelated to nonunion.
Figures A and B are coronal and sagittal CT scans of the cervical spine, respectively, demonstrating a noncomminuted type II odontoid fracture with minimal posterior displacement and angulation.
Incorrect
Responses:

Question 79:

A 35-year-old active woman with rheumatoid arthritis experiences right shoulder pain following an extended course of corticosteroids (Figures 96a and 96b).

Options:

Humeral head resurfacing/shoulder hemiarthroplasty
Anatomic total shoulder arthroplasty (TSA)
Reverse total shoulder arthroplasty (rTSA)
Rotator cuff repair
Open reduction and internal fixation (ORIF)

Correct Answer: Humeral head resurfacing/shoulder hemiarthroplasty

Explanation:

DISCUSSION
The indication for anatomic TSA is end-stage glenohumeral arthritis with an intact rotator cuff. For the 62-year-old man, his radiographs reveal osteoarthritis, and his MR image shows an intact rotator cuff. Although humeral head replacement has historically been employed for this disorder, pain relief is not as reliable as with TSA, and the revision rate is higher. rTSA is generally reserved for patients with a nonfunctional rotator cuff.
For this 58-year-old patient with a full-thickness rotator cuff tear, preserved motion, and weakness in forward elevation, a rotator cuff repair is the most appropriate treatment. In the absence of degenerative changes, shoulder hemiarthroplasty or anatomic TSA is not indicated. Although indications for rTSA continue to evolve, well-compensated range of motion and a medium-sized rotator cuff tear in a younger patient are not among them.
rTSA is an emerging treatment for comminuted proximal humerus fractures in elderly patients. Although hemiarthroplasty has been a traditional treatment, current evidence suggests rTSA more reliably restores range of motion, and this 78-year-old patient's CT scan shows a small and comminuted greater tuberosity fragment that is unlikely to heal. ORIF is another option, but the CT scan also shows a small humeral head fragment that suggests osteopenia, making fixation more tenuous and likely less reliable.
A common problem associated with hemiarthroplasty for glenohumeral osteoarthritis is symptomatic glenoid degeneration that necessitates revision. This 55-year-old patient’s images reveal this is the case, although his infection workup is negative. His examination findings suggest an intact subscapularis repair. With a functioning rotator cuff and symptomatic glenoid arthritis, a conversion to anatomic TSA is indicated. In the absence of a functioning rotator cuff in an older patient, an rTSA is a better option.
This 72-year-old patient has classic symptoms and radiographs of cuff tear arthropathy. For patients with massive rotator cuff tear and glenohumeral arthritis, neither anatomic TSA nor rotator cuff repair is indicated. Hemiarthroplasty has historically been indicated for cuff tear arthropathy, but rTSA outcomes for this disorder have been superior and are now the preferred option.
Comminuted proximal humerus fractures in young, active patients are treated primarily with ORIF. The absence of glenohumeral arthritis removes anatomic TSA as a possibility, and concerns about implant longevity in younger, active patients such as this 40-year-old laborer contraindicate rTSA. Hemiarthroplasty is still employed in 3- and 4-part fractures but is generally reserved for subacute presentations or dislocations in which the humeral head is dysvascular and unlikely to survive. In this acute setting, a fixation procedure is preferred.
The 71-year-old patient who has had 2 failed rotator cuff repairs has an MR image that reveals another recurrent tear that is retracted to the glenoid. Her examination findings reveal classic signs
of a decompensated rotator cuff tear with pseudoparalysis and weakness in forward elevation. Although infection is a concern in the setting of multiply failed rotator cuff repair, the workup is negative in this scenario. Because this patient has a dysfunctional rotator cuff and has failed previous attempts at repair, a conversion to rTSA is the better option. In the absence of degenerative changes, hemiarthroplasty and anatomic TSA are not indicated.
The indications for hemiarthroplasty continue to narrow, but it is still a consideration for young patients with unipolar shoulder degeneration. In this 35-year-old patient, her MR image shows avascular necrosis in the humeral head, and her arthroscopy suggests arthritic change only on the humeral side with an uncompromised glenoid. To best treat young and active patients, a hemiarthroplasty that articulates with healthy glenoid cartilage can provide good pain relief and functional outcomes. Anatomic TSA is also reasonable but not an optimal option considering the normal glenoid condition. rTSA is not a consideration when a young patient’s MR images reveal an intact rotator cuff.
RECOMMENDED READINGS
Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with the Neer prosthesis: longterm results. J Shoulder Elbow Surg. 1997 Nov-Dec;6(6):495-505. PubMed PMID: 9437598.
View
Abstract at PubMed
Chalmers PN, Slikker W 3rd, Mall NA, Gupta AK, Rahman Z, Enriquez D, Nicholson GP. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg. 2014 Feb;23(2):197-204. doi: 10.1016/j.jse.2013.07.044. Epub 2013 Sep 27. PubMed PMID: 24076000.
View Abstract at PubMed
Groh GI, Wirth MA. Results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular component systems. J Shoulder Elbow Surg. 2011 Jul;20(5):778-82. doi: 10.1016/j.jse.2010.09.014. Epub 2011 Jan 13. PubMed PMID: 21232989.
View Abstract at PubMed
Orfaly RM, Rockwood CA Jr, Esenyel CZ, Wirth MA. Shoulder arthroplasty in cases with avascular necrosis of the humeral head. J Shoulder Elbow Surg. 2007 May-Jun;16(3 Suppl):S27-32. Epub 2006 Nov 16. PubMed PMID: 17113317.
View Abstract at PubMed
Sershon RA, Van Thiel GS, Lin EC, McGill KC, Cole BJ, Verma NN, Romeo AA, Nicholson GP. Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years. J Shoulder Elbow Surg. 2014 Mar;23(3):395-400. doi: 10.1016/j.jse.2013.07.047. Epub 2013 Oct 12. PubMed PMID: 24129052.
View Abstract at PubMed

Question 80:

All of the following techniques can help to prevent valgus angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT:

Options:

Use of a blocking screw lateral to midline in the proximal segment
Use of a blocking screw lateral to midline in the distal segment
Use of a lateral tibial nail starting point
Use of supplementary plate and screw fixation
Suprapatellar nailing portal

Correct Answer: Use of a blocking screw lateral to midline in the proximal segment

Explanation:

Question 81:

What three structures are considered the primary constraints necessary for elbow stability?

Options:

Coronoid, ulnar part of the lateral collateral ligament, capsule
Capsule, anterior band of the medial collateral ligament, radial head
Radial head, ulnar part of the lateral collateral ligament, capsule
Anterior band of the medial collateral ligament, coronoid, radial head
Ulnar part of the lateral collateral ligament, anterior band of the medial collateral ligament, coronoid

Correct Answer: Ulnar part of the lateral collateral ligament, anterior band of the medial collateral ligament, coronoid

Explanation:

Question 82:

Options:

Infection
Injury of the superior gluteal nerve
Loosening of the acetabular component
Loosening of the femoral component
Osteolysis

Correct Answer: Osteolysis

Explanation:

Question 83:

Which of the following is the most relevant clinical factor in the maturation assessment of an adolescent female athlete contemplating anterior cruciate ligament (ACL) reconstruction?

Options:

Parental height
Height of older male sibling
Age of menarche
Recent change in shoe size
Presence of breast buds

Correct Answer: Age of menarche

Explanation:

Question 84:

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 85:

Options:

Obturator artery
Central sacral vessels
Internal iliac vein
Ascending lumbar vein
Iliolumbar vein

Correct Answer: Iliolumbar vein

Explanation:

Question 86:

Options:

equal to the bone-patellar tendon-bone graft.
one half the failure load of the bone-patellar tendon-bone graft.
one quarter the failure load of the bone-patellar tendon-bone graft.
approximately two times the failure load of the bone-patellar tendon-bone graft.
four times the failure load of the bone-patellar tendon-bone graft.

Correct Answer: approximately two times the failure load of the bone-patellar tendon-bone graft.

Explanation:

Question 87:

What term best describes the process involved when a growth factor produced by an osteoblast stimulates the differentiation of an adjacent undifferentiated mesenchymal cell during fracture repair?

Options:

Mechanical
Autocrine
Paracrine
Endocrine
Systemic

Correct Answer: Paracrine

Explanation:

Question 88:

Options:

Open reduction and internal fixation with a plate
Open reduction and internal fixation with a cable
Revision with a short stem and plate fixation
Revision with allograft prosthesis composite
Removal of the proximal femoral bone and replacement with a cemented segmental prosthesis

Correct Answer: Revision with allograft prosthesis composite

Explanation:

Question 89:

When planning scoliosis surgery for a patient with a 50-degree thoracolumbar curve and spinal muscular atrophy, it is most important to include

Options:

an anterior release and fusion.
a diaphragmatic pacer to assist postoperative pulmonary function.
a preoperative gait analysis.
an evaluation for lower extremity muscle contractures.
assessment of muscle biopsy findings obtained within the last 6 months to clarify the patient’s life expectancy and thus the value of the surgery.

Correct Answer: an evaluation for lower extremity muscle contractures.

Explanation:

Question 90:

What are the proposed biomechanical advantages of the Grammont reverse total shoulder arthroplasty when compared to a standard shoulder arthroplasty?

Options:

Lateralization of the center of rotation, lengthening the deltoid, and decreasing the deltoid moment arm
Lateralization of the center of rotation, shortening the deltoid, and decreasing acromial stress
Lateralization of the center of rotation, lengthening the deltoid, and increasing the transverse force couple
Medialization of the center of rotation, lengthening the deltoid, and increasing the deltoid moment arm
Medialization of the center of rotation, shortening the deltoid, and decreasing acromial stress

Correct Answer: Medialization of the center of rotation, lengthening the deltoid, and increasing the deltoid moment arm

Explanation:

DISCUSSION: The Grammont reverse total shoulder arthroplasty is designed to medialize the center of rotation, thereby increasing the deltoid moment arm and lengthening the deltoid.
REFERENCES: Werner CM, Steinmann PA, Gilbert M: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005;87:1476-1486.
Rittmeister M, Kerschbaumer M: Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg 2001;10:17-22.

Question 91:

The third plantar intrinsic muscle layer of the foot consists of which of the following structures?

Options:

Flexor digiti minimi, flexor hallucis brevis, adductor hallucis brevis
Quadratus plantae, flexor hallucis brevis, flexor digiti minimi
Quadratus plantae and plantar interosseous muscles
Quadratus plantae, flexor digitorum brevis, flexor hallucis brevis
Abductor hallucis, flexor digitorum brevis, flexor hallucis brevis

Correct Answer: Flexor digiti minimi, flexor hallucis brevis, adductor hallucis brevis

Explanation:

Question 92:

Options:

Reaching back to hit a forehand in tennis
External rotating the shoulder to spike a volleyball
Performing a bench press with large amounts of weight
Performing a biceps curl with large amounts of weights
Throwing a baseball at the point of late cocking/early acceleration

Correct Answer: Performing a bench press with large amounts of weight

Explanation:

Question 93:

Options:

Partial weight bearing in a walking cast for an additional 6 weeks
Open reduction and internal fixation
Open reduction and internal fixation with autologous bone grafting
No treatment
Non-weight-bearing in a cast for an additional 6 weeks

Correct Answer: Open reduction and internal fixation with autologous bone grafting

Explanation:

Question 94:

Options:

Total shoulder arthroplasty and rotator cuff repair
Rotator cuff repair
Reverse total shoulder arthroplasty
Interpositional arthroplasty and rotator cuff repair
Hemiarthroplasty and rotator cuff repair

Correct Answer: Total shoulder arthroplasty and rotator cuff repair

Explanation:

Question 95:

Options:

Posterior capsular tightness
Tightness of the rotator cuff interval
Anterior inferior glenohumeral ligament laxity
Excessive retroversion of the proximal humerus
Subacromial impingement

Correct Answer: Posterior capsular tightness

Explanation:

Question 96:

Options:

Radial
Ulnar
Median
Posterior interosseous
Anterior interosseous

Correct Answer: Radial

Explanation:

Question 97:

Options:

Giant cell tumor
Chondrosarcoma
Osteosarcoma
Infection
Paget’s disease

Correct Answer: Chondrosarcoma

Explanation:

Question 98:

Options:

Distal femoral pin and 90-90 traction for 3 weeks, followed by a spica cast
Closed reduction and stabilization with an external fixator
Closed reduction and stabilization with an interlocking nail
Closed reduction and stabilization with multiple flexible intramedullary nails
Open reduction and stabilization with a plate and screws

Correct Answer: Closed reduction and stabilization with multiple flexible intramedullary nails

Explanation:

Question 99:

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

Options:

physical therapy.
restriction from contact sports.
periodic observation, but no activity restriction.
immobilization with a thoracolumbosacral orthosis (TLSO).
direct surgical repair.

Correct Answer: periodic observation, but no activity restriction.

Explanation:

Question 100:

Options:

axillary nerve.
musculocutaneous nerve.
median nerve.
radial nerve.

Correct Answer: musculocutaneous nerve.

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

OITE & ABOS Orthopedic Board Prep MCQs: Trauma, Sports Medicine & Hand | Part 6

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 6

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index