OITE & ABOS Orthopedic MCQs: Knee, Shoulder & Tumor

About This Board Review Set

This is Part 8 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 8

This module focuses heavily on: Arthroplasty, Knee, Shoulder, Tumor.

Sample Questions from This Set

Sample Question 1: When 6 weeks of noninvasive nonsurgical management fails to provide relief for a lumbar disk herniation, a trial of epidural steroid injections is likely to yield which of the following results?...

Sample Question 2: A 47-year-old man undergoes a posterior cervical procedure for a benign tumor. Postoperatively, severe dysfunction with decreased forward elevation and abduction develops and he has lateral winging of the scapula. What is the recommended tr...

Sample Question 3: A patient sustained a sharp laceration to the base of his left, nondominant thumb 4 months ago. Examination reveals no active flexion but full passive motion of the interphalangeal joint. What is the best treatment option?...

Sample Question 4: A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with...

Sample Question 5: In long-term follow-up studies of cemented total knee arthroplasty (TKA), the lowest rates of osteolysis have been associated with which design feature?...

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

When 6 weeks of noninvasive nonsurgical management fails to provide relief for a lumbar disk herniation, a trial of epidural steroid injections is likely to yield which of the following results?

Explanation

DISCUSSION: Lumbar epidural steroid injections appear to play a role in management of a lumbar disk herniation that has failed to respond to at least 6 weeks of nonsurgical treatment. Approximately 42% to 56% of patients report significant pain relief compared with 92% to 98% of those patients treated with diskectomy. Patients with extruded or sequestered herniations report the greatest and most rapid relief. Similarly, those with well-hydrated disk fragments report rapid relief of symptoms. A smaller percentage of patients report symptom relief compared with those having surgery, but the degree of improvement is similar for both groups and the improvement lasts up to 3 years.
REFERENCES: Butterman GR: Treatment of lumbar disc herniation: Epidural steroid injection compares with discectomy: A prospective, randomized study. J Bone Joint Surg Am 2004;86:670-679.
Butterman GR: Lumbar disc herniation regression after successful epidural steroid injection.

J Spinal Disord Tech 2002;15:469-476.

Question 2

A 47-year-old man undergoes a posterior cervical procedure for a benign tumor. Postoperatively, severe dysfunction with decreased forward elevation and abduction develops and he has lateral winging of the scapula. What is the recommended treatment to best restore motion and function? Review Topic

Explanation

The patient has sustained a permanent injury to the spinal accessory nerve and has resultant scapular winging (lateral winging) because of trapezius palsy with weakness in abduction and forward elevation. The modified Eden-Lange procedure (transfer of the rhomboid minor, major, and levator scapulae) has been shown to reliably restore range of motion and function. Split pectoralis major transfer is performed to restore serratus anterior function. The long head of the triceps and infraspinatus tendon transfers are rarely used for any shoulder muscle transfer. A scapulothoracic fusion can also be performed for this problem, but the results are not as effective as the Eden-Lange procedure.

Question 3

A patient sustained a sharp laceration to the base of his left, nondominant thumb 4 months ago. Examination reveals no active flexion but full passive motion of the interphalangeal joint. What is the best treatment option?

Explanation

DISCUSSION: The patient has a chronic flexor tendon laceration. There are options to restore motion and strength; therefore, fusion is not necessary. Full range of motion is present so the soft tissues are suitable for a tendon transfer. A transfer of the flexor digitorum superficialis of the ring finger to the insertion of the flexor pollicis longus on the distal phalanx provides good results with a one-stage operation.
REFERENCES: Schneider LH, Wiltshire D: Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer. J Hand Surg Am 1983;8:98-101.
Posner MA: Flexor superficialis tendon transfers to the thumb: An alternative to the free tendon graft for treatment of chronic injuries within the digital sheath. J Hand Surg Am 1983;8:876-881.

Question 4

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

Explanation

DISCUSSION: An isolated avulsion of the lesser tuberosity occurs very rarely and usually is found in 12- and 13-year-old adolescents. The MRI scans reveal a tear of the humeral attachment of the inferior glenohumeral ligament, a so-called HAGL lesion. This injury to the inferior glenohumeral ligament occurs much less commonly than the classic Bankart lesion (anterior inferior labral tear). A tear of the subscapularis occurs with a similar mechanism of injury but generally occurs in older individuals.
REFERENCES: Bokor DJ, Conboy VB, Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br 1999;81:93-96.
Wolf EM, Cheng JC, Dickson K: Humeral avulsion of the inferior glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607.

Question 5

In long-term follow-up studies of cemented total knee arthroplasty (TKA), the lowest rates of osteolysis have been associated with which design feature?

Explanation

DISCUSSION
The lowest reported rates of osteolysis involving cemented TKAs are associated with monolithic tibial components. Modular components and cemented metal-backed patella components are associated with a high prevalence of backside tibial insert wear and osteolysis.

Question 6

A 24-year-old collegiate pitcher has had increasing pain over his medial elbow for 3 months. He has point tenderness over his medial epicondyle and reproduction of his symptoms with a valgus stress test. What phase of the throwing cycle most likely will reproduce his symptoms? Review Topic

Explanation

This patient is experiencing soreness over his medial (ulnar) collateral ligament. Valgus overload is likely to reproduce his symptoms and is most pronounced during the late cocking phase of the throwing cycle. In wind up, very little elbow torque is required. In early cocking, the arm is getting loaded and maximum valgus is not yet achieved at the elbow. In acceleration and deceleration, more force is generated at the level of the shoulder joint.

Question 7

An otherwise healthy 16-year-old boy who has had thoracolumbar pain with an increasingly worse deformity for the past 2 years now reports that the pain is worse at night. He responded well to nonsteroidal anti-inflammatory drugs initially, but they have become less effective. He denies any neurologic or constitutional symptoms. Examination is consistent with a mild thoracolumbar scoliosis and is otherwise normal. Laboratory studies show a normal CBC, erythrocyte sedimentation rate, and C-reactive protein. Standing radiographs show a 20 degrees left thoracolumbar scoliosis, and he has a Risser stage of 4. A bone scan shows increased uptake at L2; a CT scan through this level is shown in Figure 18. Management should now consist of

Explanation

DISCUSSION: The findings and radiographic appearance are most consistent with osteoid osteoma involving the medial pedicle. Scoliosis is commonly seen with this lesion and usually does not need surgical intervention. Excellent results have been reported with surgical excision as well as with percutaneous thermocoagulation. Nonsurgical treatment also has been described in peripheral osteoid osteoma but is not well described for lesions within the spine.
REFERENCES: Cove JA, Taminiau AH, Obermann WR, Vanderschueren GM: Osteoid osteoma of the spine treated with percutaneous computed tomography-guided thermocoagulation. Spine 2000;25:1283-1286.
Kneisl JS, Simon MA: Medical management compared with operative treatment for osteoid-osteoma. J Bone Joint Surg Am 1992;74:179-185.
Pettine KA, Klassen RA: Osteoid-osteoma and osteoblastoma of the spine. J Bone Joint Surg Am 1986;68:354-361.

Question 8

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

Explanation

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

Question 9

Figure 63 shows the radiographs of a 23-year-old man who sustained a twisting injury at work. Swelling, tenderness, and ecchymosis are noted about the entire midfoot. What associated injury is most likely to be problematic?

Explanation

DISCUSSION: This cuboid compression fracture (“nutcracker” injury) is associated with subtle injury to the Lisfranc complex. This diagnosis must be made to ensure proper treatment.
REFERENCE: Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.

Question 10

During the anterior approach for repair of a distal biceps tendon rupture, what structure, shown under the scissors in Figure 6, is at risk for injury?

Explanation

DISCUSSION: The most commonly injured neurovascular structure during an anterior approach for the repair of a distal biceps tendon rupture is the lateral antebrachial cutaneous nerve. This structure is located lateral to the biceps tendon and in a superficial location just deep to the subcutaneous layer. The antecubital vein is medial and superficial with the brachial artery and median nerve also medial to the biceps tendon but deep to the common flexors. The posterior interosseous nerve is deep within the supinator muscle and can be injured in the deep dissection or through the posterior approach when using a two-incision approach.
REFERENCES: Kelly EW, Morrey BF, O’Driscoll SW: Complications of repair of the distal biceps tendon with the modified two-incision technique. J Bone Joint Surg Am 2000;82:1575-1581.
Ramsey ML: Distal biceps tendon injuries: Diagnosis and management. J Am Acad Orthop Surg 1999;7:199-207.

Question 11

A 52-year-old man has pain in the sternal area after landing on his right shoulder in a fall from his bicycle. In addition, he reports that he had difficulty swallowing and breathing immediately after the fall, but the symptoms resolved. A CT scan reveals a posterior sternoclavicular dislocation. Initial management should include

Explanation

DISCUSSION: Posterior sternoclavicular dislocations require rapid treatment because of the proximity of major neurovascular structures and the airway. Initial management should consist of closed reduction under general anesthesia in the operating room with a chest surgeon available. A successful closed reduction is usually stable. Internal fixation of sternoclavicular injuries should be avoided because of the likelihood of hardware migration and possible injury to the mediastinal structures. If closed reduction is unsuccessful, open reduction is indicated. Treatment following reduction of the sternoclavicular joint includes the application of a figure-of-8 splint and a sling for 6 weeks, followed by stretching and strengthening exercises.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont IL, American Academy of Orthopaedic Surgeons, 1999, pp 287-297.
Rockwood CA Jr: Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, vol 2, pp 1010-1017.

Question 12

For the athlete performing heavy exercise, the magnitude of core temperature and heart rate increase is most proportional to

Explanation

DISCUSSION: Studies examining the impact of graded water debt have clearly shown that the magnitude of core temperature and heart rate increase accompanying work are proportional to the magnitude of water debt at the onset of exercise. Though added thermal burden from hot climates is a factor, it appears to be less significant.
REFERENCES: Latzka WA, Montain SJ: Water and electrolyte requirements for exercise. Clin Sports Med 1999;18:513-524.
Montain SJ, Sawka MN, Latzka WA, et al: Thermal and cardiovascular strain from hypohydration: Influence of exercise intensity. Int J Sports Med 1998;19:87-91.
Sawka MN, Young AJ, Francesconi RP, et al: Thermoregulatory and blood responses during exercise at graded hypohydration levels. J Appl Physiol 1985;59:1394-1401.

Question 13

A young man sustains a lumbar strain in an on-the-job motor vehicle accident. Both he and his treating physician feel that he is capable of limited duty with appropriate restrictions shortly after the injury. What term best describes his work status?

Explanation

DISCUSSION: Because the man is only recently removed from his injury and is judged capable of returning to work with some restrictions, the term that best describes his work status is temporary partial disability.
REFERENCE: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 131-137.

Question 14

A 40-year-old woman has had sciatic pain on the left side for the past 8 weeks. She reports that the pain radiates to her posterior thigh, lateral calf, and into the dorsum of her left foot. Neurologic examination shows weakness of the left extensor hallucis longus. Axial T 2 -weighted MRI scans through L4-L5 are shown in Figure 14. Management should consist of

Explanation

DISCUSSION: The MRI scans show hypertrophy of the left L4-L5 facet joint and ligamentum flavum, with a synovial cyst. Appropriate surgical management consists of a hemilaminectomy and direct decompression of the neural elements. Fusion, in addition to the decompression, may be considered, particularly in patients with an associated spondylolisthesis.
REFERENCES: Epstein NE: Lumbar laminectomy for the resection of synovial cysts and coexisting lumbar spinal stenosis or degenerative spondylolisthesis: An outcome study. Spine 2004;29:1049-1055.
Shah RV, Lutz GE: Lumbar intraspinal synovial cysts: Conservative management and review of the world’s literature. Spine J 2003;3:479-488.

Question 15

A 26-year-old female twists her knee while playing soccer and sustains the injury shown in Figure A. She undergoes a reconstructive surgery and is started on an accelerated rehabilitation program. Which of the following is true regarding this type of rehabilitation protocol? Review Topic

Explanation

The literature indicates that there is no difference in outcomes of accelerated rehabilitation programs compared with nonaccelerated rehabilitation programs after anterior cruciate ligament (ACL) reconstruction.
Rehabilitation after ACL reconstruction is necessary for a successful surgical outcome and remains an important topic of research interest. Accelerated programs allow for earlier weightbearing and certain strengthening exercises, rather than waiting several weeks before performing certain activities which put strain on the graft. Despite initial concerns that accelerated rehabilitation programs may lead to worse outcomes, many studies have demonstrated comparable outcomes between accelerated and nonaccelerated rehabilitation programs. No significant long-term differences have been reported regarding ACL laxity, range of motion, strength, or return to sports. Use of an accelerated program does not imply earlier return to sports. The optimal time to return to sports has not yet been elucidated.
Beynnon et al. performed a randomized controlled trial of patients who underwent ACL reconstruction with bone-patellar tendon-bone autograft comparing rehabilitiaton with either accelerated (19 week) or nonaccelerated (32 week) programs. At final evaluation, patients in both programs had the same increase in the envelope of knee laxity, clinical assessment, functional performance, proprioception,
and
thigh
muscle
strength.
Kruse et al. presented a systematic review evaluating studies on rehabilitation following ACL reconstruction. The authors found that accelerated rehabilitation does not appear to be harmful. It is likely safe for patients to begin immediate postoperative weight bearing, range of motion from 0-90 degrees of flexion, and perform closed-chain exercises. Bracing following ACL reconstruction is neither necessary nor beneficial and often adds to the cost of the procedure.
Figure A is a sagittal MRI demonstrating a complete ACL tear.
Incorrect

Question 16

A 3-year old child from an isolated mountain area is evaluated for multiple medical problems, including vomiting, loss of appetite, polyuria, and failure to thrive. History reveals the child was normal at birth. The parents, who appear healthy, are second cousins and have two other children who are normal. The parents state that they know of another family member who died at age 6 years after a similar medical history. Radiographs of the lower extremities show bowing of the long bones with cupping and widening of the physes. What is the most likely diagnosis?

Explanation

Hypophosphatemia-The patients who were symptomatic had obtundation,
hemolytic anemia, rhabdomyolysis, and hepatocellular injury that began during refeeding and resolved with treatment. The signs and symptoms, pathophysiology, and treatment of refeeding hypophosphatemia are reviewed.
Renal Osteodystrophy-Musculoskeletal complications in patients with chronic renal failure are common and may be related to the disease itself or to treatment. The altered metabolism in patients with chronic renal failure leads to renal osteodystrophy, which consists of osteomalacia and secondary hyperparathyroidism [1]. Erosive changes attributable to secondary hyperparathyroidism may be easily confused with rheumatoid arthritis, seronegative spondyloarthropathies, infection, or even malignancy.
Primary Hyperparathyroidism-Preferential involvement of cortical bone with apparent preservation of cancellous bone in primary hyperparathyroidism was confirmed by percutaneous bone biopsy. Over 80% of patients had a mean cortical width below the expected mean, whereas cancellous bone volume in over 80% of patients was above the expected mean.
Skeletal disease in primary hyperparathyroidism J Bone Miner Res 1989 Jun; 4(3):283-91
Nutritional vitamin D deficiency-Rickets, osteomalacia, and renal osteodystrophy are disorders of the mineralization of bone that result from a lack of available calcium, phosphorus, or both. The diseases that result from numerous mechanisms present with a symptom-sign-radiographic complex with such a high degree of stereotypy that laboratory investigation is often required to distinguish one form from another. The disorders in children, known as rickets, produce bowing and other deformities of the long bones and dwarfism. These disorders are principally related to the profound effect of the deficiency states on the epiphyseal plate; whereas the same disorders in adults produce an often severe osteopenia and pathologic fractures. Because of newer developments in our understanding of the factors affecting calcium-phosphorus
hemostasis and vitamin D metabolism, many of the children and Rickets, osteomalacia, and renal osteodystrophy.

Question 17

Which of the following is considered a potential advantage in prophylaxis for the prevention of deep venous thrombosis associated with the use of low-molecular weight heparin (LMWH) as compared with fixed-dose unfractionated heparin?

Explanation

DISCUSSION: One possible reason for improved efficacy of LMWHs is the relative improved bioavailability compared with that of unfractionated heparin. This is, in part, the result of a more predictable dose response and a longer half-life. There is no alteration of venous flow, and the rate of bleeding complications is the same or slightly higher than that of other prophylactic agents.
REFERENCES: Colwell CW Jr, Spiro TE, Trowbridge AA: Use of enoxaparin, a low-molecular weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement: A clinical trial comparing efficacy and safety. J Bone Joint Surg Am 1994;76:3-14.
Bara L, Billaud E, Kher A, Samama M: Increased anti-Xa bioavailability for a low-molecular weight heparin (PK 10169) compared with unfractionated heparin. Semin Thromb and Hemost 1985;11:316-317.
Paiement GD: Prevention and treatment of venous thromboembolic disease complications in primary hip arthroplasty patients, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 331-335.

Question 18

Figures 42a and 42b shows the radiographs of a 20-year-old man who sustained a hyperextension injury to his little finger. Multiple attempts at closed reduction have been unsuccessful. Management should now consist of

Explanation

DISCUSSION: The radiographs show a complex dislocation of the little finger metacarpophalangeal joint. This is characterized by obvious dislocation on the AP and lateral views and a type of bayonet apposition best visualized on the lateral view. Irreducibility of this injury is caused by displacement of the volar plate that has been traumatically avulsed from its origin on the metacarpal, with subsequent displacement into the metacarpophalangeal joint. This abnormal position of the volar plate causes irreducibility that can be corrected only by open reduction. This can be effected either by dorsal or palmar approaches.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,

pp 711-771.
Becton JL, Christian JD Jr, Goodwin HN, Jackson JG III: A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg Am 1975;57:698-700.
Green DP, Terry GC: Complex dislocation of the metacarpophalangeal joint: Correlative pathological anatomy. J Bone Joint Surg Am 1973;55:1480-1486.

Question 19

A 17-year-old girl has multidirectional instability of the shoulder. What is the most appropriate initial management?

Explanation

DISCUSSION: Multidirectional instability of the shoulder is defined as symptomatic instability in two or more directions (anterior, posterior) but must include a component of inferior instability. Initial treatment should always include physical therapy and instruction in a home exercise program that emphasizes periscapular and rotator cuff strengthening to improve the dynamic stability of the glenohumeral joint. Immobilization has not been shown to be effective. Open capsular shift and arthroscopic capsular plication remain the surgical options when appropriate nonsurgical management fails (typically a minimum of 6 months of dedicated therapy and home program). Thermal capsulorrhaphy remains controversial but is not recommended by many clinicians because of reported complications including recurrent instability, axillary nerve injury, chondrolysis, and capsular injury.
REFERENCES: Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908.
D’Alessandro DF, Bradley JP, Fleischli JE, et al: Prospective evaluation of thermal capsulorrhaphy for shoulder instability: Indications and results, two- to five-year follow-up.

Am J Sports Med 2004;32:21-33.
Levine WN, Clark AM Jr, D’Alessandro DF, et al: Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability: A report of two cases. J Bone Joint Surg Am 2005;87:616-621.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 278-279.

Question 20

A healthy 70-year-old man has a swollen knee after undergoing a knee replacement 10 years ago. Aspiration of the knee reveals cloudy, viscous synovial fluid. Laboratory studies show an erythrocyte sedimentation rate of 10 mm/h and a C-reactive protein level of less than 0.5. What is the most likely diagnosis?

Explanation

DISCUSSION: Polyethylene wear debris can result in significant synovitis and subsequent cloudy appearing synovial fluid. Typically, laboratory studies show a WBC of less than 30,000/mm³ and no left shift. Cytologic examination can reveal intra-articular polyethylene particles. Infected total knee arthroplasty is extremely uncommon in a healthy, immune-competent patient who has a normal preoperative erythrocyte sedimentation rate and C-reactive protein level.
REFERENCE: Barrack RL, Jennings RW, Wolfe MW, Bertot AJ: The value of preoperative aspiration before total knee revision. Clin Orthop 1997;345:8-16.

Question 21

What is the most significant factor affecting long-term survival for a patient with bone sarcoma?

Explanation

DISCUSSION: The most significant impact on long-term survival is the presence or absence of identifiable metastatic disease on initial presentation. All of these factors have been shown to be predictive of long-term survival to varying degrees.
REFERENCES: Enneking WF, Spanier SS, Goodman MA: A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res 1980;153:106-120.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

Question 22

Which of the following nerves lying between the gluteus medius and minimus is at risk for injury in a lateral approach to the hip?

Explanation

Femoral nerve is located in the anterior neurovascular bundle which does not lie between the gluteus medius minimus. Obturator arises from lumbar plexus supplies and runs with the adductor muscles. Inferior gluteal runs with the posterior neurovascular bundle which do not lie between these muscles. The lateral femoral cutaneous arises inferior and medial to the ASIS which is anterior and medial to this area as well.
The direct lateral approach (Transgluteal approach). No true intervenous plane (“split the fibers” of the gluteus medius “distal to the point where the superior gluteal nerve supplies the muscle”). “Do not (split) more than 3 cm above the upper boarder of the trochanter.”

Question 23

Figures 1 and 2 are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable. The patient fails an extensive course of physical therapy and is unable to return to baseball. He and his orthopaedic surgeon elect to proceed with surgery. During a repeat evaluation, he has negative sulcus and Beighton sign findings, and radiographs show 5° of glenoid retroversion. What is the most appropriate surgical plan?

Explanation

Posterior shoulder instability is a rare form of instability that often presents with pain rather than feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-risk position” (flexion, adduction, internal rotation). Repetitive microtrauma can lead to posterior shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral head that is forcibly reduced in follow-through, as seen in this patient. The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent subluxation at midranges of motion, at which the ligaments are lax. The rotator cuff is integral as a dynamic stabilizer of the shoulder. It works through a process called concavity compression. The four muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This prevents the humeral head from subluxing during the midranges of motion. Of the four rotator cuff muscles, the subscapularis is most important at preventing posterior subluxation. This patient has posterior instability, and various surgical techniques may be indicated depending on findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a patient has ligamentous laxity (not seen in this scenario because sulcus and Beighton sign findings would be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior opening-wedge osteotomy is appropriate. The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by recurrent instability
and degenerative joint disease.

Question 24

A 32-year-old woman sustained an injury to her left upper extremity in a motor vehicle accident. Examination reveals a 2-cm wound in the mid portion of the dorsal surface of the upper arm and deformities at the elbow and forearm; there are no other injuries. Her vital signs are stable, and she has a base deficit of minus 1 and a lactate level of less than 2. Radiographs are shown in Figures 9a and 9b. In addition to urgent debridement of the humeral shaft fracture, management should include

Explanation

DISCUSSION: With a severe injury to the upper extremity, the best opportunity for achieving a good functional result for a floating elbow is immediate debridement of the open fracture, followed by internal fixation of the fractures. The ability to do this depends on the patient’s physiologic status. In this patient, the procedure is acceptable because she has normal vital signs and no chest or abdominal injuries, and normal physiologic parameters (base excess and lactate) show adequate peripheral perfusion. The surgical approaches will be determined by the associated injury patterns and open wounds. In this patient, the humerus was debrided and stabilized through a posterior approach as was the medial condyle fracture. The ulna was fixed through an extension of the posterior incision and the radius through a separate dorsal approach.
REFERENCES: Solomon HB, Zadnik M, Eglseder WA: A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-570.
Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopedic surgery. J Trauma 2002;53:452-461.

Question 25

A 5-year-old boy reports intermittent left elbow pain. History reveals that he injured his elbow 4 months ago, but had no treatment. He is now using his arm normally but reports pain almost daily. Examination reveals tenderness over the lateral epicondyle and a prominence is evident. Range of motion is from -5 degrees to

Explanation

The patient has a nonunion of the lateral condyle of the left humerus. Observation or cast treatment at this stage is not likely to lead to healing of the fracture. MRI will not add any additional information. Open reduction, with minimal posterior soft-tissue stripping, is recommended to establish union of the fracture. Local or other bone graft may also be required. There are no studies that indicate that the displaced fracture will heal with late percutaneous fixation.
(SBQ13PE.40) Immediate spica casting is most appropriate for which of the following?: Review Topic
2-month-old girl with a displaced spiral mid-diaphyseal femur fracture
A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with <2 centimeters of shortening
3-day-old with teratologic right hip dislocation
9-year-old boy with a displaced spiral mid-diaphyseal femur fracture
12-year-old girl weighing 90 pounds with a displaced spiral mid-diaphyseal femur fracture
Children older than 6 months and up to 6 years with diaphyseal femur fractures may be treated with spica casting.
Children younger than 6 months may only require a Pavlik harness. Immediate spica casting is indicated in children 6 months to 6 years with less than 2 cm of shortening. Each additional cm of shortening at presentation doubles the risk of loss of reduction (1 cm: 12%, 2 cm: 24%, 3 cm; 50%).
Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. Their recommendation for diaphyseal femur fractures with <2 cm shortening in children 6 months to 5 years is Grade B, based on Level II evidence (two level II and one level I study). They recommend early spica or traction with delayed spica. They suggest early spica, as this is more convenient than traction.
In an earlier article, Flynn et al. review the management of pediatric femoral shaft fractures. They recommend early spica casting for the child between 1 and 6 years in
low-energy femoral fractures with up to 2 cm shortening. Illustration A shows several styles of lower extremity spica casts.
Incorrect answers:

Question 26

Figures 28a through 28d show the radiographs and MRI scans of a 20-year-old basketball player who sustained an inversion injury to his right ankle. Management should consist of

Explanation

DISCUSSION: Osteochondral fractures involving the talar dome have been classified based on radiographic and MRI findings. A nondisplaced and incomplete fracture may be treated effectively with a short leg cast and no weight bearing for 6 weeks. This patient has a complete, separated, and displaced osteochondral fragment involving the midlateral talar dome that will most likely cause pain, mechanical symptoms, and effusion if treated nonsurgically. In addition, there is very little bone remaining on the fragment, making the likelihood of healing with open reduction and internal fixation problematic. The treatment of choice includes arthroscopy, removal of the loose fragment, curettage or drilling of the base, and a rehabilitation program that emphasizes peroneal strengthening, range of motion, and proprioceptive training.
REFERENCES: Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 205-226.
Baker CL, Morales RW: Arthroscopic treatment of tranchondral talar dome fractures: A long-term follow-up study. Arthroscopy 1999;15:197-202.

Question 27

The patient develops an inability to dorsiflex her foot 2 days after surgical intervention while she is sitting in a chair after physical therapy. Initial treatment should consist of

Explanation

DISCUSSION
Gamma irradiation produces free radicals. Although these free radicals can form cross-links with other polyethylene chains, the free radicals can also form a bond with oxygen, resulting in early oxidation. Gamma irradiation in air produces the highest risk for oxidized polyethylene, resulting in the highest risk for wear, delamination, and subsequent osteolysis.
This patient demonstrates severe periarticular osteolysis. When she is asymptomatic, this suggests the acetabular and femoral components remain well fixed to the bone. Consequently, she can be treated by removing the wear generator (polyethylene exchange), along with bone grafting of the osteolytic defect. Considering the extensive amount of osteolysis, observation for 1 year would not be appropriate.
The psoas is the anatomic structure that runs anterior to the acetabulum. The femoral neurovascular structures are at risk if the retractor is placed anterior and inferior to the psoas tendon.
The patient develops a foot drop 2 days after surgery. As a result, it can be assumed that the nerve was not injured directly during the surgical procedure. Although MR imaging or a CT scan may be indicated to identify an evolving hematoma, the immediate concern is to minimize pressure on the sciatic nerve. Tension on the nerve can be decreased by flexing the surgical knee and positioning the bed flat.

Question 28

Which of the following procedures is associated with the highest risk of osteonecrosis of the metatarsal head?

Explanation

1 – Complications of distal chevron osteotomy with soft tissue release are incomplete correction and avascular necrosis (1 – 2%). 2 – Complications of distal soft tissue realignment only are recurrence of deformity, inadequate lateral release, are hallux varus. 3 – Complications of the Aken procedure are an increase in the hallux valgus deformity. 4 ,5 – Complications of proximal first metatarsal osteotomy are hallux varus and shortening.

Question 29

A 69-year-old woman has just undergone an uncomplicated total shoulder arthroplasty for glenohumeral osteoarthritis. A press-fit humeral stem and a cemented all-polyethylene glenoid component were placed. At this point, what is the postoperative rehabilitation plan? Review Topic

Explanation

The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.

Question 30

Figures 24a through 24c show the coronal T 1 -weighted, T 2 -weighted fat-saturated, and T 1 -weighted fat-saturated gadolinium MRI scans of the proximal thigh of a 52-year-old woman who reports a mass in the medial thigh and groin area. She notes that the fullness has grown in size over the course of many months. Based on these findings, what is the most likely diagnosis?

Explanation

DISCUSSION: The images show a complex, lobular lesion of the thigh that has signal characteristics that follow fat. The size of the lesion, the areas of stranding within the mass, along with mild uptake on the gadolinium sequences and the mild edema within the lesion on the T₂-weighted image make liposarcoma the most likely diagnosis and simple intramuscular lipoma far less likely. All other diagnoses listed would not follow fat characteristics shown on the MRI sequences.
REFERENCE: Sanders TG, Parsons TW: Radiographic imaging of musculoskeletal neoplasia. Cancer Control 2001;8:221-231.

Question 31

Figure 40 shows the AP radiograph of a 55-year-old man who reports left knee pain. Which of the following conditions is least likely to produce this radiographic presentation?

Explanation

DISCUSSION: The radiograph reveals densities within the articular cartilage of the knee commonly referred to as chondrocalcinosis. The term chondrocalcinosis refers to the presence of calcium-containing crystals detected as radiodensities in cartilage. Calcium-containing crystals other than calcium pyrophosphate dihydrate may also deposit in articular cartilage and menisci, producing both radiographically detectable densities in cartilage and joint inflammation or degeneration. Hemochromatosis, alkaptonuria (ochronosis), and Wilson’s disease are characterized by cellular deposition of iron, calcium, and copper ions, respectively, into various tissues including articular cartilage and can give this appearance. Septic arthritis does not usually cause chondrocalcinosis.
REFERENCES: Klippel JH (ed): Primer on the Rheumatic Diseases, ed 11. Atlanta, GA, Arthritis Foundation, 1997, pp 226-229 and 328-331.
Resnick D, Wayama G: Diagnosis of Bone and Joint Disorders, ed 2. Philadelphia, PA, WB Saunders, 1988, pp 1675, 1779.

Question 32

What is the most common physical finding in myelopathic patients? Review Topic

Explanation

The Hoffman sign is the most common finding, occurring in 80% of myelopathic patients, and it is more common with increasing severity of the myelopathy. The prevalence of hyperreflexia has been shown to be no different from the prevalence in individuals without myelopathy. Sustained clonus and Babinski signs have been shown to occur in only one third of the patients with myelopathy.

Question 33

A 16-year-old snowboarder has significant pain and is still unable to bear weight after sustaining a lateral ankle injury in a fall 1 week ago. Examination reveals swelling and tenderness in the sinus tarsi. AP, lateral, and mortise radiographs of the ankle are unremarkable. Management should consist of

Explanation

DISCUSSION: Because there is a significant possibility that the patient may have a fracture of the lateral process of the talus, there is some disagreement as to the best radiographic study to identify this injury. A CT scan is an appropriate diagnostic tool to visualize the fracture and identify any displacement. Displaced lateral process fractures are best treated surgically.
REFERENCES: Kirkpatrick DP, Hunter RE, Janes PC, Mastrangelo J, Nicholas RA: The snowboarder’s foot and ankle. Am J Sports Med 1998;26:271-277.
Ebraheim NA, Skie MC, Podeszwa DA, Jackson WT: Evaluation of process fractures of the talus using computed tomography. J Orthop Trauma 1994;8:332-337.

Question 34

Figures 1 through 3 are the radiographs of a 55-year-old woman who underwent a volar plating of an extra-articular distal radius fracture 2 weeks ago. She is experiencing weakness with flexion of the interphalangeal (IP) thumb joint. IP joint flexion was normal before surgery. What is the best next step?

Explanation

at which flexor tendons are most closely opposed to the distal radius (Figure 4). In this scenario, the lateral radiograph shows that the plate is not distal to the watershed line (W) and is between the critical line (C) and the line parallel to the volar cortex of the radius (R). This is the optimal position for the plate. Placement of a volar locking plate distal to the watershed line of the distal radius and excessive plate prominence has been associated with FPL tendon rupture. This patient is only 2 weeks past surgery and there is some FPL function. FPL weakness after volar distal radius plating is common and has been seen in as many as 50% of patients. This usually recovers spontaneously by 2 months, and no treatment is needed. A nerve conduction study would be indicated if an anterior interosseous nerve compression were considered, but it is too early for this test. A CT scan could be obtained to judge the alignment of the fracture fragment and position of the screws, but it is not indicated in this case. Exploration could be performed if an FPL rupture were considered, but, because it is only 2 weeks after surgery, there is some FPL function, the plate is proximal to the watershed line, and immediate exploration is not indicated. If this does not improve after 2 to 3 months, further investigation with ultrasound or MRI would be indicated.

Question 35

Which of the following findings can cause a dorsal bunion in a patient with neuromuscular disease?

Explanation

DISCUSSION: Unopposed action of the tibialis anterior with weakness of the peroneus longus will lead to a dorsal bunion and supination deformity. Overpull of the gastrocnemius-soleus complex and posterior tibialis with weakness of the peroneus brevis will cause equinovarus deformity. A strong posterior tibialis with weakness of the peroneals will cause varus of the hindfoot. Unopposed peroneus brevis and incompetence of the posterior tibialis will lead to a flatfoot deformity. The etiology of a cavus foot is complex, but findings usually include a contracted plantar fascia and weakness of the tibialis anterior.
REFERENCES: Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992, pp 289-302.
Tachdjian MO: Pediatric Orthopedics ed 2. Philadelphia, PA, WB Saunders, 1990,

pp 1937-1946.

Question 36

A 37-year-old laborer falls 12 feet and sustains a comminuted tibial plafond fracture. Three years after treatment using standard techniques, what will be the most likely outcome?

Explanation

DISCUSSION: Two recent studies by Pollak and associates and Marsh and associates have focused on function after high-energy tibial plafond fractures. Findings are unfavorable even when anatomic reduction is performed in the best centers and patients are provided excellent rehabilitation. Function improves up to 2 years after injury, but even basic walking skills remain adversely affected. Virtually all patients have long-term adverse general health effects compared to their gender and age-matched peers. Posttraumatic degenerative arthritis is present in most ankles. Patients should be told early about the long-term prognosis, and early vocational/psychological counseling should be given. Despite these adverse outcomes, only a minority of patients require fusion or arthroplasty.
REFERENCES: Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.
Marsh JL, Weigel DP, Dirschl DR: Tibial plafond fractures: How do these ankles function over time? J Bone Joint Surg Am 2003;85:287-295.

Question 37

Figure below shows the standing AP radiograph obtained from a 55-year-old man who has a 5-year history of daily left knee medial joint line pain with weight-bearing activities. He denies night pain or symptoms of instability. On examination, his range of motion is 0° to 140°. He has a mild, fully correctable varus deformity and a negative Lachman test result. Nonsurgical treatment has failed. What is the UKA survivorship for a 55- year-old patient, compared with the survivorship for total knee arthroplasty?

Explanation

DISCUSSION:
A patient with medial compartment arthritis and a correctable varus deformity with no clinical or examination findings of knee instability most likely has an intact anterior cruciate ligament (ACL). The pattern of medial compartment osteoarthritis most commonly associated with an intact ACL is that of anteromedial osteoarthritis. An incompetent ACL is commonly associated with a fixed varus deformity and radiographic signs of posteromedial wear. An incompetent ACL is a relative contraindication to a mobile-bearing UKA. When evaluating patients for a mobile-bearing UKA, a stress radiograph aids the orthopaedic surgeon in determining the correction of the varus deformity and assessing the lateral compartment. An inability to fully correct the deformity or narrowing of the lateral compartment with valgus stress should influence the surgeon against UKA. Joint registries across the world have shown decreased survivorship associated with TKA and UKA in men compared with other age groups, but survivorship is lower for UKA than for TKA. No studies to date have shown any differences in survivorship between fixed-bearing and mobile-bearing UKAs. The complication that is unique to mobile-bearing UKA is bearing spinout, which occurs in less than 1% of mobile-bearing UKA procedures. In vivo and in vitro polyethylene wear in mobile-bearing UKA are low. Arthritis may progress
faster in patients with mobile-bearing UKAs than in those with fixed-bearing UKAs.

Question 38

Figures 28a and 28b show the sagittal and axial lumbar MRI scans of a 72-year-old man who reports dull aching back pain that spreads to his legs, calves, and buttocks. He has had the pain for several years and it is precipitated by standing and walking and relieved by sitting. His symptoms have been worsening over the past year and he notes that he is leaning forward while walking to help relieve his symptoms. He has had no treatment to date. What is his prognosis if he chooses to pursue nonsurgical management for this condition?

Explanation

DISCUSSION: The patient has lumbar spinal stenosis and the MRI scans reveal the pathology at L4-5, which is secondary to posterior disk bulging and hypertrophy and infolding of the ligamentum flavum, as well as degenerative facet arthrosis. The degree of spinal stenosis is moderate and his symptoms are positional in nature. Tadokoro and associates reported on a prospective study of 89 patients older than 70 years of age who underwent nonsurgical management for lumbar spinal stenosis. They found the prognosis to be relatively good with patients scoring at “excellent” or “good” for activities of daily living at final follow-up. However, they did note that patients with a complete block on myelography did not respond favorably to nonsurgical management. Amundsen and associates reported on a 10-year prospective study comparing surgical care to nonsurgical management. They concluded that, while the long-term results largely favored surgical treatment, more than half of the nonsurgically managed patients had a satisfactory outcome. They also concluded that a delay of surgery for some months did not worsen the prognosis. Therefore, their recommendation was for an initial primarily nonsurgical approach.
REFERENCES: Amundsen T, Weber H, Nordal HJ, et al: Lumbar spinal stenosis: Conservative or surgical management? A prospective 10-year study. Spine 2000;25:1424-1435.
Hilibrand AS, Rand N: Degenerative lumbar stenosis: Diagnosis and management. J Am Acad Orthop Surg 1999;7:239-249.
Tadokoro K, Miyamoto H, Sumi M, et al: The prognosis of conservative treatments for lumbar spinal stenosis: Analysis of patients over 70 years of age. Spine 2005;30:2458-2463.

Question 39

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

Explanation

DISCUSSION: The radial head is covered by cartilage on 360 degrees of its circumference. However, with the normal range of forearm rotation of 160 to 180 degrees, there is a consistent area that is nonarticulating. This area is found by palpation of the radial styloid and Lister’s tubercle. The hardware should be kept within a 90-degree arc on the radial head subtended by these two structures.
REFERENCES: Smith GR, Hotchkiss RN: Radial head and neck fractures: Anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg 1996;5:113-117.
Caputo AE, Mazzocca AD, Santoro VM: The nonarticulating portion of the radial head: Anatomic and clinical correlations for internal fixation. J Hand Surg Am 1998;23:1082-1090.

Question 40

maximize physical capacity and 4) obtain local control of the disease. Other trivia from the references include: After the lung and liver the skeletal system is the third most common site of metastasis. The spine is the most common site of skeletal metastasis. 60% of all skeletal lesions and 36% are asymptomatic. Breast, prostate, lung and renal carcinoma comprise 80% of the carcinomatous skeletal metastasis. 70% metastasis occur in the thoracic and thoracolumbar regions. 21% had involvement of the lumbar and sacral regions. 8% involved the cervical and cervicothoracic regions together. As many as 90% of patients who die of cancer may have Spinal metastasis at autopsy, and only half of patients who die from cancer will have symptoms from spinal mets. Fewer than 10% with spinal mets are treated surgically. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont IL., American academy of orthopaedic surgeons, 2002, pp 723-736. back to this question next question 03 What is the most frequently encountered complication following juvenile hallux valgus correction?

Explanation

Postoperative complications have been frequently reported following juvenile hallux valgus corrections. Recurrence following surgery is probably the most frequently reported complication and is likely due to the high rate of congruency associated with a juvenile hallux valgus deformity.

OKU Foot and Ankle 2 Rosemont IL., American academy of orthopaedic surgeons, pp135-150.
back to this question next question

Question 41

What is the most common cause of errors that harm patients? Review Topic

Explanation

The AMA report identified communication breakdown as the most common cause of errors that harm patients. It is extremely important to learn to communicate effectively with your patients. Understanding cultural and language differences helps avoid communication errors.

Question 42

The anatomy of the sciatic nerve as it exits the pelvis is best described as exiting through the

Explanation

DISCUSSION: The sciatic nerve is formed by the roots of the lumbosacral plexus. It exits the pelvis through the greater sciatic notch and appears in the buttock anterior to the piriformus. From that point, the sciatic nerve passes posteriorly over the superior gemellus, obturator internus, inferior gemellus, and quadratus femoris before it passes deep to the biceps femoris. The tendon of the obturator internus passes through the lesser sciatic notch.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 347.
Anderson JE: Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-34, 4-36.
Hollingshead WH: Anatomy for Surgeons: The Back and Limbs, ed 2. Hagerstown, MD, Harper & Row, 1969, pp 607-609.

Question 43

Figure A shows intraoperative images of a right knee in an 8-year-old boy after he sustained an injury. Which of the following is the most common indication for performing this procedure? Review Topic

Explanation

This patient has undergone arthroscopic saucerization of his discoid meniscus. The indication for this procedure is treatment of a symptomatic meniscal tear.
Arthroscopic treatment of lateral discoid meniscus injuries has the advantages of reducing trauma, precise resection or repair of the meniscus and saucerization of the remaining discoid meniscus. Operative treatment is usually limited to patients with pain and mechanical symptoms that are undergoing partial meniscectomy or repair. Asymptomatic discoid meniscus without tears are not considered a surgical indication for routine saucerization.
Kramer et al. reviewed the diagnosis and treatment of traumatic discoid meniscal tears in children. They report that knee shape, size and skeletal maturity must be considered when determining the optimal method of repair. However, all symptomatic torn discoid menisci are best treated with saucerization and repair.
Good et al. looked at the arthroscopic techniques of discoid meniscus repair. Arthroscopic saucerization was successful in 28 of 30 knees and meniscal repair in 23 of 30 knees. At final follow-up, all patients exhibited full knee flexion beyond 135 degrees. In 3 of 30 patients there was residual knee pain, and four reported intermittent mechanical symptoms.
Figure A shows a series of arthroscopic images of the right knee lateral compartment. There is a sequential saucerization of the discoid meniscus.
Incorrect Answers:
(SBQ13PE.83) 8-year-old boy complains of intermittent painless clicking in his knee. His physical examination is normal. His family doctor orders an MRI, which reveals an incomplete lateral discoid meniscus without evidence of tear. What is the most appropriate treatment? Review Topic
Observation only
Diagnostic arthroscopy
Saucerization of meniscus
Saucerization of meniscus and microfracture
Saucerization and stabilization of the mensicus
The clinical presentation is consistent with a asymptomatic discoid meniscus. The most appropriate treatment at this time would be observation only.
MRI scans of the knee are very sensitive for identifying discoid menisci. Diagnosis is usually made when there are 3 or more 5mm sagittal MRI images showing meniscal continuity. Treatment is mostly focused on conservative modalities. Asymptomatic tears are usually treated with observation only. Saucerization is indicated for recurrent locking, swelling, persistent pain, or radiographic evidence of a meniscal tear.
Watanabe et al. described three types of discoid lateral menisci based on arthroscopic appearance. In this classification, discoid menisci with normal peripheral attachments are either type I (complete) or type II (incomplete). Type III discoid menisci, the so-called Wrisberg ligament type, are lacking posterior capsular attachments with the exception of the posterior meniscofemoral ligament.
Kramer et al. looked at the presentation of pediatric knee pain and discoid meniscus. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the meniscus.
Illustration A shows the cross-section of normal meniscus. Illustration B shows the Watanabe classification.
Incorrect Answers:

Question 44

-The use of a soft cervical orthosis is most supported for which injury?

Explanation

Question 45

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

Explanation

DISCUSSION: Fractures in this area of the fifth metatarsal have a high incidence of delayed union, nonunion, and recurrence with nonsurgical management. In an acute fracture, prolonged casting in a non-weight-bearing cast may allow for healing; however, in the presence of prolonged symptoms, recurrent fracture, and intermedullary sclerosis, surgical treatment is preferred. Surgery most commonly consists of intermedullary fixation or medullary curettage and bone grafting, followed by application of a non-weight-bearing cast.
REFERENCES: Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M: Fractures of the base of the fifth metatarsal distal to the tuberosity: Classification and guidelines for nonsurgical and surgical management. J Bone Joint Surg Am 1984;66:209-214.
DeLee JC: Fractures and dislocations of the foot, in Mann R, Coughlin M (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby, 1993, pp 1465-1503.

Question 46

An 84-year-old female community ambulator with a history of hypertension undergoes a right hip hemiarthroplasty for a femoral neck fracture. When performed in the post-operative period, the timed up and go (TUG) test may be used to predict which patient outcome?

Explanation

The timed up and go (TUG) test may be used as a clinical indicator of function and the need for a walking aid in patients treated with hip hemiarthroplasty for femoral neck fracture at 2-year follow-up.
Hip fractures are a cause of significant functional decline for elderly patients. Many outcome tests have been developed to prediction function after hip fracture to manage patient expectations and to assist in rehabilitation planning. The TUG test objectively measures functional mobility and dynamic balance. The test is performed by timing the amount of seconds it requires for a patient to stand up from a chair, walk 10ft (3.05m), return to the chair, and sit.
Laflamme et al performed a prospective study evaluating the utility of the TUG test to predict functional outcomes in patients undergoing hip hemiarthroplasty for femoral neck fracture. The TUG scores were significantly higher at 4-days and 3-weeks postoperatively in patients requiring a walking aid compared with patients walking independently at two-years. Patients who performed the test in >58s at 4-days postoperatively had an eightfold greater risk of requiring an assistive device.
Springer et al prospectively analyzed the unipedal stance test (UPST) with eyes open and closed in healthy subjects to establish normative values for the test across age and gender groups. Performance on the test was found to be age-specific and not related to gender. The UPST is a method of quantifying static balance ability.
Kristensen et al studied the relative and absolute inter tester reliability of TUG in patients with hip fractures. The authors found that the TUG has a high interobserver reliability and an improvement by 6.2 seconds for a patient with a baseline of 20s indicates a change in functional mobility.
Video A shows the timed up and go test.
Incorrect Answers:

Question 47

A 30-year-old man landed on his shoulder in a fall off his mountain bike. An AP radiograph and CT scan are shown in Figures 34a and 34b. Management should consist of

Explanation

DISCUSSION: The radiograph shows a valgus impacted four-part fracture. The humeral head is deeply depressed into the metaphysis but is still articulating with the glenoid as seen on the CT scan. Unlike a “classic” four-part fracture in which the head is dislocated out of the glenoid and devoid of any soft-tissue attachments (high risk of osteonecrosis), this valgus impacted head will have a medial soft-tissue hinge with a lower risk of osteonecrosis. It is most amenable to open reduction and internal fixation with minimal soft-tissue stripping techniques. Bone grafting may be necessary on occasion. Nonsurgical management for displaced proximal humeral fractures generally results in a poor outcome. This patient does not have a humeral head defect. A hemiarthroplasty is not indicated.
REFERENCES: Jakob RP, Miniaci A, Anson PS, et al: Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br 1991;73:295-298.
Resch H, Povacz P, Frohlich R, et al: Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Br 1997;79:295-300.

Question 48

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

Explanation

DISCUSSION: The radiograph and intraoperative photograph show osteonecrosis with near complete head loss/collapse. A stemmed implant is more appropriate in this patient because there is very little bone to support a resurfacing implant. In a younger patient, a glenoid implant should be delayed as long as possible because of the eventual need for revision secondary to glenoid loosening and wear, especially in a young active male. The hemiarthroplasty may be converted to a total shoulder arthroplasty in the future.
REFERENCES: Levy O, Copeland SA: Cementless surface replacement arthroplasty of the shoulder: 5- to 10-year results with the Copeland mark-2 prosthesis. J Bone Joint Surg Br 2001;83:213-221.
Burroughs PL, Gearen PF, Petty WR, et al: Shoulder arthroplasty in the young patient.

J Arthroplasty 2003;18:792-798.

Question 49

A 13-year-old boy has pain and a firm mass in his left knee. A radiograph and MRI scan are shown in Figures 2a and 2b, and a biopsy specimen is shown in Figure 2c. Based on these findings, what is the most likely diagnosis?

Explanation

DISCUSSION: The most likely diagnosis is osteosarcoma. The imaging studies show an aggressive primary tumor of bone, and the histology slide shows a typical chondroblastic osteosarcoma, with osteoid deposited along the surface of bone trabeculae. Ewing’s sarcoma histologically consists of small round blue cells. Osteochondroma and periosteal chondroma can occur near the knee but have different radiographic and histologic patterns. Chondrosarcoma rarely occurs in children.
REFERENCES: Simon M, Springfield D, et al: Osteogenic sarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 267.
Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990,
pp 14-15.

Question 50

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

Explanation

Patients with severe open fractures should be managed at a trauma center. A patient with an isolated open forearm fracture may not require transfer if her injury is isolated, relatively free of contamination and not otherwise complicated by other factors such as tissue ischemia or tissue loss.
While most patients can receive all their definitive care at any hospital to which they present, early recognition of those that require transfer to a trauma center is essential to maximizing outcomes. Inherent in such identification is physician's' assessment of their own and their institutions' abilities and the limits thereof.
Van Olden et al. prospectively studied severely injured patients consecutively presenting to two community hospitals in the Netherlands. Comparison was made between patients treated prior to and after introduction of ATLS training to physicians at the studied hospitals. There was no difference in overall mortality between the two groups. however, there was a significant reduction in mortality in the first 60 minutes after admission, from 24.2% pre-ATLS to 0.0% post-ATLS.
Ali et al. studied trauma outcomes and mortality in patients presenting to the largest hospital in Trinidad and Tobago for the four years prior to and after introduction of ATLS training for physicians in the emergency department. Trauma mortality decreased to 33.5% from 67.5% after introduction of ATLS. Post-injury functional outcomes were also improved.
Illustration A shows the ATLS guidelines for interfacility transfer in table format. Incorrect answers:

Question 51

A 28-year-old male sustains a fall on icy ground and fractures his ankle. An intraoperative fluoroscopy image is shown in Figure A. This fixation suggests that the mechanism of injury was one of

Explanation

Moore I
Moore II
Schatzker III
Schatzker V
OTA type 41B3
Figure A shows a Moore Type II fracture. Moore type II fractures consist of fractures involving the entire tibial condyle, where the fracture line begins in the opposite compartment and extends across the tibial eminence.
A number of classification systems are used to describe tibial plateau fractures. The main classification systems that are widely used include Schatzker, AO/OTA, Hohl and Moore. The Moore classification describes high energy fracture-subluxation injuries of the knee. This is thought to have clinical implications as the type of fracture pattern can indicate an associated soft-tissue injury.
Moore retrospectively reviewed over a 1000 proximal tibia fractures to devise a classification systems based on the characteristic of five types of tibia plateau fracture patterns. He believed this system helped to better understand knee instability and concomitant soft-tissue injury. For example, Moore Type III fractures (rim avulsion) are associated with a high rate of neurovascular injury.
Figure A shows a fracture involving the entire tibial condyle. Illustration A shows a schematic diagram of the Moore classification (I - V). Illustration B shows a table that
describes the Moore classification (I - V).
Incorrect Answers:

Question 52

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 53

A 34-year-old man underwent a transtibial amputation as the result of a work-related injury. The amputation was performed at the inferior level of the tibial tubercle. The residual limb has a soft-tissue envelope composed of gastrocnemius muscle that is used as soft-tissue cushioning for the distal tibia. Despite undergoing several prosthetic fittings, he continues to report pain and instability. Examination reveals that the prosthesis appears to fit well with no apparent pressure points or areas of skin breakdown. He is not willing to have any further surgery. Which of the following modifications will most likely provide relief?

Explanation

DISCUSSION: While transtibial amputees can be fitted with a prosthesis with a residual limb as short as 5 cm, or with retention of the insertion of the patellar tendon, this patient has an unstable gait because of the limited ability of the prosthetic socket to maintain a snug and stable fit. While cumbersome and bulky, double metal uprights and a corset is the only predictable method of gaining stability. The other methods attempt to add an element of stability; however, they are unlikely to be successful.
REFERENCES: Bowker JH, Goldberg B, Poonekar PD: Transtibial amputation: Surgical procedures and postsurgical management, in Bowker JH, Michael JW (eds): Atlas of Limb Prosthetics. St Louis, MO, Mosby Year Book, 1992, pp 429-452.
Kapp S, Cummings D: Transtibial amputation: Prosthetic management, in Bowker JH, Michael JW (eds): Atlas of Limb Prosthetics. St Louis, MO, Mosby Year Book, 1992, pp 453-478.

Question 54

A 56-year-old woman sustains a type IIIB open tibial shaft fracture. She undergoes irrigation and debridement and intramedullary nailing with flap coverage 24 hours later. Cultures are taken pre-debridement and post-debridement. She develops a surgical site infection at 6 weeks, which requires removing the hardware and placing show Commented [1]: an external fixator. Deep cultures are most likely to pathogens found in

Explanation

Discussion: One study found only 8% of organisms grown on pre-debridement cultures eventually caused infection; 7% of cases with negative pre-debridement cultures became infected. Of cases that did become infected, pre-debridement cultures grew the infecting organism only 22% of the time. Post-debridement cultures were more accurate in predicting infection. However, of cases that became infected, the infecting organism was present on post-debridement cultures only 42% of the time. It is concluded that pre-debridement and post-debridement bacterial cultures from open fracture wounds are of essentially no value. It is recommended that they not be done.
In another study, before any interventions were performed, initial aerobic and anaerobic cultures of the wounds of 117 consecutive open extremity fractures grades I through III were obtained. The results of these cultures were correlated with the development of a wound infection. If an infection occurred, the organism grown from the infected wound was compared with any organism grown from the primary wound cultures. Of the initial cultures, 76% (89/117) did not demonstrate any growth, while the other 24% (28/117) only grew skin flora. There were only 7 (6%) wound infections, and 71% (5/7) initially did not grow any organisms. Of the isolates that grew from the initial cultures, none were the organisms that eventually led to

Question 55

An 19-year-old male presents to the emergency room following an motor vehicle accident as an unrestrained driver. Examination reveals unilateral jugular vein engorgement. Chest and special view radiographs are seen in Figures A and B respectively. Following CT scan of the chest, the next step in management is Review Topic

Explanation

This patient has a right posterior sternoclavicular (SC) dislocation. Management involves closed reduction and bracing. Closed reduction should be performed with a thoracic surgeon available in the event of mediastinal involvement.
The SC joint can dislocate anteriorly or posteriorly. Posterior dislocations are first treated with closed reduction. If closed reduction fails, open reduction is indicated. Early complications of posterior SC dislocation include pneumothorax, laceration/erosion/occlusion of great vessels, esophageal rupture and brachial plexus compression. Late complications include tracheoesophageal fistula, stridor and dysphagia.
Groh et al. reviewed traumatic SC injuries. Reduction maneuvers in posterior SC dislocation include: (1) traction on the arm and slowly bringing it into extension, (2) traction with the arm in adduction and posterior pressure applied to the shoulder, and
(3) pulling anteriorly on a towel clip encircling the medial clavicle. Chronic instability after posterior SC dislocations can be managed with figure-of-8 semitendinosus graft or medial clavicle resection and reattachment of the clavicle to the first rib with dacron tape.
Glass et al. performed a systematic review on SC dislocations. They found mediastinal compression occurred 30% of the time with posterior dislocations.
Figures A and B are radiographs demonstrating asymmetry of the SC joints, characteristic of a right posterior SC dislocation (Figure B is not a serendipity view). Illustration A demonstrates how in POSTERIOR dislocation, the clavicle appears INFERIOR, and in ANTERIOR dislocation, the clavicle appears SUPERIOR on a serendipity view radiograph respectively. Illustration B shows the imaging technique for a serendipity view radiograph. Illustration C is a reconstructed CT image of the patient showing left posterior SC dislocation.
Incorrect Answers:

Question 56

In a patient with a soft-tissue sarcoma treated by wide excision and radiation therapy, the risk of subsequent fracture is probably most influenced by

Explanation

DISCUSSION: While most pathologic fractures are in the lower extremity in patients treated for soft-tissue sarcomas by wide excision and adjuvant radiation therapy, risk factors for such fractures are bone resection associated with excision of the tumor and soft-tissue sarcomas of the thigh that require periosteal stripping at the time of resection. Such fractures can occur late, often more than 6 months after surgery, are difficult to treat, and often result in nonunion.
REFERENCES: Bell RS, O’Sullivan B, Nguyen C, et al: Fractures following limb-salvage surgery and adjuvant irradation for soft-tissue sarcoma. Clin Orthop 1991;271:265-271.
Lin PP, Boland PJ, Healey JH: Treatment of femoral fractures after irradiation. Clin Orthop 1998;352:168-178.

Question 57

A 45-year-old man undergoes an anterior cervical diskectomy and fusion at C5-6 and C6-7 with instrumentation. During the first postoperative visit at 1 week, the patient reports difficulty swallowing and mild anterior cervical tightness. The anterior wound is benign and the patient denies any dyspnea or shortness of breath. A postoperative radiograph is seen in Figure 25. What is the most appropriate management at this time?

Explanation

DISCUSSION: The radiograph shows significant prevertebral soft-tissue swelling following a two-level anterior cervical diskectomy and fusion. The incidence of dysphagia 2 years after anterior cervical spine surgery is 13.6%. Risk factors for long-term dysphagia after anterior cervical spine surgery include gender, revision surgeries, and multilevel surgeries. The use of instrumentation, higher levels, or corpectomy versus diskectomy did not significantly increase the prevalence of dysphagia. Lee and associates demonstrated that while dysphagia after anterior cervical spine surgery is a common early finding, it generally decreases significantly by

6 months with nonsurgical management. A minority of patients experience moderate or severe symptoms by 6 months after the procedure. Female gender and multiple surgical levels have been identified as risk factors for the development of postoperative dysphagia.
REFERENCES: Lee MJ, Bazaz R, Furey CG, et al: Risk factors for dysphagia after anterior cervical spine surgery: A two-year prospective cohort study. Spine J 2007;7:141-147.
Bazaz R, Lee MJ, Yoo JU: Incidence of dysphagia after anterior cervical spine surgery:

A prospective study. Spine 2002;27:2453-2458.

Question 58

A patient notes pain under the first metatarsophalangeal joint following a soccer injury. The MRI scans shown in Figures 27a and 27b reveal what pathologic finding?

Explanation

DISCUSSION: The MRI scans show a complete disruption of the sesamoid complex with proximal retraction of the medial sesamoid and high signal originating from the site normally occupied by the plantar plate (metatarsophalangeal ligament). This injury is the result of a hyperextension injury and is a severe variant of a turf toe.
REFERENCES: Watson TS, Anderson RB, Davis WH: Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin 2000;5:687-713.
Tewes DP, Fischer DA, Fritts HM, et al: MRI findings of acute turf toe: A case report and review of anatomy. Clin Orthop 1994;304:200-203.

Question 59

Figure 8 shows the AP radiograph of a 33-year-old woman who sustained a midshaft clavicle fracture from a motorcycle accident 15 months ago. She continues to have significant pain with activities of daily living. Management should consist of

Explanation

DISCUSSION: The patient has a symptomatic painful atrophic midclavicular nonunion, and the treatment of choice is rigid internal fixation with a dynamic compression plate and autogenous bone grafting. A tension band effect is desired and achieved by placing the plate superiorly. Excellent success rates of 90% to 100% have been reported using this technique. Intramedullary screw fixation without bone grafting has a decreased success rate. Partial claviculectomy is not a preferred option.
REFERENCES: Jupiter JB, Leffert RD: Non-union of the clavicle: Associated complications and surgical management. J Bone Joint Surg Am 1987;69:753-760.
Simpson NS, Jupiter JB: Clavicular nonunion and malunion: Evaluation and surgical management. J Am Acad Orthop Surg 1996;4:1-8.

Question 60

A 43-year-old man who works as a plumber has a painful stiff elbow in his dominant arm. He notes that while he recalls no single event of injury, he thinks the many years of pulling wrenches and soldering pipes have resulted in his problem. He reports that he has pain with any motion in bending his arm and can no longer straighten his elbow. Examination reveals generalized swelling of the elbow, both medial and lateral with a range of motion that lacks 45 degrees of extension and flexes only to 110 degrees. Pronation and supination are also limited to 45 degrees. Audible crepitus is perceived but there is no instability. Radiographs reveal advanced osteoarthritis at the radiocapitellar and ulnohumeral joints with complete loss of articular cartilage. What is the most appropriate initial treatment option? Review Topic

Explanation

Osteoarthritis of the elbow is more common in the middle-age laborer such as this plumber, whereas rheumatoid arthritis is more common in older females. Treatment
must respect the physical demands of the patient while trying to preserve joint motion and function with tolerable symptoms. Osteophyte resection and capsular release have offered many patients significant improvement in their symptoms while allowing them to return to most activities. The osteophyte resection and releases can be done effectively by an open or arthroscopic approach. Whereas total elbow arthroplasty would likely result in better and more thorough pain relief, it would not tolerate the occupational demands of this individual. There is no role for physical therapy initially in the face of advanced, painful arthritis associated with long-standing fixed joint contractures. Elbow fusion results in severe loss of function and its indication is rare and usually considered in the face of unmanageable sepsis. Radial head resection may improve symptoms related to the radial capitellar arthritis but would not improve range of motion or end range impingement pain. Also, radial head resection should be avoided in heavy laborers with elbow arthritis because it would lead to increased loads across the arthritic ulnohumeral joint.

Question 61

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 62

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 63

A 14-year-old boy reports a 4-month history of increasing backache with difficulty walking long distances. His parents state that he walks with his knees slightly flexed and is unable to bend forward and get his hands to his knees. He denies numbness, tingling, and weakness in his legs and denies loss of bladder and bowel control. A lateral radiograph of the lumbosacral spine is shown in Figure 18. What is the best surgical management for this condition?

Explanation

DISCUSSION: The patient has a grade 4 spondylolisthesis. Optimal surgical management is posterior spinal fusion from L4 to the sacrum. The use of instrumentation is controversial. Vertebrectomy is typically reserved for spondylo-optosis (grade 5) cases. Spinal fusion from

L5 to S1 usually is not successful for a slip that is greater than 50%. Isolated anterior spinal fusion has not been successful, and direct repair of the pars defect is only useful for spondylolysis without spondylolisthesis.

REFERENCES: Lenke LG, Bridwell KH: Evaluation and surgical treatment of high-grade isthmic dysplastic spondylolisthesis. Instr Course Lect 2003;52:525-532.
Ginsburg GM, Bassett GS: Back pain in children and adolescents: Evaluation and differential diagnosis. J Am Acad Orthop Surg 1997:5:67-78.

Question 64

Use of long-term (at least 5 years) bisphosphonate medications for osteoporosis is associated with

Explanation

DISCUSSION
Fragility or osteoporotic fractures are common in postmenopausal women and older men and include fractures of the proximal humerus and distal radius and hip and vertebral compression fractures. The most reliable predictor of a fragility fracture is a past fragility fracture; consequently, it is important to elicit history. Assessment of vitamin D and calcium levels is important when treating these patients because many of them have low levels.
Use of bisphosphonates for treatment of osteoporosis results in atypical femur fractures and a decrease in risk for fragility fractures (including hip fractures). There also are reports of osteonecrosis of the mandible with prolonged use of these drugs. Current medical literature suggests stopping these drugs after 3 to 5 years to allow bone remodeling.
RECOMMENDED READINGS
Shane E, Burr D, Ebeling PR, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster D, Einhorn TA, Genant HK, Geusens P, Klaushofer K, Koval K, Lane JM, McKiernan F, McKinney R, Ng A, Nieves J, O'Keefe R, Papapoulos S, Sen HT, van der Meulen MC, Weinstein RS, Whyte M; American Society for Bone and Mineral Research. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2010 Nov;25(11):2267-94. doi: 10.1002/jbmr.253. Erratum in: J Bone Miner Res. 2011 Aug;26(8):1987. PubMed PMID: 20842676. View Abstract at PubMed
Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster DW, Ebeling PR, Einhorn TA, Genant HK, Geusens P, Klaushofer K, Lane JM, McKiernan F,McKinney R, Ng A, Nieves J, O'Keefe R, Papapoulos S, Howe TS, van der Meulen MC, Weinstein RS, Whyte MP. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American society for bone and mineral research. J Bone
Miner Res. 2014 Jan;29(1):1-23. doi:10.1002/jbmr.1998. Epub 2013 Oct 1. PubMed PMID: 23712442. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 92 THROUGH 95
A 23-year-old man is involved in a motorcycle collision and sustains a displaced transcervical femoral neck fracture with an associated open comminuted femoral shaft fracture.

Question 65

In the normal adult, the distance between the basion and the tip of the dens with the head in neutral position is how many millimeters?

Explanation

DISCUSSION: In the normal adult, the distance between the basion and the tip of the dens is 4 mm to 5 mm. Any distance greater than 5 mm is considered abnormal. This is one way to detect occipitocervical dissociation other than using the Power’s ratio, which relies on an anterior dislocation.
REFERENCES: Wiesel SW, Rothman RH: Occipitoatlantal hypermobility. Spine 1979;4:187-191.
Wholey MH, Browner AJ, Baker HL Jr: The lateral roentgenogram of the neck: With comments on the atlanto odontoid-basion relationship. Radiol 1958;71:350-356.

Question 66

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 67

What is the most important feature in choosing an outcome instrument to assess shoulder disorders?

Explanation

DISCUSSION: There has been a recent increase in the use of outcome instruments to document and measure effects of treatment of medical conditions, including shoulder disorders. The most important feature of an instrument is whether it actually measures what it purports to measure; this is defined as its validity.
REFERENCES: Leggin BG, Iannotti JP: Shoulder outcome measurement, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999, p 1027.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 47-55.

Question 68

A 15-year-old high school soccer player collides with an opponent and is unconscious when the trainer arrives on the field. He is conscious within 15 seconds, breathing appropriately, and denies any headache, neck pain, or nausea. It is his first head injury. Provided that the athlete is free of symptoms, when should he be allowed to return to athletic activity?

Explanation

DISCUSSION: The loss of consciousness indicates a grade 2 concussion, which necessitates a
week period out of sport. The last week prior to return must be symptom-free and the athlete should not have symptoms in practice.
REFERENCES: Cantu RC: Return to play guidelines after a head injury. Clin Sports Med 1998;17:45-60.
Stevenson KL, Adelson PD: Pediatric sports-related head injuries, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 1, p 781.

Question 69

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

Explanation

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

Question 70

Figure 76 is the MR image of a 16-year-old high school football player who sustained a traumatic dominant shoulder dislocation during a game. On-field reduction was unsuccessful. The shoulder is reduced in the emergency department, and the player and his family followup in clinic. Which factor is most associated with failure of surgical treatment in this scenario?

Explanation

DISCUSSION
The MR image reveals a Bankart lesion. Arthroscopic Bankart repair failure likelihood is increased by numerous factors. Age, number of recurrences, and bony defects are most associated with failure of arthroscopic repair. Shoulder dominance, amount of periosteal
stripping, and difficulty of reduction do not correlate with increased recurrence risk following surgery.
CLINICAL SITUATION FOR QUESTIONS 77 THROUGH 79
A 17-year-old volleyball player has a 3-month history of gradually worsening right shoulder pain. She describes a vague sensation of her shoulder “popping out of place” and weakness associated with overhead activities. She has intermittent generalized paresthesias in her right upper extremity, and she has discontinued participation in sports as a result of her symptoms. Glenohumeral range of motion is symmetric bilaterally. Empty can test findings are negative with full strength of the supraspinatus. An active compression test is negative, and sulcus sign findings are positive. An anterior apprehension test produces pain that is unrelieved with a relocation test. A cervical spine examination is unremarkable.

Question 71

A healthy 16-year-old boy has had increasing pain in the right knee for the past 3 months. Examination reveals warmth and swelling around the distal femur. Radiographs and an MRI scan are shown in Figures 51a through 51c, and a biopsy specimen is shown in Figure 51d. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs show a bone-producing lesion in the distal femoral metaphysis in this case of classic osteosarcoma presenting in the most common location, the distal femur. The coronal MRI scan reveals a marrow-occupying lesion with extension into the soft tissues. The histology shows osteoid production by pleomorphic cells consistent with an osteosarcoma. Ewing’s sarcoma is a bone tumor characterized by uniform small blue cells on histology. Rhabdomyosarcoma is the most common childhood soft-tissue sarcoma. Osteomyelitis has an inflammatory appearance on histology. Malignant fibrous histiocytoma of bone has a lytic radiographic appearance and a pleomorphic storiform pattern without osteoid on histology.
REFERENCES: Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 179.
McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 205.

Question 72

Figures 23a and 23b show the radiograph and clinical photograph of a patient who reports a reduced ability to flex the interphalangeal joint of her great toe after undergoing a Chevron-Akin bunionectomy. What is the most likely cause?

Explanation

DISCUSSION: The flexor hallucis longus tendon is at risk during a Chevron-Akin osteotomy because of its close relationship to the base of the proximal phalanx. The radiograph reveals a reduced ability to flex the interphalangeal joint secondary to the flexor hallucis longus laceration. The other complications are not supported by the radiograph.
REFERENCES: Tollison ME, Baxter DE: Combination chevron plus Akin osteotomy for hallux valgus: Should age be a limiting factor? Foot Ankle Int 1997;18:477-481.
Scaduto AA, Cracchiolo A III: Lacerations and ruptures of the flexor or extensor hallucis longus tendons. Foot Ankle Clin 2000;5:725-736.

Question 73

Which of the following tendons is found in the same dorsal compartment of the wrist as the posterior interosseous nerve?

Explanation

DISCUSSION: The terminal branch of the posterior interosseous nerve is contained in the fourth dorsal compartment. The contents of the various dorsal wrist compartments are as follows:
1^st Compartment: Abductor pollicis longus, extensor pollis brevis
2^nd Compartment: Extensor carpi radialis brevis, extensor carpi radialis longus
3^rd Compartment: Extensor pollicis longus
4^th Compartment: Extensor digitorum comminus, extensor indicus proprius, posterior interosseous nerve
5^th Compartment: Extensor digiti minimi
6^th Compartment: Extensor carpi ulnaris
The extensor indicis proprius is also contained in the fourth dorsal compartment. The extensor digiti minimi is located in the fifth dorsal compartment. The extensor carpi radialis brevis is located in the second dorsal compartment. The extensor pollicis longus is located in the third dorsal compartment, and the abductor pollicis longus is located in the first dorsal compartment.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 150-151.
Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System, Part 1: Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy Corporation, 1987, vol 8, p 60.

Question 74

A 9-year-old child has right groin pain after falling from a tree. Examination reveals that the right leg is held in external rotation, and there is significant pain with attempts at passive range of motion. Radiographs are shown in Figures 43a and 43b. Management should consist of

Explanation

DISCUSSION: The complications of femoral neck fractures in children include osteonecrosis, malunion, nonunion, and premature physeal closure. It is presumed that the risk of osteonecrosis is directly related to the amount of displacement at the time of injury and is not affected by the type of treatment. The risk of the other complications can be decreased depending on the type of treatment. Anatomic reduction by either closed or open methods can reduce the risk of malunion. The addition of internal fixation allows for maintenance of the reduction. In young children who cannot comply with a partial or non-weight-bearing status, the addition of a spica cast gives added protection.
REFERENCES: Canale ST: Fractures of the hip in children and adolescents. Orthop Clin North Am 1990;21:341-352.
Hughes LO, Beaty JH: Fractures of the head and neck of the femur in children. J Bone Joint Surg Am 1994;76:283-292.

Question 75

A 51-year-old female sustained a comminuted radial head fracture with 4 fragments and an associated elbow dislocation. She was initially closed reduced and splinted with the elbow joint in a reduced position and presents to the orthopedists office 10 days later. In response to the patient's question of what treatment offers the best chance for a good outcome, the surgeon should recommend?

Explanation

DISCUSSION: In a classic article, Ring et al reported that ORIF of radial head fractures with more than 3 fragments has poor results and recommend radial head replacement for these fractures. Metallic implants are the material of choice for radial head replacement. Silicone implants were often used in the past, have many well-documented complications including prosthesis failure, adverse tissue reaction, and poor load transfer . Excision is not appropriate in the setting of a radial head fracture associated with elbow instability.

Question 76

A 47-year-old woman who reports mild, aching pain in her knee has no history of trauma. Examination of the knee is normal. Figure 23a shows the AP radiograph. A bone scan shows increased uptake at this site only. Figure 23b shows the CT scan, and Figure 23c shows the histology from the CT scan-guided needle biopsy. Treatment should include

Explanation

Patients with giant cell tumors typically present with local pain, swelling and tenderness. Radiographs usually reveal a lesion destructive of both medullary and cortical bone. The lesion is characterized by an expanding zone of radiolucency that is located eccentrically in the end of a long bone in an adult.
The modern technique for the removal of a giant cell tumor involves wide decortication of all the bone overlying the area of the tumor. The cavity is filled with methylmethacrylate bone cement and covered with demineralized bone matrix to stimulate the restoration of strong cortical
boundaries. The other procedures are much more invasive and not necessary to treat a low-grade neo-plastic lesion such as a giant cell tumor. Fewer complications and better functional results have been found after intralesional excision and insertion of methylmethacrylate than other techniques.

Question 77

If the structure marked by the tip of the probe in Figure 94 is repaired to the bony glenoid with suture anchors during an arthroscopic stabilization procedure, what is the most likely result? Review Topic

Explanation

The probe is on the middle glenohumeral ligament (MGHL), which, in this case, is a cord-like and robust structure, commonly known as a Buford complex. The space between the bony glenoid and the MGHL (in this case, a cord-like Buford complex) is a normal variant and should not be repaired or tightened to the bony glenoid with a soft-tissue anchor or other repair. If this structure is inadvertently repaired, the most common scenario is loss of external rotation with the arm at the side, as the MGHL/Buford complex becomes tight with the arm in this position. The loss of external rotation is more pronounced with the arm at the side than abducted at 90 degrees as the MGHL/Buford complex becomes tighter with the arm at the side than abducted.

Question 78

Osteoarthritic cartilage is characterized by decreased

Explanation

Water content is increased early in the OA cartilage and is associated with the loss of proteoglycan and an increase in the collagen/proteoglycan ratio. Collagen synthesis is increased, but the majority of the material synthesized is Type II, not Type I collagen. Type I collagen increases slightly, particularly in the osteophyte region.
Chondrocytes in OA are much more metabolically active than those of normal cartilage. Studies reveal measuring the levels of utilization on sulfate and H-glucosamine informing components of cartilage matrix. The amount of DNA also rises in OA cartilage most noticeable at the articular chondrocyte.
The synthesis of hyaluronate increases. Recent data suggests 1) hyaluronate that is synthesized is abnormal and, hence, does not allow aggregation; or 2) The excess synthesis is a response to a rapid degradation of synthesized product. This is in light of the fact that synthesis increases, yet concentration of hyaluronate decreases.
The correct answer is that proteoglycan content decreases. The synthesis of proteoglycan increases in OA, but due to the increased rate of breakdown of proteoglycan there is a net result of lowered proteoglycan content.

Question 79

An 18-year-old woman injures her left knee playing soccer. At the time of anterior cruciate ligament (ACL) reconstruction, she was noted to have an irreparable posterior horn medial meniscus tear. Partial meniscectomy will have what primary effect? Review Topic

Explanation

The medial meniscus distributes force through the medial compartment. Peak loads in the affected compartment are increased by partial and complete meniscectomy. The posterior horn of the medial meniscus is also an important secondary restraint to anterior tibial translation in the ACL-deficient knee. In situ forces in the reconstructed ACL are increased with loss of the posterior horn of the medial meniscus.

Question 80

Figures 1 and 2 are the radiographs of a 55-year-old man who has a 3-year history of right shoulder pain. He has maximized nonoperative management and is interested in operative treatment. He had an open Bankart repair 20 years ago and did well until a few years ago. What is most important to know when deciding on the best surgical treatment for this patient?

Explanation

The radiographs show severe osteoarthritis of the shoulder. The best surgical option would be an arthroplasty. The major determining factor for which type of arthroplasty to choose is the integrity of the rotator cuff tendons.
Although the radiographs do not reveal any obvious signs of rotator cuff failure, the patient had had an open Bankart 20 years ago. The integrity of the subscapularis tendon following a previous open shoulder procedure is crucial in deciding which type of arthroplasty to consider. Range of motion and infraspinatus strength do not affect the decision-making process, assuming the rotator cuff is intact. Activity level can be important when deciding whether to proceed with an arthroplasty, but it is not as important as the rotator cuff integrity when choosing which
arthroplasty to use.

Question 81

When treating a stable 2-part intertrochanteric hip fracture with a sliding hip screw construct, what is the minimum amount of screw holes that are needed in the side plate for successful fixation?

Explanation

DISCUSSION: A two part stable intertrochanteric femur fracture can be treated with a sliding hip screw, with good biomechanical and clinical results.
The referenced article by Bolhofner et al reviews a series of 69 patients with a sliding hip screw and two hole side plate and notes that they did not have any failure of the side plate construct.
The referenced article by McLoughlin et al is a biomechanical evaluation of 2 versus 4 hole plates and found that peak load in the failure test was not found to be statistically different between the two-hole and four-hole designs. In cyclic testing, the two-hole configuration exhibited statistically smaller fragment migration in both shear and distraction than the four-hole design.

Question 82

Which of the following genetic disorders has an X-linked recessive inheritance pattern?

Explanation

Hemophilia A is inherited in an X-linked recessive fashion.
linked recessive disorders occur when a mutation occurs on the X chromosome that causes the phenotype to be expressed in males and in females who are homozygous for the gene mutation. These disorders are much more common in males since they only have one X chromosome. Other X-linked recessive disorders include: Duchenne muscular dystrophy, Becker's muscular dystrophy, Hunter's syndrome, and spondyloepiphyseal dysplasia (SED) tarda.
Vanderhave et al. reviewed the orthopaedic consideration in patients with hemophilia. Amongst other things, they discuss arthroplasty in patients with this condition. While they are at higher risk for stiffness and acute hemarthrosis following total knee arthroplasty, ~90-95% of patients have good or excellent results.
Illustration A shows how hemophilia is inherited through a punnett square. Illustration B shows how a weak clotting mechanism causes increased bleeding in patients with hemophilia.
Incorrect Answers:

Question 83

Following a partial muscle laceration, keeping the affected extremity immobilized for 2 weeks before starting an exercise program will likely lead to: Review Topic

Explanation

Muscle lacerations immobilized for 2 weeks would likely experience significant muscle atrophy affecting final functional outcome. For muscle injuries, including partial lacerations, current literature suggests the affected extremity should be immobilized no more than 3-5 days, followed by a progressive strengthening and stretching program.
Healing a muscle injury involves two competing processes: regeneration of muscle fibers and formation of granulation tissue. Starting motion too soon after injury may increase the area of fibrous scar, and limit the ability of new muscle fibers to penetrate this area. Prolonged immobilization limits scar production but penetrating muscle fibers will lack appropriate orientation, and the muscle as whole begins to atrophy. Three to 5 days of immobilization has been shown to limit scar tissue production
while the early motion helps generate appropriately organized muscle fibers and maintain strength and range of motion.
Järvinen et al. present a review of muscle injury and healing. They found that immediate mobilization led to a large area of dense scar tissue that regenerating muscle fibers could not adequately penetrate. Prolonged immobilization allowed muscle fibers to regenerate but they lacked appropriate morphology. Following 3-5 days of immobilization they found less scar tissue, better penetration of regenerated muscle fibers, and the regenerated fibers were more well aligned with the uninjured fibers surrounding them.
Menetrey et al. present a mouse model of muscle laceration comparing a short period of immobilization (5 days) to suture repair of the muscle. They found quicker healing and greater strength in the suture repair group. Tetanus strength at one month after injury was (compared to an uninjured control) 81% for sutured muscle, 35% for the early mobilization only group, and 18% for the prolonged immobilization group.
Illustration A is a histology section of lacerated muscle after 7 days of immobilization. The area is infiltrated with granulation tissue and few regenerating myofibers. Illustration B is a histology section of lacerated muscle after 14 days of immobilization. Further infiltration with granulation tissue and mononuclear cells can be seen with regenerating myofibers only at the periphery.
Incorrect answers:

Question 84

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

Explanation

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

Question 85

A 35-year-old man is seen in the emergency department with a bullet wound to the foot that occurred 2 hours ago. Examination reveals a 0.5-cm entrance wound on the dorsum of the foot and a 1.5-cm exit wound on the plantar aspect. Exploration of the plantar wound in the emergency department reveals bone and metal fragments. Radiographs reveal a comminuted, unstable fracture of the base of the first metatarsal and cuneiform. Management should consist of tetanus toxoid, and

Explanation

DISCUSSION: The patient sustained a type I unstable fracture that requires debridement of superficial fragments from the sole and surgical stabilization. Low-velocity wounds less than 8 hours old are considered type I open fractures. In contrast, gunshot wounds with associated fractures more than 8 hours old are considered type II open fractures using the Gustilo and Anderson classification. Gustilo type I stable fractures due to gunshot wounds and seen within 8 hours can be treated with tetanus toxoid (if no history of immunization or booster within 5 years), surface irrigation, and casting or a hard sole shoe. Antibiotics are not required unless gross contamination is present. However, if the extent of contamination is unclear, or if a joint is penetrated, then routine antibiotic prophylaxis is recommended. Indications for surgery include: articular involvement, unstable fractures, presentation 8 or more hours after injury, tendon involvement, and superficial fragments in the palm or sole. Type I unstable fractures may be stabilized with internal or external fixation. Type II unstable fractures should be treated with external fixation and repeat debridements until clean.
REFERENCES: Holmes GB Jr: Gunshot wounds of the foot. Clin Orthop Relat Res

2003;408:86-91.
Bartlett CS, Helfet DL, Hausman MR, et al: Ballistics and gunshot wounds: Effects on musculoskeletal tissues. J Am Acad Orthop Surg 2000;8:21-36.

Question 86

A B Figures 90a and 90b are MR images of a 34-year-old man who is referred to your office by his primary care physician after failing 4 months of nonsurgical treatment that included epidural steroids for severe right arm pain occurring in a C6 distribution. He also has associated paresthesias in this region. The patient is weak in elbow flexion and wrist extension. What are his likely outcomes if he is treated with a posterior foraminotomy instead of anterior cervical diskectomy and fusion (ACDF)?

Explanation

DISCUSSION
This patient has a right-sided C5-C6 disk herniation causing C6 radicular symptoms in the right upper extremity. Studies have shown that both ACDF and posterior foraminotomy confer similar results in terms of pain relief and functional outcome. Patients treated with posterior foraminotomy are at higher risk for neck pain and recurrence of radiculopathy at the same level. Those who receive ACDF are at higher risk for occurrence of radiculopathy at an adjacent level.
RECOMMENDED READINGS
Rao RD, Currier BL, Albert TJ, Bono CM, Marawar SV, Poelstra KA, Eck JC. Degenerative cervical spondylosis: clinical syndromes, pathogenesis, and management. J Bone Joint Surg Am. 2007 Jun;89(6):1360-78. Review. PubMed PMID: 17575617. View Abstract at PubMed Bolesta MJ, Gill K. Acute neck pain and cervical disk herniation. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:227-234.

Question 87

Figures below show the radiographs, MRI, and MR arthrogram obtained from a 25-year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has competed or practiced 5 to 6 times per week since the age of 10. He denies any specific hip injury that necessitated treatment, but his trainer contends that he had a groin pull. He reports groin pain with passive flexion and internal rotation of the left hip, and his hip has less internal rotation than his asymptomatic right hip. He is otherwise healthy. What is the primary cause of a cam deformity?

Explanation

Multiple studies have confirmed that cam or pincer anatomy is commonly present in asymptomatic hips. According to a large systematic review, cam deformities are present in approximately one-third of asymptomatic hips in young adults, and the proportion is higher than 50% in the subgroup of athletes. Ganz and associates proposed that femoral acetabular impingement is the root cause of osteoarthritis in most nontraumatic, nondysplastic hips, and functional improvement with surgical correction of the deformity has been demonstrated. Despite the link between cam deformity and hip osteoarthritis, a corresponding link between the correction of the deformity and prevention of osteoarthritis has never been proven. The results of cam deformity correction, typically including repair of the degenerative labral tear, are much poorer when substantial joint space loss is present. A typical joint space cutoff of 2 mm or less is used to recommend against hip preservation surgery.

Question 88

When planning revision of a total hip arthroplasty where an acetabular reconstruction will be required, what prerequisite is important to ensure long-term success of a cementless component?

Explanation

DISCUSSION: In bone defects where host bone support is less than 50%, the failure rate is 70% at 5.1 years. The presence or absence of columns or hip position is of relatively little importance if the supportive bone is not present in at least 50% of the surface area around the future acetabular implant.
REFERENCE: Gross AE, Allan DG, Catre M, et al: Bone grafts in hip replacement surgery: The pelvic side. Orthop Clin North Am 1993;24:679-695.

Question 89

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

Explanation

Erb’s palsy is the most common form of obstetrical plexus palsy resulting in C5, C6, or upper trunk deficits. This causes loss of shoulder abduction and elbow flexion. The biceps muscle and the brachialis muscles are predominately responsible for flexion of the elbow. Each of these muscles is innervated by individual branches of the musculocutaneous nerve which are supplied predominately by axons from the C6 nerve root and the upper trunk of the brachial plexus

Question 90

The use of multiagent adjuvant chemotherapy is associated with a clear survival benefit in which of the following diseases?

Explanation

DISCUSSION: The use of multiagent chemotherapy has been shown to be associated with a survival benefit in patients with osteosarcoma. The use of chemotherapy in adults with soft-tissue sarcoma remains somewhat controversial. It has not been associated with improved survival rates in patients with renal carcinoma, dedifferentiated chondrosarcoma, or melanoma.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 53.
Link M, Goorin A, Miser A, et al: The effect of adjuvant chemotherapy and relapse free survival in patients with osteosarcoma of the extremity. N Engl J Med 1986;314:1600-1606.

Question 91

Figure 36 shows the AP pelvic radiograph of a 26-month-old boy who has a limp. He has no significant medical history and no pain. What is the most appropriate treatment plan? Review Topic

Explanation

The radiograph reveals a complete hip dislocation. A Pavlik harness is an accepted method of treatment for a dislocated hip up until 6 months of age. Closed reduction and spica casting with an arthrogram is often successful in young children up to 1-1/2 years to 2 years of age. Open reduction, capsulorrhaphy, and a spica cast is commonly recommended for younger children when attempts at closed reduction have failed or when the child is older than 2 years of age. A femoral shortening is also generally recommended in children older than 2 years of age in an attempt to reduce the muscle/compressive forces on the reduced hip.
(SBQ13PE.38) Pavlik harness treatment is appropriate for which of the following?: Review Topic
4 year old with a diaphyseal femur fracture and a neuromuscular disorder with lower extremity spasticity
2 month old with a displaced spiral mid-diaphyseal femur fracture
9 month old with a diaphyseal femur fracture with <2cm shortening
9 month old with a diaphyseal femur fracture with >2cm shortening
4 year old with a diaphyseal femur fracture, closed head injury and chest trauma
Treatment with Pavlik harness or spica cast are options for patients <6 months of age with diaphyseal femur fractures. Pavlik harness provides adequate pain control for the short time required for healing in this age group. Significant remodeling potential can be expected.
Because of the significant remodeling and quick healing, treatment of diaphyseal femur fractures in children younger than 6 months focuses on providing comfort and avoiding complications. Spica casting likewise results in stable union without longterm sequelae but minor skin complications are more common and some favor Pavlik treatment in this age group.
Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. Their recommendation for diaphyseal femur fractures in children less than 6 months is Grade C, based on Level IV evidence (one retrospective comparative study and one case series). They recommend that Pavlik and spica casting are both acceptable treatment options in this age group.
Flynn et al. review the management of pediatric femoral shaft fractures. They recommend Pavlik treatment for children 6 months of age or less in preference to a spica cast, sometimes supplemented with a simple splint. This avoids the skin complications of spica casting.
Incorrect answers:

Question 92

A 16-year-old high school student undergoes a routine preparticipation physical examination at the beginning of the school year. Examination reveals marked laxity of both shoulders but only mild generalized laxity in other joints. The load and shift test allows for anterior humeral translation to the glenoid rim and posterior humeral translation beyond the glenoid rim. The sulcus sign is present. What is the next most appropriate step in management?

Explanation

DISCUSSION: This patient has shoulder laxity without apprehension. Because there is a wide range of normal laxity in asymptomatic shoulders, the physician should inform the student of these findings, recommend shoulder strengthening exercises, and allow unrestricted sports participation unless symptoms develop.
REFERENCES: Harryman DT, Sidles JA, Harris SL, Matsen FA III: Laxity of the normal glenohumeral joint: A quantitative in vivo assessment. J Shoulder Elbow Surg 1992;1:66-76.
Hawkins RJ, Bokor RJ: Clinical evaluation of shoulder problems, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, p 186.
McFarland EG, Campbell G, McDowell J: Posterior shoulder laxity in asymptomatic athletes. Am J Sports Med 1996;24:468-471.
Linter SA, Levy A, Kenter K, Speer KP: Glenohumeral translation in the asymptomatic athlete’s shoulder and its relationship to clinically measurable anthropometric variables. Am J Sports Med 1996;24:716-720.

Question 93

1 mg/L). Aspiration of the right knee reveals hazy yellow fluid with a white blood cell count of 120 and 1% neutrophils. No growth of organisms is seen on routine culture. What is the best next step?

Explanation

DISCUSSION:
This patient has a chronic quadriceps tendon rupture after total knee arthroplasty. Two previous primary repair attempts have failed, which is not surprising based on the poor results of primary repair reported in the literature. The patient also has an unstable knee and will require revision of some or all of the prosthesis to achieve a stable knee. Revision total knee arthroplasty with extensor mechanism allograft allows an allograft reconstruction of the ruptured quadriceps tendon. The other option is to utilize a synthetic mesh extensor mechanism reconstruction. These are likely to have the best result in this situation. Revision total knee arthroplasty with liner change and primary quadriceps repair is not the best form of management, because it involves a third attempt at primary tendon repair, which will likely fail again. Resection knee arthroplasty and arthrodesis with antegrade nail is a possible option but is not the best, because it would likely make driving and other daily activities difficult. Two-stage revision total
knee arthroplasty with extensor mechanism allograft is not the best option because the laboratory results
show no signs of infection, so a single-stage procedure is preferred.

Question 94

The injection shown in Figures 1a and 1b would most benefit a patient who reports which of the following symptoms? Review Topic

Explanation

The images demonstrate a L5 selective root block as it exits the L5-S1 foramen. This root block best helps relieve pain or paresthesias in the L5 distribution, which is the dorsal first web space and the great toe. The lateral foot is an S1 distribution and would need to be blocked through the posterior first sacral foramen. The anterior shin and thigh represent the L4 root which exits a level above this at the L4-5 foramen. A stocking distribution is nonanatomic and not indicative of a specific root.

Question 95

Which of the following represents a contraindication for interspinous process decompression for the treatment of lumbar spinal stenosis? Review Topic

Explanation

Kondrashov and associates noted stable good outcomes at 4 years in 14 of 18 patients treated with X-STOP interspinous process decompression as defined as an improvement over preoperative Oswestry scores of 15 points or more. Similar results were seen after 1 year in a European study by Siddiqui and associates. Exclusion and inclusion criteria for these studies varied somewhat, but cauda equina syndrome was the only exclusion criteria listed in both studies. All of the other choices did not represent exclusion criteria in either study.

Question 96

A 59-year-old man reports moderate shoulder pain and very restricted range of motion after undergoing humeral arthroplasty for osteoarthritis 1 year ago. An AP radiograph is shown in Figure 32. Management should now consist of

Explanation

DISCUSSION: The radiograph reveals that an insufficient amount of the proximal humerus was excised in the index procedure, resulting in malalignment of the humeral component, overstuffing of the glenohumeral joint, and glenoid arthritis. It is unlikely that physical therapy or soft-tissue releases alone will be adequate. Revision of the humeral component, recutting of the proximal humerus to allow a more anatomic alignment of the humeral component, appropriate soft-tissue releases, and glenoid arthroplasty will offer the best chance of improvement in this difficult situation.
REFERENCES: Neer CS II, Kirby RM: Revision of humeral head and total shoulder arthroplasties. Clin Orthop 1982;170:189-195.
Petersen SA, Hawkins RJ: Revision of failed total shoulder arthroplasty. Orthop Clin North Am 1998;29:519-533.

Question 97

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

Explanation

DISCUSSION: Celiac sprue results in rapid gastrointestinal transit and fatty stools that impair the absorption of calcium and vitamin D and result in nutritional-deficiency osteomalacia with secondary hyperparathyroidism. The radiographs show marked osteopenia with brown tumors. A pathologic fracture is seen in the proximal humerus through a large brown tumor. Serum findings include low or normal calcium, low phosphate, elevated alkaline phosphatase, low 1,25(OH)2D, and increased PTH levels. Secondary hyperparathyroidism is associated with a variety of conditions including malabsorption syndromes.
REFERENCES: Potts JT: Parathyroid hormone: Past and present. J Endocrinol 2005;187:311-325.
Corazza GR, Di Stefano M, Maurino E, et al: Bones in coeliac disease: Diagnosis and treatment. Best Pract Res Clin Gastroenterol 2005;19:453-465.
Mankin HJ, Mankin CJ: Metabolic bone disease: An update. Instr Course Lect 2003;52:769-784.

Question 98

What is a common clinical finding in patients with severe hypercalcemia secondary to bony metastasis?

Explanation

DISCUSSION: Increased levels of calcium are known to cause anorexia, nausea, vomiting, dehydration, muscle weakness, polyuria, and polydipsia. Treatment may include hydration, saline diuresis, and bisphosphonates.
REFERENCE: Frassica FJ, Gitelis S, Sim FH: Metastatic bone disease: General principles, pathophysiology, evaluation, and biopsy. Instr Course Lect 1992;41:293-300.

Question 99

A 40-year-old woman with history of intravenous drug abuse and ongoing Staphylococcus aureus septicemia is referred for intractable neck pain with radiation down her arm. She also complains of progressive hand weakness. Examination reveals long tract signs in the lower extremities. Her MRI scan is shown in Figure A. Besides intravenous antibiotics, what is the most appropriate next step in treatment? Review Topic

Explanation

This patient has spondylodiscitis of C5-C7 with neurological deficit, acute kyphotic deformity and anterior prevertebral and epidural abscess. The abscess and necrotic tissue need to be drained via an anterior approach, and the deformity needs to be corrected and stabilized both anteriorly and posteriorly.
Spinal epidural abscesses are more common in immunodeficient patients and IV drug abusers. They result in verebral body destruction and instability. In addition to draining the abscess and necrotic bone, the instability has to be addressed by instrumentation and fusion, even in the face of infection. Structural support can include cages with morselized bone graft, or structural allograft fixation of anterior and middle column and/or pedicle screw instrumentation of the posterior column.
Shousha et al. reviewed the treatment of cervical spondylodiscitis in 30 patients. They found an epidural abscess in 80% of patients, and noncontiguous discitis in 47% of cases. Thus, they recommend MRI of the entire spine in all cases, and surgery for intractable neck pain, septicemia, epidural abscess, neurological compromise, gross
kyphotic deformity with extensive destruction, and failure of conservative treatment.
Heyde et al. reviewed cervical spondylodiscitis in 20 patients. All cases had postoperative antibiotic therapy for 8–12 weeks. At 37 months (range 24–63), all cases went on to union and there were no recurrences of infection. There was improvement in preoperative neurological status in all cases, leading them to recommend early surgical intervention.
Figure A is an MRI scan showing spondylodiscitis C5–C7 with partial destruction of the vertebral bodies and epidural abscess formation. Illustration A shows the lateral xray (left) and MRI (right) of the same patient 9 months postoperatively after corpectomy C5 and C6 and posterior instrumentation.
Incorrect

Question 100

Which of the following radiographic findings would be characteristic of the knee joints of a patient with neuropathic osteoarthropathy of the knee?

Explanation

Neuropathic osteoarthropathy (a.k.a. Charcot joint) develops most often in weight-bearing joints. The most likely cause is diabetes mellitus, but it is also associated with syphilis, leprosy, yaws, congenital insensitivity to pain, spina bifida, myelomeningocele, syringomyelia, aerodystrophic neuropathy, amyloid neuropathy, peripheral neuropathy of alcoholism, spinal cord injury, peripheral nerve injury, post-transplant neuropathy, and intraarticular steroid injections.
The loss of sensation to the joint is followed by severe degenerative changes, osteophyte formation, articular and subchondral fractures, and often calcification of surrounding soft tissues. In the knee, this is a tricompartmental disease and will not selectively affect one compartment over another.

Full Question & Answer Text (for Search Engines)

Question 1:

When 6 weeks of noninvasive nonsurgical management fails to provide relief for a lumbar disk herniation, a trial of epidural steroid injections is likely to yield which of the following results?

Options:

Eighty percent to ninety percent of patients report rapid and long-lasting relief of symptoms.
Patients with extruded disk herniations report greater relief of symptoms than patients with contained herniations.
Patients with less hydrated disk herniations report the most rapid relief of symptoms.
Patients may experience temporary relief that lasts a maximum of 6 months.
The percentage of patients who report significant improvement is similar to that of patients undergoing diskectomy.

Correct Answer: Patients with extruded disk herniations report greater relief of symptoms than patients with contained herniations.

Explanation:

Question 2:

Options:

Rhomboids and levator transfer
Split pectoralis major transfer
Long head of triceps transfer
Scapulothoracic fusion
Infraspinatus transfer

Correct Answer: Rhomboids and levator transfer

Explanation:

Question 3:

Options:

Interphalangeal joint fusion
Intercalary tendon graft
Silicone rod placement
Primary flexor pollicis longus repair
Flexor digitorum superficialis transfer

Correct Answer: Flexor digitorum superficialis transfer

Explanation:

DISCUSSION: The patient has a chronic flexor tendon laceration. There are options to restore motion and strength; therefore, fusion is not necessary. Full range of motion is present so the soft tissues are suitable for a tendon transfer. A transfer of the flexor digitorum superficialis of the ring finger to the insertion of the flexor pollicis longus on the distal phalanx provides good results with a one-stage operation.
REFERENCES: Schneider LH, Wiltshire D: Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer. J Hand Surg Am 1983;8:98-101.
Posner MA: Flexor superficialis tendon transfers to the thumb: An alternative to the free tendon graft for treatment of chronic injuries within the digital sheath. J Hand Surg Am 1983;8:876-881.

Question 4:

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

Options:

an avulsion of the lesser tuberosity.
a midsubstance tear of the capsule.
a tear of the anterior inferior labrum.
a tear of the subscapularis.
a tear of the humeral insertion of the inferior glenohumeral ligament.

Correct Answer: a tear of the humeral insertion of the inferior glenohumeral ligament.

Explanation:

Question 5:

In long-term follow-up studies of cemented total knee arthroplasty (TKA), the lowest rates of osteolysis have been associated with which design feature?

Options:

Metal-backed patellar components
Modular cruciate-retaining tibial inserts
Modular cruciate-substituting tibial inserts
Monolithic tibial trays

Correct Answer: Monolithic tibial trays

Explanation:

Question 6:

Options:

Early cocking
Late cocking
Acceleration
Deceleration

Correct Answer: Late cocking

Explanation:

Question 7:

Options:

percutaneous aspiration and appropriate antibiotic therapy.
an underarm Boston brace for 23 hours per day.
a referral for radiation therapy.
posterior instrumented arthrodesis from one level above to one level below the deformity.
removal of the lesion and local arthrodesis if necessary.

Correct Answer: removal of the lesion and local arthrodesis if necessary.

Explanation:

Question 8:

Options:

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

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

Explanation:

Question 9:

Options:

Peroneal tendon tear
Lateral process talus fracture
Talar neck fracture
Lisfranc injury
Deltoid ligament tear

Correct Answer: Lisfranc injury

Explanation:

DISCUSSION: This cuboid compression fracture (“nutcracker” injury) is associated with subtle injury to the Lisfranc complex. This diagnosis must be made to ensure proper treatment.
REFERENCE: Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.

Question 10:

During the anterior approach for repair of a distal biceps tendon rupture, what structure, shown under the scissors in Figure 6, is at risk for injury?

Options:

Brachial artery
Median nerve
Posterior interosseous nerve
Lateral antebrachial cutaneous nerve
Antecubital vein

Correct Answer: Lateral antebrachial cutaneous nerve

Explanation:

Question 11:

Options:

a snug figure-of-8 splint and observation for spontaneous reduction.
closed reduction under general anesthesia.
closed reduction under general anesthesia and percutaneous pinning.
open reduction and capsuloligamentous repair.
open reduction and wire stabilization of the joint.

Correct Answer: closed reduction under general anesthesia.

Explanation:

Question 12:

For the athlete performing heavy exercise, the magnitude of core temperature and heart rate increase is most proportional to

Options:

water debt at the onset of exercise.
sodium debt at the onset of exercise.
potassium debt at the onset of exercise.
ambient temperature.
percentage of lean body mass.

Correct Answer: water debt at the onset of exercise.

Explanation:

Question 13:

Options:

Temporary total disability
Temporary partial disability
Temporary partial illness
Permanent total disability
Permanent partial disability

Correct Answer: Temporary partial disability

Explanation:

Question 14:

Options:

CT-guided needle biopsy at L4-L5.
a bone survey.
anterior interbody fusion.
left L4-L5 microdiskectomy.
left L4-L5 hemilaminectomy and partial facetectomy.

Correct Answer: left L4-L5 hemilaminectomy and partial facetectomy.

Explanation:

Question 15:

Options:

Increased knee laxity compared with nonaccelerated rehabilitation programs
No weightbearing allowed for 2-weeks post-operatively
Accelerated rehabiliation program duration is 32-weeks
Equal outcomes compared with nonaccelerated rehabilitation programs
Improved range of motion compared with nonaccelerated rehabilitation programs

Correct Answer: Increased knee laxity compared with nonaccelerated rehabilitation programs

Explanation:

Question 16:

Options:

Cystinosis
Hypophosphatemia
Renal osteodystrophy
Primary hyperparathyroidism
Nutritional vitamin D deficiency

Correct Answer: Cystinosis

Explanation:

Question 17:

Options:

Reduction in free fibrinogen radicals
Reduction in bleeding complications
Increased venous flow
Improved bioavailability
Inhibition of factors V, VI, and IX

Correct Answer: Improved bioavailability

Explanation:

Question 18:

Options:

external traction.
open reduction and internal stabilization.
repeat closed reduction under general anesthesia.
open reduction.
percutaneous pin fixation in the current position.

Correct Answer: open reduction.

Explanation:

DISCUSSION: The radiographs show a complex dislocation of the little finger metacarpophalangeal joint. This is characterized by obvious dislocation on the AP and lateral views and a type of bayonet apposition best visualized on the lateral view. Irreducibility of this injury is caused by displacement of the volar plate that has been traumatically avulsed from its origin on the metacarpal, with subsequent displacement into the metacarpophalangeal joint. This abnormal position of the volar plate causes irreducibility that can be corrected only by open reduction. This can be effected either by dorsal or palmar approaches.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 711-771.
Becton JL, Christian JD Jr, Goodwin HN, Jackson JG III: A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg Am 1975;57:698-700.
Green DP, Terry GC: Complex dislocation of the metacarpophalangeal joint: Correlative pathological anatomy. J Bone Joint Surg Am 1973;55:1480-1486.

Question 19:

A 17-year-old girl has multidirectional instability of the shoulder. What is the most appropriate initial management?

Options:

Immobilization in a sling and swathe
Open capsular shift
Arthroscopic capsular plication
Thermal capsulorrhaphy
Physical therapy and home exercises

Correct Answer: Physical therapy and home exercises

Explanation:

DISCUSSION: Multidirectional instability of the shoulder is defined as symptomatic instability in two or more directions (anterior, posterior) but must include a component of inferior instability. Initial treatment should always include physical therapy and instruction in a home exercise program that emphasizes periscapular and rotator cuff strengthening to improve the dynamic stability of the glenohumeral joint. Immobilization has not been shown to be effective. Open capsular shift and arthroscopic capsular plication remain the surgical options when appropriate nonsurgical management fails (typically a minimum of 6 months of dedicated therapy and home program). Thermal capsulorrhaphy remains controversial but is not recommended by many clinicians because of reported complications including recurrent instability, axillary nerve injury, chondrolysis, and capsular injury.
REFERENCES: Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908.
D’Alessandro DF, Bradley JP, Fleischli JE, et al: Prospective evaluation of thermal capsulorrhaphy for shoulder instability: Indications and results, two- to five-year follow-up.
Am J Sports Med 2004;32:21-33.
Levine WN, Clark AM Jr, D’Alessandro DF, et al: Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability: A report of two cases. J Bone Joint Surg Am 2005;87:616-621.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 278-279.

Question 20:

Options:

Infected total knee arthroplasty
Polyethylene wear-related synovitis
Rheumatoid arthritis synovitis
Gout
Tibial component loosening

Correct Answer: Polyethylene wear-related synovitis

Explanation:

DISCUSSION: Polyethylene wear debris can result in significant synovitis and subsequent cloudy appearing synovial fluid. Typically, laboratory studies show a WBC of less than 30,000/mm
3
and no left shift. Cytologic examination can reveal intra-articular polyethylene particles. Infected total knee arthroplasty is extremely uncommon in a healthy, immune-competent patient who has a normal preoperative erythrocyte sedimentation rate and C-reactive protein level.
REFERENCE: Barrack RL, Jennings RW, Wolfe MW, Bertot AJ: The value of preoperative aspiration before total knee revision. Clin Orthop 1997;345:8-16.

Question 21:

What is the most significant factor affecting long-term survival for a patient with bone sarcoma?

Options:

Presence of metastatic disease at presentation
Grade of tumor
Size of tumor
Depth of tumor invasion
Presence of necrosis

Correct Answer: Presence of metastatic disease at presentation

Explanation:

DISCUSSION: The most significant impact on long-term survival is the presence or absence of identifiable metastatic disease on initial presentation. All of these factors have been shown to be predictive of long-term survival to varying degrees.
REFERENCES: Enneking WF, Spanier SS, Goodman MA: A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res 1980;153:106-120.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

Question 22:

- Which of the following nerves lying between the gluteus medius and minimus is at risk for injury in a lateral approach to the hip?

Options:

Femoral
Obturator
Inferior gluteal
Superior gluteal
Lateral femoral cutaneous

Correct Answer: Superior gluteal

Explanation:

Question 23:

Options:

Arthroscopic infraspinatus tenodesis
Arthroscopic posterior labral repair
Arthroscopic capsular shift and rotator interval closure
Posterior glenoid opening-wedge osteotomy

Correct Answer: Arthroscopic posterior labral repair

Explanation:

Question 24:

Options:

closed management of the medial condyle and humeral shaft fractures and open reduction and internal fixation of the both bones forearm fracture.
closed management of the humeral shaft fracture and open reduction and internal fixation of the medial condyle and the both bones forearm fractures.
open reduction and internal fixation of the humeral shaft, medial condyle, and the both bones forearm fractures.
open reduction and internal fixation of the medial condyle and both bones forearm fractures, and external fixation of the humeral shaft fracture.
delayed stabilization of all fractures after the open wound has healed.

Correct Answer: open reduction and internal fixation of the humeral shaft, medial condyle, and the both bones forearm fractures.

Explanation:

Question 25:

Options:

open reduction and internal fixation.
cast immobilization.
percutaneous pin fixation.
observation, with follow-up in 3 months.
an MRI scan of the elbow.

Correct Answer: percutaneous pin fixation.

Explanation:

The patient has a nonunion of the lateral condyle of the left humerus. Observation or cast treatment at this stage is not likely to lead to healing of the fracture. MRI will not add any additional information. Open reduction, with minimal posterior soft-tissue stripping, is recommended to establish union of the fracture. Local or other bone graft may also be required. There are no studies that indicate that the displaced fracture will heal with late percutaneous fixation.
(SBQ13PE.40) Immediate spica casting is most appropriate for which of the following?:
Review Topic
2-month-old girl with a displaced spiral mid-diaphyseal femur fracture
A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with <2 centimeters of shortening
3-day-old with teratologic right hip dislocation
9-year-old boy with a displaced spiral mid-diaphyseal femur fracture
12-year-old girl weighing 90 pounds with a displaced spiral mid-diaphyseal femur fracture
Children older than 6 months and up to 6 years with diaphyseal femur fractures may be treated with spica casting.
Children younger than 6 months may only require a Pavlik harness. Immediate spica casting is indicated in children 6 months to 6 years with less than 2 cm of shortening. Each additional cm of shortening at presentation doubles the risk of loss of reduction (1 cm: 12%, 2 cm: 24%, 3 cm; 50%).
Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. Their recommendation for diaphyseal femur fractures with <2 cm shortening in children 6 months to 5 years is Grade B, based on Level II evidence (two level II and one level I study). They recommend early spica or traction with delayed spica. They suggest early spica, as this is more convenient than traction.
In an earlier article, Flynn et al. review the management of pediatric femoral shaft fractures. They recommend early spica casting for the child between 1 and 6 years in
low-energy femoral fractures with up to 2 cm shortening. Illustration A shows several styles of lower extremity spica casts.
Incorrect answers:

Question 26:

Figures 28a through 28d show the radiographs and MRI scans of a 20-year-old basketball player who sustained an inversion injury to his right ankle. Management should consist of

Options:

open reduction and internal fixation.
a short leg cast for 6 weeks.
ankle arthroscopy, removal of the fragment, and drilling of the base of the lesion.
ankle arthroscopy and internal fixation.
functional ankle rehabilitation that emphasizes range of motion, peroneal strengthening, and proprioceptive training.

Correct Answer: ankle arthroscopy, removal of the fragment, and drilling of the base of the lesion.

Explanation:

Question 27:

The patient develops an inability to dorsiflex her foot 2 days after surgical intervention while she is sitting in a chair after physical therapy. Initial treatment should consist of

Options:

lying completely supine in bed.
remaining seated and placing the postsurgical leg on a stool.
transferring back to bed with the head of the bed no lower than 60 degrees.
transferring back to bed with the head of the bed level and the surgical knee flexed.

Correct Answer: transferring back to bed with the head of the bed level and the surgical knee flexed.

Explanation:

Question 28:

- Which of the following procedures is associated with the highest risk of osteonecrosis of the metatarsal head?

Options:

Distal chevron osteotomy with soft-tissue release
Distal soft-tissue realignment only
Closing wedge osteotomy (Aken) of the proximal phalanx
Proximal first metatarsal osteotomy only
Soft-tissue realignment with a proximal metatarsal osteotomy

Correct Answer: Distal chevron osteotomy with soft-tissue release

Explanation:

Question 29:

Options:

Maintain sling immobilization for 6 weeks, and then begin a global range-of-motion program.
Maintain sling immobilization for 3 weeks, and then begin a global range-of-motion program.
Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.
Immediately begin a passive range-of-motion program for forward elevation only; no external rotation is allowed for 6 weeks.
Immediately begin active range of motion in forward elevation and external rotation to the side with a progression to full rotator cuff strengthening in 3 weeks.

Correct Answer: Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.

Explanation:

Question 30:

Options:

Malignant fibrous histiocytoma
Liposarcoma
Synovial cell sarcoma
Leiomyosarcoma
Clear cell sarcoma

Correct Answer: Liposarcoma

Explanation:

DISCUSSION: The images show a complex, lobular lesion of the thigh that has signal characteristics that follow fat. The size of the lesion, the areas of stranding within the mass, along with mild uptake on the gadolinium sequences and the mild edema within the lesion on the T
2
-weighted image make liposarcoma the most likely diagnosis and simple intramuscular lipoma far less likely. All other diagnoses listed would not follow fat characteristics shown on the MRI sequences.
REFERENCE: Sanders TG, Parsons TW: Radiographic imaging of musculoskeletal neoplasia. Cancer Control 2001;8:221-231.

Question 31:

Figure 40 shows the AP radiograph of a 55-year-old man who reports left knee pain. Which of the following conditions is least likely to produce this radiographic presentation?

Options:

Hemochromatosis
Alkaptonuria
Wilson’s disease
Septic arthritis
Calcium pyrophosphate dihydrate crystal deposition

Correct Answer: Septic arthritis

Explanation:

Question 32:

What is the most common physical finding in myelopathic patients? Review Topic

Options:

Babinski sign
Hoffman sign
Hyperreflexia
Clonus
Ataxic gait

Correct Answer: Hoffman sign

Explanation:

Question 33:

Options:

an elastic bandage, cold packs, and weight bearing as tolerated.
non-weight-bearing and a CT scan of the talus.
cast immobilization for 10 days, followed by progressive rehabilitation.
cast immobilization for 6 weeks, followed by progressive rehabilitation.
stirrup splinting, cold packs, and aggressive rehabilitation.

Correct Answer: non-weight-bearing and a CT scan of the talus.

Explanation:

Question 34:

Options:

Observation
Electromyogram/nerve conduction study (EMG/NCS)
CT scan
Immediate exploration

Correct Answer: Observation

Explanation:

EXPLANATION:
Prevalence of flexor tendon rupture after distal radius fracture is between 2% and 12%. The FPL tendon is the most common flexor tendon rupture associated with volar plating. It is usually seen with plates that are distal to the watershed line (W) and with plates extending volar to the critical line (C) (Figure below). The watershed line (W) is the location of the origin of the volar carpal ligaments and the bone prominence
at which flexor tendons are most closely opposed to the distal radius (Figure 4). In this scenario, the lateral radiograph shows that the plate is not distal to the watershed line (W) and is between the critical line (C) and the line parallel to the volar cortex of the radius (R). This is the optimal position for the plate. Placement of a volar locking plate distal to the watershed line of the distal radius and excessive plate prominence has been associated with FPL tendon rupture. This patient is only 2 weeks past surgery and there is some FPL function. FPL weakness after volar distal radius plating is common and has been seen in as many as 50% of patients. This usually recovers spontaneously by 2 months, and no treatment is needed. A nerve conduction study would be indicated if an anterior interosseous nerve compression were considered, but it is too early for this test. A CT scan could be obtained to judge the alignment of the fracture fragment and position of the screws, but it is not indicated in this case. Exploration could be performed if an FPL rupture were considered, but, because it is only 2 weeks after surgery, there is some FPL function, the plate is proximal to the watershed line, and immediate exploration is not indicated. If this does not improve after 2 to 3 months, further investigation with ultrasound or MRI would be indicated.

Question 35:

Which of the following findings can cause a dorsal bunion in a patient with neuromuscular disease?

Options:

Contracted plantar fascia and weakness of the tibialis anterior
Overpull of the gastrocnemius-soleus complex and weakness of the anterior tibialis
Overpull of the posterior tibialis and weakness of the peroneals
Overpull of the peroneus brevis and weakness of the posterior tibialis
Overpull of the tibialis anterior and weakness of the peroneus longus

Correct Answer: Overpull of the tibialis anterior and weakness of the peroneus longus

Explanation:

Question 36:

A 37-year-old laborer falls 12 feet and sustains a comminuted tibial plafond fracture. Three years after treatment using standard techniques, what will be the most likely outcome?

Options:

Need for ankle fusion or arthroplasty
Return to normal function
Ankle stiffness without pain
Severe constant pain and inability to work
Adversely affected general health status and posttraumatic arthritis

Correct Answer: Adversely affected general health status and posttraumatic arthritis

Explanation:

Question 37:

Options:

Equal at 10 years B. Lower at 10 years C. Higher at 10 years
Not known when using a mobile-bearing UKA

Correct Answer: Not known when using a mobile-bearing UKA

Explanation:

Question 38:

Options:

He can expect complete resolution of his symptoms during the first month.
All patients experience relief within 3 months and continue to improve over the next 4 years.
Most patients experience some pain relief within the first 3 months.
He may experience some improvement but if he requires surgery at a later date he will have a poorer result because of the delay.
The patient requires immediate surgery to avoid permanent nerve damage.

Correct Answer: Most patients experience some pain relief within the first 3 months.

Explanation:

DISCUSSION: The patient has lumbar spinal stenosis and the MRI scans reveal the pathology at L4-5, which is secondary to posterior disk bulging and hypertrophy and infolding of the ligamentum flavum, as well as degenerative facet arthrosis. The degree of spinal stenosis is moderate and his symptoms are positional in nature. Tadokoro and associates reported on a prospective study of 89 patients older than 70 years of age who underwent nonsurgical management for lumbar spinal stenosis. They found the prognosis to be relatively good with patients scoring at “excellent” or “good” for activities of daily living at final follow-up. However, they did note that patients with a complete block on myelography did not respond favorably to nonsurgical management. Amundsen and associates reported on a 10-year prospective study comparing surgical care to nonsurgical management. They concluded that, while the long-term results largely favored surgical treatment, more than half of the nonsurgically managed patients had a satisfactory outcome. They also concluded that a delay of surgery for some months did not worsen the prognosis. Therefore, their recommendation was for an initial primarily nonsurgical approach.
REFERENCES: Amundsen T, Weber H, Nordal HJ, et al: Lumbar spinal stenosis: Conservative or surgical management? A prospective 10-year study. Spine 2000;25:1424-1435.
Hilibrand AS, Rand N: Degenerative lumbar stenosis: Diagnosis and management. J Am Acad Orthop Surg 1999;7:239-249.
Tadokoro K, Miyamoto H, Sumi M, et al: The prognosis of conservative treatments for lumbar spinal stenosis: Analysis of patients over 70 years of age. Spine 2005;30:2458-2463.

Question 39:

Options:

2 cm distal to the articular surface of the radial head
1 cm distal to the articular surface of the radial head
Within a 90-degree arc or safe zone
Within a 120-degree arc or safe zone
Within a 180-degree arc or safe zone

Correct Answer: Within a 90-degree arc or safe zone

Explanation:

DISCUSSION: The radial head is covered by cartilage on 360 degrees of its circumference. However, with the normal range of forearm rotation of 160 to 180 degrees, there is a consistent area that is nonarticulating. This area is found by palpation of the radial styloid and Lister’s tubercle. The hardware should be kept within a 90-degree arc on the radial head subtended by these two structures.
REFERENCES: Smith GR, Hotchkiss RN: Radial head and neck fractures: Anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg 1996;5:113-117.
Caputo AE, Mazzocca AD, Santoro VM: The nonarticulating portion of the radial head: Anatomic and clinical correlations for internal fixation. J Hand Surg Am 1998;23:1082-1090.

Question 40:

Options:

Recurrence of the deformity
Hallux varus
back answer
Transfer metatarsalgia
Nonunion of the first metatarsal osteotomy
Osteonecrosis of the first metatarsal osteotomy 77.03

Correct Answer: Recurrence of the deformity

Explanation:

Coglin’s referenced paper is a study out of Idaho. 11 year retrospective study of 45 patients (60 feet). A multiprocedural approach was used to surgically correct the deformity. There were 6 recurrences of the deformities and eight
complications (6 cases of hallux varus, one case of wire breakage and one case of undercorrection.) So according to their reference this question has two correct answers.
Postoperative complications have been frequently reported following juvenile hallux valgus corrections. Recurrence following surgery is probably the most frequently reported complication and is likely due to the high rate of congruency associated with a
juvenile hallux valgus deformity.
OKU Foot and Ankle 2 Rosemont IL., American academy of orthopaedic surgeons, pp135-150.
back to this question next question

Question 41:

What is the most common cause of errors that harm patients? Review Topic

Options:

Communication breakdown
Equipment breakdown
Nursing competence
Patient noncompliance
Physician competence

Correct Answer: Communication breakdown

Explanation:

Question 42:

The anatomy of the sciatic nerve as it exits the pelvis is best described as exiting through the

Options:

greater sciatic notch and passing between the inferior gemellus and the obturator externus.
greater sciatic notch and passing between the piriformis and the superior gemellus.
obturator foramen and passing between the obturator internus and the obturator externus.
lesser sciatic notch and passing between the piriformis and the superior gemellus.
lesser sciatic notch and passing between the superior gemellus and the inferior gemellus.

Correct Answer: greater sciatic notch and passing between the piriformis and the superior gemellus.

Explanation:

DISCUSSION: The sciatic nerve is formed by the roots of the lumbosacral plexus. It exits the pelvis through the greater sciatic notch and appears in the buttock anterior to the piriformus. From that point, the sciatic nerve passes posteriorly over the superior gemellus, obturator internus, inferior gemellus, and quadratus femoris before it passes deep to the biceps femoris. The tendon of the obturator internus passes through the lesser sciatic notch.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 347.
Anderson JE: Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-34, 4-36.
Hollingshead WH: Anatomy for Surgeons: The Back and Limbs, ed 2. Hagerstown, MD, Harper & Row, 1969, pp 607-609.

Question 43:

Options:

Prevention of knee hyperextension
Correct of valgus instability
Correction of varus malalignment
Treatment of symptomatic meniscal tear
Treatment of an asymptomatic abnormally shaped meniscus

Correct Answer: Correct of valgus instability

Explanation:

This patient has undergone arthroscopic saucerization of his discoid meniscus. The indication for this procedure is treatment of a symptomatic meniscal tear.
Arthroscopic treatment of lateral discoid meniscus injuries has the advantages of reducing trauma, precise resection or repair of the meniscus and saucerization of the remaining discoid meniscus. Operative treatment is usually limited to patients with pain and mechanical symptoms that are undergoing partial meniscectomy or repair. Asymptomatic discoid meniscus without tears are not considered a surgical indication for routine saucerization.
Kramer et al. reviewed the diagnosis and treatment of traumatic discoid meniscal tears in children. They report that knee shape, size and skeletal maturity must be considered when determining the optimal method of repair. However, all symptomatic torn discoid menisci are best treated with saucerization and repair.
Good et al. looked at the arthroscopic techniques of discoid meniscus repair. Arthroscopic saucerization was successful in 28 of 30 knees and meniscal repair in 23 of 30 knees. At final follow-up, all patients exhibited full knee flexion beyond 135 degrees. In 3 of 30 patients there was residual knee pain, and four reported intermittent mechanical symptoms.
Figure A shows a series of arthroscopic images of the right knee lateral compartment. There is a sequential saucerization of the discoid meniscus.
Incorrect Answers:
(SBQ13PE.83) 8-year-old boy complains of intermittent painless clicking in his knee. His physical examination is normal. His family doctor orders an MRI, which reveals an incomplete lateral discoid meniscus without evidence of tear. What is the most appropriate treatment?
Review Topic
Observation only
Diagnostic arthroscopy
Saucerization of meniscus
Saucerization of meniscus and microfracture
Saucerization and stabilization of the mensicus
The clinical presentation is consistent with a asymptomatic discoid meniscus. The most appropriate treatment at this time would be observation only.
MRI scans of the knee are very sensitive for identifying discoid menisci. Diagnosis is usually made when there are 3 or more 5mm sagittal MRI images showing meniscal continuity. Treatment is mostly focused on conservative modalities. Asymptomatic tears are usually treated with observation only. Saucerization is indicated for recurrent locking, swelling, persistent pain, or radiographic evidence of a meniscal tear.
Watanabe et al. described three types of discoid lateral menisci based on arthroscopic appearance. In this classification, discoid menisci with normal peripheral attachments are either type I (complete) or type II (incomplete). Type III discoid menisci, the so-called Wrisberg ligament type, are lacking posterior capsular attachments with the exception of the posterior meniscofemoral ligament.
Kramer et al. looked at the presentation of pediatric knee pain and discoid meniscus. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the meniscus.
Illustration A shows the cross-section of normal meniscus. Illustration B shows the Watanabe classification.
Incorrect Answers:

Question 44:

-The use of a soft cervical orthosis is most supported for which injury?

Options:

Whiplash
C4 burst fracture
Rotatory subluxation at C1-C2
Displaced type II odontoid fracture
Ligamentous injury with translation of C4 on C5

Correct Answer: Whiplash

Question 45:

Options:

intermedullary fixation.
a brace or taping to limit inversion stress.
a short leg walking cast or a fracture walker.
a non-weight-bearing short leg cast.
a rigid orthotic insole, with early motion exercises.

Correct Answer: intermedullary fixation.

Explanation:

Question 46:

Options:

Stair climbing ability
Need for a walking aid
Implant failure
Balance impairment
Independent performance of activities of daily living (ADL)

Correct Answer: Stair climbing ability

Explanation:

Question 47:

A 30-year-old man landed on his shoulder in a fall off his mountain bike. An AP radiograph and CT scan are shown in Figures 34a and 34b. Management should consist of

Options:

immobilization in a sling and swathe.
open reduction and internal fixation.
humeral arthroplasty.
subscapularis transfer into the humeral head articular defect.
a hanging cast.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 48:

Options:

Resurfacing hemiarthroplasty
Resurfacing hemiarthroplasty with fascial glenoid resurfacing
Resurfacing hemiarthroplasty with cemented glenoid component
Stemmed hemiarthroplasty
Stemmed total shoulder arthroplasty

Correct Answer: Stemmed hemiarthroplasty

Explanation:

DISCUSSION: The radiograph and intraoperative photograph show osteonecrosis with near complete head loss/collapse. A stemmed implant is more appropriate in this patient because there is very little bone to support a resurfacing implant. In a younger patient, a glenoid implant should be delayed as long as possible because of the eventual need for revision secondary to glenoid loosening and wear, especially in a young active male. The hemiarthroplasty may be converted to a total shoulder arthroplasty in the future.
REFERENCES: Levy O, Copeland SA: Cementless surface replacement arthroplasty of the shoulder: 5- to 10-year results with the Copeland mark-2 prosthesis. J Bone Joint Surg Br 2001;83:213-221.
Burroughs PL, Gearen PF, Petty WR, et al: Shoulder arthroplasty in the young patient.
J Arthroplasty 2003;18:792-798.

Question 49:

Options:

Osteosarcoma
Osteochondroma
Ewing’s sarcoma
Chondrosarcoma
Periosteal chondroma

Correct Answer: Osteosarcoma

Explanation:

Question 50:

Options:

A 29-year-old man with an open pelvic fracture
A 42-year-old man with a major extremity crush injury
A 31-year-old woman with an open forearm fracture
A 36-year-old man with a spleen laceration after blunt trauma who is clinically stable and whose spleen laceration does not meet criteria for operative management
An 18-year-old woman with multiple proximal long bone fractures

Correct Answer: A 29-year-old man with an open pelvic fracture

Explanation:

Question 51:

A 28-year-old male sustains a fall on icy ground and fractures his ankle. An intraoperative fluoroscopy image is shown in Figure A. This fixation suggests that the mechanism of injury was one of

Options:

Pronation-abduction
Supination-adduction
Pronation-external rotation
Supination-external rotation
Dorsiflexion-axial loading

Correct Answer: Pronation-abduction

Explanation:

The fixation of the medial malleolus in the figure consists of a contoured reconstruction plate placed in buttress (antiglide) mode with screws running parallel to the joint surface and perpendicular to the fracture line. This fixation is indicated for vertical fractures of the medial malleolus from a supination-adduction (SA) shearing force.
A vertical fracture of the medial malleolus is characteristic of a Lauge-Hansen SA fracture. Bimalleolar SA fractures will also demonstrate a distal fibular avulsion. Another characteristic is impaction of anteromedial distal tibia by the talar dome. An anteromedial surgical approach allows visualization of this region, elevation of impaction, and bone grafting of the defect if necessary.
Dumigan et al. analyzed 4 different methods of treating vertical shear fractures with polyurethane models. They found that fixation with a 4 hole 1/3 tubular plate with 2 screws in the distal fragment was stiffer than fixation with the same plate with 1 screw in the distal fragment (3 in the proximal), fixation with two 3.5mm cortical screws with washers, and fixation with two 4mm cortical screws with washers. They recommend plating over screw-alone constructs.
McConnell et al. reported 8 cases of anteromedial marginal impaction in SA fractures. They note that 44 fractures were SA type. Following reduction and fixation, all 8 patients had excellent outcome and no arthritis. They recommend an anteromedial approach to the medial malleolus for visualization.
Figure A is a lateral radiograph showing fixation of both malleoli with reconstruction plates. Illustration A is an postoperative AP fluoroscopy image. Illustration B is an injury film demonstrating the same SA ankle fracture. Illustration C shows articular impaction at the medial shoulder of the ankle joint typical of SA injuries. Illustration D shows marginal impaction in SA fractures.
Incorrect Answers
(SBQ12TR.76) A 24-year-old male sustains the fracture dislocation shown in Figure
A. How is this fracture pattern best classified?
Moore I
Moore II
Schatzker III
Schatzker V
OTA type 41B3
Figure A shows a Moore Type II fracture. Moore type II fractures consist of fractures involving the entire tibial condyle, where the fracture line begins in the opposite compartment and extends across the tibial eminence.
A number of classification systems are used to describe tibial plateau fractures. The main classification systems that are widely used include Schatzker, AO/OTA, Hohl and Moore. The Moore classification describes high energy fracture-subluxation injuries of the knee. This is thought to have clinical implications as the type of fracture pattern can indicate an associated soft-tissue injury.
Moore retrospectively reviewed over a 1000 proximal tibia fractures to devise a classification systems based on the characteristic of five types of tibia plateau fracture patterns. He believed this system helped to better understand knee instability and concomitant soft-tissue injury. For example, Moore Type III fractures (rim avulsion) are associated with a high rate of neurovascular injury.
Figure A shows a fracture involving the entire tibial condyle. Illustration A shows a schematic diagram of the Moore classification (I - V). Illustration B shows a table that
describes the Moore classification (I - V).
Incorrect Answers:

Question 52:

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 53:

Options:

Add double metal uprights and a leather corset.
Add a supracondylar suspension to the soft suspension.
Add supracondylar and suprapatellar suspensions to the socket design.
Replace the socket insert with a silicone suction socket with locking bolt suspension.
Replace the prosthetic socket with a negative pressure vacuum system.

Correct Answer: Add double metal uprights and a leather corset.

Explanation:

Question 54:

Options:

pre-debridement cultures.
post-debridement cultures.
neither debridement culture.
anaerobic specimens.

Correct Answer: neither debridement culture.

Explanation:

Question 55:

Options:

Nonsurgical management and follow-up CT scan in 6 weeks
Closed reduction in the emergency room under sedation
Closed reduction in the operating room under general anesthesia with thoracic surgery on standby, followed by figure-of-8 clavicle strap immobilization for 4 weeks
Closed reduction in the operating room under general anesthesia with thoracic surgery on standby, followed by compression plating
Open reduction in the operating room under general anesthesia, followed by transarticular pinning with K-wires

Correct Answer: Closed reduction in the emergency room under sedation

Explanation:

Question 56:

In a patient with a soft-tissue sarcoma treated by wide excision and radiation therapy, the risk of subsequent fracture is probably most influenced by

Options:

location of the sarcoma in the lower extremity.
excision of cortical bone with en bloc resection.
a radiation dose of 60 Gy (6,000 cGy) versus 50 Gy (5,000 cGy).
the addition of adjuvant chemotherapy.
excision of the periosteum.

Correct Answer: excision of cortical bone with en bloc resection.

Explanation:

Question 57:

Options:

Admit for observation and reassurance
Surgical exploration and removal of the anterior instrumentation
Esophageal swallowing study
Soft cervical collar and early range-of-motion exercises
CT of the cervical spine

Correct Answer: Admit for observation and reassurance

Explanation:

DISCUSSION: The radiograph shows significant prevertebral soft-tissue swelling following a two-level anterior cervical diskectomy and fusion. The incidence of dysphagia 2 years after anterior cervical spine surgery is 13.6%. Risk factors for long-term dysphagia after anterior cervical spine surgery include gender, revision surgeries, and multilevel surgeries. The use of instrumentation, higher levels, or corpectomy versus diskectomy did not significantly increase the prevalence of dysphagia. Lee and associates demonstrated that while dysphagia after anterior cervical spine surgery is a common early finding, it generally decreases significantly by
6 months with nonsurgical management. A minority of patients experience moderate or severe symptoms by 6 months after the procedure. Female gender and multiple surgical levels have been identified as risk factors for the development of postoperative dysphagia.
REFERENCES: Lee MJ, Bazaz R, Furey CG, et al: Risk factors for dysphagia after anterior cervical spine surgery: A two-year prospective cohort study. Spine J 2007;7:141-147.
Bazaz R, Lee MJ, Yoo JU: Incidence of dysphagia after anterior cervical spine surgery:
A prospective study. Spine 2002;27:2453-2458.

Question 58:

A patient notes pain under the first metatarsophalangeal joint following a soccer injury. The MRI scans shown in Figures 27a and 27b reveal what pathologic finding?

Options:

Sesamoid fracture
Phalangeal fracture
Osteochondral lesion
Disruption of the plantar plate
Rupture of the flexor hallucis tendon

Correct Answer: Disruption of the plantar plate

Explanation:

Question 59:

Options:

use of an electrical bone stimulation unit.
open reduction and internal fixation with a dynamic compression plate placed superiorly and autogenous bone grafting.
open reduction and internal fixation with a dynamic compression plate placed inferiorly and autogenous bone grafting.
intramedullary screw fixation.
partial claviculectomy.

Correct Answer: open reduction and internal fixation with a dynamic compression plate placed superiorly and autogenous bone grafting.

Explanation:

Question 60:

Options:

Elbow fusion
Radial head resection
Total elbow arthroplasty
Osteophyte resection and capsular release
Physical therapy with dynamic extension and flexion splints

Correct Answer: Osteophyte resection and capsular release

Explanation:

Question 61:

Options:

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

Correct Answer: Coexisting endocrine disorder

Explanation:

Question 62:

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 63:

Options:

Vertebrectomy of L5
Posterior spinal fusion with or without instrumentation from L4 to S1
Posterior spinal fusion without instrumentation from L5 to S1
Anterior spinal fusion from L4 to L5
Direct repair of the spondylolysis defect

Correct Answer: Posterior spinal fusion with or without instrumentation from L4 to S1

Explanation:

DISCUSSION: The patient has a grade 4 spondylolisthesis. Optimal surgical management is posterior spinal fusion from L4 to the sacrum. The use of instrumentation is controversial. Vertebrectomy is typically reserved for spondylo-optosis (grade 5) cases. Spinal fusion from
L5 to S1 usually is not successful for a slip that is greater than 50%. Isolated anterior spinal fusion has not been successful, and direct repair of the pars defect is only useful for spondylolysis without spondylolisthesis.
REFERENCES: Lenke LG, Bridwell KH: Evaluation and surgical treatment of high-grade isthmic dysplastic spondylolisthesis. Instr Course Lect 2003;52:525-532.
Ginsburg GM, Bassett GS: Back pain in children and adolescents: Evaluation and differential diagnosis. J Am Acad Orthop Surg 1997:5:67-78.

Question 64:

Use of long-term (at least 5 years) bisphosphonate medications for osteoporosis is associated with

Options:

- increased risk for atypical femoral fractures.
- increased risk for femoral neck fractures.
- decreased risk for proximal humerus and wrist fractures.
- decreased risk for mandible osteonecrosis.

Correct Answer: - increased risk for atypical femoral fractures.

Explanation:

DISCUSSION
Fragility or osteoporotic fractures are common in postmenopausal women and older men and include fractures of the proximal humerus and distal radius and hip and vertebral compression fractures. The most reliable predictor of a fragility fracture is a past fragility fracture; consequently, it is important to elicit history. Assessment of vitamin D and calcium levels is important when treating these patients because many of them have low levels.
Use of bisphosphonates for treatment of osteoporosis results in atypical femur fractures and a decrease in risk for fragility fractures (including hip fractures). There also are reports of osteonecrosis of the mandible with prolonged use of these drugs. Current medical literature suggests stopping these drugs after 3 to 5 years to allow bone remodeling.
RECOMMENDED READINGS
Shane E, Burr D, Ebeling PR, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster D, Einhorn TA, Genant HK, Geusens P, Klaushofer K, Koval K, Lane JM, McKiernan F, McKinney R, Ng A, Nieves J, O'Keefe R, Papapoulos S, Sen HT, van der Meulen MC, Weinstein RS, Whyte M; American Society for Bone and Mineral Research. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2010 Nov;25(11):2267-94. doi: 10.1002/jbmr.253. Erratum in: J Bone Miner Res. 2011 Aug;26(8):1987. PubMed PMID: 20842676.
View Abstract at
PubMed
Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster DW, Ebeling PR, Einhorn TA, Genant HK, Geusens P, Klaushofer K, Lane JM, McKiernan F,McKinney R, Ng A, Nieves J, O'Keefe R, Papapoulos S, Howe TS, van der Meulen MC, Weinstein RS, Whyte MP. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American society for bone and mineral research. J Bone
Miner Res. 2014 Jan;29(1):1-23. doi:10.1002/jbmr.1998. Epub 2013 Oct 1. PubMed PMID: 23712442.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 92 THROUGH 95
A 23-year-old man is involved in a motorcycle collision and sustains a displaced transcervical femoral neck fracture with an associated open comminuted femoral shaft fracture.

Question 65:

In the normal adult, the distance between the basion and the tip of the dens with the head in neutral position is how many millimeters?

Options:

2 to 3
4 to 5
6 to 7
7 to 8
9 to 10

Correct Answer: 4 to 5

Explanation:

Question 66:

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 67:

What is the most important feature in choosing an outcome instrument to assess shoulder disorders?

Options:

Ease of use
Validity
Ability to use it by mail or phone so the subject is not required to return in person to measure the outcome
Inclusion of radiographic assessment at follow-up
Scoring that is on a 100-point scale so that it can be compared with other instruments

Correct Answer: Validity

Explanation:

Question 68:

Options:

Immediately
After 30 minutes
After 24 hours
After 4 weeks
Next season

Correct Answer: After 4 weeks

Explanation:

Question 69:

Options:

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

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

Explanation:

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

Question 70:

Options:

Dominant shoulder
Age
Size of lesion
Periosteal stripping

Correct Answer: Age

Explanation:

Question 71:

Options:

Ewing’s sarcoma
Osteosarcoma
Rhabdomyosarcoma
Osteomyelitis
Malignant fibrous histiocytoma

Correct Answer: Osteosarcoma

Explanation:

DISCUSSION: The radiographs show a bone-producing lesion in the distal femoral metaphysis in this case of classic osteosarcoma presenting in the most common location, the distal femur. The coronal MRI scan reveals a marrow-occupying lesion with extension into the soft tissues. The histology shows osteoid production by pleomorphic cells consistent with an osteosarcoma. Ewing’s sarcoma is a bone tumor characterized by uniform small blue cells on histology. Rhabdomyosarcoma is the most common childhood soft-tissue sarcoma. Osteomyelitis has an inflammatory appearance on histology. Malignant fibrous histiocytoma of bone has a lytic radiographic appearance and a pleomorphic storiform pattern without osteoid on histology.
REFERENCES: Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 179.
McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 205.

Question 72:

Options:

Interphalangeal joint arthritis
Laceration of the flexor hallucis longus tendon
Sesamoid entrapment
Metatarsal malunion
Phalangeal malunion

Correct Answer: Laceration of the flexor hallucis longus tendon

Explanation:

Question 73:

Which of the following tendons is found in the same dorsal compartment of the wrist as the posterior interosseous nerve?

Options:

Extensor digiti minimi
Extensor carpi radialis brevis
Extensor pollicis longus
Extensor indicis proprius
Abductor pollicis longus

Correct Answer: Extensor indicis proprius

Explanation:

DISCUSSION: The terminal branch of the posterior interosseous nerve is contained in the fourth dorsal compartment. The contents of the various dorsal wrist compartments are as follows:
1
st
Compartment: Abductor pollicis longus, extensor pollis brevis
2
nd
Compartment: Extensor carpi radialis brevis, extensor carpi radialis longus
3
rd
Compartment: Extensor pollicis longus
4
th
Compartment: Extensor digitorum comminus, extensor indicus proprius, posterior interosseous nerve
5
th
Compartment: Extensor digiti minimi
6
th
Compartment: Extensor carpi ulnaris
The extensor indicis proprius is also contained in the fourth dorsal compartment. The extensor digiti minimi is located in the fifth dorsal compartment. The extensor carpi radialis brevis is located in the second dorsal compartment. The extensor pollicis longus is located in the third dorsal compartment, and the abductor pollicis longus is located in the first dorsal compartment.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 150-151.
Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System, Part 1: Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy Corporation, 1987, vol 8, p 60.

Question 74:

Options:

closed reduction and a double spica cast.
skeletal traction for 3 weeks, followed by a double spica cast.
reduction and internal fixation crossing the physis if necessary.
reduction and internal fixation with primary bone grafting.
skin traction.

Correct Answer: reduction and internal fixation crossing the physis if necessary.

Explanation:

Question 75:

Options:

excision of the radial head
ORIF of the radial head
continued splinting, no surgery
radial head arthroplasty
hinged external fixation

Correct Answer: excision of the radial head

Explanation:

Question 76:

- A 47-year-old woman who reports mild, aching pain in her knee has no history of trauma. Examination of the knee is normal. Figure 23a shows the AP radiograph. A bone scan shows increased uptake at this site only. Figure 23b shows the CT scan, and Figure 23c shows the histology from the CT scan-guided needle biopsy. Treatment should include

Options:

extended curettage and polymethylmethacrylate cementation
extra-articular resection of the knee and an allograft arthrodesis
wide resection of the proximal tibia and custom prosthetic replacement
prophylactic internal fixation and postoperative irradiation
excision of the lateral condyle and reconstruction with a hemicondylar allograft

Correct Answer: extended curettage and polymethylmethacrylate cementation

Explanation:

Question 77:

Options:

Loss of external rotation with the glenohumeral joint abducted 90 degrees
Loss of external rotation with the arm at the side of the body
Loss of internal rotation with the glenohumeral joint abducted 90 degrees
Loss of internal rotation up the back
Loss of flexion

Correct Answer: Loss of external rotation with the arm at the side of the body

Explanation:

Question 78:

Osteoarthritic cartilage is characterized by decreased

Options:

water content.
Synthesis of type I collagen.
Proteoglycan content.
Activity of chondrocytes.
Synthesis of hyaluronate.

Correct Answer: Proteoglycan content.

Explanation:

Question 79:

Options:

Increase medial femoral-tibial peak contact loads
Increase medial compartment contact area
Decrease in situ forces in the ACL graft
Decrease anterior tibial translation
Increase posterior tibial translation

Correct Answer: Increase medial femoral-tibial peak contact loads

Explanation:

Question 80:

Options:

Range of motion
Infraspinatus strength
Activity level
Quality of the subscapularis

Correct Answer: Quality of the subscapularis

Explanation:

Question 81:

When treating a stable 2-part intertrochanteric hip fracture with a sliding hip screw construct, what is the minimum amount of screw holes that are needed in the side plate for successful fixation?

Options:

One
Two
Three
Four
Five

Correct Answer: One

Explanation:

Question 82:

Which of the following genetic disorders has an X-linked recessive inheritance pattern?

Options:

Gaucher disease
Prader-Willi Syndrome
Diastrophic Dysplasia
Hemophilia A
Hypophosphatemic rickets

Correct Answer: Diastrophic Dysplasia

Explanation:

Question 83:

Following a partial muscle laceration, keeping the affected extremity immobilized for 2 weeks before starting an exercise program will likely lead to: Review Topic

Options:

Greater area of fibrous scar tissue than immediate mobilization
Less fatty infiltration than immediate mobilization
Atrophy limiting final functional outcome
Better penetration of ingrowing muscle fibers than a shorter period of immobilization
More uniform orientation of ingrowing muscle fibers than a shorter period of immobilization

Correct Answer: Better penetration of ingrowing muscle fibers than a shorter period of immobilization

Explanation:

Question 84:

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

Options:

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

Correct Answer: Radial nerve injury

Explanation:

Question 85:

Options:

surface irrigation, sterile dressing, and a short leg cast.
surface irrigation, sterile dressing, a short leg cast, and oral antibiotics.
surface irrigation, sterile dressing, a short leg cast, and IV antibiotics.
surgical debridement, a short leg cast, and IV antibiotics.
surgical debridement, external or internal fixation, and IV antibiotics.

Correct Answer: surgical debridement, external or internal fixation, and IV antibiotics.

Explanation:

DISCUSSION: The patient sustained a type I unstable fracture that requires debridement of superficial fragments from the sole and surgical stabilization. Low-velocity wounds less than 8 hours old are considered type I open fractures. In contrast, gunshot wounds with associated fractures more than 8 hours old are considered type II open fractures using the Gustilo and Anderson classification. Gustilo type I stable fractures due to gunshot wounds and seen within 8 hours can be treated with tetanus toxoid (if no history of immunization or booster within 5 years), surface irrigation, and casting or a hard sole shoe. Antibiotics are not required unless gross contamination is present. However, if the extent of contamination is unclear, or if a joint is penetrated, then routine antibiotic prophylaxis is recommended. Indications for surgery include: articular involvement, unstable fractures, presentation 8 or more hours after injury, tendon involvement, and superficial fragments in the palm or sole. Type I unstable fractures may be stabilized with internal or external fixation. Type II unstable fractures should be treated with external fixation and repeat debridements until clean.
REFERENCES: Holmes GB Jr: Gunshot wounds of the foot. Clin Orthop Relat Res
2003;408:86-91.
Bartlett CS, Helfet DL, Hausman MR, et al: Ballistics and gunshot wounds: Effects on musculoskeletal tissues. J Am Acad Orthop Surg 2000;8:21-36.

Question 86:

Options:

Similar incidence of postsurgical neck pain with higher risk for radiculopathy recurrence at the same level
Higher incidence of postsurgical neck pain and radiculopathy recurrence at the same level
Higher incidence of postsurgical neck pain and adjacent-level radiculopathy
Lower incidence of adjacent segment degeneration and postsurgical neck pain

Correct Answer: Higher incidence of postsurgical neck pain and radiculopathy recurrence at the same level

Explanation:

DISCUSSION
This patient has a right-sided C5-C6 disk herniation causing C6 radicular symptoms in the right upper extremity. Studies have shown that both ACDF and posterior foraminotomy confer similar results in terms of pain relief and functional outcome. Patients treated with posterior foraminotomy are at higher risk for neck pain and recurrence of radiculopathy at the same level. Those who receive ACDF are at higher risk for occurrence of radiculopathy at an adjacent level.
RECOMMENDED READINGS
Rao RD, Currier BL, Albert TJ, Bono CM, Marawar SV, Poelstra KA, Eck JC. Degenerative cervical spondylosis: clinical syndromes, pathogenesis, and management. J Bone Joint Surg Am. 2007 Jun;89(6):1360-78. Review. PubMed PMID: 17575617.
View Abstract at PubMed
Bolesta MJ, Gill K. Acute neck pain and cervical disk herniation. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:227-234.

Question 87:

Options:

A genetic problem
Repetitive activities involving an open proximal femoral physis
Early closure of the proximal femoral physis
Hip dysplasia

Correct Answer: Repetitive activities involving an open proximal femoral physis

Explanation:

Question 88:

When planning revision of a total hip arthroplasty where an acetabular reconstruction will be required, what prerequisite is important to ensure long-term success of a cementless component?

Options:

Absence of acetabular protrusio
Presence of posterior column
Presence of anterior column
Presence of at least 50% host bone
Presence of a segmental defect

Correct Answer: Presence of at least 50% host bone

Explanation:

Question 89:

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

Options:

C4
Upper trunk
Posterior cord
Lateral cord
Musculocutaneous nerve

Correct Answer: Upper trunk

Explanation:

Question 90:

The use of multiagent adjuvant chemotherapy is associated with a clear survival benefit in which of the following diseases?

Options:

Renal carcinoma
Osteosarcoma
Dedifferentiated chondrosarcoma
Adult soft-tissue sarcoma
Melanoma

Correct Answer: Osteosarcoma

Explanation:

Question 91:

Figure 36 shows the AP pelvic radiograph of a 26-month-old boy who has a limp. He has no significant medical history and no pain. What is the most appropriate treatment plan? Review Topic

Options:

Physical therapy
Application of a Pavlik harness
Arthrogram and closed reduction with spica casting under anesthesia
Femoral lengthening with a unilateral fixator
Open reduction with femoral shortening, capsulorrhaphy, and a spica cast

Correct Answer: Open reduction with femoral shortening, capsulorrhaphy, and a spica cast

Explanation:

The radiograph reveals a complete hip dislocation. A Pavlik harness is an accepted method of treatment for a dislocated hip up until 6 months of age. Closed reduction and spica casting with an arthrogram is often successful in young children up to 1-1/2 years to 2 years of age. Open reduction, capsulorrhaphy, and a spica cast is commonly recommended for younger children when attempts at closed reduction have failed or when the child is older than 2 years of age. A femoral shortening is also generally recommended in children older than 2 years of age in an attempt to reduce the muscle/compressive forces on the reduced hip.
(SBQ13PE.38) Pavlik harness treatment is appropriate for which of the following?:
Review Topic
4 year old with a diaphyseal femur fracture and a neuromuscular disorder with lower extremity spasticity
2 month old with a displaced spiral mid-diaphyseal femur fracture
9 month old with a diaphyseal femur fracture with <2cm shortening
9 month old with a diaphyseal femur fracture with >2cm shortening
4 year old with a diaphyseal femur fracture, closed head injury and chest trauma
Treatment with Pavlik harness or spica cast are options for patients <6 months of age with diaphyseal femur fractures. Pavlik harness provides adequate pain control for the short time required for healing in this age group. Significant remodeling potential can be expected.
Because of the significant remodeling and quick healing, treatment of diaphyseal femur fractures in children younger than 6 months focuses on providing comfort and avoiding complications. Spica casting likewise results in stable union without longterm sequelae but minor skin complications are more common and some favor Pavlik treatment in this age group.
Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. Their recommendation for diaphyseal femur fractures in children less than 6 months is Grade C, based on Level IV evidence (one retrospective comparative study and one case series). They recommend that Pavlik and spica casting are both acceptable treatment options in this age group.
Flynn et al. review the management of pediatric femoral shaft fractures. They recommend Pavlik treatment for children 6 months of age or less in preference to a spica cast, sometimes supplemented with a simple splint. This avoids the skin complications of spica casting.
Incorrect answers:

Question 92:

Options:

Inform the student that participation in sports is prohibited.
Order MRI of the shoulders to evaluate for labral tears.
Consider arthroscopic thermal capsulorraphy to tighten the shoulders.
Consider open capsular shift procedures to stabilize the shoulders.
Recommend a program of shoulder strengthening exercises and allow participation in sports.

Correct Answer: Recommend a program of shoulder strengthening exercises and allow participation in sports.

Explanation:

Question 93:

1 mg/L). Aspiration of the right knee reveals hazy yellow fluid with a white blood cell count of 120 and 1% neutrophils. No growth of organisms is seen on routine culture. What is the best next step?

Options:

Revision total knee arthroplasty with extensor mechanism allograft
Revision total knee arthroplasty with liner change and primary quadriceps repair
Resection knee arthroplasty and arthrodesis with antegrade nail
Two-stage revision total knee arthroplasty with extensor mechanism allograft

Correct Answer: Revision total knee arthroplasty with extensor mechanism allograft

Explanation:

Question 94:

The injection shown in Figures 1a and 1b would most benefit a patient who reports which of the following symptoms? Review Topic

Options:

Dorsal foot pain extending into the great toe
Foot pain extending along the lateral border of the foot
Pain extending into the foot in a stocking distribution
Anterior thigh and shin pain ending at the ankle
Lateral foot paresthesias

Correct Answer: Dorsal foot pain extending into the great toe

Explanation:

Question 95:

Which of the following represents a contraindication for interspinous process decompression for the treatment of lumbar spinal stenosis? Review Topic

Options:

Grade I degenerative spondylolisthesis
Inability to walk at least 100 feet
Cauda equina syndrome
Fixed sensory deficit
Intermittent foot drop

Correct Answer: Cauda equina syndrome

Explanation:

Question 96:

Options:

an aggressive program of stretching exercises.
soft-tissue release and subscapularis lengthening.
exchange of the modular humeral head to a smaller size, with glenoid arthroplasty.
revision of the humeral component, re-cutting of the humeral neck, soft-tissue releases, and glenoid arthroplasty.
glenohumeral arthrodesis.

Correct Answer: revision of the humeral component, re-cutting of the humeral neck, soft-tissue releases, and glenoid arthroplasty.

Explanation:

Question 97:

Options:

Elevated calcium level
Elevated PTH level
Elevated 1,25(OH)2D
Elevated phosphate level
Low alkaline phosphatase level

Correct Answer: Elevated PTH level

Explanation:

DISCUSSION: Celiac sprue results in rapid gastrointestinal transit and fatty stools that impair the absorption of calcium and vitamin D and result in nutritional-deficiency osteomalacia with secondary hyperparathyroidism. The radiographs show marked osteopenia with brown tumors. A pathologic fracture is seen in the proximal humerus through a large brown tumor. Serum findings include low or normal calcium, low phosphate, elevated alkaline phosphatase, low 1,25(OH)2D, and increased PTH levels. Secondary hyperparathyroidism is associated with a variety of conditions including malabsorption syndromes.
REFERENCES: Potts JT: Parathyroid hormone: Past and present. J Endocrinol 2005;187:311-325.
Corazza GR, Di Stefano M, Maurino E, et al: Bones in coeliac disease: Diagnosis and treatment. Best Pract Res Clin Gastroenterol 2005;19:453-465.
Mankin HJ, Mankin CJ: Metabolic bone disease: An update. Instr Course Lect 2003;52:769-784.

Question 98:

What is a common clinical finding in patients with severe hypercalcemia secondary to bony metastasis?

Options:

Atrial fibrillation
Seizures
Urinary retention
Muscle weakness
Hyperreflexia

Correct Answer: Muscle weakness

Explanation:

Question 99:

Options:

Percutaneous CT guided aspiration, hard cervical orthosis until bony union.
Percutaneous CT guided aspiration, hard cervical orthosis, repeat aspiration at 6-12 weeks followed by anterior corpectomy and fusion if repeat aspiration is sterile.
Anterior cervical debridement and anterior corpectomy without instrumentation
Posterior cervical debridement and instrumented posterior fusion.
Anterior cervical debridement, corpectomy and fusion followed by a posterior instrumented stabilization procedure

Correct Answer: Posterior cervical debridement and instrumented posterior fusion.

Explanation:

Question 100:

- Which of the following radiographic findings would be characteristic of the knee joints of a patient with neuropathic osteoarthropathy of the knee?

Options:

Fragmentation and subluxation of the normal joint articulation
Varus deformity with medial subchondral sclerosis
Preferential narrowing of the medial tibiofemoral compartment
Narrowing of the medial, lateral, and patellofemoral compartments
Bone proliferation at the patellar tendon and ligament insertion sites

Correct Answer: Fragmentation and subluxation of the normal joint articulation

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

OITE & ABOS Orthopedic Board Prep MCQs: Knee, Shoulder & Tumor Part 8

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 8

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index