Orthopedic Board Review MCQs: Knee & Shoulder | Part 82

About This Board Review Set

This is Part 82 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.

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Two distinct learning modes are available:

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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 82

This module focuses heavily on: Knee, Ligament, Nerve, Shoulder.

Sample Questions from This Set

Sample Question 1: In the anterior cruciate ligament-deficient knee, what structure provides an important secondary restraint to anterior tibial translation? Review Topic...

Sample Question 2: A 12-year-old boy who pitches on two “select” baseball teams has had pain in his dominant right shoulder for the past 6 weeks. The pain is present only with throwing and is associated with decreased throwing velocity and control. He has no ...

Sample Question 3: A patient reports changes in vocal quality after undergoing a right-sided anterior cervical approach to C6. Which of the following nerves has most likely been injured?...

Sample Question 4: A patient with a previously pain-free knee replacement now reports a sudden inability to ambulate. Radiographs of the knee are shown in Figures 33a and 33b. Management should consist of...

Sample Question 5: Which of the following statements about hoarseness due to vocal cord paralysis after anterior cervical diskectomy and fusion is most accurate?...

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

In the anterior cruciate ligament-deficient knee, what structure provides an important secondary restraint to anterior tibial translation? Review Topic

Explanation

Cadaveric studies have demonstrated the important role of the posterior horn of the medial meniscus in stabilizing the anterior cruciate ligament-deficient knee with significantly greater resultant force in the medial meniscus when subjected to anterior tibial loads. The posterior horn of the medial meniscus is thought to limit anterior tibial translation by acting as a buttress by wedging against the posterior aspect of the medial femoral condyle. The other soft tissues mentioned do not play any significant role in prevention of anterior tibial translation in the anterior cruciate ligament-deficient knee.

Question 2

A 12-year-old boy who pitches on two “select” baseball teams has had pain in his dominant right shoulder for the past 6 weeks. The pain is present only with throwing and is associated with decreased throwing velocity and control. He has no radiation of pain or paraesthesias of the upper extremity. An AP radiograph and MRI scan are shown in Figures 19a and 19b, respectively. Management should consist of Review Topic

Explanation

The imaging study demonstrates characteristics of Little Leaguer’s shoulder, including physeal widening. This condition is secondary to overuse (typically throwing) and responds well to rest from the inciting activity. There is no evidence from the patient’s history or examination that he has an impingement syndrome, nor is there any indication of labral pathology on the MRI scan. The changes in the proximal humerus are classic for this condition and are not suggestive of a neoplastic process requiring biopsy for definitive diagnosis.

Question 3

A patient reports changes in vocal quality after undergoing a right-sided anterior cervical approach to C6. Which of the following nerves has most likely been injured?

Explanation

Discussion: Generally, a left sided approach to the anterior cervical region is preferred because of the more constant anatomy of the recurrent laryngeal nerve, which results in changes in vocal quality.

Question 4

A patient with a previously pain-free knee replacement now reports a sudden inability to ambulate. Radiographs of the knee are shown in Figures 33a and 33b. Management should consist of

Explanation

DISCUSSION: The radiographs show a patellar tendon rupture following a total knee replacement. This infrequent, but serious, complication is reported to occur in 0.17% to 1.4% of patients after total knee arthroplasty. Although the radiographs show concerning features such as incomplete tibial and femoral periprosthetic lucencies, it is most important for the surgeon to recognize extensor mechanism disruption.
REFERENCES: Insall J, Salvati E: Patella position in the normal knee joint. Radiology 1971;101:101-104.
Lynch AF, Rorabeck CH, Bourne RB: Extensor mechanism complications following total knee arthroplasty. J Arthroplasty 1987;2:135-140.
Rand JA, Morrey BF, Bryan RS: Patellar tendon rupture after total knee arthroplasty. Clin Orthop 1989;244:233-238.

Question 5

Which of the following statements about hoarseness due to vocal cord paralysis after anterior cervical diskectomy and fusion is most accurate?

Explanation

DISCUSSION: It has been traditionally taught that a left-sided approach to the anterior cervical spine is associated with a lower incidence of injury compared to the right-sided approach. This is due in part to the anatomic differences in the path the recurrent laryngeal nerve (RLN) takes on the right as compared to the left. Both nerves ascend in the tracheoesophageal groove after branching off the vagus nerve in the upper thorax. The left-sided RLN loops around the aortic arch and stays relatively medial as compared to the right-sided RLN which loops around the right subclavian artery and is somewhat more lateral at this point, and therefore is theoretically more vulnerable as it ascends toward the larynx before becoming protected in the tracheoesophageal groove. Furthermore, the variant of a nonrecurrent inferior laryngeal nerve branching directly off the vagus nerve at the level of the midcervical spine is much more common on the right than the left. Despite this reasoning, there has been no clinical evidence to suggest that laterality of approach for anterior cervical surgery makes any difference in the incidence of vocal cord paralysis. Furthermore, two recent studies have shown that the incidence of RLN injury and vocal cord paralysis is equal with either side of approach.
REFERENCES: Beutler WJ, Sweeney CA, Connolly PJ: Recurrent laryngeal nerve injury with anterior cervical spine surgery risk with laterality of surgical approach. Spine 2001;26:1337-1342.
Kilburg C, Sullivan HG, Mathiason MA: Effect of approach side during anterior cervical discectomy and fusion on the incidence of recurrent laryngeal nerve injury. J Neurosurg Spine 2006;4:273-277.

Question 6

A 25-year-old patient undergoes the procedure seen in Figure A. Which of the following statements best describes the incorporation of the graft and biopsy results of the graft at one year? Review Topic

Explanation

The patient underwent an osteochondral autograft transfer (OAT) with multiple plugs (also known as mosaicplasty) for a full-thickness chondral defect of the medial femoral condyle. The chondrocytes in the graft remain viable, the transferred cartilage heals, and biopsy reveals articular cartilage composed primarily of type II collagen.
Articular cartilage defects can be treated by a variety of methods including debridement, fixation of unstable osteochondral fragments, marrow stimulation techniques (microfracture, abrasion chondroplasty), cartilage replacement techniques (osteochondral autograft and allograft) and cellular techniques (autologous chondrocyte implantation). Osteochondral autograft transfer is performed by harvesting normal articular cartilage with underlying bone from lesser weightbearing areas (e.g. intercondylar notch) and transferring the graft to a recipient socket at the site of the chondral defect. Graft incorporation occurs by integration of the bony graft into the subchondral bone and healing of the overlying cartilage layer.
Hangody et al. reviewed the outcomes of autologous osteochondral mosaicplasty in professional athletes. They found successful outcomes similar to that of less athletic patients, despite a higher rate of preoperative osteoarthritic changes in the athletic population. The authors noted that histological evaluation revealed good graft incorporation in all 11 cases.
Alford et al. authored a two part Current Concepts article on cartilage restoration. They constructed an algorithm (Illustration A) highlighting many factors that impact treatment choice, including patient activity level and defect characteristics such as location and size. This algorithm also illustrates comorbidities (malalignment, ligament insufficiency) that warrant correction prior to addressing the chondral defect.
Figure A shows a full-thickness chondral defect (left) and subsequent osteochondral autograft transfer (right). Illustration A is a treatment algorithm for the management of chondral defects, as discussed above. Illustration B shows a microfracture procedure, a marrow stimulation technique resulting in fibrocartilage filling of the chondral defect. Illustration C shows an osteochondral allograft transplant, a cartilage replacement technique useful for large defects in which donor graft is obtained from a cadaver hemicondyle and transferred to a recipient socket at the site of the chondral defect. Illustration D shows the autologous chondrocyte implantation technique, a two-stage procedure consisting of 1. Cartilage biopsy for growth of autologous
chondrocytes, and 2. Subsequent injection of autologous chondrocytes beneath a periosteal patch.
Incorrect

Question 7

The mother of a 5-year-old child reports that he has had a fever of 103°F (39.4°C), leg swelling, and has been unwilling to bear weight on his right lower leg for the past 7 days. Examination reveals point tenderness at the distal femur. Aspiration at the metaphysis yields 10 mL of purulent fluid, and a Gram stain reveals gram-positive cocci. In addition to hospital admission, management should include

Explanation

DISCUSSION: The patient has a subperiosteal abscess. Because aspiration revealed 10 mL of purulent fluid, the treatment of choice is surgical incision and drainage of the abscess, followed by immobilization to reduce the risk of pathologic fracture. With an adequate response to IV antibiotics and a susceptible bacteria, the patient may then be switched to oral antibiotics.
REFERENCE: Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1996, pp 149-161.

Question 8

Figure 35 shows the radiograph of a 12-year-old boy who fell off a snowmobile and landed on his left shoulder. He has a closed injury. Management should consist of

Explanation

DISCUSSION: Proximal humeral fractures in children are classified as metaphyseal or Salter-Harris type I or II fractures, and most of these fractures are treated with closed methods. Eighty percent of the growth of the humerus comes from the proximal physis; therefore, tremendous remodeling potential is present. Indications for open reduction include open fractures or severely displaced fractures in adolescents with minimal growth remaining. Acceptable limits of reduction in adolescent proximal humeral fractures include bayonet apposition and angulation of less than 35°. Common blocks to reduction in adolescents include the biceps tendon and periosteum. For this fracture, use of a shoulder sling without reduction will lead to healing and an excellent result as the proximal humerus remodels.
REFERENCES: Kohler R, Trillaud JM: Fracture and fracture separation of the proximal humerus in children: Report of 136 cases. J Pediatr Orthop 1983;3:326-332.
Beaty JH: Fractures of the proximal humerus and shaft in children. Instr Course Lect 1992;41:369-372.
Dobbs MB, Luhmann SL, Gordon JE, et al: Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop 2003;23:208-215.
Beringer DC, Weiner DS, Noble JS, et al: Severely displaced proximal humeral epiphyseal fractures: A follow-up study. J Pediatr Orthop 1998;18:31-37.
Wang P Jr, Koval KJ, Lehman W, et al: Salter-Harris type III fracture-dislocation of the proximal humerus. J Pediatr Orthop B 1997;6:219-222.

Question 9

A patient who underwent a total knee arthroplasty (TKA) 4 years ago reports acute knee pain 2 days following dental surgery. Knee joint aspiration demonstrates 40000 white blood cells/µL with 90% neutrophils. An aspirate culture grows peptostreptococcus. Treatment should consist of

Explanation

DISCUSSION
This patient has an acute hematogenous infection of a TKA. Irrigation, debridement, polyethylene liner exchange, and IV antibiotics remain the treatments of choice. However, failure of this approach has been reported in 20% to 60% of cases in various series, particularly when methicillin-resistant streptococcus aureus or methicillin-resistant streptococcus epidermis is isolated.

Question 10

The transverse diameter of the pedicle is most narrow at which of the following levels?

Explanation

DISCUSSION: Of the levels given, T5 has the most narrow pedicle in anatomic studies. One study in patients with scoliosis did note that T7 on the concave side was more narrow than T5, but T7 is not listed here as a possible answer.
REFERENCES: O’Brien MF, Lenke LG, Mardjetko S, et al: Pedicle morphology in thoracic adolescent idiopathic scoliosis: Is pedicle fixation an anatomically viable technique? Spine 2000;25:2285-2293.
Vaccaro AR, Rizzolo SJ, Allardyce TJ, et al: Placement of pedicle screws in the thoracic spine: Part I. Morphometric analysis of the thoracic vertebrae. J Bone Joint Surg Am

1995;77:1193-1199.

Question 11

A 6-year-old boy has had increasing pain and a mass in the suprapatellar region of the right femur for the past week. Examination of the mass reveals it may be firm, immobile, and tender to palpitation. The patient has no systemic symptoms. Laboratory studies show a WBC of 7000 per cubic millimeter, a hematocrit of 40%, and an erythrocyte sedimentation rate of 10 mm/hr. radiographs are normal. Figures 64a and 64b show saggital and axial T1-weighted MRI scans. Figure 64c shows frozen section pathology of the biopsy specimen. What is the most likely diagnosis?

Explanation

Multiple hints in this history, MRI and pathology section leads to the diagnosis of soft tissue abscess. The sarcomas are slow growing and mostly are asymptomatic. The mass is tender and enlarging over the past week. PVNS would give the patient a painful boggy joint and this mass is supracondyler. Esinophilic granuloma would give a punched-out lesion in the long bones on the plain radiographs. The best clue is the slide given which shows inflammatory cells. PVNS would show hemosiderin stained giant cells, synovial sarcoma would reveal a biphasic pattern of spindle cells, E.G. would show eosinophils and histiocytes, and rhabdomyosarcoma would have cross striation within the tumor cells.

Question 12

In regards to a genetic disorder, which of the following is an example of "anticipation?"

Explanation

Genetic anticipation is a phenomenon in which a genetic disorder becomes progressively more severe and earlier in onset with each generation. Examples of disorders exhibiting anticipation include Huntington's disease and myotonic dystrophy.
Genetic anticipation is an important concept in understanding the development and genetic implications of many heritable disorders. It is a common phenomenon in trinucleotide repeat expansion disorders. These disorders are due to unstable microsatellite trinucleotide repeats that expand beyond the normal threshold. In subsequent generations these expansions become longer and thus express disease characteristics at a younger age of onset, and often with greater severity.
Martorell et al. investigated the development of CTG trinucleotide repeats in patients with myotonic dystrophy type 1 (DM1) and their relatives. They discovered unaffected individuals carry a pre-mutation sequence which can lead to trinucleotide repeat expansion in subsequent generations and thus produce offspring with the disorder.
Kamsteeg et al. compare the characteristics of DM1 and DM2. Both are due to trinucleotide repeat expansions. However, while DM1 can present with earlier onset and increasing severity in each generation, DM2 does not exhibit this genetic anticipation.
Incorrect Answers

Question 13

An 18-year-old boy reports increasing pain with weight bearing on his right leg and at night. Examination reveals swelling around the right midcalf. Radiographs and an MRI scan are shown in Figures 13a through 13c, and a biopsy specimen is shown in Figure 13d. What is the preferred treatment?

Explanation

DISCUSSION: The findings are consistent with Ewing’s sarcoma. The radiographs reveal a lytic lesion in the diaphysis of the right fibula. There is elevation of the periosteum and evidence of a surrounding soft-tissue mass. The biopsy specimen shows diffuse small round blue cells surrounding the lamellar bone. It is the second most common malignant bone tumor in children. The most common treatment regimen consists of chemotherapy followed by surgical resection and/or radiation therapy. Surgical resection is employed when the lesion can be removed with wide margins and causes less morbidity than radiation therapy.
REFERENCES: McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 258.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

Question 14

Histologic studies of surgically resected tissue in lateral epicondylitis demonstrate which of the following findings? Review Topic

Explanation

The extensor carpi radialis brevis is most often cited as the anatomic location of pathology in lateral epicondylitis. Histologic examination demonstrates noninflammatory tissue, primarily angiofibroblastic tendinosis though normal tendon histology is also present. There is usually no evidence of acute inflammation or chondroblastic tissue, or significant calcium deposition.

Question 15

Figures 1 and 2 show the radiographs obtained from a 68-year-old morbidly obese man who underwent left total hip replacement 7 years ago and did well, with no symptoms prior to the current presentation. He recently rose from a seated position and felt a pop in the hip, with immediate pain and inability to bear weight. Any pressure on the left foot now produces a painful, grinding sensation with loss of left hip stability. What is the best next step?

Explanation

DISCUSSION:
The modular femoral stem has fractured. Changing the liner to a constrained design is not warranted at this time based on the information provided. Revision of the acetabular implant is appropriate because of the potential for damage to the existing cup from metal debris and femoral implant contact and to convert from a metal-on-metal articulation. Nonsurgical management would not provide pain relief or improvement; revision of the total hip arthroplasty is recommended. The implant failed in a short time, and retention of the femoral stem is not recommended because of the concern for failure with only a neck exchange. A dual-mobility bearing may be a good option if the surgeon plans to retain the acetabular component. Extended trochanteric osteotomy is a useful technique for the removal of a well-fixed femoral implant. In this patient, femoral stem removal without
osteotomy would be difficult due to the fracture of the implant’s femoral neck and the inability to gain purchase for extraction.

Question 16

A 48-year-old man who is scheduled to undergo total knee replacement has an X-linked clotting disorder that leads to abnormal bleeding and recurrent, spontaneous hemarthrosis. Before undergoing surgery, he should have replacement therapy of

Explanation

Hemophilia A is an X-linked recessive deficiency of factor VIII that can lead to significant bleeding problems including recurrent spontaneous hemarthroses that can lead to synovitis and joint destruction. von Willebrand disease is a lack of von Willebrand factor that leads to decreased platelet aggregation; more commonly patients have mucosal bleeding and not hemarthroses. Vitamin K deficiency is not hereditary; it is typically attributable to inadequate dietary intake, malabsorption, and loss of storage sites from hepatocellular disease. Protein C and S deficiencies are autosomal-dominant diseases that lead to thrombosis, not bleeding, as protein C and S shut off thrombin formation.

Question 17

What is the main function of collagen found within articular cartilage?

Explanation

DISCUSSION: The main function of collagen in articular cartilage is to provide the tissue’s tensile strength. It also immobilizes proteoglycans within the extracellular matrix. Compressive properties are maintained by proteoglycans. Cartilage metabolism is maintained by the indwelling chondrocytes. The flow of water through the tissue promotes transport of nutrients and provides a source of lubricant for the joint.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 3-44.
Mow VC, Ratcliffe A: Structure and function of articular cartilage and meniscus, in Mow VC, Hayes WC (eds): Basic Orthopaedic Biomechanics, ed 2. Philadelphia, PA, Lippincott-Raven, 1997, pp 113-177.

Question 18

40A B Figures 40a and 40b are this patient's intraoperative arthroscopic images. The abnormality seen here illustrates which of the patient's clinical findings?

Explanation

DISCUSSION
Ankle sprains are the most common musculoskeletal injury; however, most of these sprains do not progress to chronic instability. Initial injuries are treated with RICE (rest, ice, compression, elevation), range of motion, weight bearing
as tolerated, and proprioceptive therapy. Lace-up ankle braces are most effective during the subacute period after a sprain. Structured physical therapy focused on proprioception is recommended for 6 weeks. Examination findings for ankle ligament instability are unreliable because of associated subtalar joint motion. Casting is not as effective as functional rehabilitation. Stress radiographs are recommended, but a clear pathologic range of measurements is not defined. Generalized ligament laxity can result in false-positive findings of instability; therefore, contralateral stress radiographs are often necessary for comparison. The difference in anterior drawer measurement between both ankles should not exceed 5mm. Likewise, the difference in talar tilt measurement between both ankles should be 5 or fewer degrees. Patients with mechanical symptoms, a joint effusion, or continued pain may have an intra-articular pathology such as a loose body or osteochondral lesion. Ankle instability can exist without ligamentous laxity. Symptoms of chronic instability can result from osteochondral lesions of talus, peroneal tendon pathology, loose bodies, anterior ankle impingement, and fracture nonunions. Although there is not sufficient evidence to recommend arthroscopy prior to all ligament reconstructions, arthroscopy is recommended when other pathology is suspected.
RECOMMENDED READINGS
Colville MR. Surgical treatment of the unstable ankle. J Am Acad Orthop Surg. 1998 Nov-Dec;6(6):368-77. Review. PubMed PMID: 9826420. View Abstract at PubMed
DiGiovanni CW, Brodsky A. Current concepts: lateral ankle instability. Foot Ankle Int. 2006 Oct;27(10):854-66. Review. PubMed PMID: 17054892. View Abstract at PubMed
Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. 2008 Oct;16(10):608-15. Review. PubMed PMID: 18832604. View Abstract at PubMed

Question 19

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

Explanation

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

Question 20

A 67-year-old woman has persistent anterior thigh and knee pain after undergoing total knee arthroplasty 1 year ago. Examination and radiographs reveal no problems in the knee, mild hip flexor weakness (grade 4+), and decreased sensation over the anterior thigh including and proximal to the incision. MRI of the lumbar spine will most likely reveal which of the following findings?

Explanation

DISCUSSION: Degenerative spondylolisthesis at L3-4 is the most likely diagnosis. This spondylolisthesis would result in foraminal stenosis affecting the third lumbar root and leading to anterior thigh and knee pain and hip flexor weakness. L4-5 spondylolisthesis would impinge on the L4 root in the foramen. Degenerative disk disease without hypertrophy is unlikely to have root impingement. Posterolateral herniations typically affect the inferior root and are less common in this age group.
REFERENCES: Hoppenfeld S: Physical Examination of the Spine and Extremities. Upper Saddle River, NJ, Prentice Hall, 1976, p 250.
Lauerman WC, Goldsmith ME: Spine, in Miller MD (ed): Review of Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 353-378.

Question 21

Smoking has been associated with lower fusion rates in both cervical and lumbar fusion. Which of the following statements best describes an explanation for these findings?

Explanation

Tobacco smoking is now the leading avoidable cause of morbidity and mortality in the United States. The musculoskeletal effects of smoking have been implicated in osteoporosis, low back pain, degenerative disk disease, poor wound healing, and delayed fusion and fracture healing. A number of studies have demonstrated the relationship between smoking and development of pseudarthrosis. Numerous studies
have been performed to offer an explanation of the mechanism mediating this effect. Whereas all of the above have been postulated as explanations, more recent studies have demonstrated that nicotine delivered via a transdermal patch significantly enhanced posterior spinal fusion in rabbits. Thus it appears that the effects of smoking on fracture healing are multifactorial and not yet fully understood.

Question 22

Limited weight bearing usually is recommended following open reduction and internal fixation of intra-articular lower extremity fractures. A bone graft, or bone graft substitute is often placed in the metaphyseal void beneath the reduced articular fragments. Which of the following bone grafts or bone graft substitutes will most likely permit earlier weight bearing without subsidence of the articular reduction?

Explanation

Most bone graft substitutes have a low compressive strength, similar to cancellous bone. Calcium phosphate cements, when hardened, have a much higher compressive strength compared to any of the other bone grafts or bone graft substitutes. In a study of 26 patients undergoing open reduction and internal fixation of displaced tibial plateau fractures, calcium phosphate was found to produce good outcomes. Because of the high mechanical strength of the cement, the authors allowed early weight bearing after a mean postoperative period of 4.5 weeks, with a range from 1 to 6 weeks. Despite early weight bearing, only two patients in this series had a partial loss of reduction. In biomechanical studies of displaced tibial plateau fractures, calcium phosphate compared favorably to cancellous bone graft. In one clinical series of patients undergoing open reduction and internal fixation for a calcaneus fracture, those patients whose reductions were supported with calcium phosphate were allowed to begin full weight bearing at 3 weeks and displayed no radiographic evidence of reduction loss. The effectiveness of calcium phosphate to resist deformation with cyclical loading in simulated calcaneal fractures has been confirmed in a biomechanical study.

Question 23

The direct anterior (Smith-Peterson) approach to hip arthroplasty is most commonly associated with injury to what nerve?

Explanation

DISCUSSION:
Some authors have reported the incidence of lateral femoral cutaneous nerve neuropraxia following hip arthroplasty with the direct anterior approach to be near 80%, but resolution of the sensory deficits has been observed in most patients over time. Femoral nerve palsy has been reported to occur in .64% to 2.3% direct lateral (Hardinge) and anterolateral (Watson-Jones) approaches, and the superior gluteal nerve may be injured with proximal extension of the abductor muscular dissection. The posterior approach has been reported to be associated with sciatic nerve injury, especially in cases of dysplasia. Pudendal nerve injury has not been reported with the anterior, anterolateral, direct lateral, or posterior approaches to hip
arthroplasty. It has been reported following hip arthroscopy and the use of a traction table, however.

Question 24

A 7-year-old girl sustains the fracture shown in Figure 29a. Casting results in uneventful healing. Ten months later, the patient has a progressive valgus deformity of the right lower extremity. A radiograph is shown in Figure 29b. Management should now consist of

Explanation

DISCUSSION: Although fractures of the proximal tibial metaphysis in young children appear innocuous, development of a progressive valgus deformity is possible despite adequate and appropriate treatment. When treating a child with this injury, it is prudent to warn the parents that a valgus deformity of the tibia may develop. The most likely cause is asymmetric growth of the proximal tibial physis. Because spontaneous angular improvement can be expected in most patients, surgery to correct these deformities should be delayed at least 2 to 3 years and should be limited to patients who have symptoms. There are no studies that document the efficacy of bracing for this deformity.
REFERENCES: Tuten HR, Keeler KA, Gabos PG, et al: Posttraumatic tibia valga in children: A long-term follow-up note. J Bone Joint Surg Am 1999;81:799-810.
McCarthy JJ, Kim DH, Eilert RE: Posttraumatic genu valgum: Operative versus nonoperative treatment. J Pediatr Orthop 1998;18:518-521.

Question 25

A 15-year-old boy with a type I hereditary sensory motor neuropathy (Charcot-Marie-Tooth disease) reports recurrent ankle sprains and significant pain in the hindfoot and midfoot despite orthotic management. Examination reveals that he walks with a drop foot and has dynamic clawing of the toes. Clinical photographs of the left foot are shown in Figure 7. Management should consist of

Explanation

DISCUSSION: The clinical photographs show a patient with a type I hereditary sensory motor neuropathy who has cavus feet with a flexible hindfoot. The Coleman block test shows that the hindfoot corrects into valgus. To prevent progressive cavus, patients with this condition may benefit from soft-tissue releases at a younger age while the foot is flexible. Once there is fixed deformity, combined soft-tissue and bone procedures usually are necessary. Metatarsal osteotomies will correct the cavus, but will do nothing for the drop foot. Transfer of the extensor hallucis longus to the neck of the first metatarsal and modified transfer of the extensor digitorum longus to the dorsum of the foot will prevent further claw toes and improve foot dorsiflexion. Anterior transfer of the posterior tibialis tendon will also aid in dorsiflexion. Calcaneal osteotomy should be reserved for fixed hindfoot varus that does not correct with block testing, and triple arthrodesis should be avoided as long as possible because the long-term outcome is poor.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1999, pp 235-245.
Coleman SS: Complex Foot Deformities in Children. Philadelphia, Pa, Lea & Febiger, 1983, pp 147-165.
Thometz JG, Gould JS: Cavus deformity, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992, pp 343-353.

Question 26

An 18-year old man has a simple oblique fracture of the humeral shaft that requires surgical stabilization to maintain reduction and facilitate mobilization. Which of the following methods will provide the best outcome?

Explanation

DISCUSSION: The patient has a simple fracture pattern that can be reduced anatomically and stabilized with absolute stability by interfragmental compression and protection plating. This will guarantee a 95% to 98% union rate with no radial nerve palsy. Intramedullary nailing does not equal these results in a simple fracture pattern in the humerus. Bridge plating is indicated for multifragmented fracture patterns when anatomic reduction and absolute stability cannot be achieved. External fixation is reserved for severe open fractures.
REFERENCES: Chapman JR, Henley MP, Agel J, Benca PJ: Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-166.
Farragos AF, Schemitsch EH, McKee MD: Complications of intramedullary nailing for fractures of the humeral shaft: A review. J Orthop Trauma 1999;13:258-267.
Modabber M, Jupiter JB: Operative management of diaphyseal fractures of the humerus: Plate versus nail. Clin Orthop 1998;347:93-104.

Question 27

Compared to metal-on-polyethylene total hip bearing surfaces, the debris particles generated by metal-on-metal articulations are

Explanation

DISCUSSION: Retrieval studies have shown that the debris particles produced by

metal-on-metal articulations in total hip arthroplasty are several orders of magnitude smaller

and may be up to 100 times more numerous than those found with metal-on-polyethylene articulations.
REFERENCES: Davies AP, Willert HG, Campbell PA, et al: An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements.

J Bone Joint Surg Am 2005;87:18-27.
Firkins PJ, Tipper JL, Saadatzadeh MR, et al: Quantitative analysis of wear and wear debris from metal-on-metal hip prostheses tested in a physiological hip joint simulator. Biomed Mater Eng 2001;11:143-157.

Question 28

A 24-year-old avid volleyball player has noted gradual onset of shoulder fatigue and weakness limiting his game. Radiographs done by his primary care physician were normal and he has failed to improve with 6 weeks of physical therapy. Given the MRI image shown in Figure A, this patients physical exam may reveal weakness with which of the following actions? Review Topic

Explanation

The MRI demonstrates of a ganglion cyst within the suprascapular notch, leading to atrophy of both the supraspinatus and infraspinatus. Thus, the patient would have weakness with both abduction and external rotation.
Extrinsic compression or traction on the suprascapular nerve can result in suprascapular neuropathy. Compression of the nerve may occur at two distinct locations: the suprascapular notch and the spinoglenoid notch. Extrinsic compression of the suprascapular nerve by ganglion cysts can occur at the spinoglenoid notch or, less commonly, at the suprascapular notch. These cysts may originate from the transverse scapular ligament, the fibrous tissue of the scapula, or the glenohumeral joint.
Mittal et al. reviewed the literature and found that the formation of ganglionic cysts in the spinoglenoid fossa occurs with cumulative trauma and leads to entrapment neuropathy of the suprascapular nerve and denervation of the infraspinatus muscle.
Romeo et al. reported on various etiologies of suprascapular neuropathy including traction injury at the level of the transverse scapular ligament or the spinoglenoid ligament and direct trauma to the nerve. They noted that sports involving overhead motion, such as tennis, swimming, and weight lifting, may result in traction injury to the suprascapular nerve, leading to dysfunction. They also reported that the onset of weakness can be subtle and must be differentiated from cervical radiculopathy and degenerative disease of the shoulder.
Figure A depicts a T2 coronal MRI of the shoulder with a cyst easily visualized occupying the suprascapular notch. Illustration A is an algorithm for the management of suprascapular neuropathy. Illustration B is a sagittal MRI from the same patient depicting the ganglion cyst within the suprascapular notch once again leading to atrophy of both the supraspinatus and infraspinatus (asterisks).
Incorrect Answers:

Question 29

A 47-year-old landscaper presents with worsening left shoulder pain and weakness. Three years ago, he injured the left shoulder in a fall and elected for nonoperative management to minimize time off from work. Physical therapy was effective until 6 months ago when his shoulder function worsened to the point that he is now unable to work. Examination of his active range of motion reveals forward elevation 120° with pain, abduction 100°, IR at neutral to T8 and ER at neutral 5°. He has a positive ER lag sign and Hornblower's sign. Belly press and lift-off tests are normal. A recent radiograph is shown in Figures A. MRI images are shown in Figures B and C. Which of the following is the best treatment option? Review Topic

Explanation

This patient has a chronic massive posterosuperior rotator cuff tear with marked atrophy, tendon retraction and loss of external rotation strength that is impacting his daily life. The best treatment option for this middle-aged laborer with an irreparable posterosuperior rotator cuff tear is a latissimus dorsi transfer to restore external rotation strength and motion.
Irreparable rotator cuff tears are marked by: (1) Superior displacement of the humeral head (AHI < 5-7mm), (2) Fatty infiltration of the rotator cuff muscles (Goutallier stage 3-4), (3) Increased duration of the tendon tear and (4) Profound external rotation weakness. These findings are predictive of poor-quality tissue and stiffness of the muscle-tendon unit, not amenable to primary repair. In this setting, a latissimus dorsi
transfer can be utilized to restore shoulder strength, function and improve pain. Relative contraindications include subscapularis deficiency, deltoid deficiency, pseudoparalysis of the shoulder and advanced glenohumeral arthritis.
Gerber et al. performed a case series analysis of 67 patients with irreparable rotator cuff tears managed with latissimus dorsi transfer. Patients with an intact subscapularis demonstrated improvement in pain, range of motion and strength postoperatively, while no improvement was noted in patients with subscapularis deficiency. The authors conclude that latissimus dorsi transfer should not be performed in the setting of poor subscapularis function.
Iannotti et al. found that better clinical results following latissimus dorsi transfer were associated with: preserved active shoulder range of motion and strength (specifically forward elevation > 90° and external rotation > 20°), synchronous firing of the transferred latissimus dorsi muscle and male gender.
Figure A is an AP radiograph of the left shoulder with superior migration of the humeral head (AHI < 5mm) and no evidence of glenohumeral arthritis. Figures B and C show a retracted posterosuperior rotator cuff tear and Goutallier stage 4 atrophy (more fat than muscle) of the supraspinatus, infraspinatus and teres minor, rendering this tear irreparable. Illustration A shows a latissimus dorsi transfer. The latissimus dorsi tendon is positioned over the top of the humeral head, covering most of the rotator cuff defect. The tendon is then secured to the subscapularis tendon edge and lesser tuberosity anteriorly, the remnant supraspinatus and infraspinatus tendons medially, and the greater tuberosity laterally.
Incorrect Answers:

Question 30

An 83-year-old woman reports pain in her left middle finger after a minor injury. Laboratory studies show a WBC count of 7,000/mm 3 , an erythrocyte sedimentation rate of 3 mm/h, a uric acid of 10.4 mg/dL, and a normal serum protein electrophoresis. Radiographs are shown in Figures 49a and 49b. A core biopsy specimen is shown is Figure 49c. In addition to treatment of the finger fracture, treatment should include

Explanation

DISCUSSION: This clinical picture is most consistent with periarticular erosions from gout. The patient has multiple periarticular lytic lesions in the hand. The laboratory studies show an elevated serum uric acid level, and the biopsy specimen demonstrates acute and chronic inflammation with prominent clefts. Therefore, the preferred treatment is systemic control of her gout. Radiation therapy, chemotherapy, and/or amputation should be considered for a malignancy; however, the pathology does not demonstrate any evidence of pleomorphism, high nuclear-to-cytoplasmic ratio, nuclear atypia, or mitotic activity. Antibiotics for an infectious process is a consideration, but the minimal elevation in the WBC count and erythrocyte sedimentation rate does not support an infectious process.
REFERENCES: Wise CM: Crystal-associated arthritis in the elderly. Clin Geriatr Med 2005;21:491-511.
Mudgal CS: Management of tophaceous gout of the distal interphalangeal joint. J Hand Surg Br 2006;31:101-103.

Question 31

What arterial vessel is most prone to injury during posterior iliac crest bone graft harvest?

Explanation

DISCUSSION: The superior gluteal artery is most at risk with a posterior iliac crest bone graft harvest. The artery leaves the pelvis through the sciatic notch and can be injured by retractors or other sharp instruments entering the sciatic notch area. The deep circumflex iliac, iliolumbar, and fourth lumbar arteries supply the iliacus and iliopsoas muscles and can be damaged during anterior bone graft harvest. The ascending branch of the lateral femoral circumflex artery is at risk during the anterior approach to the hip.
REFERENCES: Guyer RD, Delmarter RB, Fulp T, Small SD: Complications of cervical spine surgery, in Herkowitz HN, Garfin SR, Balderston RA, Eismont FJ, Bell GR, Wiesel SW (eds): Rothman-Simeone The Spine, ed 4. Philadelphia, PA, WB Saunders, 1999, p 547.
Kurz LT, Garfin SR, Booth RE Jr: Iliac bone grafting: Techniques and complications of harvesting, in Garfin SR (ed): Complications of Spine Surgery. Baltimore, MD, Williams and Wilkins, 1989, pp 330-331.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, pp 297, 331-332.

Question 32

An 11-year-old boy sustained an injury to his arm in gym class. He denies prior pain in the arm. Radiographs are shown in Figures 48a and 48b. What is the next most appropriate step in the management of this lesion?

Explanation

DISCUSSION: This radiolucent lesion with a “fallen leaf sign” is typical for a unicameral bone cyst(UBC). The most appropriate treatment is to allow the fracture to heal with clinical and radiographic observation. Curettage and bone grafting is not the best initial management for UBC. Wide resection is not indicated for UBC. The proximal humerus is the most common site for UBC. While staging studies consisting of MRI, bone scan, and CT of the chest are appropriate for lesions suspected of being malignant, the classical appearance of this UBC is such that this work-up is not necessary initially. Following fracture healing, aspiration and injection of the cyst may be indicated.
REFERENCES: Dormans JP, Pill SG: Fractures through bone cysts: Unicameral bone cysts, aneurysmal bone cysts, fibrous cortical defects, and nonossifying fibromas. Instr Course Lect 2002;51:457-467.
Deyoe L, Woodbury DF: Unicameral bone cyst with fracture. Orthopedics 1985;8:529-531.

Question 33

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

Explanation

DISCUSSION:
Chronic opioid consumption prior to total joint arthroplasty has been associated with increased pain after surgery, increased opioid requirements, a slower recovery and longer hospital stay, and higher 90-day postoperative complications compared with patients not on chronic opioids preoperatively. Based on this information, Nguyen and associates performed a study in three patient groups that included 1) chronic opioid users who underwent no preoperative intervention, 2) chronic opioid users who were weaned down to 50% of their prior opioid regimen, and 3) patients who were not chronic opioid users. The authors found that the reduction of preoperative opioid use improved postoperative function, pain, and recovery and that the weaned group performed more like the opioid naive group than the chronic opioid user
group. Increasing opioid use prior to surgery in this patient would make it more difficult to control pain after surgery. Stopping all of his opioids just prior to surgery would place the patient at substantial risk for opioid withdrawal and is not recommended. Avoiding the use of all narcotics and using only acetaminophen postoperatively is very unlikely to provide appropriate pain relief in a chronic opioid user. The recommendation based on the provided literature is to decrease the patient's narcotic use prior to
surgery.

Question 34

A 30-year-old patient has had severe left hip pain and difficulty ambulating, necessitating the use of a cane, for the past 6 months. A photomicrograph of the femoral head sectioned at the time of surgery is shown in Figure 31. What is the most likely diagnosis?

Explanation

DISCUSSION: The photomicrograph demonstrates a wedge-shaped infarct with femoral head collapse; therefore, the diagnosis is osteonecrosis of the femoral head. Perthes disease and osteoarthritis do not involve a wedge-shaped defect. Tuberculosis of the hip joint results in greater destruction of the articular cartilage.
REFERENCES: Basset LW, Mirra JM, Cracchiolo A III: Ischemic necrosis of the femoral head: Correlation between magnetic resonance imaging and histologic sections. Clin Orthop 1987;223:181-187.
Sugano N: Osteonecrosis, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopedics. St Louis, MO, Mosby, 2002, pp 878-887.

Question 35

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

Explanation

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

Question 36

The anterior approach to total hip arthroplasty requires dissection between which of the following muscle planes?

Explanation

AL-Madena Copy
DISCUSSION: The anterior approach to the hip joint involves identifying the plane between the tensor fascia lata and the sartorius muscles.
REFERENCES: Berger RA, Duwelius PJ: The two-incision minimally invasive total hip arthroplasty: Technique and results. Orthop Clin North Am 2004;35:163-172.
Matta JM, Shahrdar C, Ferguson T: Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005;441:115-124.
28 • American Academy of Orthopaedic Surgeons

Figure 3Id Figure 31e

Question 37

A 45-year-old woman awakens with the acute onset of burning left shoulder pain that radiates toward the axilla. She denies any history of trauma. On examination, she is unable to abduct her arm but has full passive shoulder motion. Her sensation is intact. Cervical spine examination reveals full range of motion and a negative Spurling’s test. Radiographs and MRI studies are normal for the cervical spine and shoulder. What is the most likely diagnosis? Review Topic

Explanation

The definition of brachial neuritis or Parsonage-Turner syndrome is a rare disorder of unknown etiology that causes pain or weakness of the shoulder and upper extremity. The loss of active motion excludes cervical C6-7 radiculopathy and impingement. A normal MRI scan and full passive motion exclude a rotator cuff tear and adhesive capsulitis, respectively.

Question 38

A 40-year-old woman reports the atraumatic onset of severe knee pain and swelling after undergoing an uncomplicated elective cholecystectomy 1 week ago. She denies any history of diabetes mellitus or HIV but has had occasional episodes of mild knee pain and swelling that have always responded to nonsteroidal anti-inflammatory drugs. Radiographs are shown in Figures 5a and 5b. A knee aspiration yields a WBC count of 35,000/mm 3 . The aspirate should also yield which of the following findings?

Explanation

DISCUSSION: The radiographs reveal chondrocalcinosis of the menisci. This is caused by calcium pyrophosphate crystals, which are weakly positive birefringent rhomboid-shaped crystals. Frequently, this condition is asymptomatic; however, routine abdominal surgery may cause precipitation of these crystals and pain. Gout, which is caused by strongly negative birefringent needle-shaped sodium urate crystals, is not associated with chondrocalcinosis and is rare in younger women. Gross blood is uncommon without trauma. Infection is not likely in a healthy patient who underwent uncomplicated surgery.
REFERENCES: Fisseler-Eckhoff A, Muller KM: Arthroscopy and chondrocalcinosis. Arthroscopy 1992;8:98-104.
Hough AJ Jr, Webber RJ: Pathology of the meniscus. Clin Orthop 1990;252:32-40.

Question 39

A 14-year-old competitive gymnast has had activity-related low back pain for the past month. Examination reveals no pain with forward flexion, but she has some discomfort when resuming an upright position. She also has pain with extension and lateral bending of the spine. The neurologic examination is normal. Popliteal angles measure 20 degrees. AP, lateral, and oblique views of the lumbar spine are negative. What is the next most appropriate step in management?

Explanation

DISCUSSION: Symptoms of activity-related low back pain, physical findings of pain with extension, lateral bending, and resuming an upright position, and relative hamstring tightness are consistent with spondylolysis. While the initial diagnostic work-up should include plain radiographs of the lumbosacral spine, the findings may be negative because it can take weeks or months for the characteristic changes to become apparent. SPECT has been a useful adjunct in the diagnosis of spondylolysis when plain radiographs are negative. Since the patient’s pain is activity related and she is otherwise healthy, evaluation for infection is not indicated. Because the neurologic examination is normal, electromyography, nerve conduction velocity studies, and MRI are not indicated. CT can be used in those instances in which SPECT and bone scans

are negative.
REFERENCES: Ciullo JV, Jackson DW: Pars interarticularis stress reaction, spondylolysis, and spondylolisthesis in gymnasts. Clin Sports Med 1985;4:95-110.
Collier BD, Johnson RP, Carrera GF, et al: Painful spondylolysis or spondylolisthesis studied by radiography and single photon emission computed tomography. Radiology 1985;154:207-211.
Jackson DW, Wiltse LL, Cirincione RT: Spondylolysis in the female gymnast. Clin Orthop 1976;117:68-73.
Ginsberg GM, Bassett GS: Back pain in children and adolescents: Evaluation and differential diagnosis. J Am Acad Orthop Surg 1997;5:67-78.
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Question 40

Vertebral fractures are common in the thoracolumbar spine. What is the most important factor that determines the strength of the cancellous bone in the vertebral body?

Explanation

DISCUSSION: Cancellous bone strength and stiffness are determined primarily by the apparent density (the amount of bone per unit volume). Strength varies approximately as the square of the density, and stiffness as the cube of the density; therefore, these are very strong relationships. Cancellous bone strength also depends on the mineral content, the rate of loading (it is viscoelastic), the anatomic level, and the trabecular number (an histomorphometry term), but all to a markedly lesser extent than density.
REFERENCES: Carter DR, Hayes WC: The compressive behavior of bone as a two-phase porous structure. J Bone Joint Surg Am 1977;59:954-962.
Keaveny TM: Strength of trabecular bone, in Cowin SC (ed): Bone Mechanics Handbook. Boca Raton, FL, CRC Press, 2001, pp 16-1-16-8.

Question 41

Explanation

Discussion: Radial deficiency is associated with other abnormalities. 40% of patients with unilateral and 77% of bilateral involvement will have associated malformations:
Holt-Oram syndrome – Radial deficiency and cardial septal defect.
Fanconi syndrome – Severe aplastic anemia
TAR syndrome
Trisomy 17
VATER syndrome
Because of the association with severe aplastic anemia, a platelet count should be done before any surgical intervention.

Question 42

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

Explanation

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

Question 43

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

Explanation

THA is the best long term solution for displaced femoral neck fractures (FNF) in active elderly patients.
The aims of surgery for FNF in elderly patients are immediate pain relief, rapid mobilization, and low complications and revision. THA has best pain relief, fewer reoperations, best survivorship and is most cost-effective but has longer operative/anesthetic time, blood loss, higher infection rate, and potential instability compared with HA.
Healy and Iorio examined the optimal treatment for elderly FNF. They compared internal fixation (120 patients) with arthroplasty (HA, 43 patients; THA, 23 patients). There was no different in reoperation or mortality rates between the 2 groups, but arthroplasty was more cost effective, had independent living, and longer interval to reoperation/death. THA had less pain, better function, and lower rates of reoperation than HA, and was most cost-effective. They concluded that THA was the best treatment.
Yu et al. performed a meta-analysis of randomized controlled trials to determine whether THA or hemiarthroplasty (HA) was superior. They found that THA had lower risk of reoperation (RR = 0.53), higher risk of dislocation (RR = 1.99), and
higher functional scores at 1 and 4 years. There was no difference in mortality, infection and complication rates.
Figure A shows a displaced left femoral neck fracture. Incorrect Answers:

Question 44

A 6-year-old child has a fixed flexion deformity of the interphalangeal (IP) joint of the right thumb. The thumb is morphologically normal, with a nontender palpable nodule at the base of the metacarpophalangeal joint. Clinical photographs are shown in Figures 42a and 42b. Based on these findings, what is the treatment of choice?

Explanation

DISCUSSION: The child has a trigger thumb deformity. A trigger thumb is a developmental mechanical problem rather than a congenital deformity. The anomaly generally is not noted at birth. A fixed flexion deformity of the IP joint of the thumb most commonly occurs in children in the first 2 years of life. A stretching and splinting program may correct the deformity in the first year of life, but nonsurgical management after age 3 years results in a success rate of only 50%. Release of the proximal annular pulley of the flexor sheath is recommended at this age.
REFERENCES: Tan AH, Lam KS, Lee EH: The treatment outcome of trigger thumb in children. J Pediatric Orthop B 2002;11:256-259.
Slakey JB, Hennrikus WL: Acquired thumb flexion contracture in children: Congenital trigger thumb. J Bone Joint Surg Br 1996;78:481-483.
Herring JA: Disorders of the upper extremity: Thumb dysplasia, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, p 445.

Question 45

What adaptations occur in the dominant shoulder of throwers compared to their nondominant shoulder? Review Topic

Explanation

Pitchers change rotation during adolescent growth with external rotation of the proximal humerus. The result is increased external rotation and decreased internal rotation, resulting in a normal total arc of motion. External rotation lengthens the arc of acceleration, resulting in increased velocity. The shorter arc of internal rotation, associated with a tight posterior capsule, makes deceleration of the arm more difficult, which may lead to overuse injuries.

Question 46

Which of the following patients with cerebral palsy is considered the ideal candidate for a selective dorsal rhizotomy?

Explanation

DISCUSSION: The enthusiasm with which dorsal rhizotomy was received led to the broadening of selection criteria with poorer results. The ideal candidate is an ambulatory 4- to 8-year-old child with spastic diplegia who does not use assistive devices or have joint contractures. The child must be old enough to actively participate in the rigorous postoperative physical therapy program. The use of the procedure in an ambulatory 16-year-old patient is less desirable because joint contractures will most likely have developed to a varying degree. The hemiplegic child is best treated by orthopaedic interventions.
REFERENCES: Oppenheim WL: Selective posterior rhizotomy for spastic cerebral palsy: A review. Clin Orthop 1990;253:20-29.
Renshaw TS, Green NE, Griffin PP, Root L: Cerebral palsy: Orthopaedic management. J Bone Joint Surg Am 1995;77:1590-1606.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1996, pp 19-27.

Question 47

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

Explanation

DISCUSSION: The imaging studies show a permeative lesion of the left hemipelvis with a large soft-tissue mass. The photomicrograph demonstrates a small blue cell tumor with pseudorosettes. The most likely diagnosis is primitive neuroectodermal tumor (Ewing’s sarcoma family of tumors). MIC-2 is a highly sensitive and specific marker for this family of tumors. Cytokeratin is an epithelial marker. Vimentin is a mesenchymal marker. Thus, Ewing’s sarcomas are cytokeratin negative and vimentin positive. Before discovery of the MIC-2 antigen, PAS and reticulin stains were commonly used to help differentiate Ewing’s sarcoma from lymphoma. In contrast to lymphoma, Ewing’s sarcomas are typically PAS positive and reticulin negative.
REFERENCES: Halliday BE, Slagel DD, Elsheikh TE, et al: Diagnostic utility of MIC-2 immunocytochemical staining in the differential diagnosis of small blue cell tumors. Diagn Cytopathol 1998;19:410-416.
Llombart-Bosch A, Navarro S: Immunohistochemical detection of EWS and FLI-1 proteins is Ewing sarcoma and primitive neuroectodermal tumors: Comparative analysis with CD99

(MIC-2) expression. Appl Immunohistochem Mol Morphol 2001;9:255-260.

Question 48

A radiograph, MRI scans, and a biopsy specimen of a 9-year-old boy with thigh pain are shown in Figures 37a through 37d. Management should consist of

Explanation

DISCUSSION: The patient has Ewing’s sarcoma. Management options for local tumor control include radiation therapy, resection, or a combination; however, in this patient wide resection is preferred over radiation therapy. Radiation therapy is associated with damage to the growth plate, pathologic fracture, radiation-induced sarcomas, and a local recurrence rate of approximately 10% to 12%. Radiation therapy is used for positive margins, unresectable tumors, or for tumors that have a poor response to chemotherapy. Amputation is not necessary since the tumor is resectable. Chemotherapy has improved overall survival rates to over 60% of patients.
REFERENCES: Sailer SL: The role of radiation therapy in localized Ewing’ sarcoma. Semin Radiat Oncol 1997;7:225-235.
Shankar AG, Pinkerton CR, Atra A, Ashley S, Lewis I, Spooner D, et al: Local therapy and other factors influencing site of relapse in patients with localised Ewing’s sarcoma. United Kingdom Children’s Cancer Study Group (UKCCSG). Eur J Cancer 1999;35:1698-1704.
Carrie C, Mascard E, Gomez F, Habrand JL, Alapetite C, Oberlin O, et al: Nonmetastatic pelvic Ewing sarcoma: Report of the French society of pediatric oncology. Med Pediatr Oncol 1999;33:444-449.
Terek RM, Brien EW, Marcove RC, Meyers PA, Lane JM, Healey JH: Treatment of femoral Ewing’s sarcoma. Cancer 1996;78:70-78.

Question 49

An adult patient has a closed humeral fracture that was treated nonsurgically and a concomitant radial nerve injury. Six weeks after injury, electromyography shows no evidence of recovery. Management should now consist of

Explanation

DISCUSSION: In patients with radial nerve injuries with closed humeral fractures, it has been reported that 85% to 95% spontaneously recover. Based on this premise, most surgeons favor expectant management of these injuries. Even if there is no evidence of recovery at 6 weeks, repeat electromyography at 12 weeks is advocated. If there is no clinical or electromyographic signs of recovery at 6 months, exploration is recommended. If the nerve is in continuity at the time of exploration, nerve action potentials are useful in helping determine the need for neurolysis, excision, and grafting, or if excision and repair is the best option.
REFERENCES: Pollock FH, Drake D, Bovill EG, et al: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.
Mohler LR, Hanel DP: Closed fractures complicated by peripheral nerve injury. J Am Acad Orthop Surg 2006;14:32-37.

Question 50

A 35-year-old physical therapist presents with right-sided back and leg pain. For the last 4 months, he has taken anti-inflammatory medications and performed exercises on his own. While his back pain has improved slightly, his leg pain remain severe and interferes with his ability to sleep and work. Examination reveals positive ipsilateral and contralateral straight leg raise at 30 degrees. He has mildly diminished big toe dorsiflexion strength on the right side. There is a small patch of diminished sensation on the dorsum of the foot. MRI scans are shown in Figures A and B. What is the most appropriate next step in treatment? Review Topic

Explanation

The clinical presentation is consistent with a paracentral disc herniation at L4/5 that has failed nonoperative treatment and continues to limit is his activities of daily living. A laminotomy and discectomy (microdisckectomy) with a midline approach would be the next most appropriate treatment.
For lumbar disc herniation, the first line of treatment is rest, physical therapy and oral medications (NSAIDs, gabapentin, steroids). The second line of treatment is selective nerve root corticosteroid injections. The last line in treatment is laminotomy and discectomy.
Pearson et al. determined which individuals (as opposed to groups) in the SPORT (Spine Patients Outcomes Research Trial) would benefit from surgery. They found that disc herniation patients improved more with surgery than without.
Lurie et al. reviewed the 8 year outcomes of the SPORT. In patients with HNP on imaging and leg symptoms persisting for at least 6 weeks, surgery was superior to nonoperative treatment in relieving symptoms and improving function.
Figures A and B are sagittal and axial T2-weighted MRI images showing a large L4/L5 herniated disc causing neural foramina narrowing and impinging on the right L5 root.
Incorrect Answers:

Question 51

A 57-year-old man involved in a motor vehicle accident sustains an injury to his right shoulder. A spot AP radiograph is shown in Figure 34. What is the next most appropriate step in the orthopaedic management of this patient?

Explanation

DISCUSSION: The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a “Velpeau” axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.
REFERENCE: Simon JA, Puopolo SM, Capla EL, et al: Accuracy of the axillary projection to determine fracture angulation of the proximal humerus. Orthopedics 2004;27:205-207.

Question 52

A 2-year-old child has marked hypotonia and depressed reflexes. History reveals that the child was normal at birth and developed normally for the first year. The child also began to ambulate, but lost this ability during the next 6 months. Laboratory studies show a creatine phosphokinase level that is within the normal range. DNA testing confirms a deletion in the survival motor neuron (SMN) gene. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has spinal muscular atrophy, type 2. This type is intermediate in severity between the Werdnig-Hoffmann type (type 1) and the Kugelberg-Welander type

(type 3). It normally manifests itself between the ages of 3 and 15 months. Survival until adolescence is common. All three types of spinal muscular atrophy have been linked to the SMN gene at the 5q12.2-13.3 locus. DNA testing is available and is preferred to muscle biopsy because it is less invasive and more definitive.
REFERENCES: Biros I, Forrest S: Spinal muscular atrophy: Untangling the knot? J Med Genet 1999;36:1-8.
Zerres K, Wirth B, Rudnik-Schoneborn S: Spinal muscular atrophy: Clinical and genetic correlations. Neuromuscul Disord 1997;7:202-207.

Question 53

A 25-year-old woman undergoes surgical treatment of a displaced proximal humeral fracture via a deltopectoral approach. At the first postoperative visit, she reports a tingling numbness along the anterolateral aspect of the forearm. What structure is most likely injured?

Explanation

DISCUSSION: Sensation along the anterolateral aspect of the forearm is supplied by the lateral antebrachial cutaneous nerve, the terminal branch of the musculocutaneous nerve. The musculocutaneous nerve can be injured by proximal humeral fractures or dislocations, and is also at risk during surgical exposure if excessive retraction is placed on the conjoint tendon. The musculocutaneous nerve enters the conjoint tendon 1 cm to 5 cm distal to the coracoid process.
REFERENCES: McIlveen SJ, Duralde XA, D’Alessandro DF, et al: Isolated nerve injuries about the shoulder. Clin Orthop 1994;306:54-63.
Warner JP: Frozen shoulder: Diagnosis and management. J Am Acad Orthop Surg

1997;5:130-140.

Question 54

The best patient-related outcomes, following the surgical treatment of cauda equina syndrome secondary to a large L5-S1 disk herniation, are most closely related to which of the following? Review Topic

Explanation

The most predictable positive outcome from spinal surgery due to a cauda equina syndrome is early surgical intervention before any significant neurologic deficit develops. Meta-analysis studies demonstrate that surgical intervention more than 48 hours after the onset of cauda equina syndrome show an increased risk for poor outcomes.

Question 55

A 25-year-old man sustained a head injury after being ejected from his car. Examination reveals a Glasgow Coma Scale score of 7 and a swollen right knee. Clinical examination shows that the knee is very unstable, suggesting tears of the medial collateral and anterior and posterior cruciate ligaments, as well as the posterior lateral corner. What is the most appropriate first step to rule out a vascular injury?

Explanation

DISCUSSION: A knee dislocation carries the potential for an arterial injury and has always brought up the question of need for arteriography to rule out this limb-threatening injury. However, arteriography has an inherent complication rate that may compromise the general care of the patient. In over 240 published cases with documented knee dislocations that were evaluated for vascular injury by physical examination (without imaging studies), not a single missed injury was reported, for a 100% negative predictive value (0% false-negative rate). This degree of accuracy at excluding major vascular injury is unsurpassed by the results obtained with arteriography but with no risk involved and a marked savings in time, equipment, and costs. Therefore, the most appropriate first step to rule out vascular injury is examination of the pedal pulses. If there is any doubt about an arterial injury, another option is the ankle-brachial index (ABI). If the ABI is greater than 0.9, the chance of arterial injury is again nonexistent. However, a positive physical examination or an ABI of less than 0.9 is not 100% predictive of an arterial injury; therefore, arteriography is recommended.
REFERENCES: Miranda FE, Dennis JW, Veldenz HC, et al: Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: A prospective study. J Trauma 2002;52:247-252.
Mills WJ, Barei DP, McNair P: The value of the ankle-brachial index for diagnosing arterial injury afterknee dislocation: A prospective study. J Trauma 2004;56:1261-1265.

Question 56

A 10-year-old boy who is active in soccer has had activity-related heel pain for the past 3 months. Examination reveals tenderness over the posterior heel and a tight Achilles tendon. Radiographs demonstrate a 2-cm cyst in the anterior body of the calcaneus. His physes have not closed. Based on these findings, what is the most appropriate management?

Explanation

DISCUSSION: The most likely diagnosis is Sever’s disease, which is considered either an apophysitis or a para-apophyseal stress fracture. It is common in athletic children and is associated with a tight Achilles tendon. Cast immobilization may be necessary if activity reduction fails. Calcaneal cysts are quite common and do not require any further diagnostic testing or treatment unless they occupy the full width of the calcaneus or one third of the length of the calcaneus.
REFERENCES: Ogden JA, Ganey TM, Hill JD, et al: Sever’s injury: A stress fracture of the immature calcaneal metaphysis. J Ped Orthop 2004;24:488-492.
Pogoda P, Priemel M, Linhart W, et al: Clinical relevance of calcaneal bone cysts: A study of 50 cysts in 47 patients. Clin Orthop Relat Res 2004;424:202-210.

Question 57

A 42-year-old man reports persistent arm pain after undergoing intramedullary nailing of a humeral shaft fracture 13 months ago. Physical exam shows near normal shoulder and elbow range-of-motion. Infection work-up is normal. A radiograph is shown in Figure

Explanation

Plate fixation (with bone graft as needed) is the procedure of choice for humeral shaft nonunions.
Rubel et al in a combined cadaveric and clinical study comparing one versus two plate constructs for humeral nonunions found that the two plate construct was significantly stiffer, but had no difference in healing rate compared with a single plate construct; 92% of the humeral shaft nonunion patients went onto union with rigid plate fixation.
Ring et al successfully treated a cohort of osteoporotic humeral shaft nonunions with locked plating. They
report 100% union rate with locking plate fixation of these humeral shaft nonunions, with use of autograft in >50% of their cases. Subjective shoulder scores were excellent or good in 22 of 24 patients.
Brinker and O'Connor analyzed the current available evidence for exchange nailing of nonunions and could not recommend this treatment for humeral shaft nonunions.
OrthoCash 2020

Question 58

Which of the following ligaments is most commonly involved in posterolateral rotatory instability of the elbow?

Explanation

DISCUSSION: Recurrent posterolateral rotatory instability of the elbow is difficult to diagnose. Such instability can be demonstrated only by the lateral pivot-shift test. The cause for this condition is laxity of the ulnar part of the lateral collateral ligament, which allows a transient rotatory subluxation of the ulnohumeral joint and a secondary dislocation of the radiohumeral joint. The annular ligament remains intact, so the radioulnar joint does not dislocate. Treatment consists of surgical reconstruction of the lax ulnar part of the lateral collateral ligament. The anterior band is the most important part of the medial collateral which is lax in valgus instability of the elbow.
REFERENCES: Morrey BF: Acute and chronic instability of the elbow. J Am Acad Orthop Surg 1996;4:117-128.
O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.

Question 59

An 18-month-old boy has 45 degrees of kyphosis in the thoracolumbar spine secondary to type I congenital kyphosis. Examination reveals that he is neurologically intact, and an MRI scan shows no evidence of intraspinal pathology. Management should consist of

Explanation

DISCUSSION: Surgery is indicated for congenital kyphosis once the deformity reaches a certain size or if significant progression is documented. In a young patient with a relatively small deformity, the treatment of choice is isolated in situ posterior fusion and postoperative immobilization. If an adequate posterior fusion can be obtained, an epiphyseodesis effect can be generated, allowing the remaining anterior growth to cause some correction. Because there is no evidence of neurologic compression and the deformity is less than 50 degrees, anterior surgery is not indicated. There is no role for bracing in the management of congenital kyphosis.
REFERENCES: Winter RB: Congenital Deformities of the Spine. New York, NY, Thieme-Stratton, 1983, pp 229-261.
Winter RB, Moe JH: The results of spinal arthrodesis for congenital spinal deformity in patients younger than five years old. J Bone Joint Surg Am 1982;64:419-432.

Question 60

An adult patient has an 8- x 4- x 10-cm soft-tissue mass located within the adductor compartment of the thigh. Staging studies should consist of

Explanation

DISCUSSION: The appropriate staging studies should consist of MRI and a radiograph of the primary lesion and CT of the chest. MRI is superior to CT for soft-tissue imaging. CT may be useful for evaluating the cortex of bone for invasion by tumor. Bone scans are not commonly used because soft-tissue sarcomas rarely metastasize to bone. CT of the abdomen and pelvis is not typically ordered except for possible liposarcoma. With liposarcoma, there may be a synchronous or metastatic retroperitoneal liposarcoma.
REFERENCES: Demetri GD, Pollock R, Baker L, et al: NCCN sarcoma practice guidelines: National Comprehensive Cancer Network. Oncology (Huntingt) 1998;12:183-218.
Pollock R, Brennan M, Lawrence W Jr: Society of Surgical Oncology practice guidelines: Soft-tissue sarcoma surgical practice guidelines. Oncology (Huntingt) 1997;11:1327-1332.

Question 61

What is the advantage of percutaneous pedicle screw fixation over open instrumentation and fusion for a thoracolumbar burst fracture without neurologic deficit?

Explanation

DISCUSSION
A prospective randomized study on short-segment treatment of burst fractures with and without fusion demonstrated similar outcomes at 5 years with lower blood loss in the nonfusion group. There is by definition no fusion performed with percutaneous stabilization, so patients often develop hardware failure. Some surgeons routinely remove instrumentation following percutaneous stabilization, thus revision surgery is common. Clinical outcomes are not improved compared to open methods.
RECOMMENDED READINGS
Koreckij T, Park DK, Fischgrund J. Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma. Neurosurg Focus. 2014;37(1):E11. doi: 10.3171/2014.5.FOCUS1494. Review. PubMed PMID: 24981899. View Abstract at PubMed Jindal N, Sankhala SS, Bachhal V. The role of fusion in the management of burst fractures of the thoracolumbar spine treated by short segment pedicle screw fixation: a prospective randomised trial. J Bone Joint Surg Br. 2012 Aug;94(8):1101-6. doi: 10.1302/0301-620X.94B8.28311. PubMed PMID: 22844053. View Abstract at PubMed
Dai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures. a five to seven-year prospective randomized study. J Bone
Joint Surg Am. 2009 May;91(5):1033-41. doi: 10.2106/JBJS.H.00510. PubMed PMID:

Question 62

A 38-year-old man is three quarters of the way through the Hawaiian Ironman events run in a temperature of 60 degrees F. He is sweating profusely and suddenly collapses. Prior to this he had been drinking large amounts of bottled water at every water stop. What is the most likely diagnosis? Review Topic

Explanation

Hyponatremia is often seen in endurance athletes such as triathloners, ultramarathoners, and marathoners after prolonged exertion. It is commonly attributed to excess free water intake that fails to replete massive sodium losses that result from sweating as reported by O'Connor. Exercise-induced hyponatremia is generally asymptomatic, particularly in patients in whom the sodium is only mildy reduced. Up to 10% of ultradistance athletes have a sodium level of 135 mEq/L or less, but those who are symptomatic usually have a sodium level of 125 mEq/L as reported by Noakes and O'Connor. The best way to prevent hyponatremia is to maintain the proper volume and types of fluid intake to ensure fluid balance during exercise. Beverages containing carbohydrates in concentrations of 4% to 8% (ie, "sports drinks") are recommended for athletes participating in exercise lasting more than an hour (eg, marathon runners, etc.) To avert brainstem herniation and death, severe, acute hyponatremia requires rapid correction. Oral rehydration with salty solutions is safe and effective in patients with mild symptoms. Too rapid correction has been reported to cause central pontine myelinolysis; therefore, correction ought to be performed slowly. Hypernatremia, hypothermia, subendocardial myocardial infarction, or ruptured berry aneurysm are unlikely in this scenario.

Question 63

Surgical restoration of sagittal balance of an adult spinal deformity will have which effect on outcome?

Explanation

DISCUSSION
The influence of sagittal balance on outcomes following fusion-based procedures for degenerative conditions of the lumbar spine has only recently been appreciated. Restoration of sagittal spinal balance improves low-back-pain outcomes and quality of life. Sagittal spinal balance has not been shown to relieve neurogenic claudication attributable to spinal stenosis.
RECOMMENDED READINGS
Li Y, Hresko MT. Radiographic analysis of spondylolisthesis and sagittal spinopelvic deformity. J Am Acad Orthop Surg. 2012 Apr;20(4):194-205. doi: 10.5435/JAAOS-20-04-194. Review. PubMed PMID: 22474089. View Abstract at PubMed
Korovessis P, Repantis T, Papazisis Z, Iliopoulos P. Effect of sagittal spinal balance, levels of posterior instrumentation, and length of follow-up on low back pain in patients undergoing posterior decompression and instrumented fusion for degenerative lumbar spine disease: a multifactorial analysis. Spine (Phila Pa 1976). 2010 Apr 15;35(8):898-905. doi: 10.1097/BRS.0b013e3181d51e84. PubMed PMID: 20354466. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 99 AND 100
Figures 99a and 99b are MR images of a 59-year-old man with a history of intravenous (IV) drug abuse who arrives at the emergency department with malaise and fever. Upon admission, the patient's temperature is 38.9°C, his white blood cell count is 17000/µL (reference range [rr], 4500-11000/µL), his erythrocyte sedimentation rate is 98 mm/h (rr, 0-20 mm/h), and his C-reactive protein level is 45 mg/L (rr, 0.08-3.1 mg/L). He is admitted to the medical service to evaluate the source of his fevers. On hospital day 1, the patient reports weakness in his left arm and leg. Blood cultures are positive for methicillin-resistant Staphylococcus aureus.

A B

Question 64

In the nonsurgical management of posterior tibial tendon dysfunction with flexible deformity, a common strategy is to prescribe an ankle-foot orthosis or a University of California Biomechanics Laboratory (UCBL) orthosis with medial posting. A high patient satisfaction rating and favorable outcome with this nonsurgical management is most likely in which of the following situations?

Explanation

DISCUSSION: Most authors recommend an initial trial of nonsurgical management in the treatment of adult-acquired flatfoot deformity such as posterior tibial tendon dysfunction. Chao and associates found that there is high patient satisfaction with ankle-foot orthoses and UCBL-type inserts in elderly patients with a relatively sedentary lifestyle. Alternatively, there was a higher dissatisfaction rate in young active patients, those with balance and ambulation difficulties (Parkinson’s, severe arthritis of the hip or knee), and patients with inflammatory systemic disorders.
REFERENCES: Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int 1996;17:736-741.
Noll KH: The use of orthotic devices in adult acquired flatfoot deformity. Foot Ankle Clin 2001;6:25-36.

Question 65

Which of the following forms of nonsurgical management is considered best for acute low back pain without radiculopathy?

Explanation

DISCUSSION: Temporary bed rest (less than 4 days) with gradual resumption of activities can be efficacious. Epidural steroid injections may be indicated for acute low back pain with radiculopathy. Acupuncture, facet joint injections, or ligamentous (sclerosant) injections are not indicated.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, Appendix A15.
Helfgott SM: Sensible approach to low back pain. Bull Rheum Dis 2001;3:50.

Question 66

What is the mechanism of action of an intramuscular injection of botulinum type A toxin in reducing spasticitiy?

Explanation

DISCUSSION: The use of intramuscular botulinum type A toxin has been shown to be a useful adjuvant in the management of dynamic deformity in patients with cerebral palsy. Botulinum type A toxin is a neurotoxin produced by Clostridium botulinum that works by interfering with presynaptic acetylcholine release at cholinergic nerve terminals. At the cellular level, the mechanism involves endocytosis of the intact botulinum toxin molecule by cells in the end plate, followed by disulfide cleavage and translocation of the light chain into the cytosol where it disrupts the normal binding of the synaptosomal vesicles to the axon terminal membrane. Neither the nerve terminal nor the neuromuscular junction is damaged. The muscle paralysis is reversible and dose-dependent. Baclofen is a neuropharmacologic agent that functions as a GABA agonist. Dorsal rhizotomy is a neurosurgical procedure that reduces spasticity by dividing afferent (excitatory) fibers in the posterior rootlet of the spinal nerves.
REFERENCES: Koman LA, Mooney JF III, Smith B, Goodman A, Mulvaney T: Management of cerebral palsy with botulinum-A toxin: Preliminary investigation. J Pediatr Orthop 1993;13:489-495.
Brin MF: Botulinum toxin: Chemistry, pharmacology, toxicity, and immunology. Muscle Nerve Suppl 1997;6:S146-168.

Question 67

Figure 100 is the MR image of a 19-year-old man who sustains recurrent anterior shoulder dislocations. The lesion shown occupies approximately 10% of the articular surface. What is the most appropriate treatment?

Explanation

DISCUSSION
The MR image shows a bony Bankart lesion involving less than 20% of the glenoid joint surface. One series reported high success rates after arthroscopic treatment when the defect was incorporated into the repair. Anterior bony deficiencies occupying more than 25% to 30% of the glenoid joint surface treated with soft-tissue repair only are associated with high
recurrence rates. In these patients, an open or arthroscopic coracoid transfer or distal tibial allograft reconstruction should be considered. ORIF has been reported for treatment of large acute glenoid rim fractures, but is not recommended for recurrent anterior shoulder instability in the setting of a 10% glenoid rim fracture.

Question 68

A 38-year-old woman who tripped and fell on her outstretched arm reports pain with movement. Examination reveals swelling. AP and lateral radiographs are shown in Figures 43a and 43b. Management should consist of

Explanation

DISCUSSION: The patient has a type I (Hahn-Steinthal) capitellar fracture that is best seen on the lateral radiograph. If a fracture fragment is seen proximal to the radial head, a capitellar fracture is the most likely injury because radial head fractures do not migrate proximally. The fragment is large enough for fixation. Excision is the preferred treatment for small shear osteochondral type II (Kocher-Lorenz) capitellar fractures. Closed reduction usually is not successful because of rotation of the displaced fragment.
REFERENCES: Mehdian H, McKee M: Management of proximal and distal humerus fractures. Orthop Clin North Am 2000;31:115-127.
Ring D, Jupiter J, Gulotta L: Articular fractures of the distal part of the humerus. J Bone Joint Surg Am 2003;85:232-238.

Question 69

Figures 26a through 26c show the MRI scans of a 47-year-old man who underwent arthroscopic shoulder surgery 6 months ago and continues to have pain despite a prolonged course of rehabilitation. Management should now consist of Review Topic

Explanation

The MRI scans show an os acromiale of the mesoacromion type. This represents an unfused acromial apophysis. Pain is thought to be caused by either motion at the site or downward displacement of the anterior aspect of the acromion onto the rotator cuff, causing impingement. Most patients can be treated nonsurgically as they are usually asymptomatic. In those patients with persistent symptoms of pain and tenderness over the acromion, surgery consisting of rigid internal fixation and bone grafting has yielded satisfactory results. Excision may be a viable treatment option for the preacromion type.

Question 70

What is the most prevalent adverse event associated with allogeneic blood transfusion?

Explanation

DISCUSSION: Clerical error leading to acute hemolysis and even death occurs in 1:12,000 to 1:50,000 transfusions. Bacterial contamination leading to sepsis/shock occurs in 1:1 million transfusions. HIV transmission is approximately 1:500,000 transfusions and hepatitis C is 1:103,000 transfusions. Anaphylactic reactions occur in 1:150,000 transfusions.
REFERENCES: Aubuchon JP, Birkmeyer JD, Busch MP: Safety of the blood supply in the United States: Opportunities and controversies. Ann Intern Med 1997;127:904-909.
Popovsky MA, Whitaker B, Arnold NL: Severe outcomes of allogeneic and autologous blood donation: Frequency and characterization. Transfusion 1995;35:734-737.

Question 71

An obese (BMI = 35) 72-year-old woman with diabetes mellitus, hyptertension and a 22-pack-year smoking history is scheduled to undergo posterior spinal fusion from T10 to S1 with a pedicle subtraction osteotomy at L3 for the spinal deformity seen in Figure 1. Which of the following risk factors is most predictive of major complication following surgery Review Topic

Explanation

The patients age (> 60 years) is the most significant risk factor for a major perioperative complication during posterior spinal fusion for adult spinal deformity correction.
The surgical treatment of adult spinal deformity often requires multilevel arthrodesis with complex osteotomies including three column osteotomies such as pedicle
subtraction (PSO) and vertebral column resection (VCR). They can involve both anterior and posterior surgical approaches. Surgical time, blood loss, length of hospital stay, and length of recovery can be greater than it is for the more common degenerative conditions.
Auerbach et al. characterized the risk factors for the development of major complications in patients undergoing 3-column osteotomies for adult spinal deformity correction. They also aimed to determine whether the presence of complications affected the ultimate clinical outcome. They found age > 60 years, > or = 3 comorbid conditions and preoperative sagittal imbalance of = 40mm was associated with a major complication. However, the presence of a major complication did not affect the ultimate clinical outcomes at 2 years or more.
Daubs et al. conducted a retrospective analysis of forty-six patients = 60 years of age who underwent major spinal deformity surgery requiring a minimum 5-level arthrodesis procedure to determine the rate of complication and outcomes. The overall complication rate was 37% and the major complication rate was 20%. Increasing age was a significant factor (p<0.05) in predicting the presence of a complication, while presence of comorbidities was found to have no association.
Figure A is a standing preoperative lateral radiograph of the spine demonstrating a thoracic kyphosis of ~25° and thoracolumbar kyphosis of ~25°. Illustration A demonstrates proper sagittal balance after spinal fusion from T10 to S1 and L3 PSO.
Incorrect Answers:

Question 72

Which of the following nonunions is appropriately treated with exchange reamed nailing without bone graft augmentation?

Explanation

DISCUSSION: Exchange nailing is indicated for nonunions of diaphyseal femoral and tibia fractures in the absence of infection, comminution, or segmental bone loss. Hypertrophic nonunions need better stability (increased nail diameter) to acheive union. Where as atrophic nonunions often need better biology (bone graft, flap coverage, etc.) The referenced article by Brinker et al reviews the indications for exchange nailing. They argue, on the basis of the available literature, that exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral and tibia fractures. Zelle et al. demonstrated 95% success with reamed exchange nailing for the treatment of aseptic tibial shaft nonunions that were initially treated with nonreamed intramedullary nailing.

Question 73

Design factors that enhance the long-term survival of proximally coated cementless hip implants include both initial stability and

Explanation

DISCUSSION: Proximally coated femoral components were conceived in response to the proximal stress shielding seen with extensively coated total hip stems, but initial patient studies showed problems with osteolysis, thigh pain, and stability. However, Mont and Hungerford now report that second-generation devices that have been in use more than 5 years clinically have shown very low aseptic loosening rates (1% to 3%), and patients report less thigh pain (less than 5% in most studies). These results can be attributed to improved geometry, instruments, and technique, which ensure initial implant stability. The authors suggest that proximal coating must be circumferential to seal the diaphysis from wear debris, and they note that the concept of proximal coating for cementless femoral stems seems viable as long as the twin requirements of circumferential coating and rigid initial stability are realized.
REFERENCES: Mont MA, Hungerford DS: Proximally coated ingrowth prostheses: A review. Clin Orthop 1997;344:139-149.
Engh CA, Hooten JP Jr, Zettl-Schaffer KF, Ghaffarpour M, McGovern TF, Bobyn JD: Evaluation of bone ingrowth in proximally and extensively porous-coated anatomic medullary locking prostheses retrieved at autopsy. J Bone Joint Surg Am 1995;77:903-910.
Urban RM, Jacobs JJ, Sumner DR, Peters CL, Voss FR, Galante JO: The bone-implant interface of femoral stems with non-circumferential porous coating. J Bone Joint Surg Am 1996;78:1068-1081.

Question 74

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

Explanation

DISCUSSION: The anatomic lesion in this patient is not exactly defined, but she has most likely sustained an injury about the knee. A Salter-Harris type I proximal tibial physeal fracture is likely. The normal radiograph reading can be misleading because these injuries may displace and spontaneously reduce. The child is at risk of compartment syndrome although she is currently not displaying signs of it. Thus, even though this injury may seem trivial by radiographic findings, it should be treated like a knee dislocation with a risk of late developing compartment syndrome. MRI or CT may be necessary to define the injury. She does not require emergent treatment, but merits close observation for possible compartment syndrome. Any of the possible injuries about the knee can be unstable and require internal fixation after reduction.
REFERENCES: McGuigan JA, O’Reilly MJ, Nixon JR: Popliteal arterial thrombosis resulting from disruption of the upper tibial epiphysis. Injury 1984;16:49-50.
Burkhart SS, Peterson HA: Fractures of the proximal tibial epiphysis. J Bone Joint Surg Am
1979;61:996- 1002.

Question 75

A 23-year-old woman with a history of bilateral recurrent ankle sprains, progressive cavovarus feet, and a family history of high arches and foot deformities is seen for evaluation. Management consisting of bracing and physical therapy has been poorly tolerated. Heel varus is partially corrected with a Coleman block. There are thick calluses under the first metatarsal heads. Sensation to touch and

Explanation

The history and presentation are consistent with type I Charcot-Marie-Tooth (CMT), the most common form of hereditary peripheral motor sensory neuropathy. Type I CMT is the most common, occurring in 50% of patients with CMT, and is characterized by marked slowing of motor neuron velocities, and inconsistent slowing of sensory neuron velocities. Peroneus longus to brevis transfer is indicated to release the overpull of the peroneus longus, and restore the eversion and dorsiflexion function of the peroneus brevis. A lateralizing calcaneal osteotomy with proximal translation is indicated to correct heel varus given that the Coleman block only allows for partial correction of heel varus. Proximal translation of the posterior tuber corrects for the increased calcaneal dorsiflexion, improving the lever arm for the triceps surae. A medial column closing wedge osteotomy is often required to correct a rigid, or semirigid plantar flexed first ray to allow for a balanced, plantigrade foot. Triple arthrodesis is indicated for rigid, arthritic hindfoot deformities. Transfer of the posterior tibial tendon to the tibialis anterior is not indicated since it is an out-of-phase transfer. Transfer of the posterior tibial tendon, when performed, should be to the lateral aspect of the foot. A medializing calcaneal osteotomy would accentuate the heel varus. There is no indication for Botox in CMT; Botox injection of the calf would further weaken push-off during gait. Bracing of a progressive semirigid or rigid deformity is not recommended.

Question 76

Figure 1 is the MR image of a 14-year-old football player who injured his right knee during a game. He describes feeling a "pop" and then needing help walking off the field. His knee is visibly swollen. Knee range of motion is between 0° and 70°. What is the most appropriate treatment option?

Explanation

DISCUSSION:
The MR image shows bone bruises (“kissing contusions”) consistent with an ACL tear. During the ACL subluxation event, the posterolateral tibial plateau subluxes anteriorly, making contact with the mid portion of the lateral femoral condyle and resulting in this characteristic bone bruise pattern on MRI. Randomized clinical trials comparing early accelerated versus nonaccelerated rehabilitation programs have demonstrated no significant differences in long-term results with regard to function, reinjury, and successful return to play. These studies did not address timing of return to play with an early accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity, number of graft failures, or KOOS scores.

Question 77

A 40-year-old male who sustained an open pilon fracture 2 weeks ago is scheduled for a below-the-knee amputation (BKA). What laboratory value is the best predictor for wound healing?

Explanation

DISCUSSION: Albumin is the best measure of nutrition that is vital for wound healing. Total protein is a valuable measure as well, however it is not as sensitive as albumin levels. Calcium levels and ESR/C-reactive protein levels play no role.

Question 78

A 50-year-old patient who plays tennis sustained the deformity shown in Figure 27 following a high volley. Further diagnostic work-up should include

Explanation

DISCUSSION: The patient has a rupture of the long head of the biceps; however, patients older than age 45 years are at greater risk of having an associated rotator cuff tear. An MRI scan should be ordered to avoid missing concomitant rotator cuff pathology. While patients may report pain radiating down the arm at the time of the tendon rupture, an EMG is not indicated. The short head of the biceps is intact and needs no further work-up, even though the muscle descends in most cases. The anterior labrum can be injured but is not associated with this deformity.
REFERENCES: Neer CS II, Bigliani LU, Hawkins RJ: Rupture of the long head of the biceps related to the subacromial impingement. Orthop Trans 1977;1:114.
Hawkins RJ, Murnaghan JP: The shoulder, in Gruess RL, Ronnie WRJ (eds): Adult Orthopaedics. New York, NY, Churchill Livingstone, 1984, pp 945-1054.

Question 79

A 77-year-old man who underwent right total knee replacement surgery 2 and a half years ago has had knee pain since surgery. The pain is diffuse, constant, and made worse with activity. He notes warmth and swelling in his knee. Examination shows a well-healed incision, no erythema, moderate warmth, synovitis, and an effusion. The knee is stable, and has an arc of flexion between 3° and 120°. Radiographs show well-fixed and well-aligned implants. What is the most appropriate initial treatment?

Explanation

DISCUSSION:
This patient's history and physical findings are concerning for deep infection. Inflammatory markers, including ESR and CRP, should be obtained first. If the levels are elevated, knee aspiration should be performed for the synovial cell count and culture. A bone scan is not indicated in an initial investigation for deep infection; it is rarely helpful and is not cost effective. CT to assess implant rotation is an appropriate investigation for knee pain when the clinical scenario is not suspicious for a deep infection and when infection has been excluded.

Question 80

What is the most appropriate treatment for a chordoma involving the sacrum?

Explanation

DISCUSSION: Chordomas are very radio- and chemotherapy resistant; therefore, en bloc resection with a negative margin is the preferred treatment. Lesions at or below S3 can be resected without compromising pelvis stability, and continence usually is maintained. The mean survival rate for patients with sacral chordomas is approximately 7 years. Patients with chordoma of the mobile (cervical, thoracic, or lumbar) spine have a mean survival rate of approximately 5 years. This difference is most likely the result of an earlier diagnosis.
REFERENCES: Fardin DF, Garfin SR, Abitbol J, et al (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 123-133.
Stener B, Gunterberg B: High amputation of the sacrum for extirpation of tumors: Principles and technique. Spine 1978;3:351-366.
Stener B: Resection of the sacrum for tumors. Chir Organi Mov 1990;75:S108-S110.

Question 81

A 4-year-old child sustains a spiral fracture to the tibia in an unwitnessed fall. History reveals three other fractures to long bones, and the parents are vague about the etiology of each. There is no family history of bone disease. The parents ask if the child has osteogenesis imperfecta (OI); however, there are no clinical or radiographic indications of this diagnosis. In addition to fracture care, management should include

Explanation

DISCUSSION: Child abuse and OI are frequently both in the differential diagnosis of a child with multiple fractures. If OI is suspected, testing is appropriate to confirm this diagnosis. This may include skull radiographs to look for wormian bones and/or fibroblast culturing and collagen analysis of a punch biopsy. Unfortunately, because of the large number of mutations that can yield the disease, DNA testing is not commercially available for OI. In this patient, however, the physician suspects nonaccidental trauma and is legally obligated in most states to notify child protective services. Because the child may be at considerable risk of further injury, hospitalization is indicated to protect the child until child protective services can complete a home investigation and assess the degree of risk. Work-up for both OI and child abuse can be done during the hospitalization.
REFERENCES: Rockwood CA, Wilkins KE, King RE (eds): Fractures in Children. Philadelphia, PA, JB Lippincott, 1984, vol 3, pp 173-175.
Kempe CH, Silverman FN, Stelle BF, Droegemueller W, Silver HK: The battered-child syndrome. JAMA 1962;181:17-24.
Akbarnia BA, Akbarnia NO: The role of the orthopedist in child abuse and neglect. Orthop Clin North Am 1976;7:733-742.

Question 82

A college athlete has a knee injury requiring surgery. He has acne, gynecomastia, and well-developed muscles related to the use of anabolic steroids. What association with steroid use is concerning for surgery and anesthesia? Review Topic

Explanation

Anabolic steroids increase procoagulant factors VII and IX and thromboxane, all of which lead to hypercoagulability which would decrease bleeding time. Liver function is usually upregulated as oral steroids induce hepatic enzymes and patients are therefore less sensitive to anesthetic agents. Anabolic steroids have a mineralocorticoid effect and users frequently use diuretics to mask this effect. Both can lead to fluid and electrolyte imbalances. Cardiovascular effects include hypertension, left ventricular hypertrophy, impaired diastolic filling, and thrombosis. Large muscle mass and high calorie intake lead to high ventilatory requirements caused by increased oxygen consumption and carbon dioxide production. Anabolic steroids have no effect on the spleen.

Question 83

Figure 35 is the sagittal MR image of a 56-year-old woman who has a 3-year history of severe back pain. Her pain is worse with flexion at the lumbosacral junction and is relieved with extension. She denies any pain in her lower extremities and has no symptoms of neurogenic claudication. Which mediators play roles in the pathogenesis of this condition?

Explanation

DISCUSSION
The patient has degenerative disk disease with diskogenic back pain. Several studies in both humans and animals have implicated TNF-a, IL-1, and MMP in extracellular matrix degeneration and disk degradation. TGF-ß, BMP-2, latent membrane protein 1, and growth and development factor-5 are all postulated to play anabolic roles in the intervertebral disk. Biglycan is a small leucine-rich proteoglycan that regulates extracellular matrix assembly within the disk. Noggin and gremlin are biochemical factors not involved in disk degradation.
RECOMMENDED READINGS
Kim HT, Yoon ST, Jarrett C. Articular cartilage and intervertebral disk. In: Fischgrund JS, ed. Orthopaedic Knowledge Update 9. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:23-33.
Hoyland JA, Le Maitre C, Freemont AJ. Investigation of the role of IL-1 and TNF in matrix degradation in the intervertebral disc. Rheumatology (Oxford). 2008 Jun;47(6):809-14. doi: 10.1093/rheumatology/ken056. Epub 2008 Apr 8. PubMed PMID: 18397957. View Abstract at PubMed
Gruber HE, Ingram JA, Hanley EN Jr. Immunolocalization of MMP-19 in the human intervertebral disc: implications for disc aging and degeneration. Biotech Histochem. 2005 May-Aug;80(3-4):157-62. PubMed PMID: 16298901. View Abstract at PubMed

Question 84

A 44-year-old woman has bilateral knee pain, and history reveals bilateral hip replacements. Radiographs are seen in Figure 28a, and histopathologic specimens from the total hip replacement are shown in Figures 28b and 28c. Laboratory studies reveal anemia. What is the most likely diagnosis?

Explanation

DISCUSSION: Rheumatoid arthritis is an inflammatory arthritis that usually involves multiple joints. Radiologic findings of periarticular erosion, osteopenia, and minimal osteophyte formation favor rheumatoid arthritis over osteoarthritis. Pigmented villonodular synovitis and Charcot arthropathy are more often considered monoarticular diseases. There are no radiographic findings of Paget’s disease.
REFERENCE: Dutkowsky J: Miscellaneous non traumatic disorders, in Crenshaw A (ed): Campbell’s Operative Orthopaedics. St Louis, MO, Mosby, 1992, pp 2007-2012.

Question 85

What is the predominant type of collagen in the tissue resulting from the surgical procedure shown in Figures 40a through 40c?

Explanation

DISCUSSION: The arthroscopic images show a microfracture procedure. Perforation of the subchondral bone results in so-called “marrow stimulation” that results in the formation of fibrocartilage. This reparative tissue is composed predominantly of type I collagen with a disorganized matrix lacking a true tidemark, as opposed to hyaline cartilage which is composed primarily of type II collagen. This operation is indicated for full-thickness chondral defects without associated degenerative arthrosis. Microfracture is most commonly performed in the knee, though it has also been applied to other joints. Type III collagen is not a predominant component of fibrocartilage. Type IX and X are minor collagenous components of cartilage.
REFERENCES: Magnussen RA, Dunn WR, Carey JL, et al: Treatment of focal articular cartilage defects in the knee: A systematic review. Clin Orthop Relat Res 2008;466:952-962.
Williams RJ III, Hamly HW: Microfracture: Indications, technique, and results. Instr Course Lect 2007;56:419-428.
Mithoefer K, Williams RJ III, Warren RF, et al: Chondral resurfacing of articular cartilage defects in the knee with the microfracture technique: Surgical technique. J Bone Joint Surg Am 2006;88:294-304.

Question 86

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

Explanation

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

Question 87

A patient who is an observant Jehovah’s Witness requires major surgery for scoliosis that will likely result in significant blood loss. Which of the following might the patient consider allowing the surgical team to use? Review Topic

Explanation

Jehovah’s Witnesses will not accept the transfusion of blood or blood products such as packed red or white cells, platelets, or plasma. However, many Jehovah’s Witnesses will accept the use of a cell saver in a “closed circuit.”

Question 88

A 2-year-old girl has had a swollen right knee for the past 7 weeks. There is no history of significant trauma, and she has not had a fever or been ill. Her parents report that she is stiff in the morning but otherwise does not report pain. A CBC count and erythrocyte sedimentation rate are normal. Treatment with naproxen at appropriate doses for the past 2 weeks has resulted in some improvement. Radiographs show only soft-tissue swelling. Examination reveals a healthy-appearing child with a warm and swollen right knee that is only slightly tender but lacks full extension by 20 degrees. What is the next most appropriate step in management?

Explanation

DISCUSSION: Up to 30% of children with juvenile rheumatoid arthritis (increasingly known now as juvenile idiopathic arthritis or JIA) already have potentially damaging uveitis at the time of diagnosis. This patient has typical oligoarticular JRA (JIA) and therefore is at significant risk for uveitis. MRI, radioisotope scanning, or an ACE level most likely would not provide additional useful diagnostic information because intra-articular derangement, osteomyelitis, or sarcoidosis are all unlikely. Arthrocentesis and triamcinolone hexacetonide joint injection might be indicated if continued use of nonsteroidal medication does not result in improvement, but should be held off for at least an additional 4 to 6 weeks to see if continued use of naproxen results in control of the arthritis.
REFERENCES: Wolf MD, Lichter PR, Ragsdale CG: Prognostic factors in the uveitis of juvenile rheumatoid arthritis. Ophthalmology 1987;94:1242.
Cassidy JT, Petty RE: Textbook of Pediatric Rheumatology. Philadelphia, PA, WB Saunders, 2001, p 220.
Chalom ED, Goldsmith DP, Koehler MA, et al: Prevalence and outcome of uveitis in a regional cohort of patients with juvenile rheumatoid arthritis. J Rheumatol 1997;24:2031-2034.

Question 89

A 24-year-old dancer reports posterior ankle pain when in the “en pointe” position. Examination reveals posteromedial tenderness, no pain reproduction with passive forced planter flexion, and pain with motion of the hallux. What is the most likely diagnosis?

Explanation

DISCUSSION: Flexor hallucis longus tendinitis is a common cause of posterior ankle pain in dancers. It tends to be more posteromedial and is characterized by a clicking or catching sensation posteromedially with motion of the great toe. A painful os trigonum typically causes more posterolateral ankle pain and may occur after an ankle sprain or plantar flexion injury where there may be a fracture of the os trigonum.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 249-261.
Hamilton WG, Geppert MJ, Thompson FM: Pain in the posterior aspect of the ankle in dancers: Differential diagnosis and operative treatment. J Bone Joint Surg Am 1996;78:1491-1500.

Question 90

The dorsal (Thompson) approach to the proximal forearm uses which of the following intermuscular intervals?

Explanation

DISCUSSION: The Thompson posterior approach is used in treatment of fractures of the proximal radius. Dissection is carried out through the interval between the extensor carpi radialis brevis (radial nerve) and the extensor digitorum communis (posterior interosseous nerve). To identify this interval, the forearm is pronated and the mobile lateral wad of muscles (the ulnar-most belly is the extensor carpi radialis brevis) is grasped with the thumb and finger and pulled from the much less mobile mass of the extensor digitorum communis. The furrow created is marked with a skin marker for subsequent skin incision. The skin incision follows a line from the lateral epicondyle of the humerus to a point corresponding to the middle of the posterior aspect of the wrist. Distally, the intermuscular plane is between the extensor carpi radialis brevis and the extensor pollicis longus.
REFERENCES: Crenshaw AH Jr: Surgical techniques and approaches, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 9. St Louis, MO, Mosby-Year Book, 1998, vol 1, pp 128-129.
Hoppenfeld S, deBoer P: Posterior approach to the radius, in Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, Lippincott-Raven, 1992, pp 136-146.
Thompson JE: Anatomical methods of approach in operations on the long bones of the extremities. Ann Surg 1918;68:309-316.

Question 91

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

Explanation

DISCUSSION: Chronic lateral instability is commonly associated with a longitudinal split tear of the peroneus brevis tendon. The interrelationship of lateral ankle instability with superior retinacular laxity and resultant peroneus brevis split can account for persistent lateral ankle pain in this patient. Surgical treatment must identify and correct the underlying tendon pathology and should attempt to repair or debride the peroneus brevis tendon, reconstruct the superior peroneal retinaculum, flatten the posterior edge of the fibula by removing the sharp bony prominence, or deepening the fibular groove, along with addressing lateral ankle ligamentous instability. The laboratory values are not consistent with infection. A negative anterior drawer test confirms stability of the repair. Ankle arthritis is not seen on radiographs and usually takes longer than 3 months to develop.
REFERENCES: Bonnin M, Tavernier T, Bouysset M: Split lesions of the peroneus brevis tendon in chronic ankle laxity. Am J Sports Med 1997;25:699-703.
Sobel M, Geppert MJ, Warren RF: Chronic ankle instability as a cause of peroneal tendon injury. Clin Orthop Relat Res 1993;296:187-191.

Question 92

The view from an anterosuperior portal of the right shoulder shown in Figure 12 reveals which of the following findings?

Explanation

DISCUSSION: The arthroscopic view shows a HAGL lesion. With the arthroscope directed anteroinferiorly, muscular striations of the subscapularis can be visualized through the avulsion site. In vitro strain studies indicate that glenohumeral ligament failure on the humeral side occurs in approximately 25% of patients, while clinically this lesion has been reported in approximately 9% of patients with shoulder instability. Failure to recognize and treat this lesion leads to persistent anterior instability. An ALPSA lesion, a Bankart variant, occurs on the glenoid side and is characterized by a sleeve-like medial retraction and inferior rotation. A Bankart lesion is the classic avulsion of the glenohumeral ligament from the glenoid rim. The subscapularis tendon and the rotator interval are not shown in the figure.
REFERENCES: Wolf EM, Cheng JC, Dickson K: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607.
Bigliani LU, Pollack RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197.
Warner JJ, Beim GM: Combined Bankart and HAGL lesion associated with anterior shoulder instability. Arthroscopy 1997;13:749-752.

Question 93

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

Explanation

DISCUSSION: Tillaux and triplane fractures occur in adolescents as the result of an external rotation injury of the ankle. As seen on the CT scan, the growth plate starts to close during adolescence; therefore, growth arrest resulting in limb-length discrepancy or angulation is less of a concern in this age group than achieving joint congruity. The joint should be surgically reduced if displacement is greater than 2 mm to minimize the chances of late arthrosis.
REFERENCES: Kay RM, Matthys GA: Pediatric ankle fractures: Evaluation and treatment.

J Am Acad Orthop Surg 2001;9:268-278.
Kling TF Jr: Operative treatment of ankle fractures in children. Orthop Clin North Am 1990;21:381-392.
Duchesneau S, Fallat LM: The Tillaux fracture. J Foot Ankle Surg 1996;35:127-133.

Question 94

In the United States, groups at risk for community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) within the pediatric and adolescent populations include

Explanation

CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 68
Figures 64a through 64d are the radiographs of an 11-year-old boy with a prolonged history of activity-related ankle pain. An examination is notable for restricted subtalar motion and moderate pes planovalgus.

Question 95

Figure 36 shows the hip arthrogram of a newborn. Which of the following structures is enclosed by the circle?

Explanation

DISCUSSION: The structure enclosed by the circle is the acetabular labrum. It is visible as the white point of tissue outlined by the darkly radiopaque contrast. The appearance of the contrast surrounding the sharp white point of a normal labrum is called the “rose thorn sign.” The limbus is the term reserved for a rounded, infolded labrum seen with arthrography. The pulvinar is the fatty tissue seen in the empty acetabulum when the hip is dislocated. The ligamentum teres is seen as a white stripe outlined by contrast coursing from the central acetabulum to the dislocated femoral head. The transverse acetabular ligament courses across the inferior portion of the acetabulum and is not clearly seen with arthrography.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA,

WB Saunders, 2002, vol 1, pp 532-533.
Severin E: Contribution to the knowledge of congenital dislocation of the hip joint.

Acta Chir Scand 1941;84:1.

Question 96

Figure 12 shows the radiograph of an 80-year-old woman who has had an 8-month history of back pain after a fall. What is the most likely diagnosis based on the radiographic findings at the fractured vertebrae?

Explanation

DISCUSSION: An intravertebral vacuum cleft suggests nonunion of the vertebral fracture with osteonecrosis and is not seen in routine healing fractures. MRI characteristically shows a high T2 signal in the cleft. The cleft is not indicative of an infectious or neoplastic lesion. A vacuum disk phenomenon is associated with end-stage degenerative disk disease, but those findings are not found in the vertebral body.
REFERENCES: Murakami H, Kawahara N, Gabata T, et al: Vertebral body osteonecrosis without vertebral collapse. Spine 2003;28:E323-E328.
Jang JS, Kim DY, Lee SH: Efficacy of percutaneous vertebroplasty in the treatment of intravertebral pseudarthrosis associated with noninfected avascular necrosis of the vertebral body. Spine 2003;28:1588-1592.

Question 97

A 22-year-old cheerleader who fell from the top of a pyramid now reports anterior and posterior pelvic pain. A radiograph and CT scans are shown in Figures 43a through 43c. What is the best treatment for this injury?

Explanation

DISCUSSION: Symphyseal widening of greater than 2.5 cm and less than 5 cm denotes an AP II injury and a rotationally unstable pelvis. An AP II pelvic ring injury is best treated with anterior open reduction and internal fixation. Nonsurgical management is reserved for AP I injuries. Pelvic binders are used only acutely and should not be used for definitive management. Iliosacral screws usually are not necessary in the acute management of AP II injuries.
REFERENCES: Matta JM: Indications for anterior fixation of pelvic fractures. Clin Orthop Relat Res 1996;329:88-96.
Templeman DC, Schmidt AH, Sems AS, et al: Diastasis of the symphysis pubis: Open reduction internal fixation, in Wiss D (ed): Masters Techniques in Orthopaedic Surgery-Fractures, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 639-648.
Tile M: Management, in Tile M: Fractures of the Pelvis and Acetabulum, ed 2. Philadelphia, PA, Williams and Wilkins, 1995, pp 108-134.

Question 98

Radiating pain associated with a posterolateral thoracic disk herniation typically follows what pattern? Review Topic

Explanation

Although symptomatic thoracic disk herniations can affect more caudal structures, even to the point of paralysis, the pattern of radiating pain has been described as either following the dermatomal band around the chest or feeling to the patient as if the pain passes straight anteriorly to the chest wall.

Question 99

What is the most common malignant bone tumor seen in patients with multiple hereditary exostosis?

Explanation

DISCUSSION: Secondary chondrosarcomas are most common in patients with multiple hereditary exostosis. Dedifferentiated chondrosarcoma is less common and refers to bone lesions in which a high-grade spindle cell sarcoma component is located immediately adjacent to a low-grade cartilage neoplasm. Mesenchymal chondrosarcoma, clear cell chondrosarcoma, and periosteal osteosarcoma are no more common in patients with multiple hereditary exostosis than in the general population.
REFERENCES: Mirra JM: Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia, PA, Lea and Febiger, 1989, pp 1660-1669.
Simon MA, Springfield DS, et al: Common Malignant Bone Tumors: Chondrosarcoma. Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 275-286.

Question 100

Which of the following 50-year-old patients with an irreparable rotator cuff tendon is the best candidate for an isolated latissimus dorsi muscle transfer? Review Topic

Explanation

Patients with superior escape or a torn subscapularis (demonstrated by a positive lift-off test) will not benefit from a latissimus dorsi transfer, even if combined with a pectoralis muscle transfer. In the study by Iannotti and associates, women had poorer outcomes than men, and patients with preoperative elevation below shoulder level or 90 degrees also had poorer outcomes. Patients with complete loss of external rotator function have worse function after latissimus dorsi transfer than patients with some external rotation function.

Full Question & Answer Text (for Search Engines)

Question 1:

In the anterior cruciate ligament-deficient knee, what structure provides an important secondary restraint to anterior tibial translation? Review Topic

Options:

Anterior horn of the lateral meniscus
Posterior cruciate ligament
Posterior horn of the medial meniscus
Popliteus tendon
Quadriceps muscle

Correct Answer: Posterior horn of the medial meniscus

Explanation:

Question 2:

Options:

rest from throwing activities.
a subacromial corticosteroid injection.
open reduction and internal fixation.
arthroscopic labral repair.
biopsy of the proximal humerus.

Correct Answer: rest from throwing activities.

Explanation:

Question 3:

A patient reports changes in vocal quality after undergoing a right-sided anterior cervical approach to C6. Which of the following nerves has most likely been injured?

Options:

Vagus
Phrenic
Hypoglossal
Recurrent laryngeal
Inferior thyroid

Correct Answer: Recurrent laryngeal

Explanation:

Question 4:

A patient with a previously pain-free knee replacement now reports a sudden inability to ambulate. Radiographs of the knee are shown in Figures 33a and 33b. Management should consist of

Options:

bracing and physical therapy.
insertion of a thicker polyethylene insert.
revision with a cementless modular prosthesis.
revision with a cemented semiconstrained prosthesis.
reconstruction of the extensor mechanism.

Correct Answer: reconstruction of the extensor mechanism.

Explanation:

Question 5:

Which of the following statements about hoarseness due to vocal cord paralysis after anterior cervical diskectomy and fusion is most accurate?

Options:

Vocal cord paralysis is three times as likely with a right-sided approach as compared to a left-sided approach.
Vocal cord paralysis is twice as likely with a right-sided approach as compared to a left-sided approach.
Vocal cord paralysis is equally likely with either a right-sided or a left-sided approach.
Vocal cord paralysis is three times as likely with a left-sided approach as compared to a right-sided approach.
Vocal cord paralysis is twice as likely with a left-sided approach as compared to a right-sided approach.

Correct Answer: Vocal cord paralysis is equally likely with either a right-sided or a left-sided approach.

Explanation:

DISCUSSION: It has been traditionally taught that a left-sided approach to the anterior cervical spine is associated with a lower incidence of injury compared to the right-sided approach. This is due in part to the anatomic differences in the path the recurrent laryngeal nerve (RLN) takes on the right as compared to the left. Both nerves ascend in the tracheoesophageal groove after branching off the vagus nerve in the upper thorax. The left-sided RLN loops around the aortic arch and stays relatively medial as compared to the right-sided RLN which loops around the right subclavian artery and is somewhat more lateral at this point, and therefore is theoretically more vulnerable as it ascends toward the larynx before becoming protected in the tracheoesophageal groove. Furthermore, the variant of a nonrecurrent inferior laryngeal nerve branching directly off the vagus nerve at the level of the midcervical spine is much more common on the right than the left. Despite this reasoning, there has been no clinical evidence to suggest that laterality of approach for anterior cervical surgery makes any difference in the incidence of vocal cord paralysis. Furthermore, two recent studies have shown that the incidence of RLN injury and vocal cord paralysis is equal with either side of approach.
REFERENCES: Beutler WJ, Sweeney CA, Connolly PJ: Recurrent laryngeal nerve injury with anterior cervical spine surgery risk with laterality of surgical approach. Spine 2001;26:1337-1342.
Kilburg C, Sullivan HG, Mathiason MA: Effect of approach side during anterior cervical discectomy and fusion on the incidence of recurrent laryngeal nerve injury. J Neurosurg Spine 2006;4:273-277.

Question 6:

Options:

The transplanted chondrocytes are viable and articular cartilage heals. Biopsy shows type I collagen.
The transplanted chondrocytes are viable and articular cartilage heals. Biopsy shows type II collagen.
The transplanted chondrocytes are nonviable and cartilage is used as a scaffold for growth of new articular cartilage. Biopsy shows type II collagen.
The transplanted chondrocytes are nonviable and articular cartilage is gradually replaced by fibrocartilage. Biopsy shows type I collagen.
The transplanted chondrocytes are nonviable and articular cartilage is gradually replaced by fibrocartilage. Biopsy shows mixture of type I and II collagen.

Correct Answer: The transplanted chondrocytes are viable and articular cartilage heals. Biopsy shows type I collagen.

Explanation:

Question 7:

Options:

IV antibiotics.
IV antibiotics and immobilization of the lower extremity.
IV antibiotics, surgical incision and drainage of the abscess, and immobilization of the lower extremity.
IV antibiotics and repeated aspirations of the metaphyseal region.
oral antibiotics with careful monitoring of blood levels.

Correct Answer: IV antibiotics, surgical incision and drainage of the abscess, and immobilization of the lower extremity.

Explanation:

Question 8:

Figure 35 shows the radiograph of a 12-year-old boy who fell off a snowmobile and landed on his left shoulder. He has a closed injury. Management should consist of

Options:

a shoulder spica cast.
closed reduction and percutaneous pinning.
open reduction to remove the interposed soft tissue.
a shoulder sling, followed by repeat radiographs to document fracture position.
open reduction and internal fixation with a 90° blade plate.

Correct Answer: a shoulder sling, followed by repeat radiographs to document fracture position.

Explanation:

DISCUSSION: Proximal humeral fractures in children are classified as metaphyseal or Salter-Harris type I or II fractures, and most of these fractures are treated with closed methods. Eighty percent of the growth of the humerus comes from the proximal physis; therefore, tremendous remodeling potential is present. Indications for open reduction include open fractures or severely displaced fractures in adolescents with minimal growth remaining. Acceptable limits of reduction in adolescent proximal humeral fractures include bayonet apposition and angulation of less than 35°. Common blocks to reduction in adolescents include the biceps tendon and periosteum. For this fracture, use of a shoulder sling without reduction will lead to healing and an excellent result as the proximal humerus remodels.
REFERENCES: Kohler R, Trillaud JM: Fracture and fracture separation of the proximal humerus in children: Report of 136 cases. J Pediatr Orthop 1983;3:326-332.
Beaty JH: Fractures of the proximal humerus and shaft in children. Instr Course Lect 1992;41:369-372.
Dobbs
MB
, Luhmann SL, Gordon JE, et al: Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop 2003;23:208-215.
Beringer
DC
, Weiner DS, Noble JS, et al: Severely displaced proximal humeral epiphyseal fractures: A follow-up study. J Pediatr Orthop 1998;18:31-37.
Wang P Jr, Koval KJ, Lehman W, et al: Salter-Harris type III fracture-dislocation of the proximal humerus. J Pediatr Orthop B 1997;6:219-222.

Question 9:

Options:

intravenous (IV) antibiotics only.
arthroscopic debridement and IV antibiotics.
irrigation, debridement, polyethylene liner exchange, and IV antibiotics.
stage exchange and IV antibiotics.

Correct Answer: irrigation, debridement, polyethylene liner exchange, and IV antibiotics.

Explanation:

Question 10:

The transverse diameter of the pedicle is most narrow at which of the following levels?

Options:

Correct Answer: T5

Explanation:

Question 11:

Options:

Synovial sarcoma
Soft-tissue abcess
Rhabdomyosarcoma
Eosinophilic granuloma
Nodular pigmented villonodular synovitis

Correct Answer: Soft-tissue abcess

Explanation:

Question 12:

In regards to a genetic disorder, which of the following is an example of "anticipation?"

Options:

Gene characteristics more severe and earlier in onset in subsequent generations
A disorder inherited from a genetic mutation specific to maternal DNA
Gene characteristics expressed to varying degrees in different individuals
Variation in the relative frequency of a genotype due to chance
The presence of an extra copy of a chromosome

Correct Answer: Variation in the relative frequency of a genotype due to chance

Explanation:

Question 13:

Options:

Chemotherapy and surgical resection
Debridement and IV antibiotics
Chemotherapy alone
Radiation therapy alone
Surgical resection alone

Correct Answer: Chemotherapy and surgical resection

Explanation:

DISCUSSION: The findings are consistent with Ewing’s sarcoma. The radiographs reveal a lytic lesion in the diaphysis of the right fibula. There is elevation of the periosteum and evidence of a surrounding soft-tissue mass. The biopsy specimen shows diffuse small round blue cells surrounding the lamellar bone. It is the second most common malignant bone tumor in children. The most common treatment regimen consists of chemotherapy followed by surgical resection and/or radiation therapy. Surgical resection is employed when the lesion can be removed with wide margins and causes less morbidity than radiation therapy.
REFERENCES: McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 258.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

Question 14:

Histologic studies of surgically resected tissue in lateral epicondylitis demonstrate which of the following findings? Review Topic

Options:

Chondroblastic proliferation
Angiofibroblastic tendinosis
Significant active inflammation
Primarily calcium deposition
No normal tendon histology

Correct Answer: Angiofibroblastic tendinosis

Explanation:

Question 15:

Options:

Revision of the acetabular implant to a constrained bearing with modular exchange of the femoral head and neck
Revision of the acetabular and femoral implants
Retention of the acetabular implant with modular exchange of the femoral head and neck
Revision of the femoral component alone with a new ceramic head

Correct Answer: Revision of the acetabular and femoral implants

Explanation:

Question 16:

Options:

protein C and S.
vitamin K.
von Willebrand factor.
factor VIII.

Correct Answer: factor VIII.

Explanation:

Question 17:

What is the main function of collagen found within articular cartilage?

Options:

Compressive properties
Tensile properties
Proteoglycan synthesis
Cartilage metabolism
Joint lubrication

Correct Answer: Tensile properties

Explanation:

Question 18:

40A B Figures 40a and 40b are this patient's intraoperative arthroscopic images. The abnormality seen here illustrates which of the patient's clinical findings?

Options:

Instability on unlevel ground
Ankle pain and swelling
Anterior laxity on lateral radiographs
Osteochondral lesion of the talus on MR imaging

Correct Answer: Ankle pain and swelling

Explanation:

DISCUSSION
Ankle sprains are the most common musculoskeletal injury; however, most of these sprains do not progress to chronic instability. Initial injuries are treated with RICE (rest, ice, compression, elevation), range of motion, weight bearing
as tolerated, and proprioceptive therapy. Lace-up ankle braces are most effective during the subacute period after a sprain. Structured physical therapy focused on proprioception is recommended for 6 weeks. Examination findings for ankle ligament instability are unreliable because of associated subtalar joint motion. Casting is not as effective as functional rehabilitation. Stress radiographs are recommended, but a clear pathologic range of measurements is not defined. Generalized ligament laxity can result in false-positive findings of instability; therefore, contralateral stress radiographs are often necessary for comparison. The difference in anterior drawer measurement between both ankles should not exceed 5mm. Likewise, the difference in talar tilt measurement between both ankles should be 5 or fewer degrees. Patients with mechanical symptoms, a joint effusion, or continued pain may have an intra-articular pathology such as a loose body or osteochondral lesion. Ankle instability can exist without ligamentous laxity. Symptoms of chronic instability can result from osteochondral lesions of talus, peroneal tendon pathology, loose bodies, anterior ankle impingement, and fracture nonunions. Although there is not sufficient evidence to recommend arthroscopy prior to all ligament reconstructions, arthroscopy is recommended when other pathology is suspected.
RECOMMENDED READINGS
Colville MR. Surgical treatment of the unstable ankle. J Am Acad Orthop Surg. 1998 Nov-Dec;6(6):368-77. Review. PubMed PMID: 9826420.
View Abstract at PubMed
DiGiovanni CW, Brodsky A. Current concepts: lateral ankle instability. Foot Ankle Int. 2006 Oct;27(10):854-66. Review. PubMed PMID: 17054892.
View Abstract at PubMed
Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. 2008 Oct;16(10):608-15. Review. PubMed PMID: 18832604.
View Abstract at PubMed

Question 19:

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

Options:

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

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

Explanation:

Question 20:

Options:

Posterolateral herniated nucleus pulposus at L3-4
Posterolateral herniated nucleus pulposus at L4-5
Degenerative disk disease at L3-4 and L4-5 with no significant facet hypertrophy
Degenerative spondylolisthesis at L3-4 with central and foramenal stenosis
Degenerative spondylolisthesis at L4-5 with central stenosis

Correct Answer: Degenerative spondylolisthesis at L3-4 with central and foramenal stenosis

Explanation:

Question 21:

Smoking has been associated with lower fusion rates in both cervical and lumbar fusion. Which of the following statements best describes an explanation for these findings?

Options:

Nicotine impairs osteoblast activity, thus interfering with bone remodeling.
The effects of smoking on bone healing are multifactorial and not yet fully understood.
The vasoconstrictive and platelet-activating properties of nicotine inhibit fracture healing.
Nicotine inhibits the function of fibroblasts, red blood cells, and macrophages.
Hydrogen cyanide inhibits oxidative metabolism at the cellular level.

Correct Answer: The effects of smoking on bone healing are multifactorial and not yet fully understood.

Explanation:

Question 22:

Options:

Autogenous iliac crest bone graft
Calcium phosphate
Calcium sulfate
Tricalcium phosphate
Coralline hydroxyapatite blocks

Correct Answer: Calcium phosphate

Explanation:

Question 23:

The direct anterior (Smith-Peterson) approach to hip arthroplasty is most commonly associated with injury to what nerve?

Options:

Lateral femoral cutaneous
Sciatic
Pudendal
Superior gluteal

Correct Answer: Lateral femoral cutaneous

Explanation:

Question 24:

Options:

observation.
proximal tibial osteotomy.
proximal tibial hemiepiphyseodesis.
a long leg brace with a varus-producing strap.
MRI to map the extent of the osseous physeal bridge.

Correct Answer: observation.

Explanation:

Question 25:

Options:

revision of the current orthotics.
metatarsal osteotomies to correct cavus.
a sliding calcaneal osteotomy to correct hindfoot varus.
triple arthrodesis, with anterior transfer of the posterior tibialis.
extensor transfer to the metatarsal necks, soft-tissue releases, and anterior transfer of the posterior tibialis tendon.

Correct Answer: extensor transfer to the metatarsal necks, soft-tissue releases, and anterior transfer of the posterior tibialis tendon.

Explanation:

Question 26:

Options:

Unreamed intramedullary nail
Reamed statically locked intramedullary nail
External fixation
Plate fixation and interfragmentary compression
Bridge plate stabilization

Correct Answer: Plate fixation and interfragmentary compression

Explanation:

Question 27:

Compared to metal-on-polyethylene total hip bearing surfaces, the debris particles generated by metal-on-metal articulations are

Options:

larger and less numerous.
larger and more numerous.
smaller and less numerous.
smaller and more numerous.
not detectable.

Correct Answer: smaller and more numerous.

Explanation:

DISCUSSION: Retrieval studies have shown that the debris particles produced by
metal-on-metal articulations in total hip arthroplasty are several orders of magnitude smaller
and may be up to 100 times more numerous than those found with metal-on-polyethylene articulations.
REFERENCES: Davies AP, Willert HG, Campbell PA, et al: An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements.
J Bone Joint Surg Am 2005;87:18-27.
Firkins PJ, Tipper JL, Saadatzadeh MR, et al: Quantitative analysis of wear and wear debris from metal-on-metal hip prostheses tested in a physiological hip joint simulator. Biomed Mater Eng 2001;11:143-157.

Question 28:

Options:

Adduction
Internal rotation
Abduction and external rotation
Abduction
External rotation

Correct Answer: Adduction

Explanation:

Question 29:

Options:

Continue physical therapy
Latissimus dorsi transfer
Arthroscopic rotator cuff repair
Pectoralis major transfer
Reverse total shoulder arthroplasty

Correct Answer: Pectoralis major transfer

Explanation:

Question 30:

Options:

colchicine and indomethacin
radiation therapy to the left hand.
systemic chemotherapy.
IV antibiotics.
through the wrist amputation.

Correct Answer: colchicine and indomethacin

Explanation:

DISCUSSION: This clinical picture is most consistent with periarticular erosions from gout. The patient has multiple periarticular lytic lesions in the hand. The laboratory studies show an elevated serum uric acid level, and the biopsy specimen demonstrates acute and chronic inflammation with prominent clefts. Therefore, the preferred treatment is systemic control of her gout. Radiation therapy, chemotherapy, and/or amputation should be considered for a malignancy; however, the pathology does not demonstrate any evidence of pleomorphism, high nuclear-to-cytoplasmic ratio, nuclear atypia, or mitotic activity. Antibiotics for an infectious process is a consideration, but the minimal elevation in the WBC count and erythrocyte sedimentation rate does not support an infectious process.
REFERENCES: Wise CM: Crystal-associated arthritis in the elderly. Clin Geriatr Med 2005;21:491-511.
Mudgal CS: Management of tophaceous gout of the distal interphalangeal joint. J Hand Surg Br 2006;31:101-103.

Question 31:

What arterial vessel is most prone to injury during posterior iliac crest bone graft harvest?

Options:

Superior gluteal
Deep circumflex iliac
Iliolumbar
Ascending branch of the lateral femoral circumflex
Fourth lumbar

Correct Answer: Superior gluteal

Explanation:

Question 32:

Options:

Open biopsy followed by curettage and bone grafting
MRI, whole-body bone scan, CT of the chest, followed by incisional biopsy
Allow the fracture to heal with nonsurgical management and serial radiographs
Open biopsy followed by wide resection and reconstruction with osteoarticular allograft
Open biopsy followed by wide resection and endoprosthetic replacement

Correct Answer: Allow the fracture to heal with nonsurgical management and serial radiographs

Explanation:

DISCUSSION: This radiolucent lesion with a “fallen leaf sign” is typical for a unicameral bone cyst(UBC). The most appropriate treatment is to allow the fracture to heal with clinical and radiographic observation. Curettage and bone grafting is not the best initial management for UBC. Wide resection is not indicated for UBC. The proximal humerus is the most common site for UBC. While staging studies consisting of MRI, bone scan, and CT of the chest are appropriate for lesions suspected of being malignant, the classical appearance of this UBC is such that this work-up is not necessary initially. Following fracture healing, aspiration and injection of the cyst may be indicated.
REFERENCES: Dormans JP, Pill SG: Fractures through bone cysts: Unicameral bone cysts, aneurysmal bone cysts, fibrous cortical defects, and nonossifying fibromas. Instr Course Lect 2002;51:457-467.
Deyoe L, Woodbury DF: Unicameral bone cyst with fracture. Orthopedics 1985;8:529-531.

Question 33:

Options:

Increase his current opioid medication regimen prior to and after surgery as needed to control his pain.
Decrease his preoperative opioid use, and work with his pain management physician to decrease his postoperative opioid requirement.
Avoid using narcotics in the perioperative period to prevent overdose, and use acetaminophen only for pain control.
Stop all his opioids 5 days before surgery, and place the patient on a morphine pain control pump postoperatively with a basal rate.

Correct Answer: Decrease his preoperative opioid use, and work with his pain management physician to decrease his postoperative opioid requirement.

Explanation:

Question 34:

Options:

Renal osteodystrophy
Pyogenic osteomyelitis
Osteoarthritis
Osteonecrosis
Tuberculosis osteomyelitis

Correct Answer: Osteonecrosis

Explanation:

DISCUSSION: The photomicrograph demonstrates a wedge-shaped infarct with femoral head collapse; therefore, the diagnosis is osteonecrosis of the femoral head. Perthes disease and osteoarthritis do not involve a wedge-shaped defect. Tuberculosis of the hip joint results in greater destruction of the articular cartilage.
REFERENCES: Basset LW, Mirra JM, Cracchiolo A III: Ischemic necrosis of the femoral head: Correlation between magnetic resonance imaging and histologic sections. Clin Orthop 1987;223:181-187.
Sugano N: Osteonecrosis, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopedics. St Louis, MO, Mosby, 2002, pp 878-887.

Question 35:

Options:

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

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

Explanation:

Question 36:

The anterior approach to total hip arthroplasty requires dissection between which of the following muscle planes?

Options:

Sartorius and gluteus maximus
Gluteus minimus and rectus femoris
Rectus femoris and sartorius
Tensor fascia lata and sartorius
Tensor fascia lata and rectus femoris

Correct Answer: Tensor fascia lata and sartorius

Explanation:

AL-Madena Copy
DISCUSSION: The anterior approach to the hip joint involves identifying the plane between the tensor fascia lata and the sartorius muscles.
REFERENCES: Berger RA, Duwelius PJ: The two-incision minimally invasive total hip arthroplasty: Technique and results. Orthop Clin North Am 2004;35:163-172.
Matta JM, Shahrdar C, Ferguson T: Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005;441:115-124.
28 • American Academy of Orthopaedic Surgeons
Figure 3Id Figure 31e

Question 37:

Options:

Cervical C6-7 radiculopathy
Impingement
Rotator cuff tear
Brachial neuritis
Adhesive capsulitis

Correct Answer: Brachial neuritis

Explanation:

Question 38:

Options:

Strongly negative needle-shaped crystals
Weakly positive birefringent rhomboid-shaped crystals
Gross blood
Gram-positive cocci
Gram-negative rods

Correct Answer: Weakly positive birefringent rhomboid-shaped crystals

Explanation:

Question 39:

Options:

Referral to a pain clinic
MRI
CBC, erythrocyte sedimentation rate, and C-reactive protein
Single photon emission computer tomography (SPECT)
Electromyography and nerve conduction velocity studies

Correct Answer: Single photon emission computer tomography (SPECT)

Explanation:

DISCUSSION: Symptoms of activity-related low back pain, physical findings of pain with extension, lateral bending, and resuming an upright position, and relative hamstring tightness are consistent with spondylolysis. While the initial diagnostic work-up should include plain radiographs of the lumbosacral spine, the findings may be negative because it can take weeks or months for the characteristic changes to become apparent. SPECT has been a useful adjunct in the diagnosis of spondylolysis when plain radiographs are negative. Since the patient’s pain is activity related and she is otherwise healthy, evaluation for infection is not indicated. Because the neurologic examination is normal, electromyography, nerve conduction velocity studies, and MRI are not indicated. CT can be used in those instances in which SPECT and bone scans
are negative.
REFERENCES: Ciullo JV, Jackson DW: Pars interarticularis stress reaction, spondylolysis, and spondylolisthesis in gymnasts. Clin Sports Med 1985;4:95-110.
Collier BD, Johnson RP, Carrera GF, et al: Painful spondylolysis or spondylolisthesis studied by radiography and single photon emission computed tomography. Radiology 1985;154:207-211.
Jackson DW, Wiltse LL, Cirincione RT: Spondylolysis in the female gymnast. Clin Orthop 1976;117:68-73.
Ginsberg GM, Bassett GS: Back pain in children and adolescents: Evaluation and differential diagnosis. J Am Acad Orthop Surg 1997;5:67-78.
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Question 40:

Vertebral fractures are common in the thoracolumbar spine. What is the most important factor that determines the strength of the cancellous bone in the vertebral body?

Options:

Mineral content
Rate of loading
Anatomic level of the vertebra
Apparent density
Trabecular number

Correct Answer: Apparent density

Explanation:

Question 41:

Options:

Surgery is being considered for a 30-month-old child who has the deformity shown in Figure 21. Which of the following studies should be ordered before proceeding with surgery?
Liver profile
Myleogram
Platelet count
CT scan of the head
Angiogram of the extremity

Correct Answer: Myleogram

Explanation:

Question 42:

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

Options:

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

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

Explanation:

Question 43:

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

Options:

Cannulated screws
Valgus intertrochanteric osteotomy
Unipolar hemiarthroplasty
Bipolar hemiarthroplasty
Total hip arthroplasty

Correct Answer: Unipolar hemiarthroplasty

Explanation:

Question 44:

Options:

Complete release of the proximal annular pulley of the flexor sheath
Removal of the nodule in the flexor pollicis longus
Fractional lengthening of the flexor pollicis longus tendon at the musculotendinous junction
Steroid injection into the palpable nodule
No treatment because this condition normally spontaneously resolves

Correct Answer: Complete release of the proximal annular pulley of the flexor sheath

Explanation:

DISCUSSION: The child has a trigger thumb deformity. A trigger thumb is a developmental mechanical problem rather than a congenital deformity. The anomaly generally is not noted at birth. A fixed flexion deformity of the IP joint of the thumb most commonly occurs in children in the first 2 years of life. A stretching and splinting program may correct the deformity in the first year of life, but nonsurgical management after age 3 years results in a success rate of only 50%. Release of the proximal annular pulley of the flexor sheath is recommended at this age.
REFERENCES: Tan AH, Lam KS, Lee EH: The treatment outcome of trigger thumb in children. J Pediatric Orthop B 2002;11:256-259.
Slakey JB, Hennrikus WL: Acquired thumb flexion contracture in children: Congenital trigger thumb. J Bone Joint Surg Br 1996;78:481-483.
Herring JA: Disorders of the upper extremity: Thumb dysplasia, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, p 445.

Question 45:

What adaptations occur in the dominant shoulder of throwers compared to their nondominant shoulder? Review Topic

Options:

Humeral anteversion with a normal total arc of motion
Tight posterior capsule with a normal total arc of motion
Lengthening of the anterior capsule with a decreased total arc of motion
Increased external rotation with a decreased total arc of motion
Decreased internal rotation with an increased total arc of motion

Correct Answer: Tight posterior capsule with a normal total arc of motion

Explanation:

Question 46:

Which of the following patients with cerebral palsy is considered the ideal candidate for a selective dorsal rhizotomy?

Options:

An ambulatory 6-year-old patient with spastic diplegia
An ambulatory 10-year-old patient with spastic right hemiplegia
An ambulatory 16-year-old patient with spastic diplegia
A nonambulatory 8-year-old patient with spastic quadriplegia
A nonambulatory 18-year-old patient with rigid quadriplegia

Correct Answer: An ambulatory 6-year-old patient with spastic diplegia

Explanation:

Question 47:

Options:

Cytokeratin positive
PAS negative
Reticulin positive
MIC-2 positive
Vimentin negative

Correct Answer: MIC-2 positive

Explanation:

DISCUSSION: The imaging studies show a permeative lesion of the left hemipelvis with a large soft-tissue mass. The photomicrograph demonstrates a small blue cell tumor with pseudorosettes. The most likely diagnosis is primitive neuroectodermal tumor (Ewing’s sarcoma family of tumors). MIC-2 is a highly sensitive and specific marker for this family of tumors. Cytokeratin is an epithelial marker. Vimentin is a mesenchymal marker. Thus, Ewing’s sarcomas are cytokeratin negative and vimentin positive. Before discovery of the MIC-2 antigen, PAS and reticulin stains were commonly used to help differentiate Ewing’s sarcoma from lymphoma. In contrast to lymphoma, Ewing’s sarcomas are typically PAS positive and reticulin negative.
REFERENCES: Halliday BE, Slagel DD, Elsheikh TE, et al: Diagnostic utility of MIC-2 immunocytochemical staining in the differential diagnosis of small blue cell tumors. Diagn Cytopathol 1998;19:410-416.
Llombart-Bosch A, Navarro S: Immunohistochemical detection of EWS and FLI-1 proteins is Ewing sarcoma and primitive neuroectodermal tumors: Comparative analysis with CD99
(MIC-2) expression. Appl Immunohistochem Mol Morphol 2001;9:255-260.

Question 48:

A radiograph, MRI scans, and a biopsy specimen of a 9-year-old boy with thigh pain are shown in Figures 37a through 37d. Management should consist of

Options:

external beam radiation.
hemipelvectomy.
hip disarticulation.
wide resection of the femur and reconstruction.
antibiotics.

Correct Answer: wide resection of the femur and reconstruction.

Explanation:

Question 49:

Options:

exploration and neurolysis/repair.
MRI of the arm.
functional electrical stimulation.
radial nerve tendon transfers.
observation.

Correct Answer: observation.

Explanation:

DISCUSSION: In patients with radial nerve injuries with closed humeral fractures, it has been reported that 85% to 95% spontaneously recover. Based on this premise, most surgeons favor expectant management of these injuries. Even if there is no evidence of recovery at 6 weeks, repeat electromyography at 12 weeks is advocated. If there is no clinical or electromyographic signs of recovery at 6 months, exploration is recommended. If the nerve is in continuity at the time of exploration, nerve action potentials are useful in helping determine the need for neurolysis, excision, and grafting, or if excision and repair is the best option.
REFERENCES: Pollock FH, Drake D, Bovill EG, et al: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.
Mohler LR, Hanel DP: Closed fractures complicated by peripheral nerve injury. J Am Acad Orthop Surg 2006;14:32-37.

Question 50:

Options:

Continued rest, formal physical therapy and anti-inflammatory medications
Targeted chemonucleolysis of the L4-5 disc
Discectomy and interbody fusion L4-5
Discectomy utilizing a midline approach between the spinous process and multifidus
Discectomy utilizing an intermuscular approach between multifidus and longissimus

Correct Answer: Discectomy and interbody fusion L4-5

Explanation:

Question 51:

Options:

Axillary view
CT of the shoulder
Closed reduction
Sling and close follow-up
Functional brace

Correct Answer: Axillary view

Explanation:

DISCUSSION: The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a “Velpeau” axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.
REFERENCE: Simon JA, Puopolo SM, Capla EL, et al: Accuracy of the axillary projection to determine fracture angulation of the proximal humerus. Orthopedics 2004;27:205-207.

Question 52:

Options:

Rett syndrome
Spinal muscular atrophy, type 2
Congenital muscular dystrophy
Duchenne muscular dystrophy
Congenital myotonic dystrophy

Correct Answer: Spinal muscular atrophy, type 2

Explanation:

DISCUSSION: The patient has spinal muscular atrophy, type 2. This type is intermediate in severity between the Werdnig-Hoffmann type (type 1) and the Kugelberg-Welander type
(type 3). It normally manifests itself between the ages of 3 and 15 months. Survival until adolescence is common. All three types of spinal muscular atrophy have been linked to the SMN gene at the 5q12.2-13.3 locus. DNA testing is available and is preferred to muscle biopsy because it is less invasive and more definitive.
REFERENCES: Biros I, Forrest S: Spinal muscular atrophy: Untangling the knot? J Med Genet 1999;36:1-8.
Zerres K, Wirth B, Rudnik-Schoneborn S: Spinal muscular atrophy: Clinical and genetic correlations. Neuromuscul Disord 1997;7:202-207.

Question 53:

Options:

Medial cord of the brachial plexus
Radial nerve
Median nerve
Axillary nerve
Musculocutaneous nerve

Correct Answer: Musculocutaneous nerve

Explanation:

Question 54:

Options:

Extent of bowel and bladder dysfunction
Extent of the motor deficit
Extent of the perianal saddle anesthesia
Timing of surgery
Location of the herniation

Correct Answer: Timing of surgery

Explanation:

Question 55:

Options:

Examination of the pedal pulses
Ankle-brachial pressure index
Duplex ultrasound
Arteriography
Exploration of the popliteal artery

Correct Answer: Examination of the pedal pulses

Explanation:

Question 56:

Options:

Bone scan
Curettage and bone grafting of the cyst
Cast immobilization
Observation with reduced activity
Skeletal survey

Correct Answer: Observation with reduced activity

Explanation:

DISCUSSION: The most likely diagnosis is Sever’s disease, which is considered either an apophysitis or a para-apophyseal stress fracture. It is common in athletic children and is associated with a tight Achilles tendon. Cast immobilization may be necessary if activity reduction fails. Calcaneal cysts are quite common and do not require any further diagnostic testing or treatment unless they occupy the full width of the calcaneus or one third of the length of the calcaneus.
REFERENCES: Ogden JA, Ganey TM, Hill JD, et al: Sever’s injury: A stress fracture of the immature calcaneal metaphysis. J Ped Orthop 2004;24:488-492.
Pogoda P, Priemel M, Linhart W, et al: Clinical relevance of calcaneal bone cysts: A study of 50 cysts in 47 patients. Clin Orthop Relat Res 2004;424:202-210.

Question 57:

Options:

What is the next most appropriate step in treatment?
Exchange nailing
Manipulation under anesthesia
Nail removal and plate fixation
Percutaneous locked plating
Nail dynamization

Correct Answer: Manipulation under anesthesia

Explanation:

Question 58:

Which of the following ligaments is most commonly involved in posterolateral rotatory instability of the elbow?

Options:

Annular
Lateral ulnar collateral
Anterior band of the medial collateral
Radial part of the lateral collateral
Posterior capsular

Correct Answer: Lateral ulnar collateral

Explanation:

Question 59:

Options:

in situ posterior fusion.
in situ anterior and posterior fusion.
observation and a follow-up examination in 6 months.
bracing.
anterior decompression and fusion with posterior fusion.

Correct Answer: in situ posterior fusion.

Explanation:

Question 60:

An adult patient has an 8- x 4- x 10-cm soft-tissue mass located within the adductor compartment of the thigh. Staging studies should consist of

Options:

MRI and a radiograph of the thigh and CT of the chest.
MRI of the thigh, a chest radiograph, and a CT of the pelvis.
MRI of the thigh, a total body bone scan, a chest radiograph, and a CT of the pelvis.
MRI of the thigh, a total body bone scan, a chest radiograph, and a CT of the abdomen and pelvis.
a CT of the chest and thigh, a total body bone scan, and a chest radiograph.

Correct Answer: MRI and a radiograph of the thigh and CT of the chest.

Explanation:

Question 61:

What is the advantage of percutaneous pedicle screw fixation over open instrumentation and fusion for a thoracolumbar burst fracture without neurologic deficit?

Options:

Better clinical outcomes
Less blood loss
Less pseudarthrosis risk
Lower revision surgery rate

Correct Answer: Less blood loss

Explanation:

DISCUSSION
A prospective randomized study on short-segment treatment of burst fractures with and without fusion demonstrated similar outcomes at 5 years with lower blood loss in the nonfusion group. There is by definition no fusion performed with percutaneous stabilization, so patients often develop hardware failure. Some surgeons routinely remove instrumentation following percutaneous stabilization, thus revision surgery is common. Clinical outcomes are not improved compared to open methods.
RECOMMENDED READINGS
Koreckij T, Park DK, Fischgrund J. Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma. Neurosurg Focus. 2014;37(1):E11. doi: 10.3171/2014.5.FOCUS1494. Review. PubMed PMID: 24981899.
View Abstract at PubMed
Jindal N, Sankhala SS, Bachhal V. The role of fusion in the management of burst fractures of the thoracolumbar spine treated by short segment pedicle screw fixation: a prospective randomised trial. J Bone Joint Surg Br. 2012 Aug;94(8):1101-6. doi: 10.1302/0301-620X.94B8.28311. PubMed PMID: 22844053.
View Abstract at
PubMed
Dai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures. a five to seven-year prospective randomized study. J Bone
Joint Surg Am. 2009 May;91(5):1033-41. doi: 10.2106/JBJS.H.00510. PubMed PMID:

Question 62:

Options:

Hypernatremia
Hypothermia
Hyponatremia
Subendocardial myocardial infarction
Ruptured berry aneurysm

Correct Answer: Hyponatremia

Explanation:

Question 63:

Surgical restoration of sagittal balance of an adult spinal deformity will have which effect on outcome?

Options:

No effect
Improve leg-related symptoms but not back pain
Improve quality of life and back pain
Improve quality of life and leg-related symptoms

Correct Answer: Improve quality of life and back pain

Explanation:

DISCUSSION
The influence of sagittal balance on outcomes following fusion-based procedures for degenerative conditions of the lumbar spine has only recently been appreciated. Restoration of sagittal spinal balance improves low-back-pain outcomes and quality of life. Sagittal spinal balance has not been shown to relieve neurogenic claudication attributable to spinal stenosis.
RECOMMENDED READINGS
Li Y, Hresko MT. Radiographic analysis of spondylolisthesis and sagittal spinopelvic deformity. J Am Acad Orthop Surg. 2012 Apr;20(4):194-205. doi: 10.5435/JAAOS-20-04-194. Review. PubMed PMID: 22474089.
View Abstract at PubMed
Korovessis P, Repantis T, Papazisis Z, Iliopoulos P. Effect of sagittal spinal balance, levels of posterior instrumentation, and length of follow-up on low back pain in patients undergoing posterior decompression and instrumented fusion for degenerative lumbar spine disease: a multifactorial analysis. Spine (Phila Pa 1976). 2010 Apr 15;35(8):898-905. doi: 10.1097/BRS.0b013e3181d51e84. PubMed PMID: 20354466.
View
Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 99 AND 100
Figures 99a and 99b are MR images of a 59-year-old man with a history of intravenous (IV) drug abuse who arrives at the emergency department with malaise and fever. Upon admission, the patient's temperature is 38.9°C, his white blood cell count is 17000/µL (reference range [rr], 4500-11000/µL), his erythrocyte sedimentation rate is 98 mm/h (rr, 0-20 mm/h), and his C-reactive protein level is 45 mg/L (rr, 0.08-3.1 mg/L). He is admitted to the medical service to evaluate the source of his fevers. On hospital day 1, the patient reports weakness in his left arm and leg. Blood cultures are positive for methicillin-resistant Staphylococcus aureus.
A B

Question 64:

Options:

Relatively young, active patient
Patient with an inflammatory systemic disorder
Elderly patient with a sedentary lifestyle
Patient with severe arthritis of the ipsilateral hip or knee
Patient with Parkinson’s disease

Correct Answer: Elderly patient with a sedentary lifestyle

Explanation:

DISCUSSION: Most authors recommend an initial trial of nonsurgical management in the treatment of adult-acquired flatfoot deformity such as posterior tibial tendon dysfunction. Chao and associates found that there is high patient satisfaction with ankle-foot orthoses and UCBL-type inserts in elderly patients with a relatively sedentary lifestyle. Alternatively, there was a higher dissatisfaction rate in young active patients, those with balance and ambulation difficulties (Parkinson’s, severe arthritis of the hip or knee), and patients with inflammatory systemic disorders.
REFERENCES: Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int 1996;17:736-741.
Noll KH: The use of orthotic devices in adult acquired flatfoot deformity. Foot Ankle Clin 2001;6:25-36.

Question 65:

Which of the following forms of nonsurgical management is considered best for acute low back pain without radiculopathy?

Options:

Acupuncture
Epidural steroid injections
Facet joint injections
Sclerosant injections
Bed rest

Correct Answer: Bed rest

Explanation:

Question 66:

What is the mechanism of action of an intramuscular injection of botulinum type A toxin in reducing spasticitiy?

Options:

Blocks the release of presynaptic acetylcholine release at the neuromuscular junction and end plate
Acts as a g -aminobutyric acid (GABA) agonist
Inhibits afferent fibers in the dorsal root of the spinal nerve
Competitively blocks the acetylcholine receptor
Destroys the neuromuscular junction

Correct Answer: Blocks the release of presynaptic acetylcholine release at the neuromuscular junction and end plate

Explanation:

Question 67:

Options:

Open distal tibial allograft reconstruction
Open reduction and internal fixation (ORIF) with cannulated screws
Arthroscopic coracoid transfer
Arthroscopic repair incorporating the bony component

Correct Answer: Arthroscopic repair incorporating the bony component

Explanation:

Question 68:

Options:

excision of the fracture fragment.
radial head replacement.
closed reduction and cast immobilization.
open reduction and internal fixation of the radial head.
open reduction and internal fixation of the capitellum.

Correct Answer: open reduction and internal fixation of the capitellum.

Explanation:

Question 69:

Options:

rotator cuff repair.
revision acromioplasty.
fragment excision.
open reduction and internal fixation.
continued rehabilitation.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 70:

What is the most prevalent adverse event associated with allogeneic blood transfusion?

Options:

Clerical error leading to transfusion reaction
Anaphylactic reaction
HIV transmission
Hepatitis C transmission
Bacterial contamination leading to sepsis/shock

Correct Answer: Clerical error leading to transfusion reaction

Explanation:

DISCUSSION: Clerical error leading to acute hemolysis and even death occurs in 1:12,000 to 1:50,000 transfusions. Bacterial contamination leading to sepsis/shock occurs in 1:1 million transfusions. HIV transmission is approximately 1:500,000 transfusions and hepatitis C is 1:103,000 transfusions. Anaphylactic reactions occur in 1:150,000 transfusions.
REFERENCES: Aubuchon JP, Birkmeyer JD, Busch MP: Safety of the blood supply in the United States: Opportunities and controversies. Ann Intern Med 1997;127:904-909.
Popovsky MA, Whitaker B, Arnold NL: Severe outcomes of allogeneic and autologous blood donation: Frequency and characterization. Transfusion 1995;35:734-737.

Question 71:

Options:

Age > 60 years
> or = 2 comorbid conditions
History of tobacco use
BMI > 30 kg/m²
Using a pedicle subtraction osteotomy

Correct Answer: > or = 2 comorbid conditions

Explanation:

Question 72:

Which of the following nonunions is appropriately treated with exchange reamed nailing without bone graft augmentation?

Options:

Infected tibial shaft nonunion 6 months status post intramedullary nail fixation
Oligotrophic humeral shaft nonunion 7 months status post non-operative management
Hypertrophic tibial shaft nonunion 7 months status post intramedullary nail fixation
Comminuted open tibial shaft nonunion with segmental bone loss 8 months status post intramedullary nail fixation
Supracondylar femoral shaft nonunion 6 months status post intramedullary nail fixation with 4 distal locking screws

Correct Answer: Infected tibial shaft nonunion 6 months status post intramedullary nail fixation

Explanation:

Question 73:

Design factors that enhance the long-term survival of proximally coated cementless hip implants include both initial stability and

Options:

circumferential porous coating.
a titanium porous coating.
a fluted stem.
a distal centralizer.
modular fixation pads.

Correct Answer: circumferential porous coating.

Explanation:

Question 74:

Options:

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

Correct Answer: Splinting, admission, and frequent neurovascular checks

Explanation:

Question 75:

Options:

Continued bracing, physical therapy, and Botox injections in the triceps surae
Peroneus longus to brevis transfer, medializing calcaneal osteotomy, and transfer of the extensor digitorum longus to the peroneus tertius
Peroneus longus to brevis transfer, and transfer of the posterior tibial tendon to the tibialis anterior tendon
Peroneus longus to brevis transfer, first metatarsal cuneiform dorsal closing wedge osteotomy, and lateralizing calcaneal osteotomy with proximal translation
Triple arthrodesis

Correct Answer: Peroneus longus to brevis transfer, first metatarsal cuneiform dorsal closing wedge osteotomy, and lateralizing calcaneal osteotomy with proximal translation

Explanation:

Question 76:

Options:

Open reduction and internal fixation of the lateral condyle
Microfracture of the chondral defect
Immediate anterior cruciate ligament (ACL) reconstruction
Delayed ACL reconstruction

Correct Answer: Delayed ACL reconstruction

Explanation:

Question 77:

A 40-year-old male who sustained an open pilon fracture 2 weeks ago is scheduled for a below-the-knee amputation (BKA). What laboratory value is the best predictor for wound healing?

Options:

serum albumin level
total protein level
calcium levels
C-reactive protein
ESR

Correct Answer: serum albumin level

Explanation:

Question 78:

A 50-year-old patient who plays tennis sustained the deformity shown in Figure 27 following a high volley. Further diagnostic work-up should include

Options:

an electromyogram (EMG) of the upper extremity.
an ultrasound of the short head of the biceps.
an MRI scan of the rotator cuff.
a CT scan with contrast of the anterior labrum.
a subclavian venogram.

Correct Answer: an MRI scan of the rotator cuff.

Explanation:

Question 79:

Options:

Knee aspiration for culture
CT of the knee to assess implant rotation
Indium-111 leukocyte/technetium-99m sulfur colloid scan of the knee
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) laboratory studies

Correct Answer: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) laboratory studies

Explanation:

Question 80:

What is the most appropriate treatment for a chordoma involving the sacrum?

Options:

Chemotherapy
External beam radiation therapy
En bloc surgical resection with negative margins
Intralesional resection followed by radiation therapy
Intralesional resection followed by chemotherapy

Correct Answer: En bloc surgical resection with negative margins

Explanation:

Question 81:

Options:

notification of child protective services and hospital admission.
a punch biopsy of skin for collagen analysis.
DNA testing for OI.
calcium, phosphate, and alkaline phosphatase studies.
placement of intramedullary rods to prevent further fractures.

Correct Answer: notification of child protective services and hospital admission.

Explanation:

Question 82:

Options:

Fluid and electrolyte imbalance
Increased bleeding time
Impaired liver function
Lowered oxygen requirements
Splenomegaly

Correct Answer: Fluid and electrolyte imbalance

Explanation:

Question 83:

Options:

Transforming growth factor-beta (TGF-ß), bone morphogenetic protein-2 (BMP-2), latent membrane protein 1
Tissue inhibitor of matrix metallo-proteinase-1 (MMP-1), growth and development factor-5, noggin
Gremlin, MMP, biglycan
Tumor necrosis factor-alpha (TNF-a), Interleukin-1 (IL-1), MMP

Correct Answer: Tumor necrosis factor-alpha (TNF-a), Interleukin-1 (IL-1), MMP

Explanation:

DISCUSSION
The patient has degenerative disk disease with diskogenic back pain. Several studies in both humans and animals have implicated TNF-a, IL-1, and MMP in extracellular matrix degeneration and disk degradation. TGF-ß, BMP-2, latent membrane protein 1, and growth and development factor-5 are all postulated to play anabolic roles in the intervertebral disk. Biglycan is a small leucine-rich proteoglycan that regulates extracellular matrix assembly within the disk. Noggin and gremlin are biochemical factors not involved in disk degradation.
RECOMMENDED READINGS
Kim HT, Yoon ST, Jarrett C. Articular cartilage and intervertebral disk. In: Fischgrund JS, ed. Orthopaedic Knowledge Update 9. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:23-33.
Hoyland JA, Le Maitre C, Freemont AJ. Investigation of the role of IL-1 and TNF in matrix degradation in the intervertebral disc. Rheumatology (Oxford). 2008 Jun;47(6):809-14. doi: 10.1093/rheumatology/ken056. Epub 2008 Apr 8. PubMed PMID: 18397957.
View Abstract
at PubMed
Gruber HE, Ingram JA, Hanley EN Jr. Immunolocalization of MMP-19 in the human intervertebral disc: implications for disc aging and degeneration. Biotech Histochem. 2005 May-Aug;80(3-4):157-62. PubMed PMID: 16298901.
View Abstract at PubMed

Question 84:

Options:

Osteoarthritis
Rheumatoid arthritis
Pigmented villonodular synovitis
Charcot arthropathy
Paget’s disease

Correct Answer: Rheumatoid arthritis

Explanation:

Question 85:

What is the predominant type of collagen in the tissue resulting from the surgical procedure shown in Figures 40a through 40c?

Options:

Type I
Type II
Type III
Type IX
TypeX

Correct Answer: Type I

Explanation:

Question 86:

Options:

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

Correct Answer: Medial collateral ligament sprain

Explanation:

Question 87:

Options:

Transfusion of whole blood
Transfusion of packed red blood cells
A cell saver with continuity maintained in a “closed circuit”
Transfusion of plasma
Transfusion of platelets

Correct Answer: A cell saver with continuity maintained in a “closed circuit”

Explanation:

Question 88:

Options:

MRI
Arthrocentesis for synovial fluid cell count and bacterial culture
Ophthalmology consultation
Angiotensin converting enzyme (ACE) level
Technetium radioisotope bone scan

Correct Answer: Ophthalmology consultation

Explanation:

DISCUSSION: Up to 30% of children with juvenile rheumatoid arthritis (increasingly known now as juvenile idiopathic arthritis or JIA) already have potentially damaging uveitis at the time of diagnosis. This patient has typical oligoarticular JRA (JIA) and therefore is at significant risk for uveitis. MRI, radioisotope scanning, or an ACE level most likely would not provide additional useful diagnostic information because intra-articular derangement, osteomyelitis, or sarcoidosis are all unlikely. Arthrocentesis and triamcinolone hexacetonide joint injection might be indicated if continued use of nonsteroidal medication does not result in improvement, but should be held off for at least an additional 4 to 6 weeks to see if continued use of naproxen results in control of the arthritis.
REFERENCES: Wolf MD, Lichter PR, Ragsdale CG: Prognostic factors in the uveitis of juvenile rheumatoid arthritis. Ophthalmology 1987;94:1242.
Cassidy JT, Petty RE: Textbook of Pediatric Rheumatology. Philadelphia, PA, WB Saunders, 2001, p 220.
Chalom ED, Goldsmith DP, Koehler MA, et al: Prevalence and outcome of uveitis in a regional cohort of patients with juvenile rheumatoid arthritis. J Rheumatol 1997;24:2031-2034.

Question 89:

Options:

Painful os trigonum
Posterior ankle soft-tissue impingement
Stricture in the knot of Henry
Flexor digitorum longus tendinitis
Flexor hallucis longus tendinitis

Correct Answer: Flexor hallucis longus tendinitis

Explanation:

Question 90:

The dorsal (Thompson) approach to the proximal forearm uses which of the following intermuscular intervals?

Options:

Extensor carpi radialis longus and the extensor carpi radialis brevis
Extensor pollicis longus and the extensor pollicis brevis
Extensor digitorum communis and the extensor carpi radialis brevis
Extensor carpi ulnaris and the extensor carpi radialis brevis
Abductor pollicis longus and the extensor carpi radialis brevis

Correct Answer: Extensor digitorum communis and the extensor carpi radialis brevis

Explanation:

Question 91:

Options:

Deep infection
Failure of repair
Peroneus longus tear
Peroneus brevis tear
Tibiotalar arthritis

Correct Answer: Peroneus brevis tear

Explanation:

DISCUSSION: Chronic lateral instability is commonly associated with a longitudinal split tear of the peroneus brevis tendon. The interrelationship of lateral ankle instability with superior retinacular laxity and resultant peroneus brevis split can account for persistent lateral ankle pain in this patient. Surgical treatment must identify and correct the underlying tendon pathology and should attempt to repair or debride the peroneus brevis tendon, reconstruct the superior peroneal retinaculum, flatten the posterior edge of the fibula by removing the sharp bony prominence, or deepening the fibular groove, along with addressing lateral ankle ligamentous instability. The laboratory values are not consistent with infection. A negative anterior drawer test confirms stability of the repair. Ankle arthritis is not seen on radiographs and usually takes longer than 3 months to develop.
REFERENCES: Bonnin M, Tavernier T, Bouysset M: Split lesions of the peroneus brevis tendon in chronic ankle laxity. Am J Sports Med 1997;25:699-703.
Sobel M, Geppert MJ, Warren RF: Chronic ankle instability as a cause of peroneal tendon injury. Clin Orthop Relat Res 1993;296:187-191.

Question 92:

The view from an anterosuperior portal of the right shoulder shown in Figure 12 reveals which of the following findings?

Options:

Rupture of the subscapularis tendon
Tear of the rotator interval
Humeral avulsion of the glenohumeral ligament (HAGL) lesion
Anterior ligamentous periosteal sleeve avulsion (ALPSA) lesion
Bankart lesion

Correct Answer: Humeral avulsion of the glenohumeral ligament (HAGL) lesion

Explanation:

Question 93:

Options:

Joint congruity
Torn anterior tibiofibular ligament
Growth arrest leading to angular deformity
Growth arrest leading to limb-length discrepancy
Osteonecrosis of the talus

Correct Answer: Joint congruity

Explanation:

DISCUSSION: Tillaux and triplane fractures occur in adolescents as the result of an external rotation injury of the ankle. As seen on the CT scan, the growth plate starts to close during adolescence; therefore, growth arrest resulting in limb-length discrepancy or angulation is less of a concern in this age group than achieving joint congruity. The joint should be surgically reduced if displacement is greater than 2 mm to minimize the chances of late arthrosis.
REFERENCES: Kay RM, Matthys GA: Pediatric ankle fractures: Evaluation and treatment.
J Am Acad Orthop Surg 2001;9:268-278.
Kling TF Jr: Operative treatment of ankle fractures in children. Orthop Clin North Am 1990;21:381-392.
Duchesneau S, Fallat LM: The Tillaux fracture. J Foot Ankle Surg 1996;35:127-133.

Question 94:

In the United States, groups at risk for community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) within the pediatric and adolescent populations include

Options:

tennis players.
toddlers in daycare.
children who are home schooled.
African Americans.

Correct Answer: toddlers in daycare.

Explanation:

DISCUSSION
CA-MRSA is a growing problem in the United States. Groups at risk for CA-MRSA include athletes in contact sports and children in daycare. Tennis players, golfers, and runners are at lowest risk because their sports do not require close contact with teammates or competitors. Outbreaks have been noted in Alaskan native, Native American, and Pacific Islander minority populations.
CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 68
Figures 64a through 64d are the radiographs of an 11-year-old boy with a prolonged history of activity-related ankle pain. An examination is notable for restricted subtalar motion and moderate pes planovalgus.

Question 95:

Figure 36 shows the hip arthrogram of a newborn. Which of the following structures is enclosed by the circle?

Options:

Limbus
Pulvinar
Ligamentum teres
Transverse acetabular ligament
Acetabular labrum

Correct Answer: Acetabular labrum

Explanation:

DISCUSSION: The structure enclosed by the circle is the acetabular labrum. It is visible as the white point of tissue outlined by the darkly radiopaque contrast. The appearance of the contrast surrounding the sharp white point of a normal labrum is called the “rose thorn sign.” The limbus is the term reserved for a rounded, infolded labrum seen with arthrography. The pulvinar is the fatty tissue seen in the empty acetabulum when the hip is dislocated. The ligamentum teres is seen as a white stripe outlined by contrast coursing from the central acetabulum to the dislocated femoral head. The transverse acetabular ligament courses across the inferior portion of the acetabulum and is not clearly seen with arthrography.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA,
WB Saunders, 2002, vol 1, pp 532-533.
Severin E: Contribution to the knowledge of congenital dislocation of the hip joint.
Acta Chir Scand 1941;84:1.

Question 96:

Options:

A healing osteoporotic compression fracture
A pathologic fracture that is the result of an underlying neoplasm
Nonunion of the fracture with osteonecrosis
Vertebral osteomyelitis
Degeneration of the adjacent intervertebral disk

Correct Answer: Nonunion of the fracture with osteonecrosis

Explanation:

Question 97:

Options:

Nonsurgical management with weight bearing as tolerated
Nonsurgical management with no weight bearing on the left side
Nonsurgical management with use of a pelvic binder
Open reduction and internal fixation of the anterior pelvis
Open reduction and internal fixation of the anterior pelvis with placement of a left-sided percutaneous posterior screw

Correct Answer: Open reduction and internal fixation of the anterior pelvis

Explanation:

DISCUSSION: Symphyseal widening of greater than 2.5 cm and less than 5 cm denotes an AP II injury and a rotationally unstable pelvis. An AP II pelvic ring injury is best treated with anterior open reduction and internal fixation. Nonsurgical management is reserved for AP I injuries. Pelvic binders are used only acutely and should not be used for definitive management. Iliosacral screws usually are not necessary in the acute management of AP II injuries.
REFERENCES: Matta JM: Indications for anterior fixation of pelvic fractures. Clin Orthop Relat Res 1996;329:88-96.
Templeman DC, Schmidt AH, Sems AS, et al: Diastasis of the symphysis pubis: Open reduction internal fixation, in Wiss D (ed): Masters Techniques in Orthopaedic Surgery-Fractures, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 639-648.
Tile M: Management, in Tile M: Fractures of the Pelvis and Acetabulum, ed 2. Philadelphia, PA, Williams and Wilkins, 1995, pp 108-134.

Question 98:

Radiating pain associated with a posterolateral thoracic disk herniation typically follows what pattern? Review Topic

Options:

Extending down the spine into the lumbosacral region
Down the inner aspect of either upper extremity
Cephalad up to the cervicothoracic junction
Around or through the chest to the anterior wall
Down the contralateral lower extremity

Correct Answer: Around or through the chest to the anterior wall

Explanation:

Question 99:

What is the most common malignant bone tumor seen in patients with multiple hereditary exostosis?

Options:

Dedifferentiated chondrosarcoma
Mesenchymal chondrosarcoma
Secondary chondrosarcoma
Clear cell chondrosarcoma
Periosteal osteosarcoma

Correct Answer: Secondary chondrosarcoma

Explanation:

Question 100:

Which of the following 50-year-old patients with an irreparable rotator cuff tendon is the best candidate for an isolated latissimus dorsi muscle transfer? Review Topic

Options:

Man with active elevation to 90 degrees
Woman with active elevation to 45 degrees
Woman with a Hornblower's sign (complete absence of external rotation with abduction)
Man with superior escape of the humeral head
Man with full motion and a positive lift-off test

Correct Answer: Man with active elevation to 90 degrees

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

Orthopedic Board Review MCQs: Knee, Shoulder & Nerve | Part 82

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 82

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index