Orthopedic Board Prep MCQs: Hip, Knee & Nerve | Pt 92

About This Board Review Set

This is Part 92 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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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 92

This module focuses heavily on: Hip, Knee, Nerve.

Sample Questions from This Set

Sample Question 1: A 12-year-old girl has had pain in her right knee for 1 month that started as activity-related and progressed to night pain. Radiographs are shown in Figures 16a and 16b, and a biopsy specimen is shown in Figure 16c. What is the recommended...

Sample Question 2: A 7-year-old girl with spinal muscular atrophy (SMA) type II has popping of the left hip. Examination reveals painless subluxation of the joint in adduction with palpable reduction in abduction. Radiographs show coxa valga, subluxation of t...

Sample Question 3: During an anterior approach to the bicipital53tuberosity, you encounter a nerve overlying the brachioradialis fascia (Figure 58). It provides innervation to the...

Sample Question 4: The illustration shown in Figure 19 shows a Chamberlain line. What is the most likely diagnosis?...

Sample Question 5: A patient reports progessive bilateral hand clumsiness and ataxia. Examination reveals a positive Hoffmann’s sign and intrinsic atrophy. MRI reveals multilevel cervical spondylosis, and lateral flexion and extension radiographs show cervica...

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

A 12-year-old girl has had pain in her right knee for 1 month that started as activity-related and progressed to night pain. Radiographs are shown in Figures 16a and 16b, and a biopsy specimen is shown in Figure 16c. What is the recommended treatment?

Explanation

DISCUSSION: This is a classic appearance for an osteosarcoma. The radiographs reveal a mixed osteolytic and osteoblastic lesion in a skeletally immature patient in the distal right femoral metaphysis. The pain pattern with progressive symptoms leading to the presence of night pain is also typical for this condition. The biopsy specimen reveals pleomorphic cells and the presence of osteoid. The current standard of care in the treatment of osteosarcoma is neoadjuvant chemotherapy followed by surgical resection or amputation followed by additional postoperative chemotherapy. Osteosarcoma is not radiosensitive.
REFERENCES: Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 179.
McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 205.

Question 2

A 7-year-old girl with spinal muscular atrophy (SMA) type II has popping of the left hip. Examination reveals painless subluxation of the joint in adduction with palpable reduction in abduction. Radiographs show coxa valga, subluxation of the left hip, and pelvic obliquity with elevation of the left hemipelvis. Treatment should consist of

Explanation

DISCUSSION: Observation is the treatment of choice. Hip subluxation and dislocation are not uncommon in patients with SMA type II who are unlikely to be ambulatory. Scoliosis occurs in these patients 100% of the time and frequently creates pelvic obliquity. However, in long-term follow-up, patients with SMA type II and hip dislocations had little associated pain or functional limitations because of hip instability. In addition, recurrent hip subluxation after surgical treatment has been documented. Given the rarity of symptoms from hip instability in long-term follow-up, and the possibility of recurrent dislocation, surgical intervention for hip instability may expose SMA type II patients to undue surgical risk for minimal if any functional gain.
REFERENCES: Sporer SM, Smith BG: Hip dislocation in patients with spinal muscular atrophy. J Pediatr Orthop 2003;23:10-14.
Thompson CE, Larsen LJ: Recurrent hip dislocation in intermediate spinal atrophy.

J Pediatr Orthop 1990;10:638-641.

Question 3

During an anterior approach to the bicipital 53 tuberosity, you encounter a nerve overlying the brachioradialis fascia (Figure 58). It provides innervation to the

Explanation

DISCUSSION
The structure shown is the lateral antebrachial cutaneous nerve (LABC). It is the terminal sensory branch of the musculocutaneous nerve and runs superficial to the brachioradialis. It supplies sensation to the anterolateral surface of the forearm. The flexor pollicis longus is innervated by the anterior interosseous nerve. The extensor indicis proprius is innervated by the radial nerve. The LABC does not innervate the skin of the anteromedial forearm. Careful
identification and protection of this nerve is critical to prevent the most common nerve injury during distal biceps repair.
RECOMMENDED READINGS
Agur AM. Grant's Atlas of Human Anatomy. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999:460.
Hoppenfeld S, deBoer P. Surgical Exposures in Orthopedics. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1994:118-125.
RESPONSES FOR QUESTIONS 59 THROUGH 61

Please select the image that represents the most appropriate response to the question or statement below.

Question 4

The illustration shown in Figure 19 shows a Chamberlain line. What is the most likely diagnosis?

Explanation

DISCUSSION: Basilar invagination is best defined as vertical or compressive instability at the occiput-C1 joint. Such invaginations most commonly occur in patients with rheumatoid arthritis but also can occur secondary to trauma or tumor. A Chamberlain line is used as a method to determine basilar invagination. The odontoid tip should not be more than 5 mm above a Chamberlain line.
REFERENCES: Wiesel SW, Rothman RH: Occipito-atlantal hypermobility.

Spine 1979;4:187-191.
Clark CR: The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 50-51.

Question 5

A patient reports progessive bilateral hand clumsiness and ataxia. Examination reveals a positive Hoffmann’s sign and intrinsic atrophy. MRI reveals multilevel cervical spondylosis, and lateral flexion and extension radiographs show cervical kyphosis in the neutral position, with restoration of lordosis on extension. Which of the following procedures is most likely to result in poor long-term results?

Explanation

DISCUSSION: Adequate decompression of the cervical cord can be achieved in a variety of ways depending on the pathoanatomy of the compression, but kyphosis is a relative contraindication to laminectomy alone. For laminectomy to be effective, the lordosis must be maintained so the cord can displace posteriorly away from the anterior structures. In addition, removing the posterior tension band increases the probability that the kyphosis will progress, therefore increasing the force against the front of the cord as it tents across the kyphosis.
REFERENCES: Albert TJ, Vaccaro A: Postlaminectomy kyphosis. Spine 1998;23:2738-2745.
Truumees E, Herkowitz HN: Cervical spondylotic myelopathy and radiculopthy. Instr Course Lect 2000;49:339-360.
Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.

Question 6

A 42-year-old woman with a long-standing history of rheumatoid arthritis undergoes total shoulder arthroplasty for persistent pain that has failed to respond to nonsurgical management. Intraoperative radiographs reveal an oblique, minimally displaced fracture of the greater tuberosity. Based on these findings, what is the best course of action?

Explanation

DISCUSSION: The risk of intraoperative fracture in osteoporotic bone in patients with rheumatoid arthritis is significant. Fractures most often occur during humeral head dislocation and positioning for canal reaming. If the fracture occurs at the greater tuberosity, cerclage suture fixation of the tuberosity fracture with autogenous cancellous bone graft from the resected humeral head is the treatment of choice.
REFERENCES: Wright TW, Cofield RH: Humeral fractures after shoulder arthroplasty. J Bone Joint Surg Am 1995;77:1340-1346.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 215-225.
Frankle MA, Ondrovic LE, Markee BA, et al: Stability of tuberosity reattachment in proximal humeral hemiarthroplasty. J Shoulder Elbow Surg 2002;11:413-420.

Question 7

What is the typical MRI signal intensity of bone marrow affected by acute osteomyelitis?

Explanation

DISCUSSION: The classic MRI findings of osteomyelitis are a decrease in the normally high signal intensity of marrow on T₁-weighted images and normal or increased signal intensity on T₂-weighted images. This is the result of replacement of marrow fat by inflammatory cells and edema, which causes lower signal intensity than fat on T₁-weighted images and higher signal intensity than fat on T₂-weighted images. The addition of gadolinium to a T₁-weighted sequence reveals increased signal intensity in the hyperemic marrow.
REFERENCES: Unger E, Moldofsky P, Gatenby R, et al: Diagnosis of osteomyelitis by MR imaging. Am J Roentgenol 1988;150:605-610.
Dormans JP, Drummond DS: Pediatric hematogenous osteomyelitis: New trends in presentation, diagnosis and treatment. J Am Acad Orthop Surg 1994;2:333-341.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 150-163.

Question 8

Examination of a 13-year-old boy with asymptomatic poor posture reveals increased thoracic kyphosis that is fairly rigid and accentuates during forward bending. The neurologic examination is normal. Spinal radiographs show 10 degrees of scoliosis at Risser stage 2, and there is no evidence of spondylolisthesis. A standing lateral view of the thoracic spine is shown in Figure 41. The kyphosis corrects to 50 degrees. Management should consist of

Explanation

DISCUSSION: The radiograph shows excessive thoracic kyphosis (normal 20 degrees to

50 degrees) with multiple contiguous vertebral wedging and end plate irregularity, all consistent with the diagnosis of Scheuermann’s kyphosis. The patient is skeletally immature; therefore, there is the potential for progression of the kyphotic deformity. Extension bracing has shown efficacy in the treatment of Scheuermann’s kyphosis that measures 50 degrees to 74 degrees, and has actually reduced the curvature permanently in some patients. A thoracolumbosacral orthosis may be used if the apex of kyphosis is at T7 or lower. Indications for surgical treatment are controversial, but spinal fusion most likely should not be considered for a painless kyphosis measuring less than 75 degrees.
REFERENCES: Murray PM, Weinstein SL, Spratt KF: The natural history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg Am 1993;75:236-248.
Wenger DR, Frick SL: Scheuermann kyphosis. Spine 1999;24:2630-2639.
Tribus CB: Scheuermann’s kyphosis in adolescents and adults: Diagnosis and management.

J Am Acad Orthop Surg 1998;6:36-43.

Question 9

A 24-year-old man who was involved in a high speed motor vehicle accident is transferred for definitive care after having been diagnosed with an acute spinal cord injury from a fracture-dislocation at C6-7. He has a complete C6 neurologic level and it is now approximately 10 hours from his injury. What is the most appropriate pharmacologic treatment at this time?

Explanation

DISCUSSION: The standard practice in the pharmacologic treatment of a spinal cord injury in the United States has been the administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours, in accordance with the findings of the second and third National Acute Spinal Cord Injury Studies (NASCIS). Although the studies have subsequently drawn criticism for their methodology and outcomes, it has been generally accepted that beneficial neurologic outcomes were anticipated in patients who were able to start the protocol within 8 hours of their initial injury. Further improvement was noted in patients receiving the methylprednisolone within 3 hours of their injury and continuing an infusion for

48 hours. In this patient, who is outside the 8-hour treatment window, no studies have supported starting the methylprednisolone protocol at this time.
REFERENCES: Braken MB, Shepard MJ, Holford TR, et al: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury: Results of the third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997;277:1597-1604.
Kwon BK, Tetzlaff W, Grauer JN, et al: Pathophysiology and pharmacologic treatment of acute spinal cord injury. Spine J 2004;4:451-464.

Question 10

A 42-year-old man who is right-hand dominant injured his right shoulder when he fell from a ladder onto his outstretched arm 1 hour ago. Radiographs reveal a two-part greater tuberosity anterior fracture-dislocation. Initial management should consist of

Explanation

DISCUSSION: Greater tuberosity anterior fractures associated with anterior glenohumeral dislocations respond very well to closed methods in the majority of patients. Closed reduction of the glenohumeral joint often anatomically reduces the greater tuberosity into its cancellous bed, without the need for open fixation or cuff repair. Once closed reduction of the joint is performed, tuberosity displacement and joint articulation should be evaluated radiographically with AP and scapular lateral views as well as an axillary view. The axillary view will not only definitively show the joint articulation but also demonstrate posterior displacement of the greater tuberosity missed on the AP and lateral views. If no or minimal (5 mm) displacement is found, then nonsurgical management consisting of a sling and gentle passive range-of-motion exercises can be instituted.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Flatow EL, Cuomo F, Maday MG, Miller SR, McIlveen SJ, Bigliani LU: Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am 1991;73:1213-1218.

Question 11

An AP radiograph of the pelvis is shown in Figure 4. What muscle attaches to the avulsed fragment of bone identified by the arrow?

Explanation

DISCUSSION: The radiograph reveals an avulsion of the ischial apophysis, most likely the result of violent contraction of the attached hamstring tendons (semimembranosus, semitendinosus, and long head of the biceps femoris). The short head of the biceps femoris arises from the linea aspera on the posterior femur. The pectineus and adductor longus attach to the pubic portion of the pelvis. The piriformis runs from the sacrum to the femur.
REFERENCES: Woodburne RT (ed): Essentials of Human Anatomy. New York, NY, Oxford University Press, 1978, pp 542-545.
Metzmaker JN, Pappas AM: Avulsion fractures of the pelvis. Am J Sports Med 1985;13:349-358.

Question 12

The cortical injury to the posterolateral distal fibula shown in Figure 25 indicates involvement of which of the following structures?

Explanation

DISCUSSION: The patient has a rim avulsion fracture that is the result of a forceful twisting injury as the superior peroneal retinaculum is avulsed from its fibular attachment along with a small rim of bone. Injuries to the anterior talofibular ligament or calcaneal fibular ligament would show cortical avulsions more anteriorly or distally at the fibular tip. Deltoid ligament injuries would reveal medial radiographic changes. In a true injury to the syndesmosis, if osseous structures do show avulsion, it would be more directly posterior or anterior on the distal fibula or would occur on the tibial surface.
REFERENCES: Murr S: Dislocation of the peroneal tendons with marginal fracture of the lateral malleolus. J Bone Joint Surg Br 1961;43:563-565.
Clanton TO: Athletic injuries to the soft tissues of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1090-1209.

Question 13

When performing the exposure for an anterior approach to the cervical spine, excessive retraction of the trachea and esophagus should be avoided to prevent injury of the

Explanation

DISCUSSION: The recurrent laryngeal nerve lies between the trachea and the esophagus and is subject to stretch injury if excessive retraction is applied. The vagus nerve lies in the carotid sheath. The sympathetic trunk lies anterior to the longus colli muscles. The hypoglossal nerve and superior laryngeal nerve are both at risk during the exposure but are not located between the trachea and esophagus.
REFERENCES: An HS: Principles and Techniques of Spine Surgery. Baltimore, MD,

Williams and Wilkins, 1998, chapter 2.
Flynn TB: Neurologic complication of anterior cervical interbody fusion. Spine 1982;7:536-539.

Question 14

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain.What is the most likely cause of this patient's pain?

Explanation

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has important functions for hip stability and maintenance of the suction seal of the joint.

Question 15

Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

Explanation

Tension band wiring may not provide adequate stability to prevent displacement in a comminuted fracture. Plate fixation is most commonly recommended for comminuted fractures of the olecranon. Additionally, plate fixation is used for oblique fractures distal to the midpoint of the trochlear notch, fractures that involve the coronoid process, and those associated with Monteggia fracture-dislocations. Tension band wiring is best indicated for simple transverse fractures through the midpoint of the trochlear notch.

Question 16

In articular cartilage, Interleukin 1 (IL-1) increases

Explanation

IL-1 stimulates matrix metalloproteinase that directly degrade cartilage. It also stimulates enzymes such as cyclooxygenase 2 and nitric oxide synthetase, which further cause tissue catabolism and damage. Glucosamine has anabolic effects on proteoglycan synthesis and can also prevent tissue catabolism by preventing an IL-1 beta-induced decrease in proteoglycan synthesis. Transforming growth factor beta has chondroprotective functions and has been shown to increase both collagen and proteoglycan synthesis while inhibiting matrix degradation and cell proliferation. Insulin-like growth factor 1 (IGF1) is produced by articular chondrocytes and increased collagen and proteoglycan synthesis. It has a role in the development of osteoarthritis. Decreased expression of IGF1 and increased binding proteins decrease the availability of the growth factors, accelerating tissue catabolism in arthritic cartilage.

Question 17

03 A 28-year-old man underwent surgical fixation for an intra-articular distal humeral fracture 8 weeks ago now reports progressively restricted elbow motion. Radiographs at the time of union are shown in Figures 13a and 13b. Management should now consist of

Explanation

The radiographs show HO posteriorly in the triceps tendon and also anteriorly in the tendon. The fracture appears well-healed. At this point, oral indomethacin or single dose irradiation would not help as the HO is already there and these are typically used to prevent HO. Option #3 also would not help since there appears to be more of a bony block than soft tissue contracture. This leaves options 4 and 5. In the past, ectopic bone resection was
delayed until the heterotopic ossification was “mature”. This was signified by a cold bone scan and normal serum alk phos, as well as a mature appearance on xray. It was thought that by waiting until the HO was mature, recurrence would be avoided. However, in the cited reference, out of the widely read Journal of Hand Surgery, the authors obtained good results with increased range of motion, resolution of cubital tunnel syndrome and no recurrence of contractures or loss of motion with excision of ectopic bone and elbow release that was performed once bony union of fracture was obtained. They also used a 5 day course of indomethacin post-op.
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Question 18

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

Explanation

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

Question 19

A 63-year-old male, with history of myocardial infarction, presents with buttock and leg pain. He states the pain is worse when climbing stairs, and is absent when walking down a hill. He reports when walking on a flat surface the pain begins after roughly 50 meters, but if he stops walking and remains standing upright, the pain resolves after a few minutes. He denies any leg pain when sitting and driving a car. These symptoms are most consistent with: Review Topic

Explanation

This clinical presentation is most consistent with vascular claudication.
Vascular claudication refers to the pain, aching or fatigue of the muscles of the buttocks, thigh and/or calf that occurs with exertion, and is related to a failure to meet muscular oxygen requirements, usually caused by peripheral vascular disease impeding blood flow to the peripheral muscles.
Neurogenic claudication is the classic symptom caused by lumbar spinal stenosis. Neurogenic claudication classically presents with bilateral buttock pain with upright activities, but seems to improve by postural changes that flex the lumbar spine. These posture changes are thought to increase the cross sectional area of the central canal, which relieves pressure on the affected area.
Issack et al. reviewed degenerative lumbar spinal stenosis. They state that patients with vascular claudication will have similar symptoms of leg cramping, whether ambulating or riding a stationary bicycle. In comparison, patients with neurogenic
claudication have diminished symptoms of claudication while positioned seated.
Young et al. reviewed the use of lumbar epidural/transforaminal steroids for managing spinal disease. They report that two thirds of acute low back pain episodes resolve within 7 weeks, so the utility and practice patterns regarding the timing and number of epidural/transforaminal steroid injections is usually based on expert opinion, rather than high level research evidence.
Illustration A shows an angiogram of a patients with normal (left) vs abnormal (right) arterial vasculature. Illustration B shows the typical MRI of a patient with spinal stenosis.
Incorrect

Question 20

A 23-year-old male college quarterback presents with acute left shoulder pain after being tackled. A radiograph of the injury is shown in figure A. After successful closed reduction, what shoulder position should be avoided in order to minimize the risk of a repeat injury? Review Topic

Explanation

The patient presents with a traumatic posterior shoulder dislocation and radiographic evidence of a reverse Hill-Sachs type injury. The patient should avoid adduction, 90 degrees flexion, and internal rotation in order to decrease the risk of re-dislocation.
Shoulder stability is achieved through the both dynamic and static stabilizers. The static stabilizers include the bony morphology of the joint, glenoid labrum, capsule, and glenohumeral ligaments. The contributions of the glenohumeral ligaments to shoulder stability are dependent upon the position of the humerus relative to the glenoid. Posterior stability is afforded to the joint by the superior glenohumeral ligament (SGHL) and the posterior band of the inferior glenohumeral ligament (IGHL). The SGHL specifically is taught and provides posterior stability with the shoulder in flexion, adduction, and internal rotation.
Kim et. al. reviewed their experience treating 27 athletes diagnosed with traumatic posterior shoulder instability and treated with arthroscopic posterior labral repair and capsular shift. Most patients were found to have an incompletely stripped posterior capsulolabral complex. After arthroscopic repair and shift, all 26 of the 27 patients treated had improved shoulder function and objective scores, a stable shoulder, and were able to return to sport.
Millett et. al. reviewed posterior shoulder instability. They describe the static restraints of the posterior shoulder as the SGHL, posterior band of IGHL, and the coraohumeral ligament (CHL). The SGHL and CHL are both taught in the position of flexion, adduction, and internal rotation, whereas the posterior band of the IGHL is taught in abduction. They describe posterior instability occuring secondary to overhead sports due to repetitive microtrauma causing gradual capsular failure.
Figure A is an axillary radiograph of the left shoulder demonstrating a posterior dislocation and an engaging reverse Hill-Sachs lesion.
Incorrect Answers:

Question 21

A 15-year-old boy reports feeling a pop and notes sudden giving way of the left knee while playing basketball. He has immediate pain and swelling in the knee. An AP radiograph is shown in Figure 32. A small avulsion fragment from the lateral tibial margin is the only finding. What is the most likely diagnosis?

Explanation

DISCUSSION: An avulsion fracture from the lateral tibial margin carries the eponym Segond fracture and is pathognomonic for an anterior cruciate ligament (ACL) tear. The fragment is located posterior to Gerdy’s tubercle and is superior and anterior to the fibular head. It represents an avulsion of the lateral capsular ligament of the knee and is caused by the same mechanism that causes the ACL tear. The pes anserinus is the insertion point of the medial hamstrings and would not be affected in a lateral avulsion injury. The posterior cruciate ligament may be seen on a lateral view if associated with an avulsion fragment, but a tear of the PCL generally cannot be diagnosed on an AP view. The insertion of the iliotibial band is broad and is unlikely to produce an avulsion injury such as that seen in the radiograph. This view is not consistent with the appearance of a lateral collateral ligament injury.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 533-557.
Larson RL, Tailon M: Anterior cruciate ligament insufficiency: Principles of treatment. J Am Acad Orthop Surg 1994;2:26-35.

Question 22

Where is the most common site for tuberculosis (TB) spondylitis in children? Review Topic

Explanation

In children, the main route of infection in skeletal TB is through hematogenous spread from a primary source. The mycobacterium is deposited in the end arterials in the vertebral body adjacent to the anterior aspect of the vertebral end plate. Thus, the anterior portion of the vertebral body is most commonly involved. The lower thoracic region is the most common segment; next in decreasing order of frequency are the lumbar, upper thoracic, cervical, and sacral regions.

Question 23

A 13-year-old girl with adolescent idiopathic scoliosis is otherwise healthy with a normal neurologic examination and she began her menstrual cycle 3 months ago. Standing radiographs show a high left thoracic curve from T1-T6 that measures 29 degrees, a right thoracic curve from T7-L1 that measures 65 degrees, and a left lumbar curve from L1-L5 that measures 31 degrees, correcting to 12, 37, and 10 degrees, respectively, on bending films. Her Risser sign is 1. What is the most appropriate management? Review Topic

Explanation

The patient has typical adolescent idiopathic scoliosis with a right thoracic curve. This represents a Lenke-1B curve pattern; therefore, only treatment of the thoracic curve is required. The proximal thoracic and thoracolumbar curves are very flexible. The patient is Risser 1 and has just started her menstrual cycles; therefore, she is at significant risk for further curve progression. Bracing is not appropriate for a curve of this magnitude and will not halt the progression of this curve, nor will vertebral body stapling stop this curve. Vertebral body stapling is sometimes useful in small thoracic curves of less than 35 degrees and skeletally immature patients. Anterior and posterior spinal fusion is not required because the patient has no other risk factors, such as neurofibromatosis nor is she at risk for crankshaft. Anterior fusion is an option, but it is not listed.

Question 24

The stiffness of a 16-mm femoral stem is mostly influenced by the

Explanation

DISCUSSION: The stiffness is most influenced by the geometry, in particular the diameter of the stem. The bending rigidity increases to the fourth power of the radius. The elastic modulus of the material increases as a direct linear relationship. The surface coating does not affect the bending rigidity greatly unless it increases the diameter significantly.
REFERENCE: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, p 458.

Question 25

Figures 1 through 4 are the radiographs, sagittal-cut CT scan, and coronal T1 MR image of a 16-year-old boy who has wrist stiffness and pain after sustaining an injury 2 years ago. There is no bleeding from the proximal pole during surgery. Which procedure will most likely result in restoration of alignment and healing?

Explanation

EXPLANATION:
The imaging studies show an established scaphoid waist nonunion with a humpback deformity (significant flexion through the nonunion site) and carpal collapse. In addition, the proximal pole appears sclerotic on the plain radiographs and appears poorly perfused on the MR image. Correction of alignment of this scaphoid nonunion would require a volar approach with a structural bone graft. Additionally, the graft would need to provide a vascular supply to the bone. Both the 1,2 ICSRA (the Zaidenberg graft) and the 4+5 ECA grafts are vascularized grafts from the dorsal distal radius. Neither of these grafts would correct the humpback deformity, and the 4+5 ECA graft pedicle is not long enough to reach the scaphoid. An iliac crest bone graft could be used to correct the deformity, but would not provide an adequate blood supply. A free-vascularized medial femoral condyle graft provides both adequate bone graft to correct the deformity and revascularization of the scaphoid.

Question 26

A 60-year-old man reports that he has had shoe pressure pain over his right great toe for several years but has minimal discomfort when barefoot or in sandals. A clinical photograph and radiographs are shown in Figures 1a through 1c. Management should consist of

Explanation

DISCUSSION: Some patients have minimal symptoms associated with hallux rigidus despite significant radiographic evidence of osteoarthritis. This patient’s symptoms are primarily related to shoe pressure from the exostosis and can be managed with extra-depth shoe wear.
REFERENCES: Smith RW, Katchis SD, Ayson LC: Outcomes in hallux rigidus patients treated nonoperatively: A long-term follow-up study. Foot Ankle Int 2000;21:906-913.
Shereff MJ, Baumhauer JF: Hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint. J Bone Joint Surg Am 1998;80:898-908.

Question 27

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

Explanation

The anatomic lesion in this patient is not exactly defined, but she has most likely sustained an injury about the knee. A Salter-Harris type I proximal tibial physeal fracture is likely. The normal radiograph reading can be misleading because these injuries may displace and spontaneously reduce. The child is at risk of compartment syndrome although she is currently not displaying signs of it. Thus, even though this injury may seem trivial by radiographic findings, it should be treated like a knee dislocation with a risk of late developing compartment syndrome. MRI or CT may be necessary to define the injury. She does not require emergent treatment, but merits close observation for possible compartment syndrome. Any of the possible injuries about the knee can be unstable and require internal fixation after reduction.

Question 28

Figures A and B are radiographic images of an 85-year-old woman with isolated left hip pain. She describes a non-syncopal fall from standing 4 hours ago. Physical examination reveals pain with log-rolling the left thigh and the inability to bear weight on the affected leg. The radiologist reports no fracture in the left hip. What would be the next best step? Review Topic

Explanation

Absent plantar sensation at presentation
Depression at 3 months post-injury
Use of an intramedullary nail
Free tissue transfer instead of rotational flap
Need for multiple debridements
The presence of depression at the 3 months post-injury is a significant predictor of worse long term outcome as well as lower return to work rates in patients that present with limb threatening lower extremity trauma.
The findings of the Lower Extremity Assessment Project (LEAP study) has challenged many of the long-held beliefs of lower extremity trauma surgery, including the concept that patients with absent plantar sensation should undergo immediate amputation . The LEAP study has also brought to light the importance of socioeconomic and psychosocial factors in patient outcomes following these injuries.
Bosse et al analyzed a subgroup of 55 patients from the LEAP study with absent plantar sensation at presentation. Those patients that underwent limb salvage despite absent sensation (n=26) had no significant difference in functional outcome when compared with either insensate patients who underwent amputation or a matched control group of sensate patients with similar injuries. All but one patient in the salvage group had return of some sensation at 2-year follow up and the authors concluded that an insensate plantar foot at presentation should not be included in the algorithm for amputation.
Mackenzie and Bosse reviewed the results of the LEAP study with particular emphasis on the social and economic variables that influence outcomes in severe lower extremity. The authors note that 19% of patients screened positive for severe depression. The presence of anxiety, pain and depression at 3 months post-injury were significant predictors of poor outcome
Incorrect Answers:
tissue for type IIIB tibia fractures. Answer 5: The number of debridements has not been shown to influence outcome.

Question 29

Figure 7 shows the radiograph of an 18-year-old hockey player who sustained a shoulder injury during a fall into the side boards. Examination reveals a significant prominence at the acromioclavicular joint. Management should consist of

Explanation

DISCUSSION: The radiograph shows a type V acromioclavicular separation with greater than 100% superior elevation of the clavicle. This finding implies detachment of the deltoid and trapezius from the distal clavicle. Because of severe compromise of function and potential compromise to the overlying skin, surgery is the treatment of choice for type V acromioclavicular separations. During reduction and repair, meticulous repair of the deltotrapezial fascia will also aid in securing the repair.
REFERENCES: Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:11-18.
Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU: Surgical treatment of complete acromioclavicular dislocations. Am J Sports Med 1995;23:324-331.

Question 30

Which of the following is considered a potential advantage of arthroscopic repair for anterior instability of the shoulder? Review Topic

Explanation

Arthroscopic anterior labral repair spares the subscapularis, and does not require significant mobilization or incision of the anterior capsule. Therefore, it is less likely to result in significant impairment in external rotation of the glenohumeral joint when compared with traditional open stabilization procedures. Recurrent instability rates are either slightly higher or equivalent to open procedures. Both procedures can be performed on an outpatient basis and require generally identical recovery times.

Question 31

A 78-year-old woman undergoes her third lumbar decompression and fusion from L3 to L5 without complication. On the morning of postoperative day 3, examination reveals painless, flaccid weakness of both lower extremities. She also has an absent bulbocavernous reflex and a mild saddle paresthesia. MRI scans of the lumbar spine are shown in Figures 26a and 26b. What is the most appropriate management at this time?

Explanation

DISCUSSION: The MRI scans reveal a large postoperative hematoma causing significant thecal compression. An epidural hematoma with neurologic deficit is a surgical emergency requiring immediate evacuation of the hematoma. Although the incidence of postoperative epidural hematomas is rare, the consequences of a missed diagnosis can be catastrophic. Early recognition and evacuation are essential in preserving or restoring neurologic function. Uribe and associates attributed delayed postoperative hematomas to previous multiple lumbar surgeries as a possible contributing factor.
REFERENCES: Yi S, Yoon do H, Kim KN, et al: Postoperative spinal epidural hematoma: Risk factor and clinical outcome. Yonsei Med J 2006;47:326-332.
Uribe J, Moza K, Jimenez O, et al: Delayed postoperative spinal epidural hematomas. Spine J 2003;3:125-129.

Question 32

Figures 5a and 5b show the radiographs of a 21 -year-old wrestler who reports that his leg was rolled over while wrestling. The patient has decreased sensation and function in the distribution of the peroneal nerve, and he has absent pulses. What is the most appropriate initial management at this time?

Explanation

DISCUSSION: The patient has an acute traumatic anteromedial dislocation of the knee with occlusion of the popliteal artery with a possible tear. Treatment should include reduction and reevaluation of the vascular status. At this time, if pulses are symmetric, observation may be appropriate without surgical
intervention of the artery, but documentation with studies would be appropriate. Delayed reconstruction of injured structures is appropriate.
REFERENCES: Fanelli GC, Orcutt DR, Edson CJ: The multiple- ligament injured knee: Evaluation, treatment, and results. Arthroscopy 2005;21:471 -486.
McDonough EB Jr, Wojtys EM: Multiligamentous injuries of the knee and associated vascular injuries.
Am J Sports Med 2009;37:156-159.
Wascher DC: High-velocity knee dislocation with vascular injury: Treatment principles. Clin Sports Med 2000;19:457-477.

Question 33

A 5-year-old boy has had midfoot pain with activity for the past 3 months. He has no pain at rest. Radiographs are shown in Figures 29a and 29b. Management should consist of

Explanation

DISCUSSION: The radiographs show classic findings for Koehler’s disease (osteochondrosis of the navicular). The patient’s age and clinical history are typical for this self-limiting condition. Patients will improve with time, but the duration of symptoms is much shorter if the patient is placed in a cast. There is no role for surgery in this disease.
REFERENCE: Williams GA, Cowell HR: Koehler’s disease of the tarsal navicular. Clin Orthop 1981;158:53-58.

Question 34

..First-line treatment recommendations include

Explanation

RESPONSES FOR QUESTIONS 47 THROUGH 52
Ultrasound
MRI scan of the thigh
Chest CT scan and whole-body bone scan
Positron emission tomography (PET) scan
Presurgical radiation therapy
Marginal resection
Radical resection and postsurgical radiation
Transverse incision centered over the mass
Incision centered over the mass in line with long axis of limb
Sentinel node biopsy
Core needle biopsy
For each soft-tissue mass clinical scenario or question below, match the most appropriate next evaluation or treatment step listed above.

Question 35

A newborn has an anterolateral bow of the tibia and a duplication of the great toe. Which of the following conditions will develop as the infant grows?

Explanation

DISCUSSION: Anterolateral bowing of the tibia is normally associated with congenital pseudarthrosis of the tibia. This, in turn, is associated with neurofibromatosis. Posterior bowing is more benign and usually corrects spontaneously. However, anterolateral bowing also corrects spontaneously, and the limb-length discrepancy may be the only remaining sequela when associated with duplication of the great toe. Lisch nodules and axillary freckling are pathognomonic findings in neurofibromatosis but would not be expected in this patient because this type of tibial deformity is not associated with neurofibromatosis.
REFERENCE: Weaver KM, Henry GW, Reinker KA: Unilateral duplication of the great toe with anterolateral tibial bowing. J Pediatr Orthop 1996;16:73-77.

Question 36

Evaluation of the percent of necrosis in the resected specimen after preoperative chemotherapy is of prognostic value for what type of sarcoma?

Explanation

DISCUSSION: To date, only the percent of necrosis after induction chemotherapy in high-grade osteosarcomas seems to be of prognostic value. The value in soft-tissue sarcoma and rhabdomyosarcoma is being evaluated but has not been substantiated. Chondrosarcomas and parosteal osteosarcomas are not treated with chemotherapy.
REFERENCES: Rosen G, Marcove RC, Caparros B, Nirenberg A, Kosloff C, Huvos AG: Primary osteogenic sarcoma: The rationale for pre-operative chemotherapy and delayed surgery. Cancer 1979,43:2163-2177.
Davis AM, Bell RS, Goodwin PJ: Prognostic factors in osteosarcoma: A critical review. J Clin Oncol 1994;12:423-431.
Wunder JS, Paulian G, Huvos AG, Heller G, Meyers PA, Healey JH: The histological response to chemotherapy as a predictor of the oncological outcome of operative treatment of Ewing sarcoma. J Bone Joint Surg Am 1998;80:1020-1033.
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Question 37

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

Explanation

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

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

Question 38

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

Explanation

DISCUSSION:
This 86-year-old woman has poor bone quality and osteoarthritis of the left hip. Her lateral radiograph confirms Dorr type C bone quality. A hybrid left THA with a cemented femoral stem would be the treatment of choice.

Question 39

Which of the following is the most sensitive parameter to detect the increased inflammatory response seen with both postoperative infection and the use of instrumentation in spinal surgery?

Explanation

CORRECT
DISCUSSION: The most sensitive parameter to detect inflammation elicited by implants and infection is the C-reactive protein (CRP).
CRP is an acute phase reactant that increases sharply immediately after surgery within 6 hours after tissue damage. CRP then peaks 2-3 days later and returns to normal levels 5-21 days after the inciting event. In contrast, ESR reaches its peak on days 4-11, then remains elevated for a prolonged period of time.
Takahashi et al performed a Level 3 study of patients who had undergone spinal surgery with and without instrumentation, with a primary outcome of infection. They concluded that renewed elevation of C-reactive protein, white blood cell count, and body temperature after postoperative days 4 to 7 may be a key indicator of postoperative infection.

Question 40

Which of the following is considered a contraindication to the use of a reverse total shoulder arthroplasty? Review Topic

Explanation

The reverse total shoulder arthroplasty depends on a functional deltoid muscle which is innervated by the axillary nerve to restore elevation for the patient. Pseudoparalysis is an indication for a reverse shoulder arthroplasty. Acromioplasty has not been correlated with poor results with a reverse shoulder arthroplasty. As long as the patient does not have an active infection, prior infections are not a contraindication. Patients can still have pain and pseudoparalysis from a chronic rotator cuff tear, despite having normal cartilage, and they will still benefit from a reverse total shoulder arthroplasty if other treatments have failed.

Question 41

A 4-year-old girl has knee pain after a fall. Examination reveals tenderness about the proximal tibia with modest deformity. She has no neurovascular deficits. A radiograph is seen in Figure 24. What should her parents be told? 2010 Pediatric Orthopaedic Examination Answer Book • 25

Explanation

DISCUSSION: The patient has a so-called Cozen fracture, and she is at significant risk for a posttraumatic genu valgum deformity. However, long-term studies have shown that when such a deformity occurs, it frequently resolves spontaneously and therefore surgical intervention to try and prevent the deformity is not advised.
REFERENCES: Jordan SE, Alonso JE, Cook FF: The etiology of valgus angulation after metaphyseal fractures of the tibia in children. J Pediatr Orthop 1987;7:450-457.
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.

Question 42

A patient sustained a fracture of the left acetabulum. A single axial CT scan from a two-dimensional study is shown in Figure 61. This fracture pattern is best classified as

Explanation

A transverse fracture divides the innominate bone into two portions. The fracture plane is horizontal (or semihorizontal) through the acetabulum at a variable proximal distal level. The superior segment retains a portion of the acetabular roof and the lower ischiopubic segment, the intact obturator foramen. A sagittally oriented fracture line is typically seen on axial view assessment.

Question 43

Figure 9 shows the AP radiograph of a 65-year-old man who has knee pain and swelling. What is the most likely diagnosis?

Explanation

DISCUSSION: Although all the choices are known causes of joint degeneration (secondary osteoarthritis), only chondrocalcinosis shows distinct linear calcification of the cartilage due to deposition of calcium pyrophosphate crystals. Gout is a recurrent acute arthritis resulting from the deposition of monosodium urate from supersaturated hyperuricemic body fluids. Hemochromotosis is characterized by focal or generalized deposition of iron within body tissues. Arthritis may be present but is less common than other manifestations such as liver cirrhosis, skin pigmentation, diabetes mellitus, and cardiac disease. Rheumatoid arthritis is a nonspecific, usually symmetric inflammation of peripheral joints resulting in destruction of articular and periarticular structures. Ochronosis is a hereditary enzyme deficiency (homogentisic acid oxidase) resulting in deposition of homogentisic acid polymers in articular cartilage.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 188.
Berkow R (ed): The Merck Manual, ed 14. Rathway, NJ, Merck, 1984, pp 910, 1176, 1200.

Question 44

Figure 68 shows the MRI scan of a 13-year-old boy who has had knee pain and swelling following training lessons for ski racing for the past 6 months. The only abnormal finding on physical examination is an effusion. Management should consist of

Explanation

The lesion is osteochondritis dissecans. The primary determinant of treatment is an age of the patient at presentation. The presence of open physes classifies the lesion as the Juvenile form. It is theorized that, in both adult and juvenile forms, the articular cartilage softens as it loses the support of the subchondral layer of bone. If the disease process is not arrested, additional trauma causes separation of a bone fragment, and a crater remains. Most children who have juvenile osteochondritis dissecans and open physes can be successfully managed non-operatively. Cahill proposed limitation of activities until the patient was free of symptoms as well as protected weight bearing with use of splints or crutches. He recommended that nonoperative treatment be abandoned if symptoms persist for 3 months.

Question 45

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

Explanation

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

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

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

Question 46

One year after undergoing anterior cervical decompression and fusion, what percentage of patients still have dysphagia?

Explanation

DISCUSSION
Dysphagia after anterior cervical diskectomy and fusion is a common, usually transient finding after anterior cervical approaches to the spine. While it has been reported to occur in up to 70% of patients 2 weeks following surgery, in most cases the symptoms quickly resolve. There is, however, a small subset of patients for whom symptoms of dysphagia will persist. Lee and associates prospectively studied the rate of dysphagia after anterior cervical diskectomy and fusion, reporting a 15% rate of dysphagia at 12 months, and 12% at 24 months. Phillips and associates analyzed the 2-year data from the PCM FDE clinical trial and found a 12.1% incidence of dysphagia in the ACDF arm.
RECOMMENDED READINGS
Lee MJ, Bazaz R, Furey CG, Yoo J. Risk factors for dysphagia after anterior cervical spine surgery: a two-year prospective cohort study. Spine J. 2007 Mar-Apr;7(2):141-7. Epub 2007 Jan 22. PubMed PMID: 17321961. View Abstract at PubMed
Smith-Hammond CA, New KC, Pietrobon R, Curtis DJ, Scharver CH, Turner DA. Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients: comparison of anterior cervical, posterior cervical, and lumbar procedures. Spine (Phila Pa 1976). 2004 Jul 1;29(13):1441-6. PubMed PMID: 15223936. View Abstract at PubMed
Edwards CC 2nd, Karpitskaya Y, Cha C, Heller JG, Lauryssen C, Yoon ST, Riew KD. Accurate identification of adverse outcomes after cervical spine surgery. J Bone Joint Surg Am. 2004 Feb;86-A(2):251-6. PubMed PMID: 14960668. View Abstract at PubMed
Phillips FM, Lee JY, Geisler FH, Cappuccino A, Chaput CD, DeVine JG, Reah C, Gilder KM, Howell KM, McAfee PC. A prospective, randomized, controlled clinical investigation comparing PCM cervical disc arthroplasty with anterior cervical discectomy and fusion. 2-year results from the US FDA IDE clinical trial. Spine (Phila Pa 1976). 2013 Jul 1;38(15):E907-18. doi: 10.1097/BRS.0b013e318296232f.
Rihn JA, Kane J, Albert TJ, Vaccaro AR, Hilibrand AS. What is the incidence and severity of dysphagia after anterior cervical surgery? Clin Orthop Relat Res. 2011 Mar;469(3):658-65. PMID: 21140251.View Abstract at PubMed

Question 47

A 70-year-old woman has a 3-year history of gradually increasing diffuse and global right knee pain. Her main issues are difficulty with stairs, stiffness with prolonged sitting, and swelling. She has taken NSAIDs and has received intra-articular steroid injections, all with decreasing efficacy. Her right knee examination reveals a range of motion of 15° to 80° with a fixed deformity to varus and valgus stress. Her symptoms are no longer manageable nonsurgically. Radiographs reveal a 30-degree mechanical axis deformity. The deformity shown in Figure below is predominantly associated with

Explanation

DISCUSSION:
In the setting of valgus deformities, TKA poses different challenges than those encountered when varus deformities are present. Most valgus alignment is attributable to a deformity of the distal femur rather than of the proximal tibia, as seen in varus knees. One of the major anatomical differences is a hypoplastic lateral femoral condyle which, when not recognized and used as a rotational reference point, can lead to internal rotation of the femoral component. This malrotation in turn leads to patellofemoral maltracking or instability, which is a common complication associated with primary TKA.

Question 48

A 25-year-old woman with a healed proximal tibiofibular fracture treated with an intramedullary nail 2 years ago is currently wearing an ankle-foot orthosis (AFO) and reports a persistent foot drop. She is unhappy with the AFO and has not seen any functional improvement despite months of physical therapy. Serial electromyograms (EMG) show no recent change over the past year. Examination and EMG findings are consistent with a tibialis anterior 1/5, extensor hallucis longus 2/5, extensor digitorum longus 2/5, posterior tibial tendon (PTT) 5/5, peroneals 3/5, flexor hallucis longus 5/5, and gastrocsoleus 5/5. No discrete nerve lesion was identified. The patient has a flexible equinovarus contracture. What is the most appropriate management?

Explanation

DISCUSSION: This pattern of injury is consistent with an unrecognized compartment syndrome of the anterior and lateral compartments. Transfer of the PTT through a long incision in the interosseous membrane corrects the foot drop deformity, and allows adequate dorsiflexion provided that the tendon to be transferred has a strength of 5/5. Muscles/tendons typically lose one grade of strength after transfer. Transfer into the tendons at the level of the ankle prevents overtensioning or pullout of a PTT tendon that is not long enough. Debridement of the scarred muscle in the anterior compartment decreases the risk of scarring down to the tendon transfer. Transfer of the peroneus longus is not preferred given its relative lack of strength and line of pull. Continued therapy and bracing are unlikely to lead to further improvement at 2 years after injury. An ankle fusion would correct the foot drop but would not address the tendon imbalances between the tibialis anterior and the peroneus longus, and the PTT and the peroneus brevis.
REFERENCES: Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, p 192.
Atesalp AS, Yildiz C, Komurcu M, et al: Posterior tibial tendon transfer and tendo-Achilles lengthening for equinovarus foot deformity due to severe crush injury. Foot Ankle Int 2002;23:1103-1106.
Scott AC, Scarborough N: The use of dynamic EMG in predicting the outcome of split posterior tibial tendon transfers in spastic hemiplegia. J Pediatr Orthop 2006;26:777-780.
Williams PF: Restoration of muscle balance of the foot by transfer of the tibialis posterior. J Bone Joint Surg Br 1976;58:217-219.

Question 49

A healthy, active 72-year-old man trips and falls, landing on his left hip 10 weeks after an uncomplicated left primary uncemented total hip replacement. A radiograph taken 6 weeks after surgery and before the fall is shown in Figure 1. A radiograph taken after the fall is shown in Figure 2. He is unable to bear weight and is brought to the emergency department. Examination reveals a slightly shortened left lower extremity and some mild ecchymosis just distal to the left greater trochanteric region, but his skin is intact, without abrasions or lacerations. What is the most appropriate treatment?

Explanation

DISCUSSION:
This patient has a periprosthetic femoral fracture with a loose femoral stem and normal femoral bone stock, representing a Vancouver type B2 fracture. The most appropriate treatment is fixation of the fracture, along with revision of the stem. Considering his age, bone quality, and activity level, a longer uncemented stem is most predictable. Although a cylindrical stem may also be used, the fluted stem option is the only uncemented choice listed and is the most appropriate option. A cemented stem is a poorer choice because it is difficult to keep the cement out of the fracture site, which would pose a risk for nonunion at the fracture. Also, overall poorer results have been associated with long cemented stems in healthy, active people. Surgery does not need to be delayed to allow the ecchymosis to resolve, and simple open reduction and fixation does not address the loose stem.

Question 50

Which of following is pathognomonic of intervertebral disk degeneration? Review Topic

Explanation

Degradation of
large proteoglycan molecules in
the nucleus pulposus is
pathognomonic
of intervertebral disk
(IVD) degeneration.
Degeneration of the intervertebral disk (IVD) is a major pathological process implicated in low back pain and is often considered a prerequisite for intervertebral disc herniation. While the pathophysiologic causes of IVD degeneration at the molecular level are not fully known, there are many physical and molecular changes that are known to contribute to the disease process. The most significant is loss of large proteoglycan molecules and decreased water content.
An et al. showed that large proteoglycans (PGs), such as aggrecan and versican, decrease in patients with intervertebral disk (IVD) degeneration.
Kepler et al. reviewed IVD degeneration. They report that degeneration leads to changes in the expression of matrix proteins, cytokines, and proteinases. They suggest treatment with gene therapy, such as Growth and Differentiation Factor-5 (GDF-5), may help to promote the healing of degenerated intervertebral disks.
Illustration A shows a cadaveric image of normal disk anatomy (left) and IVD degeneration (right)
Incorrect Answers:

Question 51

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

Explanation

DISCUSSION: Measurable anterior cruciate ligament laxity, while frequently seen after tibial eminence fractures, usually does not cause symptoms. It is found even in patients whose fractures have been anatomically reduced and fixed, leading to speculation that it is due to stretching of the ligament at the time of injury.
REFERENCES: Willis R, Blokker C, Stall TM, et al: Long-term follow-up of anterior

eminence fractures. J Pediatr Orthop 1993;13:361-364.
Smith JB: Knee instability after fracture of the intercondylar eminence of the tibia.

J Pediatr Orthop 1984;4:462-464.

Question 52

A 28-year-old man has a painful nodule on the plantar aspect of his foot in the midarch. Use of a soft orthosis has failed to provide relief. Examination reveals that the mass is approximately 2 1/2 cm in diameter, firm, and tender to palpation. An MRI scan confirms the presence of a plantar fibroma. Management should now consist of

Explanation

DISCUSSION: Plantar fibromas have an extremely high recurrence rate (approximately 60%) with local excision only. Resection of the entire plantar fascia is effective at irradicating the lesion. There is no role for chemotherapy or amputation with plantar fibromatosis. Radiation therapy may be helpful in combination with resection of the plantar fascia.
REFERENCES: Kirby EJ, Shereff MJ, Lewis MM: Soft-tissue tumors and tumor-like lesions of the foot: An analysis of 83 cases. J Bone Joint Surg Am 1989;71:621-626.
Cavolo DJ, Sherwood GF: Dupuytren’s disease of the plantar fascia. J Foot Surg 1982;21:12-15.

Question 53

Figures 1 and 2 display the radiographs obtained from a woman who had volar plating of the distal radius 8 months earlier. Two days ago, she noticed she could not actively extend her thumb. What is the most appropriate treatment that would restore active thumb extension?

Explanation

EXPLANATION:
Although the fracture is aligned in anatomic position, prominence of a least one of the distal screws is evident on the lateral radiographic view. The prominent screw is the most likely cause of the EPL tendon rupture. If the patient chooses surgical treatment, the best option would be removal of the offending hardware combined with extensor indicis proprius to EPL tendon transfer. Intercalary grafting would also be an acceptable option. If the tendon transfer were to be performed alone, the prominent screw(s) could rupture the transferred tendon as well. Also, it is rarely possible to repair the EPL tendon primarily in such cases, because this rupture is an attrition type. Casting would obviously not provide any benefit in this situation, and IP arthrodesis would not be the first surgical treatment option. This problem can be avoided by using shorter screws or not placing screws in plate holes that direct screws into the third dorsal extensor compartment. Intraoperative fluoroscopy and special views, such as the carpal shoot-through view, are useful for avoiding this complication.

Question 54

A 6-year-old boy is being treated for acute hematogeneous osteomyelitis of the distal femur with intravenous antibiotics. The best method to determine the success or failure of initial treatment is by serial evaluations of which of the following studies?

Explanation

DISCUSSION: Successful antibiotic treatment of acute osteomyelitis should lead to a rapid decline in the CRP. The CRP is the most sensitive study to follow the treatment of osteomyelitis. The CRP should decline after 48 to 72 hours of appropriate treatment. CBC and ESR are helpful in initial evaluation and diagnosis, but remain abnormal in the early phase of treatment regardless of response. Imaging studies are useful for surgical planning or secondarily if the CRP remains elevated.
REFERENCES: Unkila-Kallio L. Kallio MJ, Eskola J, et al: Serum C-reactive protein, erythrocyte sedimentation rate, and white blood cell count in acute hematogenous osteomyelitis of children. Pediatrics 1994;93:59-62.
Herring JA(ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia. PA. WB Saunders, 2008, pp 2090-2100.
AL-Madena Copy

Question 55

Figures 42a and 42b show the radiographs of a 52-year-old man who sustained a fall from a motorcycle 6 months ago and now reports pain and stiffness in his left shoulder. What is the most reliable treatment to improve function and comfort of the shoulder?

Explanation

DISCUSSION: Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult.
REFERENCES: Gerber C, Lambert SM: Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376-382.
Spencer EE Jr, Brems JJ: A simple technique for management of locked posterior shoulder dislocations: Report of two cases. J Shoulder Elbow Surg 2005;14:650-652.
Sperling JW, Pring M, Antuna SA, et al: Shoulder arthroplasty for locked posterior dislocation of the shoulder. J Shoulder Elbow Surg 2004;13:522-527.
Hawkins RJ, Neer CS II, Pianta RM, et al: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
McLaughlin HL: Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;34:584-590.

Question 56

A 44-year-old farmer involved in a rollover accident on his tractor sustained an L1 burst fracture with a 20% loss of anterior vertebral body height, 30% canal compromise, and 15 degrees of kyphosis. He remains neurologically intact. The preferred initial course of action should consist of

Explanation

DISCUSSION: Surgical decompression is unnecessary in a patient with no neurologic deficit and canal compromise of less than 50%. A compression deformity of less than 50% and kyphosis of less than 30 degrees may be successfully treated with a TLSO extension brace. Deformity in this range will reliably heal with minimal risk for late deformity or residual pain. Although some studies suggest 6 weeks of bed rest as treatment, early mobilization and bracing is preferred.
REFERENCES: Hartman MB, Chrin AM, Rechtine GR: Nonoperative treatment of thoracolumbar fractures. Paraplegia 1995;33:73-76.
Chow GH, Nelson BJ, Gebhard JS, Brugman JL, Brown CW, Donaldson DH: Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracing and early mobilization. Spine 1996;21:2170-2175.
Kraemer WJ, Schemitsch EH, Lever J, McBroom RJ, McKee MD, Waddel JP: Functional outcome of thoracolumbar burst fractures without neurological deficit. J Orthop Trauma 1996;10:541-544.

Question 57

Figures 1 and 2 are the CT and MRI scans of a patient with shoulder instability. Contrasting these two imaging techniques for decision making in shoulder instability would suggest

Explanation

A 43-year-old woman is involved in a motor vehicle collision. She sustains the isolated injury shown in the radiograph in Figure 1. Her neurovascular examination is compromised. What is the most likely deficit?
A. Inability to flex the distal interphalangeal joint of the index finger
B. Positive Froment’s sign
C. Weakness with wrist extension
D. Decreased capillary refill

Question 58

At the time of the revision surgery shown in Figure 14, the acetabular component was found to be stable. Polyethylene exchange with a standard ultra-high molecular weight polyethylene liner and grafting was performed. The patient is at significantly increased risk for

Explanation

DISCUSSION: Maloney and associates reported a 35% increased risk of pelvic osteolysis after total hip arthroplasty with a porous-coated acetabular component without cement. All components were stable at the time of revision. Only liners were exchanged and debridement of the granuloma with or without bone graft was performed. No defects progressed and one third of the lesions were no longer visible on radiographs, regardless of bone grafting. Unfortunately, despite the technical ease of many of these types of revisions, the dislocation rate for these cases is significant. Precautions should be taken postoperatively, and patients should be educated about this risk preoperatively.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424.
Boucher HR, Lynch C, Young AM, et al: Dislocation after polyethylene liner exchange in total hip arthroplasty. J Arthroplasty 2003;18:654-657.
Maloney WJ, Herzwurm P, Paprosky W, et al: Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am 1997;79:1628-1634.

Question 59

Figures 6a through 6d show the radiographs and biopsy specimens of an 8-year-old girl with leg pain. Management of the lesion should consist of

Explanation

DISCUSSION: The biopsy specimens show a chondromyxoid fibroma with varying amounts of cartilage, benign fibrous tissue, giant cells, and loose myxoid areas. Chondromyxoid fibroma is a benign active bone lesion that is best treated with aggressive curettage and bone grafting. Although recurrences are common, more aggressive treatment is not warranted initially.
REFERENCES: Wilson AJ, Kyriakos M, Ackerman LV: Chondromyxoid fibroma: Radiographic appearance in 38 cases and in a review of the literature. Radiology 1991;179:513-518.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 167-189.

Question 60

In the evaluation of somatosensory-evoked potential waveforms for intraoperative neuromonitoring for spinal surgery, the minimum criteria for determining potentially significant changes include Review Topic

Explanation

The established criteria for interpreting a significant change are 50% decrease in signal amplitude, 10% latency increase, and/or a complete loss of potential. Intraoperative spinal cord monitoring during spinal surgery generally consists of a combination of monitoring modalities. Somatosensory-evoked potentials in combination with intraoperative electromyography can provide adequate coverage of sensory and motor components of spinal cord and nerve root function. Significant changes in evoked potential waveform characteristics can reflect dysfunction of the ascending somatosensory system.

Question 61

Which of the following factors is considered most important when assessing an ankle fracture for surgical treatment?

Explanation

DISCUSSION: Although all of these factors may influence the decision to perform surgery, the most important is the position of the talus in the mortise. The goal of treatment of ankle fractures is to maintain the talus centered in the mortise. If it is in this position, the other factors do not enter into the decision to intervene surgically.
REFERENCES: Stover MD, Kellam JF: Articular fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 105-119.
Hahn DM, Colton CL: Malleolar fractures, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 559-581.
Tile M: Fractures of the ankle, in Schatzker J, Tile M (eds): Rationale of Operative Fracture Care, ed 2. Berlin, Springer-Verlag, 1998, pp 523-561.

Question 62

Figure 12 shows the frog-lateral radiograph of a 45-year-old man who has a painful left hip. What is the most likely diagnosis?

Explanation

PHASE V: the crescent sign and articular collapse. The supporting bony architecture may become sufficiently weakened by continued resorption of trabecular bone and subchondral bone plate along the reactive interface that the stress of weight-bearing can result in subchondral bone plate fracture with focal articular cartilage buckling and eventual collapse. This is best seen in the frog-lateral radiograph.

Question 63

In an acute closed boutonniere injury, what is the most appropriate splinting technique for the proximal interphalangeal joint?

Explanation

DISCUSSION: Rupture of the central slip of the extensor mechanism and a varying degree of lateral band volar migration are the pathologic entities in an acute boutonniere injury. Splinting the proximal interphalangeal joint in full extension allows reapproximation of the central slip to the base of the middle phalanx. Distal interphalangeal joint flexion is permitted to allow movement of the lateral bands distally and dorsally, preventing contracture.
REFERENCES: Newport ML: Extensor tendon injuries in the hand. J Am Acad Orthop Surg 1997;5:59-66.
Lovet WL, McCalla MA: Management and rehabilitation of extensor tendon injuries. Orthop Clin North Am 1983;14:811-826.

Question 64

The force generated by a muscle is most highly dependent on its

Explanation

The cross-sectional area of a muscle determines to a great extent the force generated by the muscle. The force of a muscle contraction is controlled by the amount of myofibrils that contract; the greater the amount of contracting myofibrils, the greater the force of contraction. Fiber types have less to do with the force of contraction and more to do with the duration and speed of contraction. Muscle length affects contraction force through the Blix curve. The morphology of a muscle can affect the cross-sectional area by varying the angle of the fibers in relation to the force vector. Conditioning mostly affects duration and fatigability.

Question 65

What is the most common primary malignant tumor of bone in childhood?

Explanation

DISCUSSION: Osteosarcoma is the most common primary malignant tumor of bone in childhood, followed by Ewing’s sarcoma. Rhabdomyosarcoma is a soft-tissue sarcoma of childhood. Chondrosarcoma rarely occurs in childhood. Osteochondromas are benign tumors of the bone.
REFERENCES: Simon M, Springfield D, et al: Osteogenic Sarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 226.
Wold LA, et al: Osteogenic Sarcoma: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 14-15.

Question 66

A 14-year-old gymnast presents after a fall from the balance beam with a hyperextension injury to her left knee. She could ambulate with pain but was unable to continue exercise due to pain. On examination she has a swollen knee with painful

Explanation

The patient has a mild to moderately displaced tibial eminence fracture, which can be treated with closed reduction, casting, and supportive care provided successful closed reduction is achieved.
Tibial eminence fractures are rare but occur more often in pediatric populations, often in the setting of sports-related injuries. Debate continues over operative vs nonoperative treatment, as well as fixation type (screw vs suture) for openly treated fractures. Past evidence suggested closed treatment was adequate but there has been an increase in operative management. Closed treatment is suggested for minimally displaced fractures (Type I and reducible Type II) and open treatment for completely displaced fractures (non-reducible Type II and Type III).
Wilfinger et al provide the results of a closed reduction protocol at their institution including 38 patients with long term followup. All patients underwent aspiration and closed reduction in the OR under fluoroscopic guidance followed by long leg casting in hyperextension and graduated weight bearing over weeks. No patients complained of persistent pain, swelling, giving way, or disability at follow up.
However, Edmonds et al in a retrospective review compare open reduction internal fixation (ORIF), arthroscopic-assisted internal fixation (AAIF), and closed reduction with casting (CRC) for pediatric patients with displaced tibial spine fractures. They report improved reduction but also increased arthrofibrosis in ORIF and AAIF groups
compared to CRC, but of the 24% of patients with long term followup results, there was no difference in functional outcomes across all 3 groups. There was a 17% rate of later operation for the CRC group patients. They suggest closed treatment for fractures with <5mm displacement, otherwise ORIF or AAIF.
Gans et al conducted a systematic review focused on the questions of open vs closed reduction, and screw vs suture fixation. The 26-article review found insufficient evidence to have any clear recommendations. They did find reduced laxity and improved range of motion for minimally displaced fractures that had an open reduction, and that completely displaced fractures treated nonoperative had higher rates of nonunion.
Figures A and B are AP and lateral knee radiographs demonstrating a moderately displaced (Meyers and McKeever Type II) tibial spine fracture in a skeletally immature patient.
Incorrect Responses

Question 67

Figure 12 shows an arthroscopic view from an inferolateral portal of a right knee. The asterisk indicates which structure?

Explanation

DISCUSSION
The asterisk indicates the anteromedial bundle of the anterior cruciate ligament. The anterior cruciate ligament consists of 2 functional bundles: anteromedial and posterolateral. During extension of the knee, the posterolateral bundle becomes taut. In flexion, the anteromedial bundle is tight and the posterolateral bundle relaxes. Recently, techniques for double-bundle reconstruction have been described to recreate the normal anatomic relationship of the 2 bundles.
RECOMMENDED READINGS
Chhabra A, Zelle BA, Feng MT, Fu FH. The arthroscopic appearance of a normal anterior cruciate ligament in a posterior cruciate ligament-deficient knee: the posterolateral bundle (PLB) sign. Arthroscopy. 2005 Oct;21(10):1267. PubMed PMID: 16226658. View Abstract at PubMed
Cha PS, Brucker PU, West RV, Zelle BA, Yagi M, Kurosaka M, Fu FH. Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. Arthroscopy. 2005 Oct;21(10):1275. PubMed PMID: 16226666. View Abstract at
PubMed

Question 68

What bilateral surgical intervention is considered inappropriate based on the findings shown in the radiograph in Figure 52?

Explanation

DISCUSSION: The radiograph reveals osteonecrosis of both femoral heads with reasonably maintained joint surfaces. There may be some slight flattening of the femoral heads. Hip arthrodesis is difficult to perform because of the necrotic bone. Its use in patients with osteonecrotic hips is limited because of the 80% bilaterality; therefore, it is not an acceptable alternative. All the other options are acceptable interventions.
REFERENCES: Mont MA, Jones LC, Sotereanos DG, et al: Understanding and treating osteonecrosis of the femoral head. Instr Course Lect 2000;49:169-185.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.

Question 69

The underlying cause of the neoplasm is

Explanation

DISCUSSION
The bone scan reveals multiple bone lesions, which does not rule out any of the responses. The radiographs reveal dysplastic bone with a “ground glass” appearance, suggesting fibrous dysplasia as the preferred response. Multiple myeloma typically demonstrates purely lytic, “punched out” lesions and would be highly unusual in a 23-year-old woman. Multiple hereditary exostosis would demonstrate more expansile lesions concentrated in the metaphysis. Metastatic carcinoma could have a lytic or blastic appearance but is less likely to occur in a 23-year-old woman.
McCune-Albright syndrome in polyostotic fibrous dysplasia is present in as many as 50% of patients and should be evaluated for during an endocrine consultation. Adrenal, pituitary, parathyroid, and thyroid endocrinopathies may be present. Untreated hyperthyroidism can be life threatening during a surgical procedure. There is no indication to repeat the nuclear bone scan. Although phosphate wasting and, rarely, oncogenic osteomalacia have been reported in polyostotic fibrous dysplasia, an endocrinology consultation always should be sought.
Café au lait macules are the most common extraskeletal manifestation of fibrous dysplasia, often referred to as “coast of Maine” in appearance because of their irregular borders (in comparison to the “Coast of California” with smooth borders as seen in neurofibromatosis). Multiple myeloma would not ordinarily appear with increased uptake on a bone scan unless a pathologic fracture of some duration were present. A long area of bone involvement would not appear in patients with metastatic lung adenocarcinoma.
An ALK rearrangement occurs in nonsmall-cell lung cancer. The translocation t(11;14)(q13;q32) should be recognized as a poor prognosticator in multiple myeloma. The germline alteration in EXT1 and EXT2 occurs in multiple hereditary exostosis.
All forms of fibrous dysplasia are caused by a nongerm-cell mutation that occurs during early embryogenesis. A missense mutation of the GNAS1 gene, which encodes the alpha subunit of the stimulatory G-protein-couple-receptor, Gs alpha, results in G-protein activation and the production of cyclic adenosine monophosphate affecting melanocytes, endocrine cells, and osteoprogenitor cells.
RECOMMENDED READINGS
DiCaprio MR, Enneking WF. Fibrous dysplasia. Pathophysiology, evaluation, and treatment. J Bone Joint Surg Am. 2005 Aug;87(8):1848-64. Review.View Abstract at PubMed
Parekh SG, Donthineni-Rao R, Ricchetti E, Lackman RD. Fibrous dysplasia. J Am Acad Orthop Surg. 2004 Sep-Oct;12(5):305-13. Review. PubMed PMID: 15469225. View Abstract at PubMed
Shin HJ, Kim K, Lee JJ, Song MK, Lee EY, Park SH, Kim SH, Jang MA, Kim SJ, Chung JS. The t(11;14)(q13;q32) translocation as a poor prognostic parameter for autologous stem cell transplantation in myeloma patients with extramedullary plasmacytoma. Clin Lymphoma Myeloma Leuk. 2015 Apr;15(4):227-35. doi: 10.1016/j.clml.2014.12.007. Epub 2014 Dec 12.View Abstract at PubMed
Esfahani K, Agulnik JS, Cohen V. A Systemic Review of Resistance Mechanisms and Ongoing Clinical Trials in ALK-Rearranged Non-Small Cell Lung Cancer. Front Oncol. 2014 Jul 21;4:174. doi: 10.3389/fonc.2014.00174. eCollection 2014. Review. PubMed PMID: 25101240. View Abstract at PubMed

Question 70

Tendons should have what ratio of matrix protein?

Explanation

Tendons consist of mainly type I collagen (95%); a small amount of collagen types III, V, VI; and proteoglycans (< 5%). Proteoglycans have highly charged glycosaminoglycan side chains that attract water and help keep tendons well hydrated. Decorin is the most common proteoglycan in tendons and has been shown to bind to collagen. Tenascin-C is a glycoprotein upregulated in tendinopathy.

Question 71

Optimal management of the injury shown in Figure 31 should include which of the following?

Explanation

DISCUSSION: The radiograph shows a displaced calcaneal beak fracture, a tongue-type fracture variant. The fracture fragment typically includes the insertion point of the Achilles tendon, which places marked tension on the thin overlying soft-tissue envelope and can lead to full-thickness necrosis if not acutely addressed. Cast immobilization does not adequately address the increased soft-tissue tension, as the fragment will be difficult to control. Arthroscopic-assisted techniques or primary arthrodesis are not indicated because calcaneal beak fractures are typically extra-articular.
REFERENCES: Sanders RW, Clare MP: Fractures of the calcaneus, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 2, pp 2017-2073.
Sanders RW, Clare MP: Fractures of the calcaneus, in Bucholz RW, Heckman JD, Court-Brown C (eds): Rockwood and Green’s Fractures in Adults, ed 6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, vol 2, pp 2293-2336.

Question 72

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

Explanation

DISCUSSION: The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program

at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.
REFERENCES: Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.
Matsen FA III, Lippitt SB, Sidles JA, et al: Practical Evaluation and Management of the Shoulder. Philadelphia, PA, WB Saunders, 1994, pp 215-218.

Question 73

A surgeon prepares a medial gastrocnemius rotational flap to cover a medial proximal tibia defect at the time of revision knee replacement surgery. To optimize coverage, the surgeon must optimally mobilize which artery?

Explanation

DISCUSSION:
The medial sural arteries vascularize the gastrocnemius, plantaris, and soleus muscles proximally. These arteries arise from the popliteal artery. If this artery is not adequately mobilized, a gastrocnemius soleus flap can be devascularized.

Question 74

While lifting weights, a patient feels a pop in his arm. He has the deformity shown in Figure 30. If left untreated, the patient will have the greatest deficiency in

Explanation

DISCUSSION: The patient has a distal biceps rupture. While the distal biceps contributes to elbow flexion, its main function is forearm supination.
REFERENCES: Baker BE, Bierwagen D: Rupture of the distal tendon of the biceps brachii: Operative versus non-operative treatment. J Bone Joint Surg Am 1985;67:414-417.
D’Arco P, Sitler M, Kelly J, et al: Clinical, functional, and radiographic assessments of the conventional and modified Boyd-Anderson surgical procedures for repair of distal biceps tendon ruptures. Am J Sports Med 1998;26:254-261.
Pearl ML, Bessos K, Wong K: Strength deficits related to distal biceps tendon rupture and repair: A case report. Am J Sports Med 1998;26:295-296.

Question 75

-A 23-year-old man had a laparotomy and splenectomy with packing of the abdomen after a motorcycle collision. Laboratory studies show a hemoglobin level of 7.1 g/dL (reference range [rr], 14.0-17.5 g/dL) and a lactate level of 8.0 mmol/L (rr, 0.6-1.7 mmol/L). He also has a left humeral fracture,an anteroposterior compression I pelvic fracture, bilateral distal third femur fractures, and an open GustilotypeIIIA tibial diaphysis fracture with moderate contamination. What is the most appropriate treatment to administer before leaving the operating room?

Explanation

Question 76

A 21-year-old football player had severe pain and immediate swelling in the left anteromedial chest wall while bench pressing near maximal weights several days ago. Examination at the time of injury revealed a mass on the anteromedial chest wall. Follow-up examination now reveals decreased swelling, and axillary webbing is observed. The patient has weakness to adduction and forward flexion. The injured muscle originates from the

Explanation

DISCUSSION: The patient has a pectoralis major rupture, an injury that occurs most commonly during weight lifting. Grade III injuries represent complete tears of either the musculotendinous junction or an avulsion of the tendon from the humerus, the most common injury site. Examination will most likely reveal ecchymoses and swelling in the proximal arm and axilla, and strength testing will show weakness with internal rotation and in adduction and forward flexion. Axillary webbing, caused by a more defined inferior margin of the anterior deltoid as the result of rupture of the pectoralis, can be seen as the swelling diminishes. Surgical repair is the treatment of choice for complete ruptures. Nonsurgical treatment is associated with significant losses in adduction, flexion, internal rotation, strength, and peak torque. The pectoralis major originates from the proximal clavicle and the border of the sternum, including ribs two through six. The pectoralis major inserts (rather than originates) on the humerus. The coracoid process is the insertion site for the pectoralis minor, as well as the origin for the conjoined tendon. The pectoralis major has no attachment or origin from the scapula. The anterior deltoid originates from the lateral one third of the clavicle and the anterior acromion.
REFERENCES: Miller MD, Johnson DL, Fu FH, Thaete FL, Blanc RO: Rupture of the pectoralis major muscle in a collegiate football player: Use of magnetic resonance imaging in early diagnosis. Am J Sports Med 1993;21:475-477.
Wolfe SW, Wickiewicz TL, Cavanaugh JT: Ruptures of the pectoralis major muscle: An anatomic and clinical analysis. Am J Sports Med 1992;20:587-593.

Question 77

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

Explanation

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

Question 78

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

Explanation

Question 79

What is the most likely consequence of a vertebral compression fracture associated with osteoporosis?

Explanation

DISCUSSION: After an osteoporotic vertebral compression fracture, the risk of subsequent fractures at adjacent levels increases. This is felt to be the result of a shifting of the sagittal alignment more anteriorly, putting more stress on the osteopenic vertebral bodies and their anterior cortices. Pain generally resolves with rest, but this may take weeks or months. It has been demonstrated experimentally that osteoporotic vertebral bodies are actually less stiff and weaker after a compression fracture; therefore, deformity predisposes to further deformity. The extensor musculature often fatigues over time and usually does not hypertrophy. Frontal plane deformity is a rare development.
REFERENCES: Heaney RP: The natural history of vertebral osteoporosis: Is low bone mass an epiphenomenon? Bone 1992;13:S23-S26.
Tohmeh AG, Mathias JM, Fenton DC, et al: Biomechanical efficacy of unipedicular versus bipedicular vertebroplasty for the management of osteoporotic compression fractures. Spine 1999;24:1772-1776.

Question 80

A 16-year-old girl has had hip pain for 1 year. Approximately 2 months ago she noted the development of a hard mass in the right buttock that has steadily increased in size. She now reports severe pain in the right buttock, with radiation down the leg and numbness involving the right foot and toes. A radiograph is shown in Figure 70a and an axial postcontrast T 1 -weighted MRI scan is shown in Figure 70b. A biopsy specimen is shown in Figure 70c. The chest CT shows multiple lung metastases. Treatment of this lesion should consist of

Explanation

DISCUSSION: Ewing’s sarcoma is the second most common primary tumor of bone in children. Depending on the site and extent of disease, chemotherapy, radiation therapy, and surgery are all treatment options. In this patient with extensive pelvic and metastatic disease, chemotherapy and radiation therapy offer the best oncologic control while preserving functional outcome.
REFERENCES: Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.
Thacker MM, Temple HT, Scully SP: Current treatment for Ewing’s sarcoma. Expert Rev Anticancer Ther 2005;5:319-331.
Weber KL: Current concepts in the treatment of Ewing’s sarcoma. Expert Rev Anticancer Ther 2002;2:687-694.

Question 81

The use of a screw between the clavicle and the coracoid process to maintain the clavicle and acromioclavicular (AC) joint in a reduced position is a treatment option for AC joint separations. Screw removal is generally recommended after soft-tissue healing. What effect does this rigid coracoclavicular fixation have on shoulder kinematics?

Explanation

DISCUSSION: This issue has been debated since Inman published his classic study on clavicular rotation in 1944. Subsequently, it has been shown by several authors that the clinical evaluation of patients with either coracoclavicular screws in place or with arthrodesis of the coracoclavicular reveals little to no loss of shoulder motion. This is most likely the result of synchronous motion of the scapula and clavicle in shoulder movements.
REFERENCES: Flatow EL: The biomechanics of the acromioclavicular, sternoclavicular, and scapulothoracic joints. Instr Course Lect 1993;42:237-245.
Kenedy JC, Cameron H: Complete dislocation of the acromioclavicular joint. J Bone Joint Surg Br 1954;36:202-208.
Rockwood CA Jr, Williams GR, Young CD: Disorders of the acromioclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 483-553.
Inman VT, Saunders JB, Abbott LC: Observations of the function of the shoulder joint. Clin Orthop 1996;330:3-12.

Question 82

Because the patient shown in Figure 27 can no longer fit in shoes, treatment of the deformity should consist of

Explanation

DISCUSSION: In local gigantism, a ray resection allows proper fitting of shoes. The ray resection narrows the foot and shortens the length. The foot may require further surgery with growth. Debulking, physeal arrest, and distal phalanx amputation are unlikely to be effective.
REFERENCES: Turra S, Santini S, Cagnoni G, Jacopetti T: Gigantism of the foot: Our experience in seven cases. J Pediatr Orthop 1998;18:337-345.
Guidera KJ, Brinker MR, Kousseff BG, et al: Overgrowth management in Klippel-Trenaunay-Weber and Proteus syndromes. J Pediatr Orthop 1993;13:459-466.

Question 83

The patient in Figure 55 is actively attempting to make a fist. This clinical scenario suggests which of the following anatomic lesions?

Explanation

DISCUSSION: The clinical presentation is characteristic of a high median nerve palsy. When trying to make a fist, the patient is unable to flex the thumb and index fingers due to paralysis of flexion of the distal interphalangeal joint of the thumb and the distal and proximal interphalangel joints of the index finger. This hand attitude differs from the anterior interosseous nerve lesion in which loss of distal interphalangeal joint flexion is seen in the thumb, index, and middle fingers. Posterior interosseous nerve syndrome presents with dropped fingers at the metacarpophalangeal joints with wrist extension in radial deviation. Wrist and finger drop is the typical posture of patients with radial nerve lesions.
REFERENCE: Kline DG, Hudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries, Entrapments and Tumors. Philadelphia, PA, WB Saunders, 1995, p 189.

Question 84

The most appropriate next surgical procedure is

Explanation

DISCUSSION
This patient’s arthritis likely has progressed to the lateral compartment. The location and degree of local pain and tenderness are the most important physical findings. History and physical findings indicate arthritis progression to the lateral and anterior compartments. This scenario suggests the need for conversion of the unicompartmental arthroplasty to TKA.

Question 85

03 advancement at age 6 years. What is the most likely diagnosis?

Explanation

Figure 15a shows areas of permeative lucency and sclerosis in the proximal femur as well as evidence of a screw (from the previous trochanteric advancement). Figure 15b shows the CT scan of the femur with possible thickening of the cortex and a moth eaten appearance of the bone. Figure 15c shows the biopsy specimen with mixed inflammatory cells. These are all indicative of osteomyelitis. The first radiographic sign of osteomyelitis tends to be an ill-defined area of lucency, followed by areas of sclerosis and periosteal new bone formation as the bone reacts to the infection. Biopsy specimens should show mixed inflammatory cells.
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Question 86

A tendon repair is thought to be weakest during which phase of tendon healing?

Explanation

Healing after a tendon repair or rupture has the following stages: inflammatory, cellular proliferation, and remodeling. During the inflammatory phase, neutrophils and macrophages migrate into the injury site and release chemotactic factors that recruit fibroblasts. A tendon is thought to be weakest 5 to 21 days after repair, which coincides with the inflammatory phase. During the proliferative phase, inflammatory cells secrete cytokines and growth factors (platelet-derived growth factor, insulin-like growth factor, bone morphogenetic protein (BMP)-12 and BMP 13, and transforming growth factor-beta) that promote differentiation of fibroblasts. Fibrosis and decreased cellularity are the hallmarks of the remodeling stage.

Question 87

Which of the following is true regarding anterior sternoclavicular joint dislocations?

Explanation

DISCUSSION: From the Bicos article, “Anterior SC joint instability should primarily be treated conservatively. The patients should be informed that there is a high risk of persistent instability with nonoperative or operative care, but that the persistent instability will be well tolerated and have little functional impact in the vast majority. Therefore, operative intervention for anterior SC joint instability is mainly cosmetic in nature."

Question 88

What is the most common cause of mechanical failure of an orthopaedic biomaterial during clinical use?

Explanation

DISCUSSION: In most orthopaedic applications, the materials are strong enough to withstand a single cycle of loading in vivo. However, these loads may be large enough to initiate a small crack in the implant that can grow slowly over thousands or millions of cycles, eventually leading to gross failure. Such fatigue failure has occurred with virtually every type of implant, including stainless steel fracture plates and screws, bone cement in joint arthroplasty, and polyethylene inserts in total knee arthroplasty.
REFERENCES: Lewis G: Fatigue testing and performance of acrylic bone-cement materials: State-of-the-art review. J Biomed Mater Res Br 2003;66:457-486.
Stolk J, Verdonschot N, Huiskes R: Stair climbing is more detrimental to the cement in hip replacement than walking. Clin Orthop 2002;405:294-305.
Wright TM, Maher SA: Biomaterials, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, in press.

Question 89

A 13-year-old girl who competes in gymnastics reports the insidious onset of lateral left elbow pain over the past 6 months. She also notes occasional catching episodes in the elbow; however, she denies any history of trauma. Examination reveals tenderness over the lateral epicondyle and extensor muscle origin. The elbow is stable and has full flexion, but lacks 10° of full extension. An AP plain radiograph and an MRI scan are shown in Figures 17a and 17b. Management of the elbow should consist of

Explanation

DISCUSSION: The radiograph and MRI scan show osteochondritis dissecans of the capitellum, and the patient’s history suggests a loose body. The treatment of choice is arthroscopic removal of the loose body and microfracture of the crater. Excision of the radial head, a cortisone injection, or tennis elbow release does not treat the pathology in the capitellum. Nonsurgical treatment would not relieve the mechanical symptoms of the loose body or promote healing in the crater.
REFERENCES: Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med

1998;26:520-530.
Jackson DW, Silvino N, Reiman P: Osteochondritis in the female gymnast’s elbow. Arthroscopy 1989;5:129-136.
Ruch DS, Cory JW, Poehling GG: The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 1998;14:797-803.

Question 90

In total knee arthroplasty, in vitro testing has shown that cross-linking can diminish the rate of polyethylene wear by 30% to 80%. What other change in material properties is possible when polyethylene is highly cross-linked?

Explanation

DISCUSSION:
The most important concern regarding highly cross-linked polyethylene relates to decreased mechanical properties. Cross-linking results in reduced ductility, tensile strength, and fatigue crack propagation resistance. These problems have not been shown to cause implant failure in the most recent clinical trials, but they remain the most important mechanical issues associated with current material processing methods.

Question 91

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 92

Figures 1 and 2 are the radiographs of an 18-year-old man who had surgery 6 months ago at an outside institution. He is being referred now because he has persistent pain. He is tender over the scaphoid at the snuffbox. What is the most appropriate next imaging step in his pain workup?

Explanation

EXPLANATION:
Scaphoid nonunions are difficult to diagnose on plain radiographs, which offer poor reliability when attempting to determine if there is bridging trabeculae crossing the fractures site. CT scans are more useful for diagnosing scaphoid nonunion. When scanned using conventional axial cuts, the slices mayskip through the fracture nonunion site, thereby missing the defect, even with reformats. MR imaging is useful in diagnosing acute scaphoid fractures and has a high sensitivity and diagnostic value for excluding scaphoid fractures as well. Contrast does not enhance the utility of MR imaging in fracture diagnosis.

Question 93

A 35-year-old man sustained a 1-inch stab incision in his proximal forearm while trying to use a screwdriver 2 weeks ago. The laceration was routinely closed, and no problems about the incision site were noted. He now reports that he has been unable to straighten his fingers or thumb completely since the injury. Clinical photographs shown in Figures 30a and 30b show the man passively flexing the wrist. What is the most appropriate management?

Explanation

DISCUSSION: The clinical photographs indicate that the tenodesis effect of digit flexion with passive wrist extension and digit extension with passive wrist flexion is intact, indicating no discontinuity of the extensor or flexor tendons. The most likely injury is a laceration of the posterior interosseous nerve.
REFERENCE: Feldon P, Terrono AL, Nalebuff EA, et al: Rheumatoid arthritis and other connective tissue diseases, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 2069.

Question 94

All of the following indicators of resuscitation may be within normal limits for a trauma patient that is in "compensated" shock EXCEPT:

Explanation

DISCUSSION: Historically, normal blood pressure, heart rate, and urine output have been endpoints to signal complete resuscitation in the polytrauma patient. The review article by Porter et al states that there is a high incidence of patients (as much as 85%) in "compensated" shock despite normal vital signs and urine output parameters. Compensated shock is secondary to a maldistribution of blood flow and tissue oxygenation as splanchnic organs have less distribution of the cardiac output compared to the heart and the brain. The article by Elliott is also a review, and it states that serum lactate is the best indicator of peripheral organ perfusion and tissue oxygenation. It also states that base deficit and gastric mucosal pH are appropriate end points to determine the complete resuscitation of trauma patients.

Question 95

The postoperative neurologic prognosis of a patient who has a tumor that is compressing the spinal cord and causing a neurologic deficit depends primarily on the

Explanation

DISCUSSION: The tumor biology, location, and pretreatment neurologic status are the best predictors of a patient’s postoperative neurologic prognosis. Between 60% to 90% of patients who are ambulatory at the time of diagnosis will retain this ability after treatment. Location is important in that less space is available for the cord in the thoracic spine. Lesions located in vascular watershed regions may disrupt the vascular supply of the cord.
REFERENCES: Weinstein JN: Differential diagnosis and surgical treatment of primary benign and malignant neoplasms, in Frymoyer JW (ed): The Adult Spine: Principles and Practice. New York, NY, Raven Press, 1991, vol 1, pp 829-860.
Siegal T, Siegal T: Current considerations in the management of neoplastic spinal cord compression. Spine 1989;14:223-228.

Question 96

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

Explanation

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

Question 97

-What is the recommended treatment for this injury?

Explanation

DISCUSSION FOR QUESTIONS 85 THROUGH 87
The hypertrophic zone of the growth plate has been implicated as the weak link in the physis in acute injuries. Epiphysiolysis of the proximal humerus in throwing athletes occurs as the result of tension and shear on the physis. More than 90% of affected patients who are treated with rest for an average of 3 months become asymptomatic. Prevention is the best option. Set limitations of the number of pitches and types of pitches depending on the age of the player. Also recommend use of proper pitching mechanics.

Question 98

The patient returns 4 days after surgery and says he has noticed a red, swollen knee since yesterday. He reports a fever of 38.0°C since last evening and denies traumatic injury. He has an erythematous knee with a large, tense effusion; his range of motion is limited; and the surgical incisions are not draining. Radiographs taken in the office show no change from the immediate postsurgical images. Aspiration in the office returns 50 cc of cloudy, blood-tinged synovial fluid, and analysis of the fluid reveals a white blood cell count of 92000 (reference range 4500-11000 /µL). Which bacteria is most commonly responsible for this clinical scenario?

Explanation

Video 39 for reference
This patient has a history of failed primary and revision ACL reconstructions, both times with medial meniscus repairs. The clinical scenario suggests a recurrent ACL injury with a recurrent medial meniscus tear that is now locked. The most critical risk factor for ACL reconstruction is age younger than 20 years. The meniscal repair success rate using an all-inside device is between 80% and 90%. Traditionally, it was believed that healing rates were
higher in ACL reconstruction, but current literature demonstrates a similar rate of healing associated with ACL reconstruction and no reconstruction of stable knees.
The images show a vertical femoral tunnel resulting from this patient’s prior reconstruction and revision. The MR images reveal a locked bucket-handle tear of the medial meniscus, and the examination shows a positive Lachman test finding attributable to ACL graft failure. In the setting of a young individual who has failed 2 meniscal repairs, a third repair is not indicated. In addition to a revision ACL reconstruction to stabilize the knee, a partial medial meniscectomy is indicated. An attempt at revision medial meniscus repair would be indicated if the technique were poor in the first attempt, but a failed repair otherwise should indicate the need for partial meniscectomy. The postsurgical images reveal a much more anatomic position of the femoral tunnel that should provide better rotational control of the knee, thereby improving the pivot shift (compared to the vertical femoral tunnel).
This patient has an obvious postsurgical infection based on the timing, examination, and results of the aspiration. In multiple studies of septic arthritis following ACL reconstruction, the most common pathogen was coagulase-negative staph (Staphylococcus epidermidis), followed by S. aureus. If S. aureus is the causative pathogen, the rate of necessary graft removal is higher because of the aggressive nature of this specific bacteria.

Question 99

Six months later, the patient’s fracture has healed and a CT scan to further evaluate the physis is performed (Video 85). Based on these findings, how should you advise the family?

Explanation

DISCUSSION
The hypertrophic zone is the weakest biomechanical zone of the physis and is most likely to fracture. The deep peroneal nerve supplies motor innervation to the ankle and toe
dorsiflexors (anterior compartment) and the first web space, which, in this history, have deficits. The superficial peroneal nerve supplies sensation to the dorsum of the foot and motor to the lateral compartment peroneal musculature (ankle evertors), which also has deficits. The injury must involve both peroneal branches (the common peroneal nerve). Because sensation to the sole of the foot and toe/ankle plantar flexion is intact, the tibial nerve is intact.
Because the nerve was visualized intact, a neuropraxia is the most likely type of nerve injury. This should recover in time and does not necessitate urgent exploration. In pediatric patients, an advancing Tinel sign and partial nerve recovery by 3 months is expected and can be followed clinically. If there is no sign of nerve recovery, an electromyogram should be ordered with consideration for nerve exploration if there is no sign of reinnervation. There is no sign of compartment syndrome because the patient has an unchanged neurologic deficit, is comfortable, and has no pain with passive range of motion.
These injuries are associated with a very high rate of growth arrest (up to 80% in some studies). The CT scan shows an asymmetric growth arrest, which suggests angulation through the distal femur.

Question 100

1 and 2 demonstrate the radiographs obtained from a year-old woman with end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, nonsurgical treatment, including weight loss, activity modifications, and intra-articular injections, has failed. Her infection work-up reveals laboratory findings within defined limits. Which bearing surface is contraindicated for this patient?

Explanation

DISCUSSION:
THA has proven durable and reliable for pain relief and improving function for patients with end-stage arthritis. Appropriate bearing selection is critical to minimize wear and hip complications. A metal-on- metal articulation is associated with excellent wear rates in vitro. With its capacity to offer a low wear rate with large femoral heads, it is an attractive bearing choice for THA. However, local soft-tissue reactions, pseudotumors, and potential systemic reactions including renal failure, cardiomyopathy, carcinogenesis, and potential teratogenesis with potential transfer of metal ions across the placental barrier make metal-on-metal bearings less desirable and relatively contraindicated for younger women of child- bearing age. The workup of a painful metal-on-metal hip arthroplasty necessitates a systematic approach. Several algorithms have been proposed. Routine laboratory studies including sedimentation rate, CRP, and serum cobalt and chromium ion levels should be obtained for all patients with pain. Advanced imaging including MARS MRI should be performed to evaluate for the presence of fluid collections, pseudotumors, and abductor mechanism destruction. Infection can coexist with metal-on-metal reactions, so, when indicated (if the CRP level is elevated), a hip arthrocentesis should be obtained. However, in this setting, a manual cell count and differential should be obtained because an automated cell counter may provide falsely elevated cell counts. The results of revision surgery for a failed metal-on-metal hip prosthesis can be variable. The amount of local tissue destruction and the integrity of the hip abductor mechanism can greatly influence outcomes. Instability is the most common complication following revision of failed metal-on-metal hip replacements.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Resection of the distal femur and postoperative chemotherapy
Preoperative chemotherapy followed by radiation therapy, then resection of the distal femur
Preoperative chemotherapy followed by surgical resection of the lesion and postoperative chemotherapy
Preoperative chemotherapy followed by radiation therapy, resection of the distal femur, then postoperative chemotherapy
Resection of the distal femur followed by radiation therapy

Correct Answer: Preoperative chemotherapy followed by surgical resection of the lesion and postoperative chemotherapy

Explanation:

DISCUSSION: This is a classic appearance for an osteosarcoma. The radiographs reveal a mixed osteolytic and osteoblastic lesion in a skeletally immature patient in the distal right femoral metaphysis. The pain pattern with progressive symptoms leading to the presence of night pain is also typical for this condition. The biopsy specimen reveals pleomorphic cells and the presence of osteoid. The current standard of care in the treatment of osteosarcoma is neoadjuvant chemotherapy followed by surgical resection or amputation followed by additional postoperative chemotherapy. Osteosarcoma is not radiosensitive.
REFERENCES: Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 179.
McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 205.

Question 2:

Options:

observation.
bilateral adductor and iliopsoas releases, with nighttime abduction bracing.
proximal femoral varus osteotomy with internal fixation.
proximal femoral varus osteotomy with volume-reducing periacetabular osteotomy.
proximal femoral varus osteotomy with shelf acetabular augmentation.

Correct Answer: observation.

Explanation:

DISCUSSION: Observation is the treatment of choice. Hip subluxation and dislocation are not uncommon in patients with SMA type II who are unlikely to be ambulatory. Scoliosis occurs in these patients 100% of the time and frequently creates pelvic obliquity. However, in long-term follow-up, patients with SMA type II and hip dislocations had little associated pain or functional limitations because of hip instability. In addition, recurrent hip subluxation after surgical treatment has been documented. Given the rarity of symptoms from hip instability in long-term follow-up, and the possibility of recurrent dislocation, surgical intervention for hip instability may expose SMA type II patients to undue surgical risk for minimal if any functional gain.
REFERENCES: Sporer SM, Smith BG: Hip dislocation in patients with spinal muscular atrophy. J Pediatr Orthop 2003;23:10-14.
Thompson CE, Larsen LJ: Recurrent hip dislocation in intermediate spinal atrophy.
J Pediatr Orthop 1990;10:638-641.

Question 3:

During an anterior approach to the bicipital 53 tuberosity, you encounter a nerve overlying the brachioradialis fascia (Figure 58). It provides innervation to the

Options:

flexor pollicis longus.
skin on the anteromedial forearm.
skin on the anterolateral forearm.
extensor indicis proprius.

Correct Answer: skin on the anterolateral forearm.

Explanation:

Question 4:

The illustration shown in Figure 19 shows a Chamberlain line. What is the most likely diagnosis?

Options:

Anterior atlanto-occipital dislocation
Basilar invagination
C1-C2 dislocation
Transverse ligament injury
Normal findings

Correct Answer: Normal findings

Explanation:

DISCUSSION: Basilar invagination is best defined as vertical or compressive instability at the occiput-C1 joint. Such invaginations most commonly occur in patients with rheumatoid arthritis but also can occur secondary to trauma or tumor. A Chamberlain line is used as a method to determine basilar invagination. The odontoid tip should not be more than 5 mm above a Chamberlain line.
REFERENCES: Wiesel SW, Rothman RH: Occipito-atlantal hypermobility.
Spine 1979;4:187-191.
Clark CR: The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 50-51.

Question 5:

Options:

Multilevel anterior cervical diskectomy with fusion
Anterior and posterior decompression with fusion
Anterior corpectomy and fusion with a fibula strut
Laminectomy and bilateral foraminotomies
Laminectomy and posterior fusion with lateral mass plating

Correct Answer: Laminectomy and bilateral foraminotomies

Explanation:

Question 6:

Options:

Discontinue the procedure and delay completion of the total arthroplasty until the fracture has healed.
Cement a long-stemmed humeral component to bypass the fracture site and supplement with cerclage wires.
Remove all instrumentation, perform an open reduction and internal fixation of the fracture, and delay completion of the total arthroplasty until the fracture has healed.
Insert a standard humeral component and apply a humeral orthosis postoperatively.
Insert a standard humeral prosthesis with suture fixation and autogenous cancellous bone grafting of the greater tuberosity fracture.

Correct Answer: Insert a standard humeral prosthesis with suture fixation and autogenous cancellous bone grafting of the greater tuberosity fracture.

Explanation:

Question 7:

What is the typical MRI signal intensity of bone marrow affected by acute osteomyelitis?

Options:

Decreased on T 1 -weighted imaging, increased on T 1 -weighted imaging with gadolinium enhancement, increased on T 2 -weighted imaging
Decreased on T 1 -weighted imaging, increased on T 1 -weighted imaging with gadolinium enhancement, decreased on T2-weighted imaging
Increased on T 1 -weighted imaging, increased on T 1 -weighted imaging with gadolinium enhancement, increased on T 2 -weighted imaging
Increased on T 1 -weighted imaging, increased on T 1 -weighted imaging with gadolinium enhancement, decreased on T 2 -weighted imaging
Increased on T 1 -weighted imaging, decreased on T 1 -weighted imaging with gadolinium enhancement, decreased on T 2 -weighted imaging

Correct Answer: Decreased on T 1 -weighted imaging, increased on T 1 -weighted imaging with gadolinium enhancement, increased on T 2 -weighted imaging

Explanation:

DISCUSSION: The classic MRI findings of osteomyelitis are a decrease in the normally high signal intensity of marrow on T
1
-weighted images and normal or increased signal intensity on T
2
-weighted images. This is the result of replacement of marrow fat by inflammatory cells and edema, which causes lower signal intensity than fat on T
1
-weighted images and higher signal intensity than fat on T
2
-weighted images. The addition of gadolinium to a T
1
-weighted sequence reveals increased signal intensity in the hyperemic marrow.
REFERENCES: Unger E, Moldofsky P, Gatenby R, et al: Diagnosis of osteomyelitis by MR imaging. Am J Roentgenol 1988;150:605-610.
Dormans JP, Drummond DS: Pediatric hematogenous osteomyelitis: New trends in presentation, diagnosis and treatment. J Am Acad Orthop Surg 1994;2:333-341.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 150-163.

Question 8:

Options:

electrical stimulation.
a Charleston bending brace at night.
an extension-type spinal orthosis.
posterior spinal fusion with instrumentation.
anterior spinal release and posterior spinal instrumentation.

Correct Answer: an extension-type spinal orthosis.

Explanation:

DISCUSSION: The radiograph shows excessive thoracic kyphosis (normal 20 degrees to
50 degrees) with multiple contiguous vertebral wedging and end plate irregularity, all consistent with the diagnosis of Scheuermann’s kyphosis. The patient is skeletally immature; therefore, there is the potential for progression of the kyphotic deformity. Extension bracing has shown efficacy in the treatment of Scheuermann’s kyphosis that measures 50 degrees to 74 degrees, and has actually reduced the curvature permanently in some patients. A thoracolumbosacral orthosis may be used if the apex of kyphosis is at T7 or lower. Indications for surgical treatment are controversial, but spinal fusion most likely should not be considered for a painless kyphosis measuring less than 75 degrees.
REFERENCES: Murray PM, Weinstein SL, Spratt KF: The natural history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg Am 1993;75:236-248.
Wenger DR, Frick SL: Scheuermann kyphosis. Spine 1999;24:2630-2639.
Tribus CB: Scheuermann’s kyphosis in adolescents and adults: Diagnosis and management.
J Am Acad Orthop Surg 1998;6:36-43.

Question 9:

Options:

No pharmacologic intervention is recommended at this time
Administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours
Administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 48 hours
Administration of naloxone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours
Administration of naloxone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 48 hours

Correct Answer: No pharmacologic intervention is recommended at this time

Explanation:

DISCUSSION: The standard practice in the pharmacologic treatment of a spinal cord injury in the United States has been the administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours, in accordance with the findings of the second and third National Acute Spinal Cord Injury Studies (NASCIS). Although the studies have subsequently drawn criticism for their methodology and outcomes, it has been generally accepted that beneficial neurologic outcomes were anticipated in patients who were able to start the protocol within 8 hours of their initial injury. Further improvement was noted in patients receiving the methylprednisolone within 3 hours of their injury and continuing an infusion for
48 hours. In this patient, who is outside the 8-hour treatment window, no studies have supported starting the methylprednisolone protocol at this time.
REFERENCES: Braken MB, Shepard MJ, Holford TR, et al: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury: Results of the third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997;277:1597-1604.
Kwon BK, Tetzlaff W, Grauer JN, et al: Pathophysiology and pharmacologic treatment of acute spinal cord injury. Spine J 2004;4:451-464.

Question 10:

Options:

closed reduction of the glenohumeral joint and open reduction of the displaced greater tuberosity with rotator cuff repair.
closed reduction of the glenohumeral joint, followed by radiographic assessment of the tuberosity position to determine further treatment.
open reduction of both the joint and greater tuberosity with rotator cuff repair.
open reduction of the glenohumeral joint and closed treatment of the greater tuberosity.
use of a sling until the patient reports no discomfort, then early passive range of motion.

Correct Answer: closed reduction of the glenohumeral joint, followed by radiographic assessment of the tuberosity position to determine further treatment.

Explanation:

Question 11:

An AP radiograph of the pelvis is shown in Figure 4. What muscle attaches to the avulsed fragment of bone identified by the arrow?

Options:

Short head of the biceps femoris
Adductor longus
Pectineus
Piriformis
Semitendinosus

Correct Answer: Semitendinosus

Explanation:

Question 12:

The cortical injury to the posterolateral distal fibula shown in Figure 25 indicates involvement of which of the following structures?

Options:

Deltoid ligament
Anterior talofibular ligament
Calcaneal fibular ligament
Superior peroneal retinaculum
Syndesmosis

Correct Answer: Superior peroneal retinaculum

Explanation:

Question 13:

When performing the exposure for an anterior approach to the cervical spine, excessive retraction of the trachea and esophagus should be avoided to prevent injury of the

Options:

vagus nerve.
recurrent laryngeal nerve.
superior laryngeal nerve.
hypoglossal nerve.
sympathetic trunk.

Correct Answer: recurrent laryngeal nerve.

Explanation:

DISCUSSION: The recurrent laryngeal nerve lies between the trachea and the esophagus and is subject to stretch injury if excessive retraction is applied. The vagus nerve lies in the carotid sheath. The sympathetic trunk lies anterior to the longus colli muscles. The hypoglossal nerve and superior laryngeal nerve are both at risk during the exposure but are not located between the trachea and esophagus.
REFERENCES: An HS: Principles and Techniques of Spine Surgery. Baltimore, MD,
Williams and Wilkins, 1998, chapter 2.
Flynn TB: Neurologic complication of anterior cervical interbody fusion. Spine 1982;7:536-539.

Question 14:

Options:

Femoroacetabular impingement (FAI)
Osteoarthritis of the sacroiliac joint
Intra-articular loose body
Trochanteric bursitis

Correct Answer: Femoroacetabular impingement (FAI)

Explanation:

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has
important functions for hip stability and maintenance of the suction seal of the joint.

Question 15:

Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

Options:

Comminuted fractures
Fractures that involve the coronoid process
Fractures associated with Monteggia fracture-dislocations
Oblique fractures distal to the midpoint of the trochlear notch
Transverse fractures through the midpoint of the trochlear notch

Correct Answer: Transverse fractures through the midpoint of the trochlear notch

Explanation:

Question 16:

In articular cartilage, Interleukin 1 (IL-1) increases

Options:

matrix metalloproteinase.
proteoglycan synthesis.
collagen production.
nitric oxide synthetase.

Correct Answer: matrix metalloproteinase.

Explanation:

Question 17:

Options:

oral indomethacin.
Irradiation with a single dose of 700 cGy.
Physical therapy with dynamic splinting.
Physical therapy and delayed ectopic bone excision at 12 months.
Immediate elbow release and ectopic bone excision. back answer Question 59.03

Correct Answer: Immediate elbow release and ectopic bone excision. back answer Question 59.03

Explanation:

Question 18:

Options:

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

Correct Answer: Lateral collateral ligament reconstruction

Explanation:

Question 19:

Options:

Neurogenic claudication
Vascular claudication
Lumbar radiculopathy
Cervical myelopathy
Central cord syndrome

Correct Answer: Neurogenic claudication

Explanation:

Question 20:

Options:

Abduction to 90 degrees with maximal external rotation
Forward elevation to 170 degrees with neutral rotation
Cross-body adduction at 90 degrees flexion, with internal rotation
Extension with maximal internal rotation
Flexion to 90 degrees with maximal external rotation

Correct Answer: Abduction to 90 degrees with maximal external rotation

Explanation:

Question 21:

Options:

Avulsion of the lateral collateral ligament
Avulsion of the pes anserinus
Avulsion of the iliotibial band
Tear of the anterior cruciate ligament
Tear of the posterior cruciate ligament

Correct Answer: Tear of the anterior cruciate ligament

Explanation:

Question 22:

Where is the most common site for tuberculosis (TB) spondylitis in children? Review Topic

Options:

Anterior aspect of the lower thoracic region
Anterior aspect of the cervical spine
Posterior elements of the lower thoracic region
Posterior elements of the cervical spine
Transverse process of the lower lumbar spine

Correct Answer: Anterior aspect of the lower thoracic region

Explanation:

Question 23:

Options:

Bracing
Posterior spinal fusion of only the right thoracic curve
Posterior spinal fusion from T2-L4
Vertebral body stapling to halt progression of the curve
Anterior and posterior spinal fusion

Correct Answer: Posterior spinal fusion of only the right thoracic curve

Explanation:

Question 24:

The stiffness of a 16-mm femoral stem is mostly influenced by the

Options:

elastic modulus of the material.
surface coating or treatment.
diameter of the femoral stem.
length of the femoral stem.
ultimate tensile strength.

Correct Answer: diameter of the femoral stem.

Explanation:

Question 25:

Options:

1,2 intercompartmental supraretinacular artery (ICSRA) graft
Free-vascularized medial femoral condyle graft
Iliac crest corticocancellous graft
4+5 extensor compartmental artery (ECA) vascularized bone graft

Correct Answer: Free-vascularized medial femoral condyle graft

Explanation:

Question 26:

Options:

cheilectomy.
extra-depth shoes.
steroid injection.
arthrodesis.
joint replacement arthroplasty.

Correct Answer: extra-depth shoes.

Explanation:

Question 27:

Options:

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

Correct Answer: Splinting, admission, and frequent neurovascular checks

Explanation:

Question 28:

Options:

Stress view radiographs of the left hip
Non-weight bearing and pelvic bone scan in 7 days
Non-weight bearing and repeat the CT scan after 48 hours from injury
MRI hip and pelvis
Weight bearing activity as tolerated with close follow-up

Correct Answer: Stress view radiographs of the left hip

Explanation:

The next best step would be an MRI hip and pelvis to investigate for an occult fracture of the left hip.
Moderate evidence supports MRI as the advanced imaging of choice for diagnosis of presumed hip fracture not apparent on initial radiographs. MRI has been shown to be able to detect occult fractures earlier than bone scan, with better spatial resolution. Usually the MRI should be obtained in less than 24 hours from the time of injury. For situations in which MRI is not immediately available, bone scan can be considered after 72 hours form the time of injury. However, this may compromise patient care and put the patient at risk of fracture displacement.
Cannon et al. reviewed the imaging of choice in occult hip fracture. They showed that physical examination yields a poor sensitivity identifying occult hip fractures, with log-rolling and straight-leg raise as 50% and 70%, respectively. The most sensitive modality for occult fracture identification was MRI.
Iwata et al. retrospectively reviewed a cohort of 35 patients with clinically suspected fractures of the hip that underwent MRI. All radiographs were negative. In 26 of these patients, a T1-weighted coronal MRI showed a hip fracture with 100% sensitivity.
Roberts et al. reviewed the 2015 AAOS Clinical Practice Guideline: Management of Hip Fractures in the Elderly. They report moderate evidence that supports MRI as the advanced imaging of choice for diagnosis of presumed hip fractures not apparent on initial radiographs.
Figure A is a AP radiograph of the left hip and pelvis. Apart from a healed fracture of the ischiopubic rami and generalized osteopenia, there is no obvious hip fracture. Figure B is a coronal CT image that does not demonstrate evidence of an acute hip fracture. Illustration A is a T1 weighted MR image that shows a non displaced fracture (white arrow) through the intertrochanteric region of the left proximal femur.
Incorrect Answers:
(SBQ12TR.32) A 20-year-old male is taken to the emergency department following a motorcycle collision with the injury seen in Figures A and B. He undergoes serial debridements with placement of an antibiotic bead pouch, followed by intramedullary nailing and free tissue transfer. His preoperative examination is notable for absent plantar sensation. Which of the following is predictive of a worse long term outcome in this patient?
Absent plantar sensation at presentation
Depression at 3 months post-injury
Use of an intramedullary nail
Free tissue transfer instead of rotational flap
Need for multiple debridements
The presence of depression at the 3 months post-injury is a significant predictor of worse long term outcome as well as lower return to work rates in patients that present with limb threatening lower extremity trauma.
The findings of the Lower Extremity Assessment Project (LEAP study) has challenged many of the long-held beliefs of lower extremity trauma surgery, including the concept that patients with absent plantar sensation should undergo immediate amputation . The LEAP study has also brought to light the importance of socioeconomic and psychosocial factors in patient outcomes following these injuries.
Bosse et al analyzed a subgroup of 55 patients from the LEAP study with absent plantar sensation at presentation. Those patients that underwent limb salvage despite absent sensation (n=26) had no significant difference in functional outcome when compared with either insensate patients who underwent amputation or a matched control group of sensate patients with similar injuries. All but one patient in the salvage group had return of some sensation at 2-year follow up and the authors concluded that an insensate plantar foot at presentation should not be included in the algorithm for amputation.
Mackenzie and Bosse reviewed the results of the LEAP study with particular emphasis on the social and economic variables that influence outcomes in severe lower extremity. The authors note that 19% of patients screened positive for severe depression. The presence of anxiety, pain and depression at 3 months post-injury were significant predictors of poor outcome
Incorrect Answers:
tissue for type IIIB tibia fractures. Answer 5: The number of debridements has not been shown to influence outcome.

Question 29:

Options:

a figure-of-8 clavicle strap.
a sling for comfort, followed by early range-of-motion and strengthening exercises.
open reduction and stabilization.
immobilization in a spica cast.
resection of the distal clavicle.

Correct Answer: open reduction and stabilization.

Explanation:

Question 30:

Which of the following is considered a potential advantage of arthroscopic repair for anterior instability of the shoulder? Review Topic

Options:

Decreased healing time at the glenoid-labral junction
Completion of the procedure on an outpatient basis
Faster return to play than with open procedures
Preservation of external rotation
Decreased risk of recurrent instability in comparison to open repair

Correct Answer: Preservation of external rotation

Explanation:

Question 31:

Options:

Continued serial neurologic examinations
CT with a myelogram of the lumbar spine
Immediate surgical exploration and hematoma drainage
Electromyography of bilateral lower extremities
IV antibiotics for 24 hours, followed by surgical exploration if symptoms persist

Correct Answer: Immediate surgical exploration and hematoma drainage

Explanation:

DISCUSSION: The MRI scans reveal a large postoperative hematoma causing significant thecal compression. An epidural hematoma with neurologic deficit is a surgical emergency requiring immediate evacuation of the hematoma. Although the incidence of postoperative epidural hematomas is rare, the consequences of a missed diagnosis can be catastrophic. Early recognition and evacuation are essential in preserving or restoring neurologic function. Uribe and associates attributed delayed postoperative hematomas to previous multiple lumbar surgeries as a possible contributing factor.
REFERENCES: Yi S, Yoon do H, Kim KN, et al: Postoperative spinal epidural hematoma: Risk factor and clinical outcome. Yonsei Med J 2006;47:326-332.
Uribe J, Moza K, Jimenez O, et al: Delayed postoperative spinal epidural hematomas. Spine J 2003;3:125-129.

Question 32:

Options:

Acute reconstruction of all ligamentous structures
Emergency MRI and reconstruction of all ligamentous structures
Emergency arteriogram followed by MRI
Emergency surgery with open reduction and repair of all tom structures with vascular surgery available
Closed reduction in the emergency room and reevaluation of the vascular status

Correct Answer: Closed reduction in the emergency room and reevaluation of the vascular status

Explanation:

Question 33:

A 5-year-old boy has had midfoot pain with activity for the past 3 months. He has no pain at rest. Radiographs are shown in Figures 29a and 29b. Management should consist of

Options:

a vascularized pedicle bone graft.
a short leg walking cast.
a custom-molded orthotic.
surgical debridement followed by antibiotics.
a bone stimulator.

Correct Answer: a short leg walking cast.

Explanation:

Question 34:

..First-line treatment recommendations include

Options:

synovectomy.
arthrocentesis, compressive wrap, and rest.
en bloc resection.
intra-articular radioactive nucleotide injection. DISCUSSION… The MRI scans reveal classic findings of PVNS with low signal on proton density and T2 sequences and evidence of “blooming” on gradient echo sequences. A discrete mass suggestive of a sarcoma (which would typically appear dark on T1 and bright on T2, but heterogenous and enhancing) is not seen, and synovial sarcomas rarely arise in an intra-articular location. Cartilaginous nodules of synovial chondromatosis are not seen, and the abnormal synovial process indicates that this is more than just a posttraumatic hemarthrosis. Treatment is synovectomy; radiotherapy is reserved for select recurrent cases. Arthrocentesis would be used for a simple hemarthrosis, and resection used for a sarcoma.

Correct Answer: en bloc resection.

Explanation:

Question 35:

A newborn has an anterolateral bow of the tibia and a duplication of the great toe. Which of the following conditions will develop as the infant grows?

Options:

Lisch nodules and axillary freckling
Fracture of the tibia with pseudarthrosis
Increased tibial bowing and varus deformity
Decreased tibial bowing and limb-length discrepancy
Progressive valgus of the ankle

Correct Answer: Decreased tibial bowing and limb-length discrepancy

Explanation:

Question 36:

Evaluation of the percent of necrosis in the resected specimen after preoperative chemotherapy is of prognostic value for what type of sarcoma?

Options:

Chondrosarcoma
Soft-tissue sarcoma
Rhabdomyosarcoma
Parosteal osteosarcoma
Osteosarcoma

Correct Answer: Osteosarcoma

Explanation:

Question 37:

Options:

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

Correct Answer: open reduction.

Explanation:

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

Question 38:

Options:

Cemented left total hip arthroplasty (THA)
Cementless left THA with a proximally porous coated femoral stem
Hybrid left THA
Cementless left THA with a diaphyseal engaging conical femoral stem

Correct Answer: Hybrid left THA

Explanation:

Question 39:

Which of the following is the most sensitive parameter to detect the increased inflammatory response seen with both postoperative infection and the use of instrumentation in spinal surgery?

Options:

Patient temperature
WBC count
Erythrocyte sedimentation rate
C-reactive protein
Rheumatoid Factor

Correct Answer: Patient temperature

Explanation:

CORRECT
DISCUSSION: The most sensitive parameter to detect inflammation elicited by implants and infection is the C-reactive protein (CRP).
CRP is an acute phase reactant that increases sharply immediately after surgery within 6 hours after tissue damage. CRP then peaks 2-3 days later and returns to normal levels 5-21 days after the inciting event. In contrast, ESR reaches its peak on days 4-11, then remains elevated for a prolonged period of time.
Takahashi et al performed a Level 3 study of patients who had undergone spinal surgery with and without instrumentation, with a primary outcome of infection. They concluded that renewed elevation of C-reactive protein, white blood cell count, and body temperature after postoperative days 4 to 7 may be a key indicator of postoperative infection.

Question 40:

Which of the following is considered a contraindication to the use of a reverse total shoulder arthroplasty? Review Topic

Options:

Prior shoulder joint infection
Pseudoparalysis
Prior partial acromioplasty
Absent glenohumeral joint space narrowing
Axillary neuropathy

Correct Answer: Axillary neuropathy

Explanation:

Question 41:

Options:

The injury will do well with treatment in a knee immobilizer.
The injury will do well with immobilization in a long leg cast.
Long leg cast immobilization and reduction is recommended but she may develop a deformity that always requires surgical correction.
Long leg cast immobilization and reduction is recommended but she may develop a deformity; however, if the deformity develops there is a significant chance it will resolve spontaneously.
Surgery is indicated to prevent deformity that may follow with this injury.

Correct Answer: Long leg cast immobilization and reduction is recommended but she may develop a deformity; however, if the deformity develops there is a significant chance it will resolve spontaneously.

Explanation:

Question 42:

A patient sustained a fracture of the left acetabulum. A single axial CT scan from a two-dimensional study is shown in Figure 61. This fracture pattern is best classified as

Options:

both column.
anterior column.
posterior column.
transverse.
anterior column-posterior hemitransverse.

Correct Answer: transverse.

Explanation:

Question 43:

Figure 9 shows the AP radiograph of a 65-year-old man who has knee pain and swelling. What is the most likely diagnosis?

Options:

Gout
Chondrocalcinosis (pseudogout)
Hemochromatosis
Rheumatoid arthritis
Ochronosis

Correct Answer: Chondrocalcinosis (pseudogout)

Explanation:

DISCUSSION: Although all the choices are known causes of joint degeneration (secondary osteoarthritis), only chondrocalcinosis shows distinct linear calcification of the cartilage due to deposition of calcium pyrophosphate crystals. Gout is a recurrent acute arthritis resulting from the deposition of monosodium urate from supersaturated hyperuricemic body fluids. Hemochromotosis is characterized by focal or generalized deposition of iron within body tissues. Arthritis may be present but is less common than other manifestations such as liver cirrhosis, skin pigmentation, diabetes mellitus, and cardiac disease. Rheumatoid arthritis is a nonspecific, usually symmetric inflammation of peripheral joints resulting in destruction of articular and periarticular structures. Ochronosis is a hereditary enzyme deficiency (homogentisic acid oxidase) resulting in deposition of homogentisic acid polymers in articular cartilage.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 188.
Berkow R (ed): The Merck Manual, ed 14. Rathway, NJ, Merck, 1984, pp 910, 1176, 1200.

Question 44:

Options:

Cast immobilization for 6 weeks
Activity modification and re-evaluation in 2 months
Internal fixation with or without bone grafting
Retrograde drilling of the defect without articular cartilage penetration
Drilling of the defect directly through the articular cartilage

Correct Answer: Activity modification and re-evaluation in 2 months

Explanation:

Question 45:

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

Options:

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

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

Explanation:

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

Question 46:

One year after undergoing anterior cervical decompression and fusion, what percentage of patients still have dysphagia?

Options:

10% to 15%
30% to 35%
50% to 55%
70% to 75%

Correct Answer: 10% to 15%

Explanation:

DISCUSSION
Dysphagia after anterior cervical diskectomy and fusion is a common, usually transient finding after anterior cervical approaches to the spine. While it has been reported to occur in up to 70% of patients 2 weeks following surgery, in most cases the symptoms quickly resolve. There is, however, a small subset of patients for whom symptoms of dysphagia will persist. Lee and associates prospectively studied the rate of dysphagia after anterior cervical diskectomy and fusion, reporting a 15% rate of dysphagia at 12 months, and 12% at 24 months. Phillips and associates analyzed the 2-year data from the PCM FDE clinical trial and found a 12.1% incidence of dysphagia in the ACDF arm.
RECOMMENDED READINGS
Lee MJ, Bazaz R, Furey CG, Yoo J. Risk factors for dysphagia after anterior cervical spine surgery: a two-year prospective cohort study. Spine J. 2007 Mar-Apr;7(2):141-7. Epub 2007 Jan 22. PubMed PMID: 17321961.
View Abstract at PubMed
Smith-Hammond CA, New KC, Pietrobon R, Curtis DJ, Scharver CH, Turner DA. Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients: comparison of anterior cervical, posterior cervical, and lumbar procedures. Spine (Phila Pa 1976). 2004 Jul 1;29(13):1441-6. PubMed PMID: 15223936.
View
Abstract at PubMed
Edwards CC 2nd, Karpitskaya Y, Cha C, Heller JG, Lauryssen C, Yoon ST, Riew KD. Accurate identification of adverse outcomes after cervical spine surgery. J Bone Joint Surg Am. 2004 Feb;86-A(2):251-6. PubMed PMID: 14960668.
View Abstract at PubMed
Phillips FM, Lee JY, Geisler FH, Cappuccino A, Chaput CD, DeVine JG, Reah C, Gilder KM, Howell KM, McAfee PC. A prospective, randomized, controlled clinical investigation comparing PCM cervical disc arthroplasty with anterior cervical discectomy and fusion. 2-year results from the US FDA IDE clinical trial. Spine (Phila Pa 1976). 2013 Jul 1;38(15):E907-18. doi: 10.1097/BRS.0b013e318296232f.
Rihn JA, Kane J, Albert TJ, Vaccaro AR, Hilibrand AS. What is the incidence and severity of dysphagia after anterior cervical surgery? Clin Orthop Relat Res. 2011 Mar;469(3):658-65. PMID: 21140251.
View Abstract at PubMed

Question 47:

Options:

a hypoplastic lateral femoral condyle.
a contracted medial collateral ligament.
an excessive proximal tibial slope.
trochlear dysplasia.

Correct Answer: a hypoplastic lateral femoral condyle.

Explanation:

Question 48:

Options:

Continued AFO bracing and therapy
Ankle fusion
Exploration and release of the common peroneal nerve
Transfer of the PTT through the interosseous membrane with attachment to the tibialis anterior and peroneus tertius above the level of the ankle, debridement of the anterior compartment, and Achilles tendon lengthening
Transfer of the peroneus longus to the dorsum of the foot and Achilles tendon lengthening

Correct Answer: Transfer of the PTT through the interosseous membrane with attachment to the tibialis anterior and peroneus tertius above the level of the ankle, debridement of the anterior compartment, and Achilles tendon lengthening

Explanation:

DISCUSSION: This pattern of injury is consistent with an unrecognized compartment syndrome of the anterior and lateral compartments. Transfer of the PTT through a long incision in the interosseous membrane corrects the foot drop deformity, and allows adequate dorsiflexion provided that the tendon to be transferred has a strength of 5/5. Muscles/tendons typically lose one grade of strength after transfer. Transfer into the tendons at the level of the ankle prevents overtensioning or pullout of a PTT tendon that is not long enough. Debridement of the scarred muscle in the anterior compartment decreases the risk of scarring down to the tendon transfer. Transfer of the peroneus longus is not preferred given its relative lack of strength and line of pull. Continued therapy and bracing are unlikely to lead to further improvement at 2 years after injury. An ankle fusion would correct the foot drop but would not address the tendon imbalances between the tibialis anterior and the peroneus longus, and the PTT and the peroneus brevis.
REFERENCES: Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, p 192.
Atesalp AS, Yildiz C, Komurcu M, et al: Posterior tibial tendon transfer and tendo-Achilles lengthening for equinovarus foot deformity due to severe crush injury. Foot Ankle Int 2002;23:1103-1106.
Scott AC, Scarborough N: The use of dynamic EMG in predicting the outcome of split posterior tibial tendon transfers in spastic hemiplegia. J Pediatr Orthop 2006;26:777-780.
Williams PF: Restoration of muscle balance of the foot by transfer of the tibialis posterior. J Bone Joint Surg Br 1976;58:217-219.

Question 49:

Options:

Open reduction and cerclage fixation of the fracture
Open reduction and revision of the femoral implant to a long cemented stem
Open reduction and revision of the femoral implant to a long fluted and tapered uncemented stem
Application of balanced traction followed by surgery after the ecchymosis has resolved

Correct Answer: Application of balanced traction followed by surgery after the ecchymosis has resolved

Explanation:

Question 50:

Which of following is pathognomonic of intervertebral disk degeneration? Review Topic

Options:

Increased water content in the nucleus pulposus
Loss of Type X collagen in the nucleus pulposus
Decreased thickness of the inner annulus fibers
Degradation of large proteoglycans molecules in the nucleus pulposus
Annular tears and fissuring occurring most frequently in the central disc

Correct Answer: Loss of Type X collagen in the nucleus pulposus

Explanation:

Question 51:

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

Options:

Common and frequently symptomatic
Common and infrequently symptomatic
Common but generally resolves spontaneously
Rare but when present, usually symptomatic
Rare and if present, infrequently symptomatic

Correct Answer: Common and infrequently symptomatic

Explanation:

DISCUSSION: Measurable anterior cruciate ligament laxity, while frequently seen after tibial eminence fractures, usually does not cause symptoms. It is found even in patients whose fractures have been anatomically reduced and fixed, leading to speculation that it is due to stretching of the ligament at the time of injury.
REFERENCES: Willis R, Blokker C, Stall TM, et al: Long-term follow-up of anterior
eminence fractures. J Pediatr Orthop 1993;13:361-364.
Smith JB: Knee instability after fracture of the intercondylar eminence of the tibia.
J Pediatr Orthop 1984;4:462-464.

Question 52:

Options:

local resection of the fibroma.
resection of the entire plantar fascia.
local radiation therapy.
resection and adjuvant chemotherapy.
Syme amputation.

Correct Answer: resection of the entire plantar fascia.

Explanation:

Question 53:

Options:

Removal of hardware with tendon transfer
Repair of the extensor pollicis longus (EPL) tendon primarily
Thumb interphalangeal (IP) arthrodesis
Nonsurgical treatment with cast placement keeping the thumb in a fully extended position for 4 weeks

Correct Answer: Removal of hardware with tendon transfer

Explanation:

Question 54:

Options:

Radiographs
MRI
Erythrocyte sedimentation rate (ESR)
CBC with differential
C-reactive protein (CRP)

Correct Answer: C-reactive protein (CRP)

Explanation:

Question 55:

Options:

Vigorous physical therapy
Manipulation under anesthesia
Arthroscopic capsular release
Hemiarthroplasty
Arthroscopic capsular plication

Correct Answer: Hemiarthroplasty

Explanation:

DISCUSSION: Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult.
REFERENCES: Gerber C, Lambert SM: Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376-382.
Spencer EE Jr, Brems JJ: A simple technique for management of locked posterior shoulder dislocations: Report of two cases. J Shoulder Elbow Surg 2005;14:650-652.
Sperling JW, Pring M, Antuna SA, et al: Shoulder arthroplasty for locked posterior dislocation of the shoulder. J Shoulder Elbow Surg 2004;13:522-527.
Hawkins RJ, Neer CS II, Pianta RM, et al: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
McLaughlin HL: Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;34:584-590.

Question 56:

Options:

posterior spinal fusion with instrumentation.
a thoracolumbosacral orthosis (TLSO) extension brace and early mobilization.
bed rest for 6 weeks followed by mobilization in a cast.
anterior L1 corpectomy and fusion with instrumentation.
anterior corpectomy followed by posterior fusion with instrumentation.

Correct Answer: a thoracolumbosacral orthosis (TLSO) extension brace and early mobilization.

Explanation:

Question 57:

Figures 1 and 2 are the CT and MRI scans of a patient with shoulder instability. Contrasting these two imaging techniques for decision making in shoulder instability would suggest

Options:

Both CT and MRI have equivalent cost for the patient.
Both CT and MRI have equivalent safety for the patient.
Associated soft-tissue damage can be more reliably shown on CT scans.
Two-dimensional CT scans represent better definition of bone loss than two-dimensional MRI scans. Two-dimensional CT scan is generally accepted as a superior imaging modality for evaluating bone loss in shoulder instability than two-dimensional MRI scan. This advantage is offset by the relatively high radiation dose. Although CT in most situations is less costly, MRI can provide more data regarding associated soft-tissue damage that can be associated with recurrent instability. It should be noted that three-dimensional MRI has recently been shown as equivalent to three-dimensional CT in its ability to identify glenoid bone loss.

Correct Answer: Two-dimensional CT scans represent better definition of bone loss than two-dimensional MRI scans. Two-dimensional CT scan is generally accepted as a superior imaging modality for evaluating bone loss in shoulder instability than two-dimensional MRI scan. This advantage is offset by the relatively high radiation dose. Although CT in most situations is less costly, MRI can provide more data regarding associated soft-tissue damage that can be associated with recurrent instability. It should be noted that three-dimensional MRI has recently been shown as equivalent to three-dimensional CT in its ability to identify glenoid bone loss.

Explanation:

Question 58:

Options:

loosening of the femoral component.
loosening of the acetabular component.
prosthetic hip dislocation.
rapid wear of the polyethylene.
continued expansion of the lytic defects.

Correct Answer: prosthetic hip dislocation.

Explanation:

DISCUSSION: Maloney and associates reported a 35% increased risk of pelvic osteolysis after total hip arthroplasty with a porous-coated acetabular component without cement. All components were stable at the time of revision. Only liners were exchanged and debridement of the granuloma with or without bone graft was performed. No defects progressed and one third of the lesions were no longer visible on radiographs, regardless of bone grafting. Unfortunately, despite the technical ease of many of these types of revisions, the dislocation rate for these cases is significant. Precautions should be taken postoperatively, and patients should be educated about this risk preoperatively.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424.
Boucher HR, Lynch C, Young AM, et al: Dislocation after polyethylene liner exchange in total hip arthroplasty. J Arthroplasty 2003;18:654-657.
Maloney WJ, Herzwurm P, Paprosky W, et al: Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am 1997;79:1628-1634.

Question 59:

Figures 6a through 6d show the radiographs and biopsy specimens of an 8-year-old girl with leg pain. Management of the lesion should consist of

Options:

wide resection and salvage of the physis.
resection and hemicondylar osteoarticular allograft.
cryosurgery.
radiation therapy.
curettage and bone grafting.

Correct Answer: curettage and bone grafting.

Explanation:

Question 60:

Options:

10% decrease in amplitude, 50% decrease in latency.
10% decrease in amplitude, 50% increase in latency.
0% loss of amplitude, transient increase in latency.
50% decrease in amplitude, 10% increase in latency.
50% decrease in amplitude, 10% decrease in latency.

Correct Answer: 50% decrease in amplitude, 10% increase in latency.

Explanation:

Question 61:

Which of the following factors is considered most important when assessing an ankle fracture for surgical treatment?

Options:

Level of the fibular fracture
Displacement of the fibular fracture
Size of the posterior malleolus
Position of the talus in the mortise
Rupture of the deltoid ligament

Correct Answer: Position of the talus in the mortise

Explanation:

Question 62:

- Figure 12 shows the frog-lateral radiograph of a 45-year-old man who has a painful left hip. What is the most likely diagnosis?

Options:

traumatic femoral head fracture
osteonecrosis
osteoarthritis
neuropathic joint
rheumatoid arthritis

Correct Answer: osteonecrosis

Explanation:

Question 63:

In an acute closed boutonniere injury, what is the most appropriate splinting technique for the proximal interphalangeal joint?

Options:

Static splint in 30° of flexion
Static splint in full extension
Dynamic extension splint
30° extension block splint
Buddy taping to the adjacent finger

Correct Answer: Static splint in full extension

Explanation:

Question 64:

The force generated by a muscle is most highly dependent on its

Options:

cross-sectional area.
fiber type.
length.
morphology.
level of conditioning.

Correct Answer: cross-sectional area.

Explanation:

Question 65:

What is the most common primary malignant tumor of bone in childhood?

Options:

Periosteal chondroma
Ewing’s sarcoma
Osteosarcoma
Chondrosarcoma
Rhabdomyosarcoma

Correct Answer: Osteosarcoma

Explanation:

Question 66:

Options:

Immediate weight-bearing as tolerated with hinged knee brace 0-90 degrees
Transphyseal ACL reconstruction with hamstring autograft
Physeal spearing ACL reconstruction with hamstring autograft
Application of long leg cast following successful fluoroscopic closed reduction
Application of long leg cast for 1-2 weeks with transition to hinged knee brace 0-90 degrees, progressive weight-bearing, and physical therapy for quadriceps strengthening

Correct Answer: Immediate weight-bearing as tolerated with hinged knee brace 0-90 degrees

Explanation:

Question 67:

Figure 12 shows an arthroscopic view from an inferolateral portal of a right knee. The asterisk indicates which structure?

Options:

Anterior cruciate ligament, anteromedial bundle
Anterior cruciate ligament, anterolateral bundle
Anterior cruciate ligament, posteromedial bundle
Anterior cruciate ligament, posterolateral bundle

Correct Answer: Anterior cruciate ligament, anteromedial bundle

Explanation:

DISCUSSION
The asterisk indicates the anteromedial bundle of the anterior cruciate ligament. The anterior cruciate ligament consists of 2 functional bundles: anteromedial and posterolateral. During extension of the knee, the posterolateral bundle becomes taut. In flexion, the anteromedial bundle is tight and the posterolateral bundle relaxes. Recently, techniques for double-bundle reconstruction have been described to recreate the normal anatomic relationship of the 2 bundles.
RECOMMENDED READINGS
Chhabra A, Zelle BA, Feng MT, Fu FH. The arthroscopic appearance of a normal anterior cruciate ligament in a posterior cruciate ligament-deficient knee: the posterolateral bundle (PLB) sign. Arthroscopy. 2005 Oct;21(10):1267. PubMed PMID: 16226658.
View Abstract at PubMed
Cha PS, Brucker PU, West RV, Zelle BA, Yagi M, Kurosaka M, Fu FH. Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. Arthroscopy. 2005 Oct;21(10):1275. PubMed PMID: 16226666.
View Abstract
at
PubMed

Question 68:

What bilateral surgical intervention is considered inappropriate based on the findings shown in the radiograph in Figure 52?

Options:

Vascularized fibular graft
Proximal femoral osteotomy
Core decompression
Hip arthrodesis
Femoral resurfacing

Correct Answer: Hip arthrodesis

Explanation:

DISCUSSION: The radiograph reveals osteonecrosis of both femoral heads with reasonably maintained joint surfaces. There may be some slight flattening of the femoral heads. Hip arthrodesis is difficult to perform because of the necrotic bone. Its use in patients with osteonecrotic hips is limited because of the 80% bilaterality; therefore, it is not an acceptable alternative. All the other options are acceptable interventions.
REFERENCES: Mont MA, Jones LC, Sotereanos DG, et al: Understanding and treating osteonecrosis of the femoral head. Instr Course Lect 2000;49:169-185.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.

Question 69:

The underlying cause of the neoplasm is

Options:

ALK gene rearrangement.
a nongerm-cell mutation of the GNAS1 gene.
a germline alteration in EXT1 and EXT2.
an abnormality arising from the translocation t(11;14)(q13;q32).

Correct Answer: a nongerm-cell mutation of the GNAS1 gene.

Explanation:

DISCUSSION
The bone scan reveals multiple bone lesions, which does not rule out any of the responses. The radiographs reveal dysplastic bone with a “ground glass” appearance, suggesting fibrous dysplasia as the preferred response. Multiple myeloma typically demonstrates purely lytic, “punched out” lesions and would be highly unusual in a 23-year-old woman. Multiple hereditary exostosis would demonstrate more expansile lesions concentrated in the metaphysis. Metastatic carcinoma could have a lytic or blastic appearance but is less likely to occur in a 23-year-old woman.
McCune-Albright syndrome in polyostotic fibrous dysplasia is present in as many as 50% of patients and should be evaluated for during an endocrine consultation. Adrenal, pituitary, parathyroid, and thyroid endocrinopathies may be present. Untreated hyperthyroidism can be life threatening during a surgical procedure. There is no indication to repeat the nuclear bone scan. Although phosphate wasting and, rarely, oncogenic osteomalacia have been reported in polyostotic fibrous dysplasia, an endocrinology consultation always should be sought.
Café au lait macules are the most common extraskeletal manifestation of fibrous dysplasia, often referred to as “coast of Maine” in appearance because of their irregular borders (in comparison to the “Coast of California” with smooth borders as seen in neurofibromatosis). Multiple myeloma would not ordinarily appear with increased uptake on a bone scan unless a pathologic fracture of some duration were present. A long area of bone involvement would not appear in patients with metastatic lung adenocarcinoma.
An ALK rearrangement occurs in nonsmall-cell lung cancer. The translocation t(11;14)(q13;q32) should be recognized as a poor prognosticator in multiple myeloma. The germline alteration in EXT1 and EXT2 occurs in multiple hereditary exostosis.
All forms of fibrous dysplasia are caused by a nongerm-cell mutation that occurs during early embryogenesis. A missense mutation of the GNAS1 gene, which encodes the alpha subunit of the stimulatory G-protein-couple-receptor, Gs alpha, results in G-protein activation and the production of cyclic adenosine monophosphate affecting melanocytes, endocrine cells, and osteoprogenitor cells.
RECOMMENDED READINGS
DiCaprio MR, Enneking WF. Fibrous dysplasia. Pathophysiology, evaluation, and treatment. J Bone Joint Surg Am. 2005 Aug;87(8):1848-64. Review.
View Abstract at PubMed
Parekh SG, Donthineni-Rao R, Ricchetti E, Lackman RD. Fibrous dysplasia. J Am Acad Orthop Surg. 2004 Sep-Oct;12(5):305-13. Review. PubMed PMID: 15469225.
View Abstract at PubMed
Shin HJ, Kim K, Lee JJ, Song MK, Lee EY, Park SH, Kim SH, Jang MA, Kim SJ, Chung JS. The t(11;14)(q13;q32) translocation as a poor prognostic parameter for autologous stem cell transplantation in myeloma patients with extramedullary plasmacytoma. Clin Lymphoma Myeloma Leuk. 2015 Apr;15(4):227-35. doi: 10.1016/j.clml.2014.12.007. Epub 2014 Dec 12.
View Abstract at PubMed
Esfahani K, Agulnik JS, Cohen V. A Systemic Review of Resistance Mechanisms and Ongoing Clinical Trials in ALK-Rearranged Non-Small Cell Lung Cancer. Front Oncol. 2014 Jul 21;4:174. doi: 10.3389/fonc.2014.00174. eCollection 2014. Review. PubMed PMID: 25101240.
View Abstract at
PubMed

Question 70:

Tendons should have what ratio of matrix protein?

Options:

65% collagen type I and 35% proteoglycans
80% collagen type I and 20% collagen type VI
95% collagen type I and less than 5% collagen type III
95% proteglycans and 5% tenascin

Correct Answer: 95% collagen type I and less than 5% collagen type III

Explanation:

Question 71:

Optimal management of the injury shown in Figure 31 should include which of the following?

Options:

Cast immobilization in equinus
Open reduction and internal fixation once the acute soft-tissue swelling has resolved
Urgent reduction and fixation
Arthroscopic-assisted percutaneous fixation
Open reduction and internal fixation with primary subtalar arthrodesis

Correct Answer: Urgent reduction and fixation

Explanation:

Question 72:

Options:

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

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

Explanation:

DISCUSSION: The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program
at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.
REFERENCES: Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.
Matsen FA III, Lippitt SB, Sidles JA, et al: Practical Evaluation and Management of the Shoulder. Philadelphia, PA, WB Saunders, 1994, pp 215-218.

Question 73:

Options:

Profunda femoris
Middle genicular
Medial sural
Inferior medial genicular

Correct Answer: Medial sural

Explanation:

Question 74:

While lifting weights, a patient feels a pop in his arm. He has the deformity shown in Figure 30. If left untreated, the patient will have the greatest deficiency in

Options:

shoulder flexion.
elbow flexion.
forearm pronation.
forearm supination.
wrist flexion.

Correct Answer: forearm supination.

Explanation:

Question 75:

Options:

Saline lavage and splinting of the tibia and knee immobilizers of both femurs
Betadine dressing and splinting of the tibia with unlocked retrograde nailing of both femurs
Betadine dressing and external fixation of the tibia and knee immobilizers of both femurs
Irrigation and debridement and external fixation of the tibia and external fixation of both femurs
Irrigation and debridement and external fixation of the tibia and unlocked retrograde nailing ofboth femurs

Correct Answer: Irrigation and debridement and external fixation of the tibia and external fixation of both femurs

Question 76:

Options:

proximal clavicle and sternocostal margin.
proximal humerus.
coracoid process.
distal clavicle and acromion.
anterior scapula.

Correct Answer: proximal clavicle and sternocostal margin.

Explanation:

Question 77:

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

Options:

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

Correct Answer: plexiform neurofibroma.

Explanation:

Question 78:

Options:

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

Correct Answer: Late cocking

Question 79:

What is the most likely consequence of a vertebral compression fracture associated with osteoporosis?

Options:

The fractured vertebral body gradually becomes more stiff than before the fracture.
Scoliosis develops.
There is an increased risk of more vertebral fractures.
Overall sagittal alignment remains stable because the adjacent segments of the spine are able to compensate.
The extensor musculature will often hypertrophy in an attempt to stabilize the painful fracture.

Correct Answer: There is an increased risk of more vertebral fractures.

Explanation:

Question 80:

Options:

surgery alone.
neoadjuvant chemotherapy and surgical resection.
radiation therapy.
chemotherapy and radiation therapy.
chemotherapy only.

Correct Answer: chemotherapy and radiation therapy.

Explanation:

DISCUSSION: Ewing’s sarcoma is the second most common primary tumor of bone in children. Depending on the site and extent of disease, chemotherapy, radiation therapy, and surgery are all treatment options. In this patient with extensive pelvic and metastatic disease, chemotherapy and radiation therapy offer the best oncologic control while preserving functional outcome.
REFERENCES: Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.
Thacker MM, Temple HT, Scully SP: Current treatment for Ewing’s sarcoma. Expert Rev Anticancer Ther 2005;5:319-331.
Weber KL: Current concepts in the treatment of Ewing’s sarcoma. Expert Rev Anticancer Ther 2002;2:687-694.

Question 81:

Options:

Significant limitation of humeral elevation
Significant limitation of shoulder abduction
Significant loss of motion in all directions
Little to no limitation of shoulder range of motion
Limitation of humeral rotation

Correct Answer: Little to no limitation of shoulder range of motion

Explanation:

Question 82:

Because the patient shown in Figure 27 can no longer fit in shoes, treatment of the deformity should consist of

Options:

physeal arrest.
soft-tissue debulking.
ray resection.
Chopart amputation.
distal phalanx amputation.

Correct Answer: ray resection.

Explanation:

Question 83:

The patient in Figure 55 is actively attempting to make a fist. This clinical scenario suggests which of the following anatomic lesions?

Options:

Median nerve lesion in the arm
Radial nerve lesion in the arm
Anterior interosseous nerve syndrome
Posterior interosseous nerve syndrome
Median neuropathy at the wrist

Correct Answer: Median nerve lesion in the arm

Explanation:

DISCUSSION: The clinical presentation is characteristic of a high median nerve palsy. When trying to make a fist, the patient is unable to flex the thumb and index fingers due to paralysis of flexion of the distal interphalangeal joint of the thumb and the distal and proximal interphalangel joints of the index finger. This hand attitude differs from the anterior interosseous nerve lesion in which loss of distal interphalangeal joint flexion is seen in the thumb, index, and middle fingers. Posterior interosseous nerve syndrome presents with dropped fingers at the metacarpophalangeal joints with wrist extension in radial deviation. Wrist and finger drop is the typical posture of patients with radial nerve lesions.
REFERENCE: Kline DG, Hudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries, Entrapments and Tumors. Philadelphia, PA, WB Saunders, 1995, p 189.

Question 84:

The most appropriate next surgical procedure is

Options:

synovectomy.
debridement, synovectomy, and placement of a thicker polyethylene liner.
resection arthroplasty and placement of a cement antibiotic spacer.
conversion to total knee arthroplasty (TKA).

Correct Answer: conversion to total knee arthroplasty (TKA).

Explanation:

Question 85:

03 advancement at age 6 years. What is the most likely diagnosis?

Options:

Osteomyelitis
Lymphoma
Eosinophilic granuloma
Tuberculosis
Ewing’s sarcoma back answer

Correct Answer: Osteomyelitis

Explanation:

Question 86:

A tendon repair is thought to be weakest during which phase of tendon healing?

Options:

Inflammatory
Proliferation
Maturation
Remodeling

Correct Answer: Inflammatory

Explanation:

Question 87:

Which of the following is true regarding anterior sternoclavicular joint dislocations?

Options:

Reduction may result in tracheal injury
They are usually stable following closed reduction
They require fusion to hold the reduction
They are rarely symptomatic when left unreduced
They should be treated acutely with medial clavicle excision

Correct Answer: Reduction may result in tracheal injury

Explanation:

Question 88:

What is the most common cause of mechanical failure of an orthopaedic biomaterial during clinical use?

Options:

Fatigue
Tension
Compression
Shear
Torsion

Correct Answer: Fatigue

Explanation:

Question 89:

Options:

open excision of the radial head.
a cortisone injection into the extensor muscle origin.
a tennis elbow release.
arthroscopic removal of loose bodies and microfracture of the crater.
rest, physical therapy, pulsed electromagnetic therapy, and no further gymnastic activities.

Correct Answer: arthroscopic removal of loose bodies and microfracture of the crater.

Explanation:

DISCUSSION: The radiograph and MRI scan show osteochondritis dissecans of the capitellum, and the patient’s history suggests a loose body. The treatment of choice is arthroscopic removal of the loose body and microfracture of the crater. Excision of the radial head, a cortisone injection, or tennis elbow release does not treat the pathology in the capitellum. Nonsurgical treatment would not relieve the mechanical symptoms of the loose body or promote healing in the crater.
REFERENCES: Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med
1998;26:520-530.
Jackson DW, Silvino N, Reiman P: Osteochondritis in the female gymnast’s elbow. Arthroscopy 1989;5:129-136.
Ruch DS, Cory JW, Poehling GG: The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 1998;14:797-803.

Question 90:

Options:

Increased ductility
Increased wettability
Diminished fatigue strength
Decreased resistance to abrasive wear

Correct Answer: Diminished fatigue strength

Explanation:

Question 91:

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 92:

Options:

MR imaging with contrast
MR imaging without contrast
CT scan along the scaphoid axis
Axial-cut CT scans with reformats

Correct Answer: CT scan along the scaphoid axis

Explanation:

EXPLANATION:
Scaphoid nonunions are difficult to diagnose on plain radiographs, which offer poor reliability when attempting to determine if there is bridging trabeculae crossing the fractures site. CT scans are more useful for diagnosing scaphoid nonunion. When scanned using conventional axial cuts, the slices mayskip through the fracture nonunion site, thereby missing the defect, even with reformats. MR imaging is useful in diagnosing acute scaphoid fractures and has a high sensitivity and diagnostic value for excluding
scaphoid fractures as well. Contrast does not enhance the utility of MR imaging in fracture diagnosis.

Question 93:

Options:

Nerve conduction velocity studies and electromyography
Extension splinting of the fingers
Exploration and repair of the extensor tendon laceration
Exploration and repair of the posterior interosseous nerve
Observation

Correct Answer: Exploration and repair of the posterior interosseous nerve

Explanation:

Question 94:

All of the following indicators of resuscitation may be within normal limits for a trauma patient that is in "compensated" shock EXCEPT:

Options:

Systolic blood pressure
Urine output
Heart rate
Serum lactate
Mean arterial pressure

Correct Answer: Systolic blood pressure

Explanation:

Question 95:

The postoperative neurologic prognosis of a patient who has a tumor that is compressing the spinal cord and causing a neurologic deficit depends primarily on the

Options:

pretreatment neurologic status.
extent of spinal cord compression.
extent of bony deformity.
MRI findings.
dimension of the spinal canal.

Correct Answer: pretreatment neurologic status.

Explanation:

Question 96:

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

Options:

Cable
Buttress plate
Methylmethacrylate
Multiple lag screws
Multiple Kirschner wires

Correct Answer: Buttress plate

Explanation:

Question 97:

-What is the recommended treatment for this injury?

Options:

Bankart repair
Hanging arm cast
Rest and no pitching for 3 months
Resume a throwing program but avoid curveballs and sliders

Correct Answer: Rest and no pitching for 3 months

Explanation:

DISCUSSION FOR QUESTIONS 85 THROUGH 87
The hypertrophic zone of the growth plate has been implicated as the weak link in the physis in acute injuries. Epiphysiolysis of the proximal humerus in throwing athletes occurs as the result of tension and shear on the physis. More than 90% of affected patients who are treated with rest for an average of 3 months become asymptomatic. Prevention is the best option. Set limitations of the number of pitches and types of pitches depending on the age of the player. Also recommend use of proper pitching mechanics.

Question 98:

Options:

Staphylococcus epidermidis
Staphylococcus aureus (S. aureus)
Propionibacterium acnes (P. acnes)
Beta-hemolytic Streptococcus

Correct Answer: Staphylococcus epidermidis

Explanation:

Question 99:

Six months later, the patient’s fracture has healed and a CT scan to further evaluate the physis is performed (Video 85). Based on these findings, how should you advise the family?

Options:

The fracture is healed and the physis is growing well with no problems expected.
Complete physeal closure has occurred. There will be no significant leg length difference because the patient is almost done growing.
Complete physeal closure has occurred. There will be a significant (> 2-cm) leg length difference if no other surgical treatment is offered.
Asymmetric physeal closure has occurred. There will be an increasing angular deformity at the knee as well as a significant (> 2-cm) leg length difference if no other surgical treatment is offered.

Correct Answer: Asymmetric physeal closure has occurred. There will be an increasing angular deformity at the knee as well as a significant (> 2-cm) leg length difference if no other surgical treatment is offered.

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

Orthopedic Board Prep MCQs: Hip, Knee, Spine & Nerve | Part 92

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 92

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index