Score: 0%
ORTHOPEDICS HYPERGUIDE 2022 MCQ-1251-1300
QUESTION 1
Posterior antiglide plating of AO type B lateral malleolar fractures may be associated with:
1
Early loss of fixation
2
Greater wound healing complications
3
Syndesmotic irritation
4
Peroneal tendonitis or peroneal tendon lesions
5
Greater risk for nonunion
Posterior antiglide plating is associated with an increased need for hardware removal (43%) and an increased incidence of peroneal tendon lesions. The highest risk for peroneal tendon lesions was with distal placement of the plate and a protruding screw head in the most distal hole.
QUESTION 2
Displaced talar neck fractures should be treated:
1
Emergently within 6 hours to minimize the risk of avascular necrosis
2
Urgently within 1 day to minimize the risk of avascular necrosis
3
There is no correlation between emergent or urgent fixation of talar neck fractures and risk of talar avascular necrosis.
4
Emergently within 1 hour of injury
5
Emergently within 3 hours of injury
A retrospective review of 102 talar neck fractures that underwent open reduction internal fixation showed no decrease in the development of osteonecrosis in fractures that were treated earlier. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5 days for patients who did not have development of osteonecrosis.
QUESTION 3
How many weeks following open reduction and internal fixation of a right ankle fracture can patients resume driving with normal braking times:
1
6 weeks
2
9 weeks
3
12 weeks
4
16 weeks
5
18 weeks
Total braking time following open reduction and internal fixation of right ankle fractures was tested at 6, 9, and 12 weeks postoperatively. These patients were managed with a functional brace, non-weight bearing, and early range of motion in the postoperative period. Braking time was significantly slower than normal at 6 weeks, but had returned to near normal by 9 weeks postoperatively.
QUESTION 4
Time to radiographic fusion following arthroscopic ankle arthrodesis is:
1
Longer than following an open technique arthrodesis
2
Shorter than following an open technique arthrodesis
3
The same as open technique
4
Is affected by whether external bone stimulation is utilized
5
Is affected by whether two-screw or three-screw fixation is utilized
Time to radiographic fusion following arthroscopic ankle arthrodesis is shorter than following open ankle arthrodesis. Theoretically, the decreased dissection and soft-tissue stripping contributes to greater vascular inflow to heal the fusion site.
QUESTION 5
Superficial peroneal nerve injury following ankle fracture:
1
Does not occur with nonoperative treatment
2
C an best be avoided during open reduction internal fixation with a posterolateral approach to the fibula
3
Did not ultimately affect the final AOFAS ankle-hindfoot score
4
Occurs in fewer than 5% of operatively fixed fibula fractures
5
C an best be avoided during open reduction internal fixation with an anterolateral approach to the fibula
One hundred twenty patients with ankle fractures were evaluated. Symptomatic superficial peroneal nerve injury was identified in
21% of patients who underwent open reduction internal fixation and 9% of nonoperatively treated patients. AOFAS scores were decreased in patients with symptomatic superficial peroneal nerve injury. No injuries to the superficial peroneal nerve occurred in patients who underwent surgery involving a posterolateral approach to the fibula.
21% of patients who underwent open reduction internal fixation and 9% of nonoperatively treated patients. AOFAS scores were decreased in patients with symptomatic superficial peroneal nerve injury. No injuries to the superficial peroneal nerve occurred in patients who underwent surgery involving a posterolateral approach to the fibula.
QUESTION 6
Which of the following is the most reliable way to determine that a deltoid ligament injury is associated with a Weber B level lateral malleolus fracture:
1
The presence of medial tenderness on clinical examination
2
The presence of medial ecchymosis on clinical examination
3
The presence of significant medial swelling on clinical examination
4
Evidence of medial clear space widening on stress radiographs
5
The presence of lateral malleolus tenderness
Weber B supination, external rotation ankle fractures were evaluated to determine the reliability of medial tenderness, ecchymosis, and swelling in predicting deltoid incompetence. These clinical signs were poorly predictive, and stress radiographs were recommended for an accurate diagnosis of instability.
QUESTION 7
The optimal position for ankle arthrodesis is:
1
5° plantarflexion, 5° valgus, 5° external rotation
2
Neutral flexion, 5° valgus, 5° external rotation
3
Neutral flexion, 0° varus/valgus, 5° external rotation
4
Neutral flexion, 5° valgus, 5° internal rotation
5
5° dorsiflexion, 5° valgus, 5° external rotation
The optimal position for ankle arthrodesis is neutral flexion, 5° valgus, and 5° external rotation. Historically, surgeons thought that women should be fused in some amount of equinus to better allow them to wear heeled shoes. However, this can increase the development of neighboring joint arthritis and also create a knee recurvatum deformity when ambulating barefoot. C urrently it is recommended that all patients are fused in neutral dorsi-/plantarflexion.
QUESTION 8
Varus malunion following talar neck fracture is best corrected by:
1
Subtalar arthrodesis
2
Rotational calcaneal osteotomy with a bone block
3
Deltoid ligament release and lateral ligament reconstruction
4
Talar neck osteotomy with lengthening or by triple arthrodesis
5
Lateral column lengthening
The best way to address varus malunion in talar neck fractures and maintain motion is by talar neck osteotomy. However, there is a further possible risk of talar avascular necrosis with this procedure. The other acceptable treatment is a triple arthrodesis, although this eliminates all hindfoot motion.
QUESTION 9
Neighboring joint arthritis following ankle arthrodesis has not been found in the:
1
Knee joint
2
Naviculocuneiform joint
3
First metatarsophalangeal joint
4
Subtalar joint
5
Hindfoot joint
Long-term follow-up of ankle fusions show that nearly all patients develop arthritis in the hindfoot, midfoot, and 1st metatarsophalangeal joint. There is no evidence to show that the hip or knee is at greater risk for developing arthritis following ankle fusion.
QUESTION 10
Following calcaneus fracture, risk factors for later need for subtalar arthrodesis due to painful posttraumatic arthritis include all of the following except:
1
Bohlerâs angle 75% of patients
2
Are least at risk for penetrating the joint capsule over the anterolateral aspect of the ankle
3
C annot be olive wires because of a higher risk for pin-tract infection
In cadaver specimens, the anterolateral capsular reflection of the ankle joint extended proximally the highest with an average of
9.3 mm and a maximum of 12.2 mm. There was a 100% communication between the distal tibia-fibula joint and the ankle joint.
9.3 mm and a maximum of 12.2 mm. There was a 100% communication between the distal tibia-fibula joint and the ankle joint.
QUESTION 11
C linical improvement following ankle distraction arthroplasty:
1
Typically reaches its maximal improvement by the end of 1 year
2
Is accompanied by major gains in ankle range of motion
3
C an take up to 5 years to reach maximal improvement
4
Is not accompanied by improvement in radiographic joint space
5
Is usually realized within the first month following removal of the frame
Distraction arthroplasty with an Ilizarov external fixator is usually associated with half of the clinical improvement occurring within the first year, and the other half happening over the next 5 years.
QUESTION 12
Failure following supramalleolar osteotomy for ankle arthritis is associated with:
1
Inadequate correction and poor cartilage on initial arthroscopy
2
Opening wedge supramalleolar osteotomy with bone graft
3
Early weight bearing postoperatively
4
Addition of a fibular osteotomy to the procedure
5
Use of internal fixation
In their clinical series, Takakura and colleagues showed that inadequate correction and initial chondromalacia were predictors of poor outcome following supramalleolar osteotomy.
QUESTION 13
Isolated talonavicular fusion:
1
Decreases subtalar motion by 25%
2
Decreases subtalar motion by 50%
3
Locks subtalar motion
4
Has no effect on subtalar motion
5
Decreases subtalar motion by 10%
This cadaver study examined the motion that remained in the hindfoot joints following sequential immobilization of the talo- navicular, subtalar, and calcaneo-cuboid joints. Fixing the talo-navicular joint virtually locked all subtalar motion.
QUESTION 14
Following triple arthrodesis, ankle range of motion is:
1
Unaffected
2
Increased
3
Decreased
4
Improves over time
5
Increases initially, but then returns to preoperative levels
This clinical study following triple arthrodesis patients for 10 years showed a 27% loss of ankle plantarflexion but no loss of dorsiflexion.
QUESTION 15
Triple arthrodesis is associated with:
1
Long-term clinical stability with respect to pain relief
2
High rates of nonunion
3
Worse patient satisfaction when ankle arthritis is present
4
Development of ankle arthritis over time
5
No increased risk for ankle arthritis
Saltzman and colleagues followed 67 patients who underwent triple arthrodesis at 44-year follow-up. Nearly all patients had ankle arthritis at final follow-up. C linical relief of pain deteriorated over time between intermediate 25-year follow-up and 44-year
follow-up in the same group of patients.
follow-up in the same group of patients.
QUESTION 16
Isolated subtalar arthrodesis:
1
Increases transverse tarsal joint over time
2
Decreases talonavicular motion less than calcaneocuboid motion
3
Decreased talonavicular joint motion but increases calcaneocuboid joint motion
4
Decreases talonavicular motion more than calcaneocuboid motion
5
Increases subtalar motion
Subtalar fusion decreased talonavicular motion more so than calcaneocuboid motion in this cadaver study. Isolated talonavicular fusion is the most influential of the hindfoot joints, locking hindfoot motion.
QUESTION 17
Isolated subtalar fusion:
1
Is not associated with development of ankle or transverse tarsal joint arthritis
2
Is associated only with development of transverse joint arthritis, but the ankle joint is spared
3
Is associated only with development of ankle arthritis, but the transverse tarsal joints are spared
4
Is associated with the development of both ankle and transverse tarsal joint arthritis
5
Is associated with knee joint degenerative arthritis
In 48 subtalar fusions followed for 5 years, 36% of patients developed ankle arthritis and 41% of patients developed transverse tarsal joint arthritis.
QUESTION 18
Following anatomic open reduction and internal fixation of a Lisfranc fracture-dislocation:
1
Development of tarsometatarsal arthritis will not occur.
2
Tarsometatarsal arthritis may still arise in approximately 25% of patients.
3
If tarsometatarsal arthritis develops, then subsequent arthrodesis is required.
4
The screws should be routinely removed at 12 weeks.
5
The screws should be routinely removed at 6 weeks.
In a series of patients who underwent open reduction internal fixation of Lisfranc fracture dislocations, 25% of patients developed midfoot arthritis at final follow-up, but only half of these patients required eventual midfoot arthrodesis.
QUESTION 19
Which injury is likely to have a worse clinical outcome:
1
A purely ligamentous Lisfranc injury
2
A Lisfranc fracture-dislocation
Purely ligamentous Lisfranc injuries have a worse clinical outcome than injuries associated with bony fractures.
QUESTION 20
Hallux rigidus is associated with:
1
Metatarsus primus elevatus
2
First ray hypermobility
3
Long first metatarsal
4
Flat- or chevron-shaped metatarsal head
5
Bipartate sesamoid
In a large series of patients with hallux rigidus, risk factors were evaluated. The only factor that had a positive correlation with having hallux rigidus was the radiographic shape of the 1st metatarsal head. Metatarsus primus elevatus, first ray hypermobility, or long first metatarsal head were not significantly associated with hallux rigidus.
QUESTION 21
C urrently recommended indications for surgical management of hallux rigidus with an arthrodesis include:
1
Positive axial grind test on preoperative clinical examination
2
>50% of the cartilage on the metatarsal head remaining
3
Osteophytes over the dorsolateral head of the first metatarsal
4
Osteophytes over the dorsal aspect of the proximal phalanx
5
Normal first metatarsophalangeal joint motion
C oughlin and colleagues recommend that when pain with axial grind testing of the metatarsophalangeal joint is present or >50% loss of articular cartilage occurs intraoperatively, then first metatarsophalangeal arthrodesis should be performed.
QUESTION 22
A Moberg procedure for hallux rigidus is:
1
An oblique first metatarsal shortening osteotomy
2
An ostectomy of the medial eminence of the metatarsal
3
A medial closing wedge osteotomy of the proximal phalanx
4
A dorsal closing wedge osteotomy of the proximal phalanx
5
A lateral closing wedge osteotomy of the proximal phalanx
The Moberg procedure involves a dorsal closing wedge osteotomy of the proximal phalanx. This sets the hallux higher off the floor, allowing for easier toe-off with less dorsal impingement during gait.
QUESTION 23
The optimal position for hallux interphalangeal joint arthrodesis is:
1
5° to 10° of plantarflexion
2
5° to 10° of dorsiflexion
3
Neutral flexion
4
Slight supination of the toe
5
10° of valgus
The optimal position for hallux interphalangeal joint arthrodesis is 5° to 10° of plantarflexion, neutral varus-valgus, and neutral rotation. The plantarflexion helps the toe pad to contact the ground during gait.
QUESTION 24
First metatarsophalangeal prosthetic joint replacements:
1
Significantly increase joint range of motion
2
Have less complications than first metatarsophalangeal arthrodesis
3
Provide less pain relief than first metatarsophalangeal arthrodesis
4
Have not been found to undergo osteolysis or loosening
5
Provide greater pain relief than first metatarsophalangeal arthrodesis
First metatarsophalangeal joint replacement in this prospective comparative study performed poorly compared to arthrodesis. Patients with arthroplasties had greater pain and little improvement in range of motion.
QUESTION 25
Deep infection following open reduction internal fixation (ORIF) for tibial pilon fractures is most commonly associated with:
1
Open fractures
2
Postoperative wound dehiscence
3
Anterior incision
4
Medial and lateral plating
5
Low energy injury
Deep infection following ORIF of pilon fractures is correlated with postoperative wound dehiscence or skin slough but not with the presence of an open fracture in a series of 60 pilon fractures treated by ORIF.
QUESTION 26
Talar body fractures are best classified by a fracture line:
1
That extends superiorly into the trochlea
2
That extends anywhere posterior to the talar neck
3
That extends inferiorly, posterior to the lateral process
4
That extends inferiorly, anterior to the lateral process
5
That extends into the talar head
Talar neck and body fractures can be difficult to distinguish, especially when they extend superiorly into the anteromedial aspect of the trochlea. These two fractures have a different prognosis. The authors recommend classification of these fractures based on the inferior fracture line; if anterior to lateral process of the talus, then it is a neck fracture; if posterior to lateral process of the talus, then it is a body fracture.
QUESTION 27
The most effective fixation technique that will ensure adequate visualization (imaging) of avascular necrosis changes following talar neck fracture is:
1
Fixation with 0.062-inch K-wires
2
C losed reduction
3
Fixation with stainless steel mini-fragment screws
4
Fixation with titanium screws
5
Fixation with a stainless steel locking plate
High-quality magnetic resonance images of the talus can consistently be obtained in the presence of titanium screws in contrast to images obtained with stainless steel implants. Magnetic resonance imaging is better than plain radiographs at assessing the volume of talar avascular necrosis.
QUESTION 28
The plantar ecchymosis sign is:
1
An indication of possible compartment syndrome
2
Related to a specific bacterial infection
3
An indication of possible Lisfranc fracture or sprain
4
Described as a sign of plantar fascia rupture
5
Requires immediate fasciotomy
The plantar ecchymosis sign is described as an ecchymotic area on the plantar midfoot that is indicative of possible injury to the plantar tarsometatarsal ligaments.
QUESTION 29
The joint contact area of the second tarsometatarsal joint after Lisfranc dislocation diminishes the greatest with:
1
Dorsolateral subluxation
2
Dorsal subluxation
3
Lateral subluxation
4
Medial subluxation
5
Plantar subluxation
Minor degrees of displacement not apparent on plain radiographs lead to significant decrease in the contact area of the second tarsometatarsal joint. Dorsolateral subluxation of the second tarsometatarsal joint suffers a loss of contact area more severely than pure dorsal or lateral subluxation. Just 3 mm of dorsolateral subluxation causes a 38% loss of contact area.
QUESTION 30
The âfleck signâ in midfoot injuries is a result of avulsion of the:
1
Lisfranc ligament that extends from the first metatarsal base to the second metatarsal base
2
Lisfranc ligament that extends from the middle cuneiform to the first metatarsal base
3
Lisfranc ligament that extends from the medial cuneiform to the first metatarsal base
4
Lisfranc ligament that extends from the medial cuneiform to the second metatarsal base
5
Lisfranc ligament that extends from the lateral cuneiform to the third metatarsal base
The âfleck signâ was described as an avulsion of the ligament that runs from the medial cuneiform to the base of the second metatarsal, the so-called Lisfranc ligament. It is considered pathognomonic for a tarsometatarsal injury.
QUESTION 31
Delayed unions and nonunions of base of fifth metatarsal fractures have been demonstrated to heal by:
1
Prolonged cast immobilization and non-weight bearing
2
Pulsed electromagnetic fields
3
C ontinued use of a fracture boot with protected weight-bearing
4
Injection of demineralized bone matrix
5
Rigid carbon fiber shoe inserts
Nine delayed unions and nonunions of the proximal fifth metatarsal were treated with pulsed electromagnetic fields. All fractures healed in a mean of 4 months (follow-up 39 months, no refractures).
QUESTION 32
The strongest hardware configuration for fixation of talar neck fractures is:
1
Two crossed screws from distal to proximal
2
Two parallel screws inserted from distal to proximal
3
One large screw from posterior to anterior
4
Two parallel screws from posterior to anterior
5
One oblique screw from distal to proximal
Biomechanical cadaveric testing of several screw configurations showed two parallel screws from proximal to distal as the strongest fixation. The screws can be inserted either open or percutaneously. All screw configurations were stronger than K-wire configurations.
QUESTION 33
According to Sandersâ computed tomography (C T) classification for calcaneus fractures, a Sanders III fracture has:
1
One fracture line in the posterior facet
2
Two fracture lines in the posterior facet
3
Three fracture lines in the posterior facet
4
Three fracture lines in the posterior facet
5
Five fracture lines in the posterior facet
The Sanders C T classification is determined on coronal C T scans of the calcaneus at the level where the posterior facet is widest. A Sanders I is a nondisplaced fracture; Sanders II consists of a single fracture line splitting the posterior facet into two main fragments; Sanders III has two fracture lines with three main posterior facet fragments; and a Sanders IV has four or more articular fragments present.
QUESTION 34
The incidence of compartment syndrome following calcaneus fracture is:
1
5%
2
10%
3
15%
4
20%
5
30%
In a review article by Myerson, compartment syndrome was described to occur in 10% of calcaneal fractures. Of these, half will develop clawing, stiffness, or neurologic dysfunction. Diagnosis is confirmed by multistick invasive catheterization, especially the calcaneal compartment.
QUESTION 35
Posterior antiglide plating of AO type B lateral malleolar fractures may be associated with:
1
Early loss of fixation
2
Greater wound healing complications
3
Syndesmotic irritation
4
Peroneal tendonitis or peroneal tendon lesions
5
Greater risk for nonunion
Posterior antiglide plating is associated with an increased need for hardware removal (43%) and an increased incidence of peroneal tendon lesions. The highest risk for peroneal tendon lesions was with distal placement of the plate and a protruding screw head in the most distal hole.
QUESTION 36
Displaced talar neck fractures should be treated:
1
Emergently within 6 hours to minimize the risk of avascular necrosis
2
Urgently within 1 day to minimize the risk of avascular necrosis
3
There is no correlation between emergent or urgent fixation of talar neck fractures and risk of talar avascular necrosis.
4
Emergently within 1 hour of injury
5
Emergently within 3 hours of injury
A retrospective review of 102 talar neck fractures that underwent open reduction internal fixation showed no decrease in the development of osteonecrosis in fractures that were treated earlier. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5 days for patients who did not have development of osteonecrosis.
QUESTION 37
Superficial peroneal nerve injury following ankle fracture:
1
Does not occur with nonoperative treatment
2
C an best be avoided during open reduction internal fixation with a posterolateral approach to the fibula
3
Did not ultimately affect the final AOFAS ankle-hindfoot score
4
Occurs in fewer than 5% of operatively fixed fibula fractures
5
C an best be avoided during open reduction internal fixation with an anterolateral approach to the fibula
One hundred twenty patients with ankle fractures were evaluated. Symptomatic superficial peroneal nerve injury was identified in
21% of patients who underwent open reduction internal fixation and 9% of nonoperatively treated patients. AOFAS scores were decreased in patients with symptomatic superficial peroneal nerve injury. No injuries to the superficial peroneal nerve occurred in patients who underwent surgery involving a posterolateral approach to the fibula.
21% of patients who underwent open reduction internal fixation and 9% of nonoperatively treated patients. AOFAS scores were decreased in patients with symptomatic superficial peroneal nerve injury. No injuries to the superficial peroneal nerve occurred in patients who underwent surgery involving a posterolateral approach to the fibula.
QUESTION 38
Which of the following is the most reliable way to determine that a deltoid ligament injury is associated with a Weber B level lateral malleolus fracture:
1
The presence of medial tenderness on clinical examination
2
The presence of medial ecchymosis on clinical examination
3
The presence of significant medial swelling on clinical examination
4
Evidence of medial clear space widening on stress radiographs
5
The presence of lateral malleolus tenderness
Weber B supination, external rotation ankle fractures were evaluated to determine the reliability of medial tenderness, ecchymosis, and swelling in predicting deltoid incompetence. These clinical signs were poorly predictive, and stress radiographs were recommended for an accurate diagnosis of instability.
QUESTION 39
Varus malunion following talar neck fracture is best corrected by:
1
Subtalar arthrodesis
2
Rotational calcaneal osteotomy with a bone block
3
Deltoid ligament release and lateral ligament reconstruction
4
Talar neck osteotomy with lengthening or by triple arthrodesis
5
Lateral column lengthening
The best way to address varus malunion in talar neck fractures and maintain motion is by talar neck osteotomy. However, there is a further possible risk of talar avascular necrosis with this procedure. The other acceptable treatment is a triple arthrodesis, although this eliminates all hindfoot motion.
