100 Orthopedic MCQs: Trauma, Spine, Pediatrics & Basic Science | Comprehensive ABOS Board Review

If the femoral tunnel is created using guide wire A, it will be too far anterior in the intercondylar notch. The distance between a central tibial insertion for the ACL and an anterior femoral tunnel will progressively increase as the knee is flexed. Therefore, if the graft is tensioned near extension, the ligament will excessively tighten as the knee flexes past 90 degrees. This will result in restricted knee flexion or failure of the graft as full flexion is gained. There will be little effect on the ligament as it extends from 20 degrees to 0 degrees of flexion. If the graft is tensioned in significant flexion (greater than 60 degrees), it will be excessively loose as the knee fully extends. Daniel DM, Fritschy D: Anterior cruciate ligament injuries, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, PA, WB Saunders, 1994, pp 1313-1360.

The radiographs show displacement of the prosthesis, and there has been large amounts of bone resected to insert the implant. Arthrodesis is indicated with interposition bone graft to stabilize the joint and restore length to the first ray.

The obturator internus originates on the obturator membrane and adjacent bone, including the quadrilateral plate, and exits the lesser sciatic notch to insert on the posterior medial greater trochanter. The structure labeled C is the pectineus, B is the sartorius, and D is the gluteus medius. Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, pp 145-150, 324.

A high index of suspicion is required to identify a possible navicular stress fracture, especially in runners. High pain tolerance in the competitive athlete and often minimal swelling contribute to frequent delays in diagnosis. Localized tenderness over the dorsal navicular (so-called "N spot") in a running athlete should alert the treating physician. In this patient, the radiographs are negative and the MRI scan shows marrow edema within the navicular. This could represent a stress reaction, stress fracture, or osteonecrosis. Appropriate management should include non-weight-bearing immobilization and obtaining a CT scan to determine if a fracture is present. Early surgical treatment may be considered but only if a fracture is identified. Lee A, Anderson R: Stress fractures of the tarsal navicular. Foot Ankle Clin 2004;9:85-104.

While guidelines for predicting fracture risk are at best imprecise, the scoring system by Mirels (pain, anatomic location, and pattern of bony destruction) has been shown to be most predictive of fracture risk. Functional pain, peritrochanteric location, and lytic bone destruction are the greatest risk factors for pathologic fracture. The factors of patient weight, age, soft-tissue mass, and location within bone are all of lesser importance. Frassica FJ, Frassica DA, McCarthy EF, Riley LH III: Metastatic bone disease: Evaluation, clinicopathologic features, biopsy, fracture risk, nonsurgical treatment, and supportive management. Instr Course Lect 2000;49:453-459.

The radiograph shows the development of a rocker-bottom foot deformity. A rocker-bottom foot occurs in the treatment of clubfoot when casting is continued in the presence of a very tight gastrocnemius-soleus complex and an uncorrected hindfoot. While there are some preliminary reports on using Botox injection and continued casting for the equinus deformity, most authors recommend posterior or posterior medial release. Percutaneous tenotomy has been recently recommended with the resurgence of the Ponsetti technique. Lehman WB, Atar D: Complications in the management of talipes equinovarus, in Drennan JC (ed): The Child's Foot and Ankle. New York, NY, Raven Press, 1992, pp 135-136. Herring JA: Tachdjian's Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002, pp 927-935.

Anterior superior iliac spine avulsion fractures are caused by sudden, forceful contractions of the sartorius and tensor fascia lata. These injuries occur in young athletes through the growth plate with the hip extended and the knee flexed, such as while sprinting or swinging a baseball bat. The athlete will often report a pop or snap at the time of injury. Displaced fractures usually can be seen on radiographs. CT or MRI can be obtained to confirm the diagnosis. In most patients, nonsurgical management consisting of rest and protected weight bearing yields satisfactory outcomes. Surgery is usually reserved for fractures with displacement of more than 3 cm and painful nonunions. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 139-153.

The radiograph shows the typical findings of achondroplasia. The defect is in fibroblast growth factor receptor 3. The pedicles narrow distally in the lumbar spine. The pelvis is low and broad with narrow sciatic notches and ping-pong paddle-shaped iliac wings. This is often called a champagne glass pelvis. Type I collagen abnormalities are typically found in osteogenesis imperfecta, and type II collagen defects are found in spondyloepiphyseal dysplasia and Kneist syndrome. COMP is defective in multiple epiphyseal dysplasia. Sulfate transport defects are seen in diastrophic dysplasia. Johnson TR, Steinbach LS: Essentials of Musculoskeletal Imaging. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 809-812.

The motor dysfunction in Charcot-Marie-Tooth disease involves the tibialis anterior muscle. Charcot-Marie-Tooth disorders most commonly cause distal motor dysfunction in the foot intrinsics, anterior compartment musculature, and peroneals. There is evidence that the peroneus brevis is affected selectively and the peroneus longus is spared. This is based on clinical muscle testing, muscle cross-sections on MRI, and electrodiagnostic testing. Mann RA, Missirian J: Pathophysiology of Charcot-Marie-Tooth disease. Clin Orthop 1988;234:221-228.

Spinal shock typically ends after 48 hours with the return of reflexes, including the bulbocavernosus reflex. Lack of motor or sensory recovery in the lower extremities with the return of reflexes generally indicates a complete cord syndrome. Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 179-187.

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

The MRI scans show a popliteal cyst (Baker's cyst) in its most common location. The cyst emerges from the knee joint between the medial head of the gastrocnemius muscle and the tendon of the semimembranosus muscle. These images are diagnostic; therefore, no further work-up is indicated. Since the patient is asymptomatic, no treatment is necessary. Dlabach JA: Nontraumatic soft tissue disorders, in Canale ST (ed): Campbell's Operative Orthopaedics, ed 10. Philidelphia, PA, Mosby, 2003, vol 1, pp 885-969.

The patient has an isolated closed injury involving the humeral diaphysis. The lack of wrist and finger extension indicates injury to the radial nerve. Based on these findings, ongoing observation of the nerve is warranted with delayed exploration after 3 to 4 months if there are no signs of progressive return of nerve function. Treatment of the fracture should include external immobilization and fracture bracing. An indication for nerve exploration and surgical stabilization would be an open fracture. Zuckerman JD, Kovil KJ: Fractures of the shaft of the humerus, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green's Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 1025-1053.

The patient's history, including the timing and type of symptoms, is typical for postoperative diskitis. The elevated ESR, 5 weeks after surgery, is also consistent with infection; a normal WBC count is not unusual. Management should consist of MRI with gadolinium; if positive, this should be followed by percutaneous biopsy to confirm the organism. Open biopsy may be considered if the percutaneous biopsy is unsuccessful. Anterior debridement and interbody fusion is reserved for the occasional patient that fails to respond to intravenous antibiotics, bed rest, and immobilization. Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 257-271.

In an adult with an anterior cortical tibial lesion, this is the classic histologic appearance and anatomic location for an adamantinoma. The histology reveals areas of epithelial cells (in a glandular pattern) within a fibrous stroma. The epithelial cells are shown in nests. They would stain positively for keratin. Adamantinoma is a rare malignant bone tumor with a propensity for late metastasis. It has a high incidence of local recurrence unless resected with a wide margin. Chemotherapy and radiation therapy are not helpful in the treatment of this disease. Amputation generally is not necessary because a diaphyseal resection is usually possible. McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 263.

This is a case of synovial sarcoma. The radiograph shows some soft-tissue swelling in the upper arm. The MRI scans show a lesion that has increased signal on T2-weighted images and low signal on T1-weighted images. There is a suggestion of a large cystic component to this lesion. The pathology shows a biphasic population of cells, a spindle cell component, and an epithelioid component. Up to 20% of synovial cell sarcomas have areas of cyst formation. The most common cytogenetic translocation with synovial cell sarcoma is X; 18. The 11; 22 translocation is most commonly associated with Ewing's sarcomas; the 12; 22 translocation is most commonly associated with clear cell sarcomas; the 2; 13 translocation is most commonly associated with alveolar rhabdomyosarcomas, and the 12; 16 translocation is most commonly associated with myxoid liposarcomas. Kawai A, Woodruff J, Healey JH, et al: SYT-SSX gene fusion as a determinant of morphology and prognosis in synovial sarcoma. New Engl J Med 1998;338:153-160.

To improve hip biomechanics and secure more suitable bone for acetabular fixation, the true acetabulum is often resurfaced in patients who have developmental dysplasia of the hip, thus lowering the hip center and lengthening the leg. Acute lengthening of more than 3 cm will place excessive tension on the sciatic nerve and require a femoral shortening to avoid sciatic nerve injury. The other maneuvers will not relieve sciatic nerve tension because of limb lengthening. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 430-431.

Boden and associates' recent article presents significant evidence that patients with rheumatoid arthritis, neurologic deterioration, and C1-2 instability are more likely to improve after surgery if the posterior alanto-odontoid interval is greater than 10 mm preoperatively. The accepted safe range for the posterior atlanto-odontoid interval is 14 mm. This measurement is believed to better represent the space available for the cord than the anterior alanto-odontoid interval. Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 273-279. Boden SD, Dodge LD, Bohlman HH, Rechtine GR: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.

Current treatment regimens for Ewing's sarcoma typically involve induction chemotherapy followed by local control and further chemotherapy. Local control consists of surgery alone, radiation therapy alone, or a combination of the two. In bones that are easily resectable (or expendable) with wide margins, surgery alone is usually recommended. For areas that are unresectable (ie, large, bulky pelvic tumors), radiation therapy alone is sometimes the preferred method of local control. If surgery is chosen and margins are close, radiation therapy can be used as an adjuvant. Amputation rarely is required for an isolated fibular lesion. Observation without adequate local therapy results in local recurrence. Nesbit ME Jr, Gehan EA, Burgert EO Jr, et al: Multimodal therapy for the management of primary, nonmetastatic Ewing's sarcoma of bone: A long-term follow-up of the First Intergroup study. J Clin Oncol 1990;8:1664-1674.

The incidence of osteolysis is minimal in studies reporting the use of all polyethylene or monolithic metal-backed tibial components. Osteolysis has been reported in patients with total knee arthroplasties using cementless implants with modular components. Micromotion between the tibial tray and the polyethylene results in backside wear, leading to osteolysis. Osteolysis also has been reported in cemented posterior cruciate-substituting modular components. O'Rourke and associates reported a 16% incidence of osteolysis in patients with a posterior stabilized implant because of the use of modular polyethylene and the subsequent abrasive wear. Oxidation of the polyethylene that is the result of the method of sterilization and shelf life has also been implicated in the high incidence of osteolysis, along with patient factors such as activity level and weight.

Based on the radiographic findings, the patient has a metallic foreign body in her foot that is consistent with a needle. She has local infection secondary to the continued presence of the foreign body. CT is not necessary to localize the foreign body as it is adequately visualized on the plain radiographs. The infection cannot be adequately treated until the foreign body is removed. Attempted removal of foreign bodies without proper anesthesia and fluoroscopy frequently results in frustration because of the inability to localize the foreign body. Removal in a surgical suite with proper anesthesia and fluoroscopy is the preferred option. Once the foreign body is removed, the local infection will resolve rapidly. Combs AH, Kernek CB, Heck DA: Orthopedic grand rounds: Retained wooden foreign body in the foot detected by computed tomography. Orthopedics 1986;9:1434-1435.

The presence of drainage 3 weeks after surgery is a sign of wound infection. This infection most likely involves deep tissues until proven otherwise. Oral or IV antibiotics, in the absence of debridement, are not sufficient. Removal of the hardware would lead to rapid progression of the scoliosis in a spine that has been surgically destabilized by removal of the facet joints. The appropriate treatment is debridement with wound culture, IV antibiotics, and retention of hardware. The wound should be closed over drains. Theiss SM, Lonstein JE, Winter RB: Wound infections in reconstructive spine surgery. Orthop Clin North Am 1996;27:105-110.

The photomicrograph shows a synovial cell sarcoma with a characteristic histology of a biphasic pattern of pleomorphic spindle cells and well-differentiated cuboidal to columnar cells forming gland-like spaces. The glandular zones contain mucous-like material that stains positively with periodic acid Schiff. Microscopic calcifications are usually found. Synovial cell sarcoma has a high rate of local recurrence as well as metastases. It is the most common malignancy found in the foot. Krall RA, Kostianovsky M, Patchefsky AS: Synovial sarcoma: A clinical, pathological and ultrastructural study of 26 cases supporting the recognition of a monophasic variant. Am J Surg Pathol 1981;5:137-151.

The MRI scans show a displaced bucket-handle medial meniscus tear that can be visualized on coronal, sagittal, and axial views. The sagittal view shows the typical "double posterior cruciate ligament sign," in which the low-signal bucket-handle fragment parallels the normal low-signal posterior cruciate ligament. The coronal and axial images both show the displaced medial meniscus in the notch. Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the knee. Am J Sports Med 2005;33:131-148.

Children with vitamin D-resistant rickets are short in stature and have genu varum, physeal widening, and generalized osteopenia. The abnormality in inherited vitamin D-resistant rickets is the renal tubule's inability to resorb phosphate leading to hypophosphatemia. Laboratory findings in the condition are normal or near normal serum calcium values, significantly decreased serum phosphate levels, elevated alkaline phosphatase levels, and normal PTH and vitamin-D levels. The most common form is inherited as an X-linked dominant trait. Nutritional rickets has a normal or low serum phosphate levels, normal or low serum calcium values, and decreased levels of 25(OH) vitamin D and 1,25-dihydroxyvitamin D. Hypophosphatasia is a rare condition characterized by a deficiency of alkaline phosphatase in the serum and tissues, leading to generalized abnormal mineralization of bone. Primary hyperparathyroidism usually is caused by a parathyroid adenoma, and the child generally has abdominal problems and hypercalcemic crisis. Laboratory findings include elevated serum calcium values, alkaline phosphatase levels, and PTH levels, and decreased serum phosphate levels. Children with renal osteodystrophy tend to have genu valgum, and laboratory findings include elevated serum phosphate, alkaline phosphatase, and PTH levels, and low serum calcium values. Findings of renal disease include elevated BUN and creatinine. Herring JA: Metabolic and endocrine bone diseases, in Herring JA (ed): Tachdjian's Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, pp 1686-1710.

The patient has internal impingement. Internal impingement is commonly seen in overhead throwing athletes. When positioned in the extreme cocking phase of the throwing cycle, the posterior glenoid impacts the articular surface of the infraspinatus and posterior fibers of the supraspinatus tendon. This impact can cause partial-thickness rotator cuff tearing and posterosuperior labral lesions. She has no evidence of anterior shoulder instability, and her range of motion is excellent which rules out adhesive capsulitis. Subacromial impingement is identified with anterolateral shoulder pain with internal rotation in the abducted position. A full-thickness rotator cuff tear in a 22-year-old individual would require significant trauma and would likely result in pain at rest and with lifting. Meister K, Buckley B, Batts J: The posterior impingement sign: Diagnosis of rotator cuff and posterior labral tears secondary to internal impingement in overhand athletes. Am J Orthop 2004;33:412-415.

Foot deformity and decreased joint motion have been associated with increased plantar pressures and an increased risk of ulceration. In a partial-thickness ulcer without exposed bone or tendon, total contact casting is highly effective. Concomitant Achilles tendon lengthening increases the likelihood that healing of the ulcer can be obtained and perhaps more importantly, maintained. Lin SS, Lee TH, Wapner KL: Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: The effect of tendo-Achilles lengthening and total contact casting. Orthopedics 1996;19:465-475.

The status of the hips (located or dislocated) in children with thoracic-level myelomeningocele has no effect on the functional outcome of these patients. Management of unstable hips in this population should be limited to treatment of the contractures that may lead to poor limb positioning in either braces or a wheelchair. The use of the Pavlik harness and/or spica cast is contraindicated because they would promote flexion and abduction contractures. In the past, open reduction either through an anterior or medial approach had been performed with a high incidence of redislocation and other complications, with little functional gain for the child. Gabriel KG: Natural history of hip deformity in spina bifida, in Sarwark JR, Lubicky JP (eds): Caring for the Child With Spina Bifida. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001, pp 89-103.

Incomplete cord syndromes have variable neurologic findings with partial loss of sensory and/or motor function below the level of injury. Incomplete cord syndromes include the anterior cord syndrome, the Brown-Séquard syndrome, central cord syndrome, and posterior cord syndrome. Central cord syndrome is characterized with greater motor weakness in the upper extremities than in the lower extremities. The pattern of motor weakness shows greater distal involvement in the affected extremity than proximal muscle weakness. Anterior cord syndrome involves a variable loss of motor function and pain and/or temperature sensation, with preservation of proprioception. The Brown-Séquard syndrome involves a relatively greater ipsilateral loss of proprioception and motor function, with contralateral loss of pain and temperature sensation. Posterior cord syndrome is a rare injury and is characterized by preservation of motor function, sense of pain, and light touch, with loss of proprioception and temperature sensation below the level of the lesion. Spinal shock is the period of time, usually 24 hours, after a spinal injury that is characterized by absent reflexes, flaccidity, and loss of sensation below the level of the injury. Penrod LE, Hegde SK, Ditunno JF: Age effect on prognosis for functional recovery in acute, traumatic central cord syndrome. Arch Phys Med Rehab 1990;71:963-968.

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

Etanercept is a fusion protein that combines the ligand-binding domain of the TNF-a receptor to the Fc portion of human immunoglobulin G (IgG). Protein serves as a competitive inhibitor of TNF-a signaling. COX2 is the target of NSAIDs, including newer formulations that are more COX2-specific. The remaining responses are not direct targets of etanercept. Weinblatt ME, Kremer JM, Bankhurst AD, et al: A trial of etanercept, a recombinant tumor necrosis factor receptor: Fc fusion protein, in patients with rheumatoid arthritis receiving methotrexate. N Engl J Med 1999;340:253-259.

With a severe injury to the upper extremity, the best opportunity for achieving a good functional result for a floating elbow is immediate debridement of the open fracture, followed by internal fixation of the fractures. The ability to do this depends on the patient's physiologic status. In this patient, the procedure is acceptable because she has normal vital signs and no chest or abdominal injuries, and normal physiologic parameters (base excess and lactate) show adequate peripheral perfusion. The surgical approaches will be determined by the associated injury patterns and open wounds. In this patient, the humerus was debrided and stabilized through a posterior approach as was the medial condyle fracture. The ulna was fixed through an extension of the posterior incision and the radius through a separate dorsal approach. Solomon HB, Zadnik M, Eglseder WA: A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-570.

The clinical findings indicate venous obstruction without arterial compression, and the venogram reveals occlusion of the subclavian vein, which is most likely the result of thoracic outlet compression. In the developed athlete, scalene muscle hypertrophy (Paget-Schroetter syndrome) causes compression of the subclavian vein. Treatment should consist of thrombolysis followed by decompressive surgery. Angle N, Gelabert HA, Farooq MM, et al: Safety and efficacy of early surgical decompression of the thoracic outlet for Paget-Schroetter syndrome. Ann Vasc Surg 2001;15:37-42.

The patient has spinal shock. Steroid administration and MRI are appropriate therapeutic and diagnostic procedures. Myelography with CT is of little value unless there is an unusual skeletal variant. Spinal cord-evoked potentials have no value. The best method to determine the patient's neurologic recovery is repeated physical examinations over the first 48 to 72 hours. Spivak JM, Connolly PF (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 183-184.

Internal impingement of the shoulder is now a well-recognized cause of shoulder pain in the throwing athlete. First described by Walch and associates, it involves contact of the rotator cuff and labrum in the maximally externally rotated and abducted shoulder, such as in the late cocking phase of the throwing motion. Schickendantz and associates have shown this contact to be physiologic in most patients and becoming pathologic with repetitive overhead activity. Schickendantz MS, Ho CP, Keppler L, Shaw BD: MR imaging of the thrower's shoulder: Internal impingement, latissimus dorsi/subscapularis strains, and related injuries. Magn Reson Imaging Clin N Am 1999;7:39-49. Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg 1992;1:238-245.

The radiographs show fragmentation of the inferior pole of the patella. This finding, along with the clinical presentation, is most consistent with Sindig-Larsen-Johansson disease. This is an overuse syndrome commonly seen in boys ages 9 to 11 years. The differential diagnosis includes bipartite patella and patellar sleeve fracture. Like most overuse syndromes, Sindig-Larsen-Johansson disease responds to activity modification and nonsteroidal anti-inflammatory drugs. While symptoms usually resolve with short periods of activity restriction, radiographic findings may persist. Stanitski CL: Anterior knee pain syndromes in the adolescent. J Bone Joint Surg Am 1993;75:1407-1416.

The subtrochanteric femur has been identified as an anatomic site that is particularly prone to pathologic fracture. An avulsion fracture of the lesser trochanter is a sign of impending femoral fracture. While the other anatomic locations are also frequently involved in metastatic bone disease, pathologic fractures occur less commonly. Simon MA, Springfield DS, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 683.

The median nerve passes through the pronator teres and deep to the flexor digitorum superficialis. The ulnar artery passes deep to both. Anderson JE (ed): Grant's Atlas of Anatomy, ed 7. Baltimore, MD, Williams and Wilkins, 1978, pp 6-55.

Insufficient caloric intake caused by either a poor diet or an eating disorder is the most common cause for the loss of menses in a female athlete. In the face of adequate caloric intake, stress is unlikely to cause amenorrhea. Oral contraceptives control menses but do not eliminate it. Diabetes mellitus does not cause the new onset of amenorrhea. Pregnancy can be a cause in a sexually active athlete. Chromosomal abnormalities can result in delayed or absent menarche but not the onset of amenorrhea in a postmenarchal female. Constantini NW: Clinical consequences of amenorrhea. Sports Med 1994;17:213-223.

Meniscal tears have many configurations and locations. The normal medial meniscus has a bow-tie configuration on the two most medial consecutive sagittal views. Toward the center of the joint the anterior and posterior horns have a triangular shape. These images show an abnormal intra-articular low-signal structure located anterior to the intact posterior cruciate ligament. This most likely represents a torn and displaced posterior horn of the medial meniscus, sometimes called "double PCL sign". A popliteal cyst and ligaments of Wrisberg and Humphry are not visible on these figures. Helms CA: MR image of the knee, in Fundamentals of Skeletal Radiology, ed 2. Philadelphia, PA, WB Saunders, 1995, pp 172-191.

Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman's T-score is within -1 to -2.5 SD. The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.

It is critical for graft isometry and knee stability that the femoral tunnel be placed as far posterior as possible on the lateral femoral condyle. Superiorly, the graft should be at the one o'clock position on the left knee. Resident's ridge is a false posterior shelf that often seems like the extreme posterior cortex. Abnormal tunnel placement results in a variety of complications, including an unstable knee, early graft failure, and joint stiffness. Johnson RJ, Beynnon BD, Nichols CE, Renstrom PA: The treatment of injuries of the anterior cruciate ligament. J Bone Joint Surg Am 1992;74:140-151.

An unconstrained prosthesis dislocation is a disconcerting problem that is not easily resolved; however, revision to a semiconstrained prosthesis would best achieve both pain relief and stability. Removal of the components and distraction arthroplasty or conversion to a resection arthroplasty are options, but the results would be unpredictable with regards to pain relief, postoperative motion, or elbow stability. Arthrodesis is poorly tolerated. With revision to another unconstrained prosthesis, there is the risk of continued redislocation because of chronic ligamentous insufficiency. Linscheid RL: Resurfacing elbow replacement arthroplasty: Rationale, technique and results, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 602-610.

The superior cluneal nerves (L1, L2, and L3) are most at risk when harvesting iliac crest bone graft during a posterior decompression and fusion. These nerves pierce the lumbodorsal fascia and cross the posterior iliac crest, beginning 8 cm lateral to the posterior superior iliac spine. The ilioinguinal nerve is more at risk during exposure of the anterior ilium during retraction of the iliacus and abdominal wall muscles. Iliohypogastric nerve injury may arise in a similar fashion to ilioinguinal neuralgia. The lateral femoral cutaneous nerve lies in close proximity to the anterior superior iliac spine and is also at risk with anterior iliac crest bone graft harvesting. The superior gluteal nerve courses through the sciatic notch and supplies motor branches to the gluteus medius, minimus, and tensor fascia lata muscles. Injury results in hip abduction weakness. An HS: Principles and Techniques of Spine Surgery. Baltimore, MD, Williams and Wilkins 1998, pp 770-773. Kurz LT, Garfin SR, Booth RE Jr: Harvesting autogenous iliac bone grafts: A review of complications and techniques. Spine 1989;14:1324-1331.

The radiograph shows bilateral flattening of the femoral heads with mottling and "fragmentation" suggestive of Legg-Calve-Perthes disease. However, when these changes occur bilaterally and are symmetric, multiple epiphyseal dysplasia or spondyloepiphyseal dysplasia should be suspected. Skeletal survey will show irregularity of the secondary ossification centers. With these conditions, there is no true osteonecrosis and no evidence that orthotic or surgical "containment" will alter the outcome of progressive degenerative arthritis. Cardiac anomalies and coagulopathies are not associated with the epiphyseal dysplasias. Crossan JF, Wynne-Davies R, Fulford GE: Bilateral failure of the capital femoral epiphysis: Bilateral Perthes disease, multiple epiphyseal dysplasia, pseudoachondroplasia, and spondyloepiphyseal dysplasia congenita and tarda. J Pediatr Orthop 1983;3:297-301.

Calcaneal apophysitis (Sever's disease) is a common cause of heel pain in children who are active in sports. The symptoms are most commonly bilateral and will often respond to a gastrocnemius-soleus complex stretching program. In addition, rest, anti-inflammatory drugs, and heel pads for the shoe may be prescribed. There is no effect on the long-term growth of the calcaneus. Micheli LJ, Ireland ML: Prevention and management of calcaneal apophysitis in children: An overuse syndrome. J Pediatr Orthop 1987;7:34-38.

The patient has a displaced scapular spine fracture that has resulted in shoulder weakness from a poor deltoid lever arm. The downward tilt may lead to subacromial impingement and rotator cuff dysfunction. Open reduction and internal fixation would best allow normal deltoid and shoulder function. Bone stimulators and abduction bracing may lead to healing but in a malunited position. Arthroscopic acromioplasty and fragment excision should be avoided. Ogawa K, Naniwa T: Fractures of the acromion and the lateral scapular spine. J Shoulder Elbow Surg 1997;6:544-548.

Nonsurgical management such as a functional brace, hanging arm cast, or sugar tong splint is the treatment of choice for a fracture of the humeral shaft that is the result of throwing. The fracture surface typically is wide and the degree of displacement is not large; therefore, surgery is not indicated in most patients. Ogawa K, Yoshida A: Throwing fracture of the humeral shaft: An analysis of 90 patients. Am J Sports Med 1998;26:242-246.

The patient has an oligotrophic nonunion of the distal femoral fracture. Although the proximal fracture appears incompletely united, it was stable at exchange nailing. The treatment of choice is exchange reamed nailing to at least 2 mm above the nail in place. Bone grafting is debatable. Recent studies have shown a 70% to 75% success rate with exchange nailing only, so in nonhypertrophic nonunions, bone grafting can be considered. Nonsurgical management consisting of observation or external stimulation runs the risk of implant failure. Plate fixation is acceptable but is considered a second choice because of the need to consider stabilization of the proximal fracture until union is achieved. Also, plate fixation definitely requires bone grafting. Webb LX, Winquist RA, Hansen ST: Intramedullary nailing and reaming for delayed union or nonunion of the femoral shaft: A report of 105 consecutive cases. Clin Orthop 1986;212:133-141. Weresh MJ, Hakanson R, Stover MD, et al: Failure of exchange reamed intramedullary nailing for ununited femoral shaft fractures. J Orthop Trauma 2000;14:335-338.

The CT scan reveals a right-sided lateral disk protrusion at L3-4 that has been symptomatic for more than 4 months despite appropriate nonsurgical management. Relative surgical indications include persistent radiculopathy despite an adequate trial of nonsurgical management, recurrent episodes of sciatica, persistent motor deficit with tension signs and pain, and pseudoclaudication caused by underlying stenosis. Whereas studies have shown improvement in patients with sciatica from a lumbar disk herniation treated either nonsurgically or surgically, those undergoing surgical treatment had an overall greater improvement of symptoms. Weinstein JN, Lurie JD, Tosteson TD, et al: Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006;296:2451-2459.

Histologic studies have shown that increased bone turnover is the rule in OI. Pamidronate (and all bisphosphonates) reduce osteoclast-mediated bone resorption. Osteoblastic new bone formation on the periosteal surface of long bones is minimally impaired. With inhibition of osteoclastic bone resorption on the endosteal surface, the cortex of the bone can begin to thicken as it does with normal growth in individuals unaffected by OI. Mineralization and collagen matrix organization are not directly affected by pamidronate. Zeitlin L, Fassier F, Glorieux FH: Modern approach to children with osteogenesis imperfecta. J Pediatr Orthop B 2003;12:77-87. Falk MJ, Heeger S, Lynch KA, et al: Intravenous bisphosphonate therapy in children with osteogenesis imperfecta. Pediatrics 2003;111:573-578.

Premature consolidation is a complication that is unique to gradual bone lengthening after corticotomy. Causes include excessive latency period, inadequate distraction rate, exuberant bone formation, patient compliance problems, and mechanical failure of the distraction apparatus. The femur and fibula are most commonly involved. This patient did not have an incomplete corticotomy, as initial distraction occurred before the distraction device was noted to seize up. The radiographs show bowing of the Ilizarov wires and mature regenerate bone, both suggestive of premature consolidation. No wire breakage or joint subluxation is seen on the radiographs. Treatment for premature consolidation includes continuing distraction until the consolidation bridge ruptures, or additional surgery may include closed rotational osteoclasis or repeat corticotomy. Paley D: Problems, obstacles and complications of limb lengthening, in Maiocchi AB, Aronson J (eds): Operative Principles of Ilizarov. Baltimore, MD, Williams & Wilkins, 1991, p 360.

The radiograph shows an incompletely ossified calcaneonavicular coalition. When symptomatic, a trial of cast immobilization is reasonable. If this fails to provide relief, the preferred treatment is resection of the coalition. Before attempting surgery, a CT scan should be obtained to rule out ipsilateral subtalar coalition. Recurrence of the coalition is usually prevented with interposition of autogenous fat graft or with local interposition of the extensor digitorum brevis muscle. Approximately 80% of patients treated in this manner have decreased pain and improved subtalar motion. When the flatfoot deformity is mild, calcaneal lengthening or medial translation osteotomy is unnecessary. Primary triple arthrodesis may be indicated if degenerative changes are present in the subtalar or midfoot joints. Peroneal lengthening has been described for treatment of the peroneal spastic flatfoot without demonstrable tarsal coalition. Gonzalez P, Kumar SJ: Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle. J Bone Joint Surg Am 1990;72:71-77. Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.

Based on the mechanism of injury and findings of medial laxity, the most likely diagnosis is injury to either the growth plate or the medial collateral ligament. With the open physeal plate, this area of injury is presumed present until proven otherwise; therefore, stress radiographs should be obtained before implementing any treatment or ordering more extensive and expensive tests. DeLee JC: Ligamentous injury of the knee, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, vol 3, pp 406-432. Clanton TO, DeLee JC, Sanders B, Neidre A: Knee ligament injuries in children. J Bone Joint Surg Am 1979;61:1195-1201.

The patient has symptoms typical of Raynaud's phenomenon secondary to underlying vascular disease. The next most appropriate step in the management of this patient should be to perform contrast angiography on the involved upper extremity to look for proximal or distal arterial lesions or insufficiencies. MRI and contrast CT are not as specific as angiography for the identification of vascular lesions of the upper extremity. Although patients with primary Raynaud's vasospastic disease can have normal angiographic findings, they typically are younger than age 40 years, are female, and have normal results on an Allen test. Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 2288-2290.

The child sustained a brachial plexus injury at birth, and internal rotation/adduction contractures frequently develop at the shoulder. Initial treatment should consist of physical therapy to increase the range of motion. If this fails, as in this patient, MRI is used to evaluate the glenohumeral joint. Commonly, there is joint deformity with increased retroversion of the glenoid and even posterior shoulder subluxation. If the deformity is mild, an anterior release, coupled with teres major and latissimus transfers, is very effective. If the deformity is severe and the shoulder is unreconstructable, then humeral derotation osteotomy is the procedure of choice. MRI of the brain, a radiograph of the elbow, and aspiration of the shoulder would not be helpful. Waters PM: Update on management of pediatric brachial plexus palsy. J Pediatr Orthop B 2005;14:233-244. Waters PM, Bae DS: Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am 2005;87:320-325.

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

Dickman and associates reported a greater than 10% incidence of vertebral artery anomalies at the C1-2 junction that would preclude the use of either unilateral or bilateral transarticular screw placement. They noted that 13 of 105 patients had a high-riding transverse foramen that precluded bilateral screw placement. In another series, 17 of 94 patients had unilateral high-riding transverse foramina and three had bilateral anomalies. Thin-cut CT with sagittal reconstructions offers the best visualization of the anomalous position of the vertebral artery. They noted that single screw placement in combination with posterior C1-2 fusion was an effective means to secure C1-2 stability. MRI gives excellent visualization of soft tissues and spinal cord compression but is not as clear as thin-cut CT for visualization of the vertebral artery foramina. Vertebral artery angiography is an invasive study with an inherent potential for complications. Electromyography does not correlate with vertebral artery anatomy. Paramore CG, Dickman CA, Sonntag VK: The anatomic suitability of the C1-2 complex for transarticular screw fixation. J Neurosurg 1996;85:221-224. Dickman CA, Sonntag VK: Posterior C1-C2 transarticular screw fixation for atlantoaxial arthrodesis. Neurosurgery 1998;43:275-280.

Patients with a mutation of the retinoblastoma gene (RB) have an increased likelihood for the development of osteosarcoma. The EWS-FLI1 gene is the fusion product of a chromosomal translocation of 11:22. EGF-R and IGF-R are growth factor receptors, but mutations in these genes have not been correlated with osteosarcoma. VEGF is a proangiogenic molecule that is involved in tumor formation in multiple sites but not the development of osteosarcoma. Scholz RB, Kabisch H, Delling G, et al: Homozygous deletion within the retinoblastoma gene in a native osteosarcoma specimen of a patient cured of a retinoblastoma of both eyes. Pediatr Hematol Oncol 1990;7:265-273.

The intrinsic muscles innervated by the ulnar nerve include the palmaris brevis, hypothenar muscles, all of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis. The superficial head of the flexor pollicis brevis is innervated by the median nerve. Goldfarb CA, Stern PJ: Low ulnar nerve palsy. JASSH 2003;3:14-26.

Garfin and associates have shown that halo pins inserted with 8 in-lb of insertion torque results in significantly less loosening with cyclical loading than pins inserted with 6 in-lb of torque. Moreover, Botte and associates reported that 8 in-lb of torque is clinically safe and effective in lowering the incidence of pin loosening and infection. Botte MJ, Byrne TP, Garfin SR: Application of the halo device for immobilization of the cervical spine utilizing an increased torque pressure. J Bone Joint Surg Am 1987;69:750-752. Garfin SR, Lee TO, Roux RD, et al: Structural behavior of the halo orthosis pin-bone interface: Biomechanical evaluation of standard and newly designed stainless steel halo fixation pins. Spine 1986;11:977-981.

The first priority is to gain control of the airway with intubation. Following intubation, management should consist of ventilation and placement of a chest tube if needed, vascular access and circulatory stabilization, radiographs of the cervical spine and chest, and CT of the brain. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Course. Instructor's Manual. Chicago, IL, American College of Surgeons, 1984.

CT studies show that approximately 10% to 20% of patients with high-grade osteosarcoma have pulmonary metastases at diagnosis. Although not visible on current staging studies, it is believed that up to 80% of patients have micrometastatic disease that requires systemic chemotherapy. Because it is not possible to identify those patients who do not have disseminated micrometastatic disease, most patients are treated presumptively with chemotherapy. Kaste SC, Pratt CB, Cain AM, et al: Metastases detected at the time of diagnosis of primary pediatric extremity osteosarcoma at diagnosis: Imaging features. Cancer 1999;86:1602-1608.

Miller and associates reported the results of a cadaveric study of the vascular risk of a posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique. The average distance from the screw to the popliteal artery was 21.1 mm (range, 18.1 mm to 31.7 mm). Other approaches, such as the transtibial tunnel technique which involves drilling an anterior-posterior tunnel, have also been studied in cadavers. Matava and associates noted that increasing flexion reduces but does not completely eliminate the risk of arterial injury during arthroscopic posterior cruciate ligament reconstruction. However, this study did not use the small, medial utility incision recommended by Fanelli and associates, which creates an interval for the surgeon's finger between the medial gastrocnemius and the posteromedial capsule so that any migration of the guidepin can be palpated and changed prior to any injury to the posterior neurovascular bundle. Matava MJ, Sethi NS, Totty WG: Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: Implications for posterior cruciate ligament reconstruction. Arthroscopy 2000;16:796-804. Miller MD, Kline AJ, Gonzales J, et al: Vascular risk associated with posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique. J Knee Surg 2002;15:137-140.

Creatine is currently used as a nutritional supplement in an attempt to enhance athletic performance. The physiologic basis for its use is based on its conversion by CK to PCr, which acts as an energy reservoir in muscle cells for the production of ATP. A number of studies that examined the effect of creatine supplementation on performance concluded that while creatine does not increase peak force production, it can increase the amount of work done in the first few anaerobic short duration, maximal effort trials. The mechanism for this enhancement of work is unknown, but it is most likely secondary to the increase in the available PCr pool. Greenhaff PL: Creatine and its application as an ergogenic aid. Int J Sport Nutr 1995;5:S100-S110. Greenhaff PL, Casey A, Short AH, Harris R, Soderlund K, Hultman E: Influence of oral creatine supplementation on muscle torque during repeated bouts of maximal voluntary exercise in man. Clin Sci 1993;84:565-571. Trump ME, Heigenhauser GJ, Putman CT, Spriet LL: Importance of muscle phosphocreatine during intermittent maximal cycling. J Appl Physiol 1996;80:1574-1580.

The patient has a displaced comminuted clavicle middle one third fracture from a high-energy mechanism. Recent literature on high-energy clavicular fractures suggests a higher rate of nonunion than previously reported. A nonunion rate of 30% has been reported by Hill and associates when the fracture fragments are displaced more than 1.5 cm. In addition, several patients had neurologic symptoms related to the injury. Robinson and associates reported an increased risk of nonunion in women, elderly patients, comminuted fractures, and injuries with a lack of cortical contact. Hill JM, McGuire MH, Crosby LA: Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79:537-539. Wick M, Muller EJ, Kollig E: Midshaft fractures of the clavicle with a shortening of more than 2 cm predispose to nonunion. Arch Orthop Trauma Surg 2001;121:207-211.

Activity levels do not affect cobalt and chromium ion levels, which are the bulk of serum ion levels. The majority of ions are produced in the run-in period in the first several years. A gradual reduction in ion levels occurs thereafter. The kidneys are responsible for the bulk of clearance from the serum, and to date there is no relationship of cancer to ion levels in the serum.

The widening of the physis associated with incomplete reduction of this fracture suggests that periosteum is interposed at the fracture site. Clinical and animal study findings suggest that the interposed periosteum may lead to premature physeal closure. Repeated forceful attempts at reduction may subject the physis to further injury and should be avoided. Growth problems are common in children with Salter-Harris type I fractures of the lower extremities. Nonunions are rare in children with Salter-Harris type I fractures. Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibial physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23:733-739.

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

The surgeon perforated the anterior longitudinal ligament and injured the common iliac artery. Bingol and associates described injuries to the vascular structures during lumbar disk surgery. The common iliac artery was most commonly affected and constituted 76.9% of injuries.

Rehabilitation of the quadriceps muscle following a partial tear of the PCL has been associated with a favorable outcome. The quadriceps acts an antagonist to the PCL because its contraction results in anterior tibial translation, which reduces the tensile stress on the injured ligament. Strengthening of the hamstring musculature increases posterior tibial translation and is contraindicated during the early rehabilitative phase following a PCL injury. Brace use has not been found to significantly alter the outcome following nonsurgical management of PCL tears. Parolie JM, Bergfeld JA: Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med 1986;14:35-38.

The incidence of femoral fracture in primary cementless total hip arthroplasty ranges from 1.5% to 27.8%. It is imperative that the implant and fracture are stable both intraoperatively and postoperatively. Cerclage wiring or cerclage cabling is the current recommended treatment for nondisplaced calcar fractures and minimally displaced proximal fractures. Berend and associates reviewed the results of 58 total hips in 55 patients with intraoperative calcar fracture managed with single or multiple cerclage wires or cables and immediate full weight bearing. Follow-up averaged 7.5 years, and there were no revisions of the femoral component. No patients had severe thigh pain. Berend KR, Lombardi AV Jr, Mallory TH, et al: Cerclage wires or cables for the management of intraoperative fracture associated with a cementless, tapered femoral prosthesis: Results at 2 to 16 years. J Arthroplasty 2004;19:17-21. Schmidt AH, Kyle RF: Periprosthetic fractures of the femur. Orthop Clin North Am 2002;33:143-152.

The leg and trunk provide a stable base for arm motion, supply rotational momentum for force generation, and generate 50% to 55% of the total force and kinetic energy in the tennis serve. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 47. McClure PW, Michener LA, Sennett BJ, et al: Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg 2001;10:269-277.

The collagen orientation changes from parallel in the superficial zone to a more random pattern in the middle zone and finally to perpendicular in the calcified zone. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 498-499.

Most studies have shown that total shoulder arthroplasties yield better pain relief and improved forward elevation when compared to hemiarthroplasty in patients with rheumatoid arthritis. Although rotator cuff tears are more common in this patient population, this patient has good forward elevation and no significant superior migration of the humeral head; therefore, a reverse arthroplasty is not indicated. The arthritis is too advanced in this patient to consider arthroscopy, but in less advanced cases it can improve range of motion and decrease pain. Metal-backed glenoid components have shown higher rates of loosening. Collin DN, Harryman DT II, Wirth MA: Shoulder arthroplasty for the treatment of inflammatory arthritis. J Bone Joint Surg Am 2004;86:2489-2496. Baumgarten KM, Lashgari CM, Yamaguchi K: Glenoid resurfacing in shoulder arthroplasty: Indications and contraindications. Instr Course Lect 2004;53:3-11.

The patient has a chronic flexor tendon laceration. There are options to restore motion and strength; therefore, fusion is not necessary. Full range of motion is present so the soft tissues are suitable for a tendon transfer. A transfer of the flexor digitorum superficialis of the ring finger to the insertion of the flexor pollicis longus on the distal phalanx provides good results with a one-stage operation. Schneider LH, Wiltshire D: Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer. J Hand Surg Am 1983;8:98-101.

Cervical laminectomy is an accepted treatment for multilevel cervical spondylotic myelopathy. When the compression is posterior, laminectomy addresses it directly; when the compression is anterior, it is addressed indirectly (the spinal cord floats posteriorly away from the anterior compression). Preexisting kyphosis is a contraindication to laminectomy because the cord is unable to float posteriorly away from the anterior compression, and the risk for increasing kyphosis is significant. Kyphosis after laminectomy is more likely to develop in younger patients who have fewer degenerative changes to stabilize the spine. Malone DG, Benzyl EC: Laminotomy and laminectomy for spinal stenosis causing radiculopathy or myelopathy, in Clark CR (ed.): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 817-825.

The pedigree documents involvement of male offspring only, and it also shows transmission through an uninvolved female carrier. This inheritance pattern is most consistent with a x-linked recessive inheritance. It would be inconsistent with a dominant inheritance pattern unless there was incomplete penetrance. Autosomal-recessive inheritance would be possible only if the family member labeled II.F was also a carrier of the same gene; however, this is unlikely. Mitochondrial inheritance is possible, but as with autosomal patterns, mitochondrial inheritance normally affects both male and female offspring. It is transmitted only through the maternal line.

Larsen grade I and II rheumatoid arthritis is best treated with synovectomy with arthroplasty reserved for later stages, especially in younger patients. Open synovectomy with or without a radial head excision has yielded good results for pain and function, with arthroscopic synovectomies yielding similar results. Arthroscopic synovectomy has been shown to be more effective in restoring function in patients with a flexion arc of less than 90 degrees. Tanaka N, Sakahashi H, Hirose K, et al: Arthroscopic and open synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 2006;88:521-525. Horiuchi K, Momohara S, Tomatsu T, et al: Arthroscopic synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 2002;84:342-347.

A high level of suspicion must be given for a fracture in any patient with ankylosing spondylitis who reports neck pain, even with minimal or no trauma. The neck should be immobilized in its normal position, which is often kyphotic, and plain radiographs should be obtained. If no obvious fracture is seen, CT with reconstruction should be obtained. The placement of in-line traction can have catastrophic effects because it may malalign the spine. Brigham CD: Ankylosing spondylitis and seronegative spondyloarthropathies, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 724-727.

This child has the potential to walk and therefore should have all the contracted structures in the feet released as necessary to place the feet in a plantigrade position for fitting of ankle-foot orthoses. Physical therapy, manipulation, and casting may provide some benefit in a newborn with flexible feet but are not effective in an older infant with rigid clubfeet. Botulinum injections and tendon transfers are of no use because there are no muscles functioning below the knee. Tendon releases are more effective than tendon transfers in children with myelomeningocele. Mazur JM: Management of foot and ankle deformities in the ambulatory child with myelomeningocele, in Sarwark JR, Lubicky JP (eds): Caring for the Child with Spina Bifida. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001, pp 155-160.

Intrafocal pinning allows the Kirschner wires to be placed through a site of comminution and then drilled through intact cortex. Generally Kapandji intrafocal pinning is done for dorsal comminuted extra-articular dorsal bending fractures, but it also may be used to elevate and buttress radial comminution. Simple intra-articular fractures can also be treated with pinning alone. Intrafocal pinning works best as a dorsal or radial buttress to prevent shortening. When there is volar comminution, the fracture is prone to shortening and supplemental external fixation or plating is recommended. Trumble TE, Wagner W, Hanel DP, et al: Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation. J Hand Surg Am 1998;23:381-394. Choi KY, Chan WS, Lam TP, et al: Percutaneous Kirschner-wire pinning for severely displaced distal radial fractures in children: A report of 157 cases. J Bone Joint Surg Br 1995;77:797-801.

The patient has a complex fracture-dislocation of the elbow. The radial head is fractured, and there is a displaced coronoid fracture. These associated fractures indicate that the elbow is at high risk for recurrent instability after initial treatment. To prevent this complication, surgical treatment will most likely be required and will consist of some or all of the following: radial head open reduction and internal fixation or replacement, coronoid open reduction and internal fixation, medial and lateral ligament repairs, and even articulated external fixation. This patient was treated with open reduction and internal fixation of the radial head, and the elbow redislocated postoperatively. Ring D, Jupiter JB: Reconstruction of posttraumatic elbow instability. Clin Orthop 2000;370:44-56. O'Driscoll SW: Classification and evaluation of recurrent instability of the elbow. Clin Orthop 2000;370:34-43.

Success of a meniscal allograft transplantation is strongly dependent on accurate graft sizing, typically within 5% of the native meniscus. Previous studies have established that donor cell viability is not mandatory for the survival of these grafts since they are replaced by the recipient's cells (at least peripherally) within several weeks. Thus, cryopreservation of the graft to ensure cell viability is not necessary. There is a limited immune response to musculoskeletal allografts; therefore, immunosuppression, as is required for visceral organ transplantation, is not indicated. Wirth CA, Kohn D: Meniscal transplantation and replacement, in Fu FH, Harner CD, Vince JG (eds): Knee Surgery. Baltimore, MD, Williams & Wilkins, 1994, vol 1, pp 631-641. Brautigan BE, Johnson DL, Caborn DM, et al: Allograft tissues, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 205-213.

Closed-chain exercise requires the distal portion of the extremity to be fixed. It is more commonly used in lower extremity exercise, and movement is produced by co-contraction of muscles. Joint compression is increased, and multiple joints are involved with closed-chain exercise. In open-chain exercise, the distal portion of the extremity is free. Braddom RL (ed): Physical Medicine and Rehabilitation, ed 2. Philadelphia, PA, Saunders, 2000, pp 975-976.

The radiographs demonstrate a rapid erosion of the bipolar component into the acetabulum. Although acetabular erosion is more common with unipolar hip arthroplasties, it can occur with bipolar components. Haidukewych and associates noted a very low erosion rate but none in the first 2 years. The second finding on the radiographs is the linear radiolucency progressing from the joint toward the end of the stem at the cement-bone interface suggesting chronic infection or diffuse loosening. The persistent pain since implantation also suggests chronic infection. High activity levels and osteoporosis do not lead to acetabular erosion in the first 2 years after hemiarthroplasty. While the cement technique is suboptimal, loosening and erosion should not be expected from this alone. An oversized bipolar head would extrude and not erode. Haidukewych GJ, Israel TA, Berry DJ: Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck. Clin Orthop Relat Res 2002;403:118-126. Lestrange NR: Bipolar hemiarthroplasty for 496 hip fractures. Clin Orthop Relat Res 1990;251:7-19.

The area of the tendon degeneration is greater than 50% of the width so a supplemental tendon transfer is needed. Debridement and repair alone do not provide adequate strength. Injection risks tendon rupture. Brisement is indicated for peritendinitis, not tendinosis. Nonsurgical management is unlikely to be of benefit after 12 months. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 94-95.

All the factors listed, with the exception of an ipsilateral femoral fracture, are representative of a low-energy stable tibial shaft fracture that will do well with closed reduction and immobilization in a long leg cast, followed by weight bearing as tolerated and then a functional brace or patellar tendon bearing cast until union is achieved. Shortening will not increase from that seen on these initial radiographs. The spiral fracture provides a broad surface for healing, and the fibular fracture at another level indicates a stable soft-tissue envelope which, with the immobilization device, will stabilize the fracture reduction. An ipsilateral femoral fracture is a strong indication to surgically stabilize both fractures. Trafton PG: Tibial shaft fractures, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 2153-2169.

The radiographs reveal a hindfoot deformity that developed following a severe, comminuted, intra-articular fracture of the calcaneus. There is deformity of the calcaneal body and collapse of the talus into the calcaneus, leading to dorsiflexion of the talus and anterior ankle joint impingement. Distraction bone block subtalar joint arthrodesis will assist with correction of the calcaneal height and will allow for an improved talar declination angle. With this procedure, care must be taken to avoid placing the hindfoot into further varus. A similar reconstruction option not listed would be a calcaneal osteotomy and arthrodesis as described by Romash. Talectomy and tibiocalcaneal arthrodesis are not warranted because the primary structure of the talus and ankle joint is well preserved. In situ subtalar joint arthrodesis will not correct the deformity, and symptoms about the ankle and hindfoot would most likely persist. Lateral wall calcaneal exostectomy may decrease pain from subfibular impingement but will not deal directly with subtalar joint arthrosis and deformity. Carr JB, Hansen ST , Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-86. Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.

In a traditional plate system, fracture security depends on the friction between the plate and the underlying bone. Bicortical fixation will decrease the toggle and improve stability. Locking plates absorb axial forces transmitted from the screws. Such plates do not require plate compression against the bone, thus preserving periosteal blood supply. Nana AD, Joshi A, Lichtman DM: Plating of the distal radius. J Am Acad Orthop Surg 2005;13:159-171.

The presence of a dorsal ulcer in the presence of weak or absent pulses strongly suggests the possibility of arterial insufficiency. The best initial noninvasive study to assess for ischemia is the Doppler arterial study. A determination of the vascular status is of a greater priority than an assessment for infection or neuropathy because of the location and presentation of the ulcer. If ankle pressures are less than 45 mm Hg, there is a high risk that these lesions will not heal without revascularization. Wagner FW Jr: The dysvascular foot: A system for diagnosis and treatment. Foot Ankle 1981;2:64-122.

Penetrating sharp wounds in proximity to major nerve or vascular structures should always be acutely explored. Because this patient did not seek treatment for a potentially treatable injury, interosseous wasting implies injury to the C8 and T1 nerve roots that contribute to ulnar nerve function. The most likely location for the brachial plexus injury is the location marked L or the inferior trunk. A wrist drop that is the result of radial nerve dysfunction would be expected with an injury at K or O. An upper brachial plexus palsy with loss of elbow flexion and shoulder abduction would be expected with an injury at B. A loss of elbow flexion alone would be expected following an injury at C. Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System. Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy, 1991, vol 8, pp 28-29. Wolock B, Millesi H: Brachial plexus-applied anatomy and operative exposure, in Gelberman RH (ed): Operative Nerve Repair and Reconstruction. Philadelphia, PA, JB Lippincott, 1991, vol 2, pp 1255-1272.

In the past, loss of plantar sensation in this grade IIIC tibial fracture would have been an indication for below-knee amputation regardless of the potential for vascular repair. However the 2002 LEAP study divided 55 patients with loss of plantar sensation into two groups, the insensate amputation group and the insensate limb salvage group, with 55% of patients in the insensate salvage group regaining normal sensation 2 years after injury. Furthermore, those in the salvage group who remained insensate after 2 years had equivalent outcomes to those in the amputation group. Because of these findings, limb salvage with vascular repair and external stabilization with delayed closure is deemed appropriate treatment. Immediate intramedullary fixation is not indicated. Because ischemia, contusion, and stretch can adversely affect the tibial nerve, the additional insult of exploration of the nerve is also not advisable given the soft-tissue compromise. Bosse MJ, McCarthy ML, Jones AL, et al: The insensate foot following severe lower extremity trauma: An indication for amputation? J Bone Joint Surg Am 2005;87:2601-2608. Lange RH, Bach AW, Hansen ST Jr, et al: Open tibial fractures with associated vascular injuries: Prognosis for limb salvage. J Trauma 1985;25:203-208. Mackenzie EJ, Bosse MJ, Kellam JF, et al: Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma 2002;52:641-649.

The patient sustained a bimalleolar ankle fracture with a syndesmosis disruption. The initial open reduction and internal fixation did not successfully reduce the distal tibiofibular joint. The patient may need a derotational distraction osteotomy of the fibula to reduce the syndesmosis. The other procedures do not address the primary problem of the fibular malunion and syndesmosis malreduction. There is no radiographic evidence of significant arthritis; therefore, ankle arthrodesis is not indicated.

The patient's history and laboratory studies are very suspicious for a postoperative diskitis. The predominant symptom often is back pain. An ESR of 90 mm/h is considered significantly elevated and normally would be expected to return to near baseline by 2 weeks postoperatively. A normal WBC result is not unusual with postoperative diskitis. Management should consist of an MRI with gadolinium to confirm the diagnosis, followed by a biopsy percutaneously to obtain tissues for pathology and microbiology. Surgical debridement is reserved for patients whose percutaneous biopsy results are negative and a high index of suspicion for diskitis remains, or when management consisting of IV antibiotics, bed rest, and spinal immobilization fails to provide relief. Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 257-271.

A variety of methodologies have been used to decrease the need for homologous blood transfusions following THA. Some of the effective strategies include preoperative donation of autologous units, intraoperative salvage and recycling, preoperative injection of erythropoietin, and regional anesthesia. Cementless fixation and use of wound drains have been shown to increase the blood loss with THA. Huo MH, Paly WL, Keggi KJ: Effect of preoperative autologous blood donation and intraoperative and postoperative blood recovery on homologous blood transfusion requirement in cementless total hip replacement operation. J Am Coll Surg 1995;180:561-567. Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB: An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 1999;81:2-10.

Because the patient has significant arthritis, arthrodesis is the treatment of choice. Adding a bone graft will prevent further shortening and add length to her toe, resulting in improved cosmesis. A cheilectomy will not alleviate her arthritis pain. The toe is too short for an effective Moberg phalangeal dorsiflexion osteotomy. A Waterman first metatarsal dorsal osteotomy will not address the degenerative joint disease or shortening. Silastic arthroplasty may help, but there is the risk of additional problems with foreign body reaction and a significant risk of failure known to occur with Silastic materials. Myerson MS, Schon LC, McGuigan FX, Oznur A:Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int 2000;21:297-306. Mann RA, Coughlin MJ: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 252-253.

The radiographs show an isolated posterior malleolus fracture which, given the injury mechanism, is highly suspicious for a Maisonneuve injury. As with any suspected extremity injury, radiographs including the joints above and below the level of injury are acutely indicated. Although MRI may reveal a ligamentous injury to the ankle and CT may show asymmetry of the ankle mortise or syndesmosis, both studies are considerably more costly and are not indicated in the absence of a complete radiographic work-up. Technetium bone scan is nonspecific and would be of limited value in this instance, as would repeat radiographs of the ankle. Walling AK, Sanders RW: Ankle fractures, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 2, pp 1973-2016.

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. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Closed ruptures of the central slip of the extensor tendon may occur with volar proximal interphalangeal joint dislocation, forced flexion of the proximal interphalangeal joint, or blunt trauma to the dorsum of the proximal interphalangeal joint. The other structures are not typically injured in proximal interphalangeal joint dislocations. Treatment typically requires static splinting of the proximal interphalangeal joint. In the more common dorsal proximal interphalangeal joint dislocation, the volar plate is injured, and early range of motion may be started after reduction. Doyle JR: Extensor tendons: Acute injuries, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1925.