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Orthopedic Board Review Mock Exam #603: 100 High-Yield MCQs

Orthopedic Surgery Mock Exam 566: 100 High-Yield MCQs for ABOS & OITE

27 Apr 2026 100 min read 85 Views
AAOS Hand and Wrist MCQs: Board Prep Part 6

Key Takeaway

Master your ABOS, OITE, and FRCS exams with Orthopedic Mock Exam Set 566. This page provides 100 high-yield multiple-choice questions covering trauma, spine, hand, peds, and sports medicine. Surgeons can test their knowledge and prepare comprehensively for certification and in-training assessments.

Comprehensive 100-Question Exam


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Question 1

During treatment of rupture of the subscapularis tendon with associated biceps instability, treatment of the biceps tendon should include which of the following?





Explanation

With subscapularis tendon ruptures that have biceps tendon pathology, treatment with tenodesis or tenotomy has improved clinical results. Subluxation or dislocation of the biceps tendon is common with subscapularis rupture. Dislocation of the biceps can occur either beneath the tendon, within the tendon, or extra-articularly. In all cases, the restraints to medial translations of the biceps have been disrupted. Attempts at recentering the biceps have not been successful, and clinical results appear to be improved when tenodesis or tenotomy is employed in the treatment of the unstable biceps associated with subscapularis tears. Edwards TB, Walch G, Sirvenaux F, et al: Repair of tears of the subscapularis: Surgical technique. J Bone Joint Surg Am 2006;88:1-10. Deutsch A, Altchek DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.

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Question 2

A 15-year-old athlete collapses suddenly during practice and dies. What is the most likely cause of death?

Sports Medicine Board Review 2004: High-Yield MCQs (Set 2) - Figure 2





Explanation

The number one cause of sudden death in the young athlete is myocardial pathology, with hypertrophic cardiomyopathy being most common. Because of cardiac muscle hypertrophy, the ventricular capacity is diminished and can result in decreased cardiac output. During exertional activities, the increased demand may not be able to be met and leads to sudden death. While the other choices can be the cause of sudden death in an otherwise healthy young athlete, their incidence is even more rare. Van Camp SP, Bloor CM, Mueller FO, et al: Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27:641-647. Maron BJ, Shirani J, Pollac LC, et al: Sudden death in young competitive athletes: Clinical, demographic, and pathological profiles. JAMA 1996;276:199-204.

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Question 3

A 22-year-old volleyball player has atrophy of the infraspinatus muscle. This deficit is the result of entrapment of what nerve?





Explanation

Suprascapular deficits, as the result of repetitive forceful internal rotation with overhead ball striking, occur in the spinoglenoid notch. Compression interferes with distal suprascapular nerve innervation to the infraspinatus, while allowing the supraspinatus to function normally. A scapular notch entrapment of this nerve would involve both the supraspinatus and the infraspinatus. The axillary, dorsal scapular, and subscapular nerves do not affect the infraspinatus. Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.

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Question 4

A patient who underwent primary total hip arthroplasty 7 years ago that resulted in excellent pain relief and a normal gait now reports pain and a limp. Postoperative and current AP radiographs are shown in Figures 2a and 2b. What is the most likely cause of the pathology seen?





Explanation

Osteolysis in the trochanteric bed can result in weakening of the bone and fracture. Nonsurgical management will provide reasonable clinical and radiographic results in patients with limited fracture displacement. Claus MC, Hopper RH, Engh CA: Fractures of the greater trochanter induced by osteolysis with the anatomic medullary locking prosthesis. J Arthroplasty 2002;17:706-712.

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Question 5

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





Explanation

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

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Question 6

Figure 26 shows the MRI scan of a 60-year-old man who has had groin pain for the past 2 months. The patient reports pain with ambulation, and examination reveals an antalgic gait. He denies any history of steroid or alcohol abuse. Plain radiographs are normal. Management should include

Hip 2001 Practice Questions: Set 3 (Solved) - Figure 8





Explanation

The patient has transient osteoporosis of the hip. Transient osteoporosis is usually a self-limited condition that is most frequently seen in women in the third trimester of pregnancy and in men in the sixth decade of life. Transient osteoporosis is best treated with protected weight bearing.

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Question 7

The load versus deformation curve of the functional spinal unit (FSU) is made up of the neutral zone, the elastic zone, and the plastic zone. What is the plastic zone of the curve believed to represent?





Explanation

Plastic deformation of viscoelastic tissues represents deformation of the soft tissues to the point of failure. The lining up of collagen fibers would be in the "toe region" of the curve, which, in the case of the FSU, would be mainly in the neutral zone. Elastin is a minor contributor to the composition of the ligaments and would be protected by the stiffer collagen fibers. The transition between flexion and extension occurs in the neutral zone, and reversible elongation occurs in the elastic zone. Fardon DF, Garfin SR, Abitbol J, et al (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 15-23.

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Question 8

What type of injury is considered the major mechanism of cervical fracture, dislocation, and quadriplegia in contact sports and diving?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 24





Explanation

A compression or burst injury occurs with vertical loading of the spine, such as from a blow to the vertex with the neck flexed (eg, spear tackling in football). This leads to vertebral end plate fractures before disk injury. At higher forces, the entire vertebra and disk may explode into the spinal canal. Analysis has shown this to be the major mechanism of cervical fracture, dislocation, and quadriplegia. With the normal head-up posture, the cervical spine has a gentle lordotic curve, and forces transmitted to the head are largely dissipated in the cervical muscles. When the neck is flexed, the cervical spine becomes straight, with the vertebral bodies lined up under one another. This allows for minimal dissipation of the impact forces to be absorbed by the neck muscles. Cantu RC: Head and spine injuries in youth sports. Clin Sports Med 1995;14:517-532. Proctor MR, Cantu RC: Head and neck injuries in young athletes. Clin Sports Med 2000;19:693-715.

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Question 9

A 64-year-old man undergoes a primary total knee arthroplasty. Three months after surgery he reports persistent pain, weakness, and difficulty ambulating. Postoperative radiographs are shown in Figures 6a through 6c. What is the best course of action at this time?





Explanation

The Merchant view reveals subluxation of the patellar component. The etiology of maltracking of the patella includes internal rotation of the femoral component, internal rotation of the tibial component, excessive patellar height, and lateralization of the patella component. The treatment of choice in this patient is revision total knee arthroplasty with external rotation of the femoral component. Preoperatively the patient also may require a lateral release, revision of the tibial component if it is internally rotated, and possibly a soft-tissue realignment. Component malalignment needs to be addressed first. Kelly MA: Extensor mechanism complications in total knee arthroplasty. Instr Course Lect 2004;53:193-199. Malkani AL, Karandikar N: Complications following total knee arthroplasty. Sem Arthroplasty 2003;14:203-214.

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Question 10

What nerve is most likely to develop a traumatic neuroma following open reducation and internal fixation of a talar neck fracture via a posterolateral approach?





Explanation

The preferred approach is posterolateral, placing the sural nerve most at risk. The dorsal intermediate cutaneous nerve is anterolateral to the ankle, and the medial and lateral plantar branches are medial and inferior to the surgical site. The saphenous nerve is anteromedial and away from the surgical approach. Swanson TV, Bray TJ, Holmes GB Jr: Fractures of the talar neck: A mechanical study of fixation. J Bone Joint Surg Am 1992;74:544-551.

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Question 11

Varus deformity after talar fractures is often seen due to collapse of the medial cortex. What artery supplies this portion of the talus?





Explanation

The artery of the tarsal canal is a branch of the posterior tibial artery. Among the branches of the artery of the tarsal canal is the deltoid artery. This arterial complex supplies the medial one third of the talar body. Disruption of this artery may lead to osteonecrosis of the medial body and subsequent collapse into varus. This is most commonly seen with talar body fractures but may be seen in Hawkins type 3 talar neck fractures. The artery of the tarsal sinus arises from the dorsalis pedis, lateral malleolar, and perforating peroneal arteries. The peroneal artery anastomoses with the calcaneal branches of the posterior tibial artery to form a plexus of vessels that supplies the posterior tubercle of the talus. Disruption of this artery would not result in collapse of the medial body, and thus would not lead to a varus deformity. Halibruton RA, Sullivan CR, Kelly PJ, et al: The extra-osseous and intra-osseous blood supply of the talus. J Bone Joint Surg Am 1958;40:1115.

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Question 12

A 21-year-old man with neurofibromatosis and multiple cutaneous neurofibromas has a rapidly enlarging painless mass on his buttock. Examination reveals a nontender, well-defined 6- x 6-cm soft-tissue mass that is deep to the fascia. The best course of action should be to order





Explanation

Patients with neurofibromatosis are at risk for development of soft-tissue sarcomas (most commonly malignant peripheral nerve sheath tumors). Clinical indications of development of a neurofibrosarcoma include a rapidly enlarging soft-tissue mass; therefore, this patient should be considered to have a neurofibrosarcoma until proven otherwise. MRI is superior to CT in characterizing the anatomic location of soft-tissue masses and the signal characteristics of the lesion. Areas of necrosis within the tumor may be apparent on MRI that cannot be appreciated on CT, suggesting a malignant tumor. Local imaging studies of suspected malignant tumors should be performed prior to needle or open biopsy so that the biopsy site can be excised at the time of definitive resection. Additionally, postbiopsy changes may lead to MRI artifacts that alter the interpretation of the MRI. Demas BE, Heelan RT, Lane J, Marcove R, Hajdu S, Brennan MF: Soft-tissue sarcomas of the extremities: Comparison of MR and CT in determining the extent of disease. Am J Roentgenol 1988;150:615-620.

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Question 13

A 21-year-old woman with scoliosis reports no pain, and her examination is unremarkable except for the scoliosis. Preoperative radiographs, including bending views, are shown in Figures 14a through 14e. The thoracic curve measures 62 degrees. Treatment should consist of





Explanation

The patient has a King type III curve with a very flexible lumbar spine that derotates and levels well on side bending. The fractional upper thoracic curve is also quite flexible and will not need to be addressed; therefore, treatment should consist of posterior spinal fusion from T4 to L1. An anterior spinal fusion at the very apex of the curve will not address the curve satisfactorily, and an approach across the diaphragm provides little benefit in this patient. King HA, Moe JH, Bradford DS, Winter RB: The selection of fusion levels in thoracic idiopathic scoliosis. J Bone Joint Surg Am 1983;65:1302-1313.

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Question 14

A 19-year-old female long-distance runner has an incomplete tension-side femoral neck stress fracture. Management should consist of





Explanation

Unlike compression-side stress fractures, tension-side stress fractures on the superior side of the femoral neck are at a very high risk of displacement, even if the patient is not bearing weight. It is highly recommended to treat these fractures like acute fractures and to proceed with internal fixation emergently. Once the fracture has displaced, the prognosis is poor in terms of returning to sports, even when reduced and internally fixed. Nonsurgical management, such as limited weight bearing and low-impact activities, works very well for other lower extremity stress fractures. A training program evaluation (shoes, tracks, schedule) is always indicated for all patients with stress fractures.

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Question 15

What is the most common complaint in patients with a developmental radial head dislocation?





Explanation

Developmental dislocation of the radial head most frequently presents as a painless mass over the posterior aspect of the elbow. Patients do not have feelings of elbow subluxation but may report pain or clicking. Limitation of motion is most frequently found in the pronation and supination arc rather than in flexion and extension. Lloyd-Roberts GC, Bucknill TM: Anterior dislocation of the radial head in children-etiology: Natural history and management. J Bone Joint Surg Am 1977;58:402.

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Question 16

Figures 34a and 34b show the axial and sagittal MRI scans of a 36-year-old man who reports the insidious onset of pain in the right shoulder. What is the most appropriate description of the acromial morphology?





Explanation

The MRI scans reveal a meso os acromiale with edema at the site in a skeletally mature patient. Sher JS: Anatomy, biomechanics, and pathophysiology of rotator cuff disease, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, p 23.

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Question 17

Figure 29 shows the radiograph of a 25-year-old woman who has had a 3-month history of ankle pain after sustaining an inversion injury to the ankle. She reports occasional catching, but no sense of instability. Examination reveals ligament stability. Management should consist of

Sports Medicine 2001 Practice Questions: Set 3 (Solved) - Figure 7





Explanation

Osteochondral lesions of the talar dome can have a traumatic or nontraumatic etiology. Most authors site a probable traumatic etiology for lateral lesions. Stage I and II lesions, which are composed of compressed subchondral bone or a partial detached osteochondral fragment, can be treated initially in a non-weight-bearing short leg cast for 6 weeks. Stage III medial lesions can also be treated in the same manner. If symptoms persist, the treament of choice is debridement of the fracture, curettage of the lesion, and drilling of the subchondral bone. This treatment also applies to lateral stage III and all stage IV lesions. If the fragment is at least one third of the size of the talar dome, management should consist of open reduction and internal fixation. In patients with more chronic lesions (4 to 6 months of persistent pain), the threshold to proceed with surgery is lower, even in a stage II lesion. Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 205-226.

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Question 18

Examination of a 9-year-old boy reveals a right thoracic prominence on forward flexion. Neurologic examination is normal, and no other abnormalities are noted. AP radiographs reveal a 30-degree right thoracic curve. Initial management should consist of





Explanation

The patient has juvenile scoliosis. MRI has shown an association between juvenile scoliosis and intraspinal abnormalities, most often syringomyelia and Arnold-Chiari malformations. All juvenile curves greater than 20 degrees should be evaluated with MRI despite the absence of neurologic findings. Weinstein SL (ed): The Pediatric Spine: Principles and Practice, ed 1. New York, NY, Raven Press, 1994, pp 685-705 Nohria V, Oakes WJ: Chiari I malformation: A review of 43 patients. Pediatr Neurosurg 1990-91;16:222-227.

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Question 19

Which of the following statements best describes why the ulnar nerve is most prone to neuropathy at the elbow?

Shoulder 2002 Practice Questions: Set 1 (Solved) - Figure 1





Explanation

The ulnar nerve is more prone to neuropathy than the radial or median nerves for many reasons. It has the greatest longitudinal excursion required to accommodate elbow range of motion, subjecting it to potential traction forces. The dimensions of the entrance of the cubital tunnel change with elbow motion, potentially causing compression in flexion. For these two reasons, the ulnar nerve is subjected to both compression and traction during elbow motion. Although it passes between two muscle heads as it enters the forearm, so do the median and radial nerves. Finally, the vascular supply is adequate because of the anastamoses between the superior ulnar collateral artery, the posterior ulnar recurrent artery, and the inferior ulnar collateral artery. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 369-378. Prevel CD, Matloub HS, Ye Z, Sanger JR, Yousif NJ: The extrinsic blood supply of the ulnar nerve at the elbow: An anatomic study. J Hand Surg Am 1993;18:433-438.

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Question 20

What postoperative complication occurs at a significantly higher rate in patients undergoing bilateral simultaneous total knee arthroplasty than in patients undergoing unilateral total knee arthroplasty?





Explanation

Parvizi and associates studied the 30-day mortality rate after more than 22,000 total knee arthroplasties and found that the rate after bilateral total knee arthroplasty was significantly higher than after unilateral total knee arthroplasty. Aseptic loosening, bleeding, and range of motion have not been shown to be statistically different between patients who had unilateral and simultaneous bilateral total knee arthroplasty.

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Question 21

Examination of a 7-year-old boy reveals 20 degrees of valgus following a lawn mower injury to the lateral femoral epiphysis. Treatment consists of total distal femoral epiphyseodesis and varus osteotomy. Following surgery, he has a limb-length discrepancy of 3 cm and 5 degrees of genu valgum. Assuming that he undergoes no further treatment, the patient's predicted limb-length discrepancy at maturity would be how many centimeters?





Explanation

The distal femoral epiphysis grows approximately 1 cm per year and in boys, growth ceases at approximately age 16 years. Therefore, the patient's limb-length discrepancy at maturity would be 12 cm (9 cm plus the 3-cm discrepancy he has from the previous surgery). Little DG, Nigo L, Aiona MD: Deficiencies of current methods for the timing of epiphyseodesis. J Pediatr Orthop 1996;16:173-179.

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Question 22

Figure 47 shows the radiograph of a 2-day-old girl who has been referred for swelling and limited use of the right upper extremity. The second of twins, the infant was breech and delivered with forceps at age 38 weeks, weighing 5.37 lb. Difficulty in moving the arm was noted shortly after birth. Examination shows no active motion of the shoulder, elbow, or wrist. Active finger flexion and extension are present. The elbow is mildly swollen, and passive motion shows lack of full extension of 20 degrees, lack of full flexion of 15 degrees, and no restriction of pronation or supination. What is the most likely diagnosis?

Pediatrics Board Review 2001: High-Yield MCQs (Set 4) - Figure 2





Explanation

Fractures involving the entire distal humeral physis may be a complication of a difficult delivery. Basing the diagnosis on radiographs can be difficult at this age because the secondary ossification center of the lateral condyle has not developed. The key to the diagnosis is the constant relationship of the radius and ulna, with medial and posterior displacement of the forearm relative to the humerus. An ultrasound can be obtained to confirm the diagnosis in newborns. Because the fracture is through cartilage, examination may reveal only mild swelling, and crepitation may be muffled or not apparent. The lack of apparent active motion of the shoulder, elbow, and wrist is secondary to pseudoparalysis. Child abuse is a common mechanism of this injury in a child who is age 1 month to age 3 years. Beaty JH, Wilkins KE: Fractures involving the entire distal humeral physis, in Rockwood CA, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, vol 3, pp 790-801. Dias JJ, Lamont AC, Jones JM: Ultrasonic diagnosis of neonatal separation of the distal humeral epiphysis. J Bone Joint Surg Br 1988;70:825-828.

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Question 23

A 45-year-old man has severe pain in both feet after his boots become wet while hunting. Examination 3 hours after the onset of symptoms reveals that his feet are cold to touch and the skin appears blanched. Management should consist of





Explanation

The patient has frostbite involving both feet. Rapid rewarming in a protected environment is the initial treatment. A footbath with water at 104.0 degrees F to 107.6 degrees F (40 degrees C to 42 degrees C) is ideal. This facilitates a uniform rewarming of the involved tissue. The other choices are less than ideal. Appliances such as heating pads provide uneven heating and may actually burn the skin. Pinzur MS: Frostbite: Prevention and treatment. Biomechanics 1997;4:14-21.

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Question 24

Eosinophilic granuloma frequently occurs as a solitary lesion in the tubular long bones. After biopsy, what is the best course of action?

Basic Science Board Review 2005: High-Yield MCQs (Set 2) - Figure 29





Explanation

Most lesions of eosinophilic granuloma are simply observed, but larger aggressive lesions may require curettage and bone grafting. Frequently, biopsy is required to rule out a malignant diagnosis. The differential diagnosis of eosinophilic granuloma is osteomyelitis, Ewing's sarcoma of bone, or osteogenic sarcoma. The biopsy alone can be followed by spontaneous resolution. In some patients, low-dose radiation therapy is used. Chemotherapy or amputation is not indicated for these benign lesions.

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Question 25

A 45-year-old man sustains an acute closed posterolateral elbow dislocation. The elbow is reduced, and examination reveals that the elbow dislocates posteriorly at 35 degrees with the forearm placed in supination. What is the best course of action?

Upper Extremity Board Review 2005: High-Yield MCQs (Set 2) - Figure 24





Explanation

Most closed simple dislocations are best managed with early range of motion. Posterior dislocation typically occurs through a posterolateral rotatory mechanism. When placed in pronation, the elbow has greater stability when the medial ligamentous structures are intact. In traumatic dislocations, MRI rarely provides additional information that will affect treatment. In elbows that remain unstable, primary repair is preferred over ligament reconstruction. Cast immobilization increases the risk of arthrofibrosis.

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Question 26

What structure is most at risk with anterior penetration of C1 lateral mass screws?





Explanation

Posterior screw fixation of the upper cervical spine has gained a great deal of popularity due to its stable fixation, obviating the use of halo vest immobilization, and its high fusion rates. The use of screws in this location, however, has introduced a whole new set of potential complications. Vertebral artery injury is one of the most feared complications associated with screws in the C1/C2 region. This structure, however, is lateral and posterior at the C2 level and then penetrates the foramen transversarium of C1 to lie cephalad to the arch of C1 before entering the foramen magnum. It is the internal carotid artery that lies immediately anterior to the arch of C1 that is particularly at risk by anterior penetration of C1 lateral mass or C1-C2 transarticular screws as demonstrated by Currier and associates. The internal carotid artery lies posterior to the pharynx. The external carotid artery and the glossopharyngeal nerve are not at risk with this method of fixation. Currier BL, Todd LT, Maus TP, et al: Anatomic relationship of the internal carotid artery to the C1 vertebra: A case report of cervical reconstruction for chordoma and pilot study to assess the risk of screw fixation of the atlas. Spine 2003;28:E461-E467. Grant JC: Grant's Atlas of Anatomy, ed 6. Baltimore, MD, Williams & Wilkins, 1972.

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Question 27

Initial management of a pathologic fracture of the humerus secondary to a unicameral bone cyst should include





Explanation

Most pathologic humeral fractures secondary to a unicameral bone cyst are minimally displaced and should be immobilized and allowed to heal. Persistent and/or progressive lesions may require treatment. Various treatments of unicameral bone cysts have been described. Acceptable treatment options include curettage and bone grafting, intralesional steroid injection, and percutaneous grafting with bone graft substitutes. MRI is not indicated when the diagnosis of unicameral bone cyst is known. Wilkins RM: Unicameral bone cysts. J Am Acad Orthop Surg 2000;8:217-224.

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Question 28

At the level of tibial bone resection in total knee arthroplasty, where does the common peroneal nerve lie?

Anatomy Board Review 2008: High-Yield MCQs (Set 2) - Figure 19





Explanation

At the level of tibial bone resection in total knee arthroplasty, the common peroneal nerve lies superficial to the lateral head of the gastrocnemius and is therefore protected by this structure. In an MRI study of 60 knees, the mean distance from the bony posterolateral corner of the tibia to the nerve was 1.49 cm, with no distance less than 0.9 cm. The distance from the bone to nerve was greater in larger legs. Clarke HD, Schwartz JB, Math KR, et al: Anatomic risk of peroneal nerve injury with the "pie crust" technique for valgus release in total knee arthroplasty. J Arthroplasty 2004;19:40-44.

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Question 29

A 63-year-old woman with a history of poliomyelitis has a fixed 30-degree equinus contracture of the ankle, rigid hindfoot valgus, and normal knee strength and stability. She reports persistent pain and has had several medial forefoot ulcerations despite a program of stretching, bracing, and custom footwear. What is the next most appropriate step in management?

Foot & Ankle 2006 Practice Questions: Set 1 (Solved) - Figure 19





Explanation

The patient has a fixed deformity of the hindfoot and an Achilles tendon contracture; therefore, the treatment of choice is triple arthrodesis with Achilles tendon lengthening. Further bracing will not be helpful. Amputation is not indicated, and ankle arthrodesis will not address the hindfoot deformity. Palliative management would be more appropriate if the knee was unstable or the quadriceps were weak, because the equinus balances the ground reaction force across the knee. Perry J, Fontaine JD, Mulroy S: Findings in post-poliomyelitis syndrome: Weakness of muscles of the calf as a source of late pain and fatigue of muscles of the thigh after poliomyelitis. J Bone Joint Surg Am 1995;77:1148-1153.

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Question 30

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

Trauma Board Review 2006: High-Yield MCQs (Set 2) - Figure 32





Explanation

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

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Question 31

A 74-year-old woman with rheumatoid arthritis reports shoulder pain that has failed to respond to nonsurgical management. AP and axillary radiographs are shown in Figures 23a and 23b. Examination reveals active forward elevation to 120 degrees and external rotation to 30 degrees. What treatment option results in the most predictable pain relief and function?





Explanation

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.

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Question 32

Figures 31a and 31b show the T1- and T2-weighted MRI scans of a patient's knee joint. What is the most likely diagnosis?





Explanation

The scans show a lipohemarthrosis. There is the characteristic layering of a superior zone containing fat (high signal intensity), a central zone containing serum (low signal intensity), and an inferior zone that contains red blood cells (low signal intensity). The most common cause of a lipohemarthrosis is an intra-articular fracture with leakage of marrow fat into the joint. Resnick D, Kang HS: Synovial joints, in Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 49-53.

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Question 33

In patients with suspected hepatitis C, which of the following tests is commonly used to confirm the diagnosis after a positive ELISA screening test?





Explanation

The basic diagnostic test for hepatitis C (HCV) is detection of an antibody to epitopes on an enzyme-linked immunosorbent anti-HCV assay (ELISA). The currently used ELISA has high sensitivity (92%) and specificity (95%). False positives, however, still occur. The currently used supplemental test for HCV is strip immunoblot assay, which is based on detection of several HCV epitopes on nitrocellulose paper by antibody-capture techniques. Molecular amplification by PCR technology is very sensitive, but difficult to standardize and susceptible to contamination. Microarray and proteomics are relatively recent molecular techniques used for analysis of genes or proteins, respectively. A Northern blot is used to detect mRNA levels of specific genes but is not used in this situation. de Medina M, Schiff ER: Hepatitis C: Diagnostic assays. Semin Liver Dis 1995;15:33-40.

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Question 34

A 28-year-old man who sustained an ankle fracture in a motor vehicle accident underwent open reduction and internal fixation 3 months ago. He continues to report significant ankle pain with ambulation. Radiographs are shown in Figure 26. What is the next most appropriate step in management?

Foot & Ankle 2006 Practice Questions: Set 3 (Solved) - Figure 9





Explanation

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.

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Question 35

What spinal nerves in the cauda equina are primarily responsible for innervation of the bladder?





Explanation

The spinal nerves primarily responsible for bladder function are the S2, S3, and S4 nerve roots. With significant compression of the cauda equina by either disk herniation, tumor, or degenerative stenosis, bladder dysfunction may result. Hoppenfeld S: Physical Examination of the Spine and Extremities. Norwalk, CT, Appleton-Century-Crofts, 1976, p 254.

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Question 36

A 5-month-old girl with arthrogryposis has a limb-length discrepancy. Examination and radiographs reveal unilateral hip dislocation. Management should consist of





Explanation

In this age group of patients with arthrogryposis, open reduction through a medial approach is generally recommended. Open reduction through an anterior approach is reserved for patients in which a medial approach has failed or for older patients who require simultaneous femoral shortening and/or pelvic osteotomy. Closed treatment of unilateral hip dislocation in association with arthrogryposis is rarely successful. In bilateral hip dislocation associated with arthrogrypsis, the consensus is that the hips are best left unreduced because of the difficulty in obtaining excellent clinical and radiographic results bilaterally. Staheli LT, Chew DE, Elliot JS, Mosca VS: Management of hip dislocations in children with arthrogryposis. J Pediatr Orthop 1987;7:681-685. Szoke G, Staheli LT, Jaffe K, Hall JG: Medial-approach open reduction of hip dislocation in amyoplasia-type arthrogryposis. J Pediatr Orthop 1996;16:127-130.

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Question 37

Figure 28 shows an AP radiograph of a 54-year-old woman who underwent lumbar laminectomy and fusion at the L4 and L5 levels with placement of a bone stimulator 8 years ago. She also underwent a left total hip arthroplasty 2 years ago; aspiration of that joint now reveals that it is infected with a gram-positive cocci organism. History is also significant for IV drug use and human immunodeficiency virus (HIV). The patient reports fever, chills, and left flank and abdominal pain. Examination reveals significant pain with resisted left hip flexion and passive hip extension. She also has lumbar hyperlordosis. Which of the following studies would best identify the underlying cause of her infection?

Anatomy 2002 Practice Questions: Set 3 (Solved) - Figure 5





Explanation

The patient's clinical signs (fever and flank, hip, and abdominal pain) suggest a primary iliopsoas abscess. With an increased patient population who abuse drugs and/or who are HIV-positive, iliopsoas abscess may be more prevalent because of systemic bacterial seeding and may be potentially unrecognized. Diagnostic imaging studies provide a better understanding of the anatomic magnitude of the infection, give concrete confirmation of the diagnosis, and may suggest an underlying cause. Neither standard abdominal radiographs nor ultrasound studies are sensitive enough to be diagnostic of this disease process. CT has been established as the standard study for identifying the underlying cause of this abscess. The hip infection has most likely developed as a result of hematogenous spread from an infected skin lesion from the patient's IV drug use. Santaella RO, Fishman EK, Lipsett PA: Primary vs secondary iliopsoas abscess: Presentation, microbiology, and treatment. Arch Surg 1995;130:1309-1313.

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Question 38

Which of the following body positions is associated with the highest intradiskal pressure?





Explanation

Intradiskal pressure is lowest when the patient is in the supine position. Sitting is associated with higher intradiskal pressures than standing. Flexion also increases intradiskal pressure. The combination of flexion and sitting produces the highest intradiskal pressure. Nachemson and Morris found that intradiskal pressure increases as position changes from lying supine, lying prone, standing, leaning forward, sitting, and sitting leaning forward. Twisting or straining in positions of relatively high intradiskal pressure may predispose patients to herniation of the intervertebral disk. Patients with a herniated disk may also notice their pain worsens with activities that increase the disk pressure, including the positions mentioned, or activities that increase intra-abdominal pressure (coughing, sneezing, straining). Nachemson A, Morris JM: In vivo measurements of intradiscal pressure. J Bone Joint Surg Am 1964;46:1077-1092.

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Question 39

Which of the following is considered a contraindication to functional bracing for the treatment of humeral shaft fractures?

Shoulder Board Review 2002: High-Yield MCQs (Set 2) - Figure 34





Explanation

Most closed humeral shaft fractures and fractures caused by a low-velocity hand gun can be managed nonsurgically with closed reduction and application of a coaptation splint followed by a functional brace. Contraindications to use of the functional brace include: 1) massive soft-tissue or bone loss; 2) an unreliable or noncompliant patient; and 3) an inability to maintain acceptable fracture alignment of up to 20 degrees of anterior or posterior angulation, 30 degrees of varus or valgus angulation, and greater than 3 cm of shortening. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286. Pollock FH, Drake D, Bovill EG, Day L, Trafton PG: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.

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Question 40

A 50-year-old competitive tennis player sustained a shoulder dislocation after falling on his outstretched arm 3 weeks ago. He now reports that he has regained motion but continues to have painful elevation and weakness in external rotation. A subacromial cortisone injection provided 3 weeks of relief, but the pain has returned. Which of the following studies will best aid in diagnosis?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 14





Explanation

Based on these findings, the most likely diagnosis is a rotator cuff injury and probable tear; therefore, MRI is the study of choice. CT is preferred for articular fractures. A bone scan is nonspecific and can identify inflammation or occult fracture. Joint aspiration is not likely to identify an effusion. Physical therapy and a functional capacity examination are used to identify weakness during recovery prior to a return to work or sports. Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ: Anterior dislocation of the shoulder in the older patient. Clin Orthop 1986;206:192-195.

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Question 41

A 19-year-old girl has had pain and swelling in the right ankle for the past 4 months. She denies any history of trauma. Examination reveals a small soft-tissue mass over the anterior aspect of the ankle and slight pain with range of motion of the ankle joint. The examination is otherwise unremarkable. A radiograph and MRI scan are shown in Figures 45a and 45b, and biopsy specimens are shown in Figures 45c and 45d. What is the most likely diagnosis?





Explanation

Giant cell tumors typically occur in a juxta-articular location involving the epiphysis and metaphysis of long bones, usually eccentric in the bone. The radiographs show a destructive process within the distal tibia and an associated soft-tissue mass. The histology shows multinucleated giant cells in a bland matrix with a few scattered mitoses. Osteosarcoma can have a similar destructive appearance but a very different histologic pattern with osteoid production. Ewing's sarcoma also can have a diffuse destructive process in the bone. The histologic pattern of Ewing's sarcoma is diffuse round blue cells. Aneurysmal bone cysts typically are seen as a fluid-filled lesion on imaging studies and have only a scant amount of giant cells histologically. Metastatic adenocarcinoma does not demonstrate the pattern shown in the patient's histology specimen. Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 198-199.

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Question 42

A 21-year-old soccer player reports pain and is unable to straighten his knee following an acute injury during a game. He is unable to continue to play. An MRI scan is shown in Figure 3. What is the next most appropriate step in management?

Sports Medicine 2007 Practice Questions: Set 1 (Solved) - Figure 8





Explanation

The patient has a locked knee that cannot be fully extended. This is most likely the result of the mechanical block of a bucket-handle tear that has flipped into the notch. Also, the pain may be so severe that the muscle spasm prevents the knee from straightening out. When the patient is anesthetized, the muscle spasm relaxes and the meniscus can be reduced out of the notch. Arthroscopy is the treatment of choice. A meniscal repair is usually possible in large bucket-handle tears because the meniscus is torn in the red-red zone where most of the vascular supply is located. If the handle portion is badly frayed or damaged, a partial meniscectomy should be performed. The classic finding on MRI is a "double PCL sign." This is due to the flipped portion of the meniscus in the notch. Critchley IJ, Bracey DJ: The acutely locked knee: Is manipulation worthwhile? Injury 1985;16:281-283.

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Question 43High Yield

A 32-year-old man has an open comminuted humeral shaft fracture. Examination reveals absence of sensation in the first web space and he is unable to fully extend the thumb, fingers, and wrist. What is the recommended treatment following irrigation and debridement of the fracture?

General Orthopedics Board Review 2026: High-Yield MCQs (Set 20) - Figure 23

Explanation

There is a high incidence of partial or complete laceration of the radial nerve with high-energy open fractures of the humeral shaft. The recommended treatment is irrigation and debridement of the fracture followed by open reduction and internal fixation and exploration of the radial nerve. If the nerve is completely lacerated, primary repair may be performed but poor outcomes have been reported. If a large zone of nerve injury is identified, delayed nerve grafting is advocated. Ring D, Chin K, Jupiter JB: Radial nerve palsy associated with high energy humeral shaft fractures. J Hand Surg 2004;29:144-147. Foster RJ, Swiontkowski MR, Bach AW, et al: Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am 1993;18:121-124.

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Question 44

Which of the following is considered the treatment of choice for a chondroblastoma of the proximal tibial epiphysis without intra-articular extension?

Basic Science 2002 Practice Questions: Set 1 (Solved) - Figure 22





Explanation

Curettage and bone grafting typically is the preferred method of treatment for chondroblastoma, with local recurrence rates of approximately 10%. Some clinicians advocate the addition of adjuvants such as phenol. Left alone, these lesions can destroy bone and invade the joint. Large intra-articular lesions may require major joint reconstruction. Wide local excision rarely is required to eradicate the tumor. Radiation therapy rarely is indicated and only for unresectable or multiply recurrent lesions. Springfield DS, Capanna R, Gherlinzoni F, Picci P, Campanacci M: Chondroblastoma: A review of seventy cases. J Bone Joint Surg Am 1985;67:748-755.

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Question 45

Figure 41a shows the AP radiograph of a 15-year-old boy who reports lateral knee pain. Figures 41b and 41c show a radiograph of the distal femur that was obtained 5 years ago and a current CT scan. The indication for surgery in this patient would be





Explanation

In a young person with solitary osteochondroma, the best surgical indication is symptoms that limit activity. A growth deformity is unlikely to occur at this age. Malignant degeneration is exceptionally rare and noted most commonly in adults. Growth is expected until skeletal maturity. Mirra JM: Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia, PA, Lea and Febiger, 1989, pp 1626-1659.

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Question 46

Figures 4a through 4c show the radiographs, CT scans, and T1-weighted MRI scan of a 19-year old man who has had increasing right hip pain and decreasing range of motion for the past several years. He also reports intermittent "locking" of the hip. What is the most likely diagnosis?





Explanation

The radiographs reveal small ossified masses around the femoral neck. The CT scans also show these masses and suggest that they are separate from the underlying cortex of the femoral neck, although they abut it. The MRI scan does not reveal significant marrow changes in the proximal femur apart from some mild reactive changes immediately adjacent to the nodules. These findings suggest a synovial or joint-based disorder as opposed to a primary bone tumor. The most likely diagnosis is synovial osteochondromatosis, which is consistent with the patient's mechanical symptoms. Crotty JM, Monu JU, Pope TL Jr: Synovial osteochondromatosis. Radiol Clin North Am 1996;34:327-342.

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Question 47

Figure 33 shows the CT scan of a 40-year-old man who injured his left shoulder while skiing. What structure is attached to the bony fragment?

Anatomy 2005 Practice Questions: Set 3 (Solved) - Figure 11





Explanation

The scan reveals a bony Bankart lesion. The anterior band of the inferior glenohumeral ligament is the major restraint to anterior translation of the humeral head and is usually injured with anterior shoulder dislocations. It inserts onto the glenoid labrum at the anteroinferior aspect of the glenoid rim. The labrum most frequently avulses from the glenoid (Bankart lesion), but occasionally the bony attachment is avulsed. O'Brien SJ, Neves MC, Arnoczky SP, et al: The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med 1990;18:449-456.

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Question 48

A 40-year-old man who is an avid weight lifter has had chronic pain in the proximal anterior shoulder for the past year. He denies any history of trauma. Examination reveals tenderness at the intertubercular groove, a positive speed test, and a positive Neer impingement sign. Nonsurgical management has failed to provide relief, and he is now considering surgery. Arthroscopic findings in the glenohumeral joint are shown in Figure 31. Based on these findings, treatment should consist of

Upper Extremity 2005 Practice Questions: Set 3 (Solved) - Figure 16





Explanation

The arthroscopic image shows a tear through more than 50% of the biceps tendon; therefore, treatment should consist of tenodesis or tenotomy of the tendon. However, because this patient is relatively young and active, the treatment of choice is tenodesis of the biceps tendon. Sethi N, Wright R, Yamaguchi K: Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999;8:644-654. Eakin CL, Faber KJ, Hawkins RJ, et al: Biceps tendon disorders in athletes. J Am Acad Orthop Surg 1999;7:300-310.

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Question 49

Figures 63a and 63b show the radiographs of an 11-year-old girl who sustained a twisting injury of the knee playing soccer. She is now asymptomatic. What is the appropriate treatment of the lesion?





Explanation

This is a nonossifying fibroma of the proximal tibia. The lesion is eccentric, cortically based, with sclerotic margins and no evidence of a soft-tissue mass. Nonossifying fibromas are benign lesions that need no biopsy or surgical treatment when classic findings appear on radiographs. A follow-up radiograph should be performed 2 to 3 months after the initial presentation to ensure that the lesion is not progressive. Surgery is reserved for large lesions with risk of pathologic fracture or for cases where a displaced pathologic fracture has occurred and internal fixation is needed for fracture treatment. Nondisplaced pathologic fractures through nonossifying fibromas are best treated by allowing the fracture to heal and observation of the lesion. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.

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Question 50

Figure 3 shows the radiographs of a 32-year-old man who fell 12 feet onto his outstretched arm and sustained a fracture-dislocation of the elbow. Initial management consisted of closed reduction of the dislocation. Surgical treatment should now include repair or reduction and fixation of the

Shoulder 2002 Practice Questions: Set 1 (Solved) - Figure 5





Explanation

The radiographs show fractures of the coronoid and radial head. The medial collateral ligament has been avulsed from the ulnar insertion, and there is a valgus opening on the medial side. The lateral collateral ligament is always disrupted in elbow dislocations and fracture-dislocations that occur secondary to falls. This is known as the terrible triad injury (dislocation and fractures of the coronoid and radial head); it has a very poor prognosis because of its propensity for recurrent or persistent instability and late arthritis. The principle in treating this injury is to repair all of the injured parts or protect them with a hinged external fixator until they heal. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354. Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.

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Question 51

A 28-year-old hockey player has a shoulder deformity after being checked into the boards. Examination reveals that swelling has improved, but there is tenderness along the distal clavicle. Radiographs reveal a grade II acromioclavicular joint separation. Initial management should consist of





Explanation

The most common shoulder injury in hockey players is to the acromioclavicular joint. Early rest and control of pain and inflammation is the preferred management. Surgery is reserved for patients with significant coracoclavicular disruption that has failed to respond to nonsurgical management. Cross-chest stretches and overhead exercises may increase symptoms. A cortisone injection within the glenohumeral joint will have little effect. Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:11-18.

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Question 52

A 24-year-old man reports the development of a foot drop following a knee dislocation 1 year ago. The common peroneal nerve was found to be in continuity at the time of surgical reconstruction of the posterolateral corner of the knee joint. He would like to eliminate the need for an ankle-foot orthosis. What is the best option to achieve elimination of the orthosis?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 2) - Figure 31





Explanation

The ankle dorsiflexor muscles have been denervated for too long a period to expect reinnervation to be successful. Even if the extensor hallucis longus tendon was functional, it is unlikely to have sufficient strength to achieve dynamic ankle dorsiflexion. The tibialis posterior tendon transfer has been shown to predictably achieve these goals in a high percentage of patients. Successful ankle fusion is likely to fail with time due to the development of forefoot equinus. Pinzur MS, Kett N, Trilla M: Combined anteroposterior tibial tendon transfer in post-traumatic peroneal palsy. Foot Ankle 1988;8:27l-275.

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Question 53

Closure of the rotator cuff interval results in elimination of which direction of shoulder instability?





Explanation

The rotator cuff interval consists of the superior glenohumeral and coracohumeral ligaments. Injury to this ligament complex leads to posteroinferior shoulder instability. Tightening of these tissues through surgical means has been shown to result in a significant reduction in posteroinferior translation of the humerus in relation to the glenoid. Harryman DT II, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66. O'Brien SJ, Schwartz RS, Warren RF, et al: Capsular restraints to anterior-posterior motion of the abducted shoulder: A biomechanical study. J Shoulder Elbow Surg 1995;4:298-308.

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Question 54

A 39-year-old man reports low back pain, lower extremity numbness, and urinary retention after being injured in a motor vehicle accident 1 day ago. He is able to walk but is in pain. A straight leg raise results in increased back pain, and examination reveals that perianal sensation is decreased. Placement of a urinary catheter results in 500 mL of urine. What is the next most appropriate step in management?





Explanation

Acute cauda equina syndrome, including saddle hypesthesia and bowel/bladder incontinence, is a red flag that demands emergent evaluation with MRI and urgent surgery if compression is confirmed. Results appear to be improved if surgery is performed within 48 hours. The other treatment approaches listed are not indicated if a cauda equina syndrome is present. Ahn UM, Ahn NU, Buchowski JM, et al: Cauda equina syndrome secondary to lumbar disc herniation: A meta-analysis of surgical outcomes. Spine 2000;25:1515-1522. Shapiro S: Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine 2000;25:348-351.

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Question 55

In overhead athletic activities, the kinetic chain generates what percentage of force from the leg and trunk segments of the chain?





Explanation

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.

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Question 56

Which of the following findings is seen in the chest radiograph shown in Figure 13?

Anatomy 2002 Practice Questions: Set 1 (Solved) - Figure 32





Explanation

Orthopaedic surgeons are often responsible for interpreting radiographs of general examinations such as the chest radiograph shown. For accurate interpretation, it is important to systematically review all of the information available on the radiograph. Using this approach, the fracture of the left proximal humerus is readily recognized. Linear air soft-tissue density at the lung periphery would suggest a pneumothorax, but this finding is not shown on the radiograph. The upper thoracic spine is well aligned. The sternoclavicular and distal clavicles are normal.

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Question 57

A 38-year-old marathon runner has had Achilles tendon pain for the past 2 months. Examination reveals that the tendon is thickened and tender proximal to the calcaneal insertion. The tendon sheath is not thickened or tender. The pathophysiology of the tendon is best described as





Explanation

Atraumatic Achilles tendon disease can be differentiated into Achilles tendinosis and peritendinitis. Thickening and tenderness of the Achilles tendon are present in both, but thickening and tenderness of the tendon sheath indicates peritendinitis. Histologic examination of Achilles tendinosis reveals an absence of acute and chronic inflammatory cells. Radiologists often diagnose partial tendon rupture by MRI and there may be microscopic longitudinal tears present, but there is no mechanical compromise as would be implied by a partial rupture. The thickening typically occurs in the portion of the tendon with the poorest blood supply, and biochemical analysis detects high levels of lactate and other products of anaerobic glycolysis. Astrom M, Rausing A: Chronic Achilles tendinopathy: A survey of surgical and histopathologic findings. Clin Orthop 1995;316:151-164. Ohberg L, Lorentzon R, Alfredson H: Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: An ultrasonographic investigation. Knee Surg Sports Traumatol Arthrosc 2001;9:233-238.

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Question 58

A 16-year-old girl has had pain and swelling along the medial arch of her left foot for the past 3 months. She also reports pain from shoe wear and while running. Nonsteroidal anti-inflammatory drugs have failed to provide relief. Radiographs are shown in Figures 40a through 40c. What is the next most appropriate step in management?





Explanation

Nonsurgical management of a symptomatic accessory navicular should be attempted prior to surgery. Good relief is often obtained with a semi-rigid orthosis with a medial arch support. Myerson MS: Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, p 655.

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Question 59

A sagittal T1-weighted MRI scan of the knee joint is shown in Figure 23. What structure is identified by the arrow?

Anatomy Board Review 2002: High-Yield MCQs (Set 2) - Figure 23





Explanation

On T1-weighted images, the posterior cruciate ligament is a low-signal (black) structure that courses from the posterior aspect of the tibia to the medial femoral condyle. The posterior cruciate ligament can appear as arcuate, U-shaped, or kinked. The other structures have similar signal but different anatomic locations. Gross ML, Grover JS, Bassett LW, Seeger LL, Finerman GA: Magnetic resonance imaging of the posterior cruciate ligament: Clinical use to improve diagnostic accuracy. Am J Sports Med 1992;20:732-737.

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Question 60

A college basketball player is struck in the eye by a player's hand while driving to the basket. Fluorescein evaluation reveals the injury shown in Figure 18. Management should consist of

Sports Medicine Board Review 2001: High-Yield MCQs (Set 2) - Figure 20





Explanation

The athlete has a corneal abrasion. Fluorescein staining identifies the break in the epithelium when examined with ultraviolet light. Topical antibiotics are used as prophylaxis against secondary bacterial infection, and the patch, applied with the lid closed, is used for comfort and to promote epithelial healing. The accompanying symptoms, including pain, tearing, and photophobia, are usually too intense to allow a return to play. Surgery is reserved for a corneal laceration with associated loss of the anterior chamber. While a proper fundoscopic examination may be a consideration, increased intraocular pressure is not typically associated with this injury. Traumatic hemorrhage in the anterior chamber (hyphema) necessitates strict bed rest during the early phases of healing; examination will most likely reveal the red fluid level of blood settling inferiorly in the anterior chamber. It is often associated with increased intraocular pressure. Brucker AJ, Kozart DM, Nichols CW, et al: Diagnosis and management of injuries to the eye and orbit, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face. St Louis, MO, Mosby-Year Book, 1991, pp 650-670.

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Question 61

A 69-year-old man reports pain over his bunion while wearing shoes and pain in the joint with push-off when barefoot. Nonsurgical management has failed to provide relief. Radiographs are shown in Figures 8a and 8b. What is the surgical procedure of choice?





Explanation

Arthrodesis is indicated for severe bunion and hallux valgus deformities, but particularly with extensive degenerative disease of the first metatarsophalangeal joint. The other bunionectomy procedures have different indications, none of which include symptomatic first metatarsophalangeal degenerative disease. Richardson EG(ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 3-15.

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Question 62

Figures 20a and 20b show the sagittal and coronal T1-weighted MRI scans of a patient's left knee. Abnormal findings include





Explanation

The MRI scans show meniscal tissue extending across the entire lateral compartment, revealing a discoid lateral meniscus. The increased signal within the lateral meniscal tissue indicates a tear. Discoid lateral menisci are congenital variants that often present with mechanical symptoms in adolescents. The other structures in the knee are normal. Ahn JH, Shim JS, Hwang CH, et al: Discoid lateral meniscus in children: Clinical manifestations and morphology. J Pediatr Orthop 2001;21:812-816.

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Question 63

The parents of a 10-year-old boy with Down syndrome are seeking sports clearance for participation in the high jump at the Special Olympics. He is asymptomatic, and the neurologic examination is normal. The hips and patellae are clinically stable. Radiographs of the cervical spine in flexion and extension show a maximum atlanto-dens interval (ADI) of 6 mm. Based on these findings, what recommendation should be made?





Explanation

In approximately 15% of children with Down syndrome, atlantoaxial instability develops because of ligament laxity, making them susceptible to spinal cord injury with relatively minor trauma. The American Academy of Pediatrics recommends lateral flexion-extension views of the cervical spine in any patient with Down syndrome who wishes to participate in sports. A normal ADI is up to 4 mm. Patients with Down syndrome with an ADI of more than 5 mm should not participate in contact sports or sports with a high risk for neck injury, such as diving, gymnastics, high jump, or butterfly stroke. Cervical fusion has a very high rate of complications in patients with Down syndrome and is recommended only for patients who have myelopathic signs or symptoms. Atlantoaxial instability in Down syndrome: Subject review. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Pediatrics 1995;96:151-154. Tredwell SJ, Newman DE, Lockitch G: Instability of the upper cervical spine in Down syndrome. J Pediatr Orthop 1990;10:602-606.

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Question 64

A right-handed 24-year-old professional baseball player injured his left shoulder 6 weeks ago when he dove forward and landed hard with the arm extended. He reports that the shoulder "slipped out" and "went back in." The shoulder did not need to be reduced. He now reports deep pain in the front of the shoulder when batting on either side and is hesitant to raise his left arm up over his head to catch a ball. Examination reveals no obvious deformities of the shoulder and a somewhat guarded, limited range of motion in all planes. Provocative tests for the rotator cuff and labrum are equivocal. MRI scans are shown in Figures 16a and 16b. What is the best course of action?





Explanation

A hard fall on an outstretched arm often results in injury to the glenoid labrum. A significant tear of the anterior/inferior labrum often leads to instability, pain, and mechanical symptoms of the shoulder. The MRI scan shows no obvious labral tear or Hill-Sachs lesion to suggest an anterior dislocation. Recent clinical studies have suggested that early stabilization of initial anterior dislocations may lead to better results than nonsurgical management in young, athletic patients. However, there are no data to support early surgery for anterior labral tears resulting from traumatic subluxation without dislocation. Initial treatment should consist of a short period of rest and immobilization, followed by a physical therapy rehabilitation program designed to restore motion, strength, and dynamic stability to the shoulder. If the athlete cannot return to play following nonsurgical management, surgical repair of the labrum, either through an open or arthroscopic approach, is indicated. There is no role for immediate thermal capsular shift in this setting. Abrams JS, Savoie FH III, Tauro JC, et al: Recent advances in the evaluation and treatment of shoulder instability: Anterior, posterior and multidirectional. Arthroscopy 2002;18:1-13.

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Question 65

Chronic anterior donor site pain following the harvest of autologous iliac crest bone graft for use during anterior cervical diskectomy and fusion is reported by approximately what percent of patients?





Explanation

Four years after surgery, more than 90% of patients are satisfied with the cosmetic appearance of the iliac donor site scar. Approximately 25% still have pain and/or functional difficulty, including 12.7% who still report difficulty with ambulation, 11.9% difficulty with recreational activities, 7.5% with sexual intercourse, and 11.2% require pain medication for iliac donor site symptoms. Silber JS, Anderson DG, Daffner SD, et al: Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine 2003;28:134-139.

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Question 66

Which of the following staging studies should be obtained for an adult with an 8-cm deep, high-grade malignant fibrous histiocytoma of the extremity?





Explanation

MRI is the preferred imaging study to evaluate the local tumor extension for soft-tissue lesions, but CT can be used if MRI is contraindicated (eg, patients with pacemakers). CT of the chest is always recommended in patients with high-grade sarcomas because 80% of metastases occur in the lungs. CT of the abdomen and pelvis is indicated in patients with lower extremity liposarcoma because some patients also have synchronous retroperitoneal liposarcoma. Lymph node metastasis occurs in up to 5% of patients with soft-tissue sarcoma. If the nodes are clinically enlarged, biopsy is indicated. Routine sentinel node biopsy currently is not recommended. Bone scan is not used in the staging of soft-tissue sarcoma as it has not been shown to be cost-effective. Demetri GD, Pollock R, Baker L, Balcerzak S, Casper E, Conrad C, et al: NCCN sarcoma practice guidelines: National Comprehensive Cancer Network. Oncology (Huntingt) 1998;12:183-218.

References:

Question 67

The superior glenohumeral ligament primarily restrains





Explanation

Several cutting studies have evaluated the primary static restraints and the role of the glenohumeral ligaments in providing static stability. With the arm at the side in adduction, the superior glenohumeral ligament and coracohumeral ligament are the primary restraints to inferior translation. The middle glenohumeral ligament functions with the arm in 45 degrees of abduction and resists anterior translation. The inferior glenohumeral ligament is the primary restraint to anterior translation at 90 degrees of abduction. Warner JJ, Deng XH, Warren RF, et al: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685.

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Question 68

A 40-year-old man has a painful mass on his anterior ankle joint with limited range of motion. A radiograph, MRI scan, a gross specimen, and a hematoxylin/eosin biopsy specimen are shown in Figures 5a through 5d. What is the most likely diagnosis?





Explanation

Synovial chondromatosis results from chondroid metaplasia within the synovium. Male to female ratio is 2:1, with a peak incidence in early adult life. Radiographs can show speckled cal

Question 69

Manipulation under anesthesia for resistant frozen shoulder should be avoided in patients with





Explanation

Severe osteoporosis is a contraindication to manipulation under anesthesia in patients with a resistant frozen shoulder because of the higher risk of humeral fracture. Manipulation is considered for frozen shoulder in patients who are symptomatic despite undergoing a reasonable course of appropriate physical therapy. Harryman DT II: Shoulder: Frozen and stiff. Instr Course Lect 1997;42:247-257.

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Question 70

What is the best surgical approach for the scapular fracture shown in Figure 46?

Shoulder Board Review 2002: High-Yield MCQs (Set 4) - Figure 10





Explanation

Indications for open reduction of glenoid intra-articular fractures include those fractures with a 5-mm articular surface displacement or when the humeral head is subluxated with the fracture fragment. Kavanaugh and associates and Leung and Lam have shown that the posterior approach with plate fixation is best for most glenoid fractures, including the Ideberg type II fracture shown here. The anterior approach is best used for anterior rim and transverse fractures. Kavanagh BF, Bradway JK, Cofield RH: Open reduction and internal fixation of displaced intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am 1993;75:479-484. Leung KS, Lam TP: Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle. J Bone Joint Surg Am 1993;75:1015-1018.

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Question 71

In a retroperitoneal approach to the lumbar spine, what nerve is commonly found on the psoas muscle?





Explanation

The genitofemoral nerve and the sympathetic plexus consistently lie on the ventral surface of the psoas muscle. The ilioinguinal and iliohypogastric nerves are the most superior branches of the lumbar plexus and emerge along the upper lateral border of the psoas muscle traveling toward the quadratus lumborum. Both the obturator and femoral nerves are deep and lateral to the psoas muscle. Watkins RG (ed): Surgical Approaches to the Spine, ed 1. New York, NY, Springer-Verlag, 1983, p 107. Johnson R, Murphy M, Southwick W: Surgical approaches to the spine, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 1559.

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Question 72

A 38-year-old man caught his index finger in a volleyball net. He noted an angular deformity of the finger that was reduced when a teammate pulled on his finger. Three weeks later, he now reports trouble extending his finger. A clinical photograph is shown in Figure 55. What anatomic structure is most likely injured?

Trauma Board Review 2009: High-Yield MCQs (Set 4) - Figure 13





Explanation

The clinical photograph shows a classic boutonniere deformity. It is likely that the patient sustained a volar dislocation of the proximal interphalangeal joint, with a concomitant rupture of the central slip insertion of the extensor tendon. Peimer CA, Sullivan DJ, Wild DR: Palmar dislocation of the proximal interphalangeal joint. J Hand Surg Am 1984;9:39-48.

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Question 73

A 65-year-old man has a painful mass of the middle finger. A clinical photograph, lateral radiograph, coronal MRI scan, and biopsy specimen are seen in Figures 20a through 20d. What is the most likely diagnosis?





Explanation

Although the degeneration of an isolated benign cartilaginous lesion into a chondrosarcoma is rare, it occurs in roughly 10% of patients with Ollier's disease. Pain is the most common symptom of chondrosarcoma. The treatment of low-grade chondrosarcoma ranges from intralesional excision to wide amputation. The intent of the surgery is to remove all the disease to decrease the chance of local recurrence. Lee FY, Mankin HJ, Fondren G, et al: Chondrosarcoma of bone: An assessment of outcome. J Bone Joint Surg Am 1999;81:326-338.

References:

Question 74

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement?

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 10





Explanation

Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424. Beck M, Leunig M, Parvizi J, et al: Anterior femoroacetabular impingement: Part II. Midterm results of surgical treatment. Clin Orthop 2004;418:67-73.

References:

Question 75

Which of the following nerves is susceptible to entrapment near the calcaneal attachment site of the plantar fascia and can mimic or co-exist with plantar fasciitis?

Sports Medicine 2001 Practice Questions: Set 1 (Solved) - Figure 31





Explanation

The first branch of the lateral plantar nerve is susceptible to entrapment beneath the deep fascia of the adductor hallucis muscle adjacent to the calcaneal attachment of the plantar fascia. This can be a cause of chronic heel pain. Additionally, the nerve is vulnerable to injury by a blind dissection in releasing the plantar fascia. The dorsal cutaneous branch of the superficial peroneal nerve supplies sensation to the dorsum of the foot. The medial calcaneal branch of the posterior tibial nerve lies in the subcutaneous tissues and innervates the skin of the heel. It is vulnerable to injury from skin incisions on the medial side of the heel. The lateral branch of the medial plantar nerve forms the second and third common digital nerves. Entrapment of the proper medial plantar nerve can occur at the master knot of Henry. This is well distal to the calcaneal attachment of the plantar fascia, and the pain usually radiates more distally in the arch, separate from heel pain. The communicating branch of the fourth common digital nerve crosses to the third common digital nerve. Therefore, the third common digital nerve receives supply from both the lateral and medial plantar nerves. This dual supply has been implicated in the increased incidence of digital neuroma of the third common digital nerve. Bordelon RL: Heel pain, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, CV Mosby, 1993, pp 837-857. Mann RA, Baxter DE: Diseases of the nerves, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, CV Mosby, 1993, pp 543-574.

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Question 76

A patient with a 5-cm synovial sarcoma located in the distal portion of the rectus femoris muscle undergoes excision of the mass. The procedure is performed through a 10-cm longitudinal incision. Only a portion of the rectus femoris is removed; the vast majority of the muscle is preserved. The plane of dissection is beyond the reactive zone, and the pathology reveals that the margins are negative. This procedure is classified as

Basic Science Board Review 2005: High-Yield MCQs (Set 2) - Figure 1





Explanation

The patient underwent a wide resection, which involves excision of the tumor along with a cuff of normal tissue that completely surrounds the tumor. The plane of resection is beyond the reactive zone. A radical resection involves removal of the entire affected muscle from origin to insertion. In a marginal excision, the plane of dissection is through the reactive zone of the tumor. A marginal excision is generally considered inadequate surgery for high-grade sarcomas. In an intralesional resection, the plane of dissection is through the tumor. Excision within the reactive zone but beyond the tumor is the same as a marginal excision. Enneking WF: Staging of musculoskeletal neoplasms, in Current Concepts of Diagnosis and Treatment of Bone and Soft Tissue Tumors. Heidelberg, Germany, Springer-Verlag, 1984.

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Question 77

A 12-year-old girl has scoliosis at T5-T10 that measures 62 degrees. A clinical photograph of the axilla is shown in Figure 56. Management should consist of

Pediatrics Board Review 2001: High-Yield MCQs (Set 4) - Figure 20





Explanation

Neurofibromatosis type 1 (NF-1) is an autosomal-dominant disorder affecting about 1 in 4,000 people. NF-1 causes tumors to grow along various types of nerves and affects the development of non-nervous tissues, such as bone and skin. The gene for NF-1 is located on the long arm of chromosome 17 and codes the protein neurofibromin. Research indicates that NF-1 acts as a tumor-suppressor gene and, as such, plays an important role in the control of cell growth and differentiation. Axillary and inguinal freckling is considered a good diagnostic marker for NF-1. The hyperpigmented spots that measure from 2 mm to 4 mm may be congenital, but these typically appear and increase later in life. Scoliosis is the most common musculoskeletal disorder of NF-1. The curves are frequently dystrophic, kyphotic, and have a high risk of pseudarthrosis following spinal fusion. Anterior and posterior spinal fusion with rigid posterior segmental instrumentation is the treatment of choice. Goldberg Y, Dibbern K, Klein J, Riccardi VM, Graham JM Jr: Neurofibromatosis type 1: An update and review for the primary pediatrician. Clin Pediatr 1996;35:545-561.

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Question 78

A 27-year-old professional baseball pitcher who underwent arthroscopic olecranon debridement continues to have medial-sided elbow pain during late cocking. Physical examination reveals laxity and pain with valgus stress testing. What is the most likely cause of his pain?





Explanation

Both the medial collateral ligament and the olecranon contribute to valgus stability of the elbow. Excessive olecranon resection increases the demand placed on the medial collateral ligament in resisting valgus forces during throwing. Bone removal from the olecranon should be limited to osteophytes. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 101-111.

References:

Question 79

Venous thrombolembolism is a common complication following total hip and total knee arthroplasty; therefore, prophylaxis is deemed efficacious. Several studies on low-molecular-weight heparin (LMWH) have shown which of the following findings?





Explanation

Prophylactic LMWH is associated with a risk of bleeding complications, especially if administered too soon after surgery. The risk of major bleeding is 0.3% for control, 0.4% for aspirin, 1.3% for warfarin, 1.8% for LMWH, and 2.6% for unfractionated heparin. Colwell and associates conducted a prospective, randomized trial on over 1,500 total hip arthroplasty patients. Overall, the risk of clinically apparent venous thrombolembolism was 3.6% for LMWH and 3.7% for warfarin. LMWH acts in several sites of the coagulation cascade, with its principal action being inhibition of factor 10a. Thrombocytopenia is less common with LMWH than with unfractionated heparin. The use of LMWH is a relative contraindication with indwelling epidural anesthesia. Colwell CW Jr, Collis DK, Paulson R, et al: Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty:. Evaluation during hospitalization and three months after discharge. J Bone Joint Surg Am 1999;81:932-940.

References:

Question 80

Lumbar disk replacement has been shown to offer which of the following results?





Explanation

There is no clear evidence that disk replacement results in pain relief that is superior to fusion. Pain relief appears to be equivalent with these two procedures. No study has clearly demonstrated that normal segmental motion has been consistently restored. Preexisting facet arthropathy is considered to be a contraindication to disk replacement. Comparative long-term data demonstrating a reduced incidence of adjacent segment disease compared to fusion are not yet available. Geisler FH, Blumenthal SL, Guyer RD, et al: Neurological complications of lumbar artificial disc replacement and comparison of clinical results with those related to lumbar arthrodesis in the literature. J Neurosurg Spine 2004;1:143-154.

References:

Question 81

Which of the following aids in correction of patellar tracking after total knee arthroplasty (TKA)?

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 19





Explanation

Correct patellofemoral tracking has proven to be a crucial aspect in TKA because a large percent of problems after TKA are related to the patellofemoral articulation. External rotation of the femoral and tibial components has been shown to aid in tracking. Likewise, medialization of the patellar button aids in patellar tracking and prevention of lateral subluxations and dislocations. Attention to the distal femoral cut is critical in maintaining the joint line and preventing patella baja or alta. Tibial sizing, however, is not directly related to patellar tracking after TKA. Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 1245-1258.

References:

Question 82

Figure 22 shows the radiograph of a 67-year-old woman who has an infected left total hip arthroplasty. The most efficient means to remove the distal cement mantle includes the use of

Hip Board Review 2004: High-Yield MCQs (Set 4) - Figure 3





Explanation

An extended trochanteric osteotomy has been shown to be very efficient in removing a well-fixed distal implant and cement with minimal complications. Direct lateral, posterior, and transtrochanteric osteotomy exposures do not provide exposure of the midfemur.

References:

Question 83

The palmar cutaneous branch of the median nerve (PCBMN) originates from the





Explanation

The PCBMN originates from the median nerve proper between 3 and 21 cm proximal to the wrist with moderate variation. It virtually always originates from the radial side of the nerve and travels distally with the median nerve, radial to the palmaris longus, and ulnar to the flexor carpi radialis. Hobbs RA, Magnussen PA, Tonkin MA: Palmar cutaneous branch of the median nerve. J Hand Surg Am 1990;15:38-43.

References:

Question 84

During primary total knee arthroplasty, what is the maximum distance the joint line can be raised or lowered before poor motion, joint instability, and increased chance of revision occur?

Hip 2004 Practice Questions: Set 1 (Solved) - Figure 1





Explanation

Positioning of the femoral and tibial components is a common cause of early failure of total knee arthroplasty. Two modes of possible position are raising or lowering the joint line from its anatomic level. Raising or lowering the joint line beyond an established threshold can cause limited range of motion, poor patellar function, and possible instability. It has been determined that a threshold of approximately 8 mm provides consistently good results after knee arthroplasty.

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Question 85

Figure 8 shows the radiograph of a 72-year-old man who has had severe pain in the left hip for the past 3 weeks. History reveals alcohol abuse. The next most appropriate step should consist of

Hip 2001 Practice Questions: Set 1 (Solved) - Figure 15





Explanation

The radiograph reveals destruction of the femoral head with loss of the articular cartilage. These findings are consistent with an infected hip, and aspiration will confirm the diagnosis. Although the patient could have advanced osteonecrosis, typically the cartilage interval is maintained and such destruction is rarely associated with osteonecrosis.

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Question 86

A 54-year-old man sustained a small superficial abrasion over the left acromioclavicular joint after falling from his bicycle. Examination reveals no other physical findings. Radiographs show a displaced fracture of the lateral end of the clavicle distal to a line drawn vertically to the coracoid process. Management should consist of

Trauma 2006 Practice Questions: Set 3 (Solved) - Figure 1





Explanation

Displaced clavicular fractures lateral to the coracoid process (Neer type II and III) are best managed nonsurgically with sling immobilization and physical therapy, starting with pendulum exercises and progressing to active-assisted exercises when comfortable. Supervised therapy should be performed for 3 months or until full painless motion is achieved. In one study by Robinson and Cairns, this form of treatment provided patients with a 86% chance of avoiding a secondary reconstructive procedure. Robinson CM, Cairns DA: Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am 2004;86:778-782.

Scientific References

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Question 87

A 27-year-old man now reports dorsiflexion and inversion weakness after an automobile collision 6 months ago in which compartment syndrome developed isolated to the anterior and deep posterior compartments. Examination reveals the development of a progressive cavovarus deformity, but the ankle and hindfoot remain flexible. In addition to Achilles tendon lengthening, which of the following procedures is most likely to improve the motor balance of his foot and ankle?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 13





Explanation

Compartment syndrome of the anterior and deep posterior compartments results in anterior tibialis and posterior tibialis tendon weakness, respectively. Furthermore, the long flexors to the hallux and lesser toes will be weak as well. The intact peroneus longus overpowers the weak anterior tibialis tendon, resulting in plantar flexion of the first metatarsal, cavus, and hindfoot varus. Therefore, transferring the peroneus longus to the dorsolateral midfoot reduces the first metatarsal plantar flexion torque, and possibly augments ankle dorsiflexion torque. Hansen ST: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott, Williams & Wilkins, 2000, pp 433-435.

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Question 88

Which of the following imaging modalities is most accurate in locating a toothpick in the plantar arch of the foot?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 2) - Figure 38





Explanation

Ultrasound is best at imaging abrupt changes in the density of adjacent tissue and therefore is best at imaging wood in the soft tissues of the foot. Mizel MS, Steinmetz ND, Trepman E: Detection of wooden foreign bodies in muscle tissue: Experimental comparison of computed tomography, magnetic resonance imaging, and ultrasonography. Foot Ankle Int 1994;15:437-443.

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Question 89

A 21-year-old right hand-dominant male collegiate swimmer reports painful clicking in the right shoulder. He states that he can occasionally feel his shoulder "slip out" when he is working out. AP, true AP, and axillary radiographs are shown in Figures 39a through 39c. What is the next most appropriate step in management?





Explanation

The radiographs show glenoid hypoplasia. The common radiographic findings of glenoid hypoplasia include an inferior and posterior glenoid deficiency, enlargement of the distal end of the clavicle, and sometimes an indentation in the glenoid. It is usually bilateral and rarely associated with other syndromes; therefore, an echocardiogram, abdominal ultrasound, or a skeletal survey is unnecessary unless the patient has stigmata of a syndrome such as Holt-Oram or Apert's. Although posterior instability has been reported, the results of glenoid osteotomy have been variable and should not be considered initially. Physical therapy is the mainstay of initial management, but the patient should be counseled that this may be a recurrent problem with early osteoarthritis developing in many patients. Radiographs of the contralateral side should be obtained because this is usually bilateral. Wirth MA, Lyons FR, Rockwood CA Jr: Hypoplasia of the glenoid: A review of sixteen patients. J Bone Joint Surg Am 1993;75:1175-1184.

References:

Question 90

When performing an inside-out lateral meniscal repair, capsule exposure is provided by developing the

Sports Medicine 2007 Practice Questions: Set 1 (Solved) - Figure 9





Explanation

Capsular exposure for an inside-out lateral meniscal repair is performed by developing the interval between the iliotibial band and biceps tendon. Posterior retraction of the biceps tendon exposes the lateral head of the gastrocnemius. Posterior retraction of the gastrocnemius provides access to the posterolateral capsule. Miller DB Jr: Arthroscopic meniscus repair. Am J Sports Med 1988;16:315-320.

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Question 91

A 16-year-old ice hockey player is struck on the chest by the puck. He skates a few strides and then collapses. What is the most likely diagnosis?





Explanation

Sudden cardiac arrest following a blow to the chest in young athletes has been termed "commotio cordis." It is most common in Little League and other youth projectile sports (eg, ice hockey, lacrosse). The cause, although not completely determined, is most likely an arrhythmia related to the impact in a vulnerable time in the cardiac cycle. Resuscitation has proven to be exceedingly difficult, resulting in a high mortality rate. Maron BJ, Strasburger JF, Kugler JD, Bell BM, Brodkey FD, Poliac LC: Survival following blunt chest impact-induced cardiac arrest during sports activities in young athletes. Am J Cardiol 1997;79:840-841.

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Question 92

A 45-year-old man is seeking evaluation of an injury sustained in a motor vehicle accident 10 weeks ago. Current radiographs are shown in Figures 2a and 2b. Based on the radiographic findings, what is the most likely diagnosis?





Explanation

An increased density of the talar body compared to the distal tibia following fracture of the talar neck is highly suggestive of vascular compromise of the talar body. Subchondral osteopenia of the talus at 6 to 8 weeks (Hawkins sign) is a favorable sign but does not eliminate the possibility of osteonecrosis. Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J: Fractures of the talus: Experience of two level 1 trauma centers. Foot Ankle Int 2000;21:1023-1029.

References:

Question 93

After excising a mass from the thigh that was thought to be a lipoma, the pathology reveals that the mass is a high-grade sarcoma. Subsequent treatment should include

Basic Science Board Review 2005: High-Yield MCQs (Set 2) - Figure 23





Explanation

Following excision of a suspected benign soft-tissue tumor that proves to be malignant, repeat excision of the tumor bed is recommended. The initial surgical margins are inadequate after an intralesional or marginal excision, necessitating additional surgery for more definitive local control. While radiation therapy and/or chemotherapy may help to reduce the risk of local recurrence in patients with microscopic residual disease, local control is improved following repeat excision. Radiation therapy alone is inadequate to address poor surgical margins, and would likely be given postoperatively. Bisphosphonates have no current role in the treatment of soft-tissue sarcoma. Noria S, Davis A, Kandel R, et al: Residual disease following unplanned excision of soft-tissue sarcoma of an extremity. J Bone Joint Surg Am 1996;78:650-655.

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Question 94

Which of the following studies has the highest sensitivity and specificity in diagnosis of osteonecrosis of the femoral head?

Hip 2001 Practice Questions: Set 1 (Solved) - Figure 9





Explanation

An MRI scan is both highly sensitive and specific for the evaluation of osteonecrosis. The measurement of increased intraosseous pressure can be technically difficult and the results have been variable. Plain radiographs can be normal early in the progression of osteonecrosis of the femoral head. The technetium Tc 99m bone scan is a very sensitive test. However, it is not specific; increased uptake can be noted in patients with arthritis, neoplastic disease, fracture, or sepsis. In addition, because of bilaterality, the frequency of false-negative scans is relatively high. Steinberg ME: Early diagnosis, evaluation, and staging of osteonecrosis, in Jackson DW (ed): Instructional Course Lectures 43. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 513-518.

References:

Question 95

A 29-year-old ultramarathoner, who is halfway into a 50-mile race, is sweating profusely. He suddenly collapses, is unresponsive, and has violent muscle contractions. Prior to these symptoms, he had been drinking water at every water stop (every 1 mile). What is the most likely diagnosis?





Explanation

Hyponatremia ("water intoxication") can occur in endurance athletes such as ultramarathoners who are sweating profusely and drinking only water as fluid replacement. Sports drinks which contain electrolytes are a better replacement in this group of athletes. Sodium is the mineral most commonly affected by physical exercise. Sodium concentration in sweat depends on diet, hydration, and heat acclimation. In most cases, sodium lost in sweat can be replaced by regular diet. Potassium plays an important role in nerve conduction and muscle contraction but is not lost in excessive amounts in sweat during exercise. The most frequent loss of potassium is through gastrointestinal disorders or excessive loss from the kidneys. Rehrer reported that overhydrating during very long-lasting exercise in the heat with low or negligible sodium intake can result in reduced performance and hyponatremia. With hyponatremia, the serum sodium is abnormally low, resulting in brain swelling, seizures, coma, and potentially death. Interestingly, hyponatremia is rarely seen in adolescent athletes and young children. Griffin LY: Emergency preparedness: Things to consider before the game starts. J Bone Joint Surg Am 2005;87:894-902.

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Question 96

During impaction of a cementless acetabular component, the posterior column was fractured and found to be displaced. Which of the following is considered the most appropriate surgical option?





Explanation

Acetabular bone loss presents a challenge during reconstruction. A cementless hemispherical cup can be used in most patients provided that the acetabular rim, particularly the posterior column, is intact. When the posterior column is disrupted, fixation with a reconstruction plate and/or the use of an antiprotrusio cage is recommended. The latter is particularly important when the posterior column is fractured and displaced, such as in this patient. Under these circumstances, reduction of the fracture and application of an antiprotrusio cage is recommended. In this particular type of case, some surgeons may elect to retain the hemispherical cup and apply an antiprotrusio cage over the cup ("cage over cup" technique). Berry DJ: Antiprotrusio cages for acetabular revision. Clin Orthop 2004;420:106-112.

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Question 97

A 26-year-old man with chronic lateral ankle instability underwent a modified Broström procedure 8 months ago. He reports persistent pain and swelling of the lateral ankle. Examination reveals lateral ankle tenderness and swelling and a negative anterior drawer test. Laboratory studies show a WBC count of 6,500/mm3 and an erythrocyte sedimentation rate of 15 mm/h. Radiographs of the ankle are normal. What is the most likely cause of this problem?





Explanation

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

References:

Question 98

Reconstruction of the posterior cruciate ligament (PCL) via the inlay technique involves exposure of the PCL tibial insertion site by a posterior

Sports Medicine Board Review 2004: High-Yield MCQs (Set 2) - Figure 9





Explanation

The posterior medial approach through the semimembranosus/medial gastrocnemius interval is used in the inlay technique for PCL reconstruction. Exposure of the posterior capsule of the knee through this interval provides the greatest margin of safety to avoid injury to the tibial nerve, motor branch of the medial gastrocnemius, and the peroneal nerve. The direct posterior approach using the medial sural cutaneous nerve allows exposure of the popliteal neurovascular structures, but deep dissection through this interval places the motor branch of the medial gastrocnemius at risk. The interval between the semitendinosus and semimembranosus is used in accessory incisions with medial meniscus repairs but does not allow exposure of the PCL insertion. Berg EE: Posterior cruciate tibial inlay reconstruction. Arthroscopy 1995;11:69-76.

References:

Question 99

A 10-year-old boy with spastic diplegic cerebral palsy walks in a crouched position with the hips and knees flexed. Maximum knee flexion is 15 degrees during early swing phase. Instrumented gait analysis shows quadriceps activity from terminal stance throughout swing phase. Treatment should consist of





Explanation

The rectus femoris muscle spans two joints and is active during running, sprinting, and walking at a fast pace during the preswing and early swing phase of gait. In these situations, the muscle helps to generate power to initiate hip flexion while absorbing or controlling the rate of knee flexion during early swing phase. Quadriceps activity, including the rectus femoris, is not normally needed when walking at a routine cadence. However, rectus femoris activity is commonly noted during preswing and the swing phase in patients with cerebral palsy, particularly those with diplegia. In an effort to initiate swing phase, the rectus femoris is "overactive." As a result, the knee flexion that commonly occurs at terminal stance and initial swing is restricted. Instead of achieving the normal 50 to 60 degrees of flexion during early swing, this patient's knee flexion is limited to 15 degrees. The goal of treatment is to retain rectus femoris activity for initiation of hip flexion but to diminish its restraint on knee flexion. Studies have shown that transfer of the distal rectus femoris tendon provides more flexion of the knee during the swing phase of gait than simply releasing the tendon. V-Y lengthening of the quadriceps tendon or a Z lengthening of the patellar tendon causes too much weakening of the quadriceps muscle and worsens the crouch deformity. In addition to transfer of the rectus femoris tendon, other procedures are often done concomitantly to obtain the best balance and realignment of hip-knee-ankle activity. Aiona MD: Guidelines for managing lower extremity problems in cerebral palsy, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1534-1541. Chambers H, Laure A, Kaufman K, Cardelia M, Sutherland D: Prediction of outcome after rectus femoris surgery in cerebral palsy: The role of cocontraction of the rectus femoris and vastus lateralis. J Pediatr Orthop 1998;18:703-711.

References:

Question 100

To preserve blood supply to the fractured bone seen in Figures 12a and 12b, care should be taken when exposing which of the following areas?





Explanation

The blood supply to the adult capitellum and lateral trochlea comes from posterior vessels arising from the radial recurrent, radial collateral, and interosseous recurrent arteries. These arteries penetrate the distal humerus posterior and superior to the capitellum.

References:

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