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

Orthopedic Board Review MCQs: Mock Exam Set 313 (100 Questions)

27 Apr 2026 96 min read 81 Views
AAOS Sports Medicine MCQs: Board Prep Part 7

Key Takeaway

This page offers 100 high-yield orthopedic surgery multiple-choice questions (MCQs) tailored for ABOS, OITE, and FRCS board exam preparation. Covering trauma, spine, sports, and reconstruction, this practice set (Set 313) helps surgeons master their exams and reinforce essential orthopedic knowledge.

Comprehensive 100-Question Exam


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Question 1

A 20-year-old man sustained a closed tibial fracture and is treated with a reamed intramedullary nail. What is the most common complication associated with this treatment?

Trauma 2006 Practice Questions: Set 1 (Solved) - Figure 9





Explanation

The most common complication is anterior knee pain (57%). The knee pain is activity related (92%) and exacerbated by kneeling (83%). Although knee pain is the most common complication, most patients rate it as mild to moderate and only 10% are unable to return to previous employment. Some authors report less knee pain with a peritendinous approach when compared to a tendon-splitting approach. In one study, nail removal resolved pain in 27%, improved it in 70%, and made it worse in 3%. The incidence of the other complications was: infection 0% to 3%, nonunion 0% to 6%, and malunion 2% to 13%. Compartment syndrome is rare after nailing. Court-Brown CM: Reamed intramedullary tibial nailing: An overview and analysis of 1106 cases. J Orthop Trauma 2004;18:96-101. McQueen MM, Gaston P, Court-Brown CM: Acute compartment syndrome: Who is at risk? J Bone Joint Surg Br 2000;82:200-203.

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Question 2

Figure 12a shows the clinical photograph of a 36-year-old man who has left shoulder pain and dysfunction after undergoing a lymph node biopsy 2 years ago. The appearance of the shoulder during abduction and a wall push-up maneuver is shown in Figures 12b and 12c, respectively. Which of the following procedures provides the best pain relief and function?





Explanation

Injury to the spinal accessory nerve can occur after penetrating trauma to the shoulder. Blunt trauma may also cause loss of trapezius function. Most commonly, surgical dissection in the posterior triangle of the neck, such as lymph node biopsy, may expose the nerve to possible damage. Surgical repair of the nerve may be considered up to 1 year after injury; after this time muscle transfer is usually associated with a better functional outcome. Steinman SP, Spinner RJ: Nerve problems in the shoulder, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA, WB Saunders, 2004, vol 2, pp 1013-1015.

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Question 3

A patient undergoes excision of a 3- x 3-cm soft-tissue sarcoma. The final histology results show tumor at the surgical margin. The surgical procedure performed is classified as





Explanation

Surgical margins are classified according to the plane of dissection in relation to the tumor. An intralesional procedure is where the plane of dissection passes through the tumor. A marginal resection involves a resection where the plane of dissection is through the reactive zone of the tumor. A wide resection is through completely normal tissue outside of the reactive zone. A radical resection removes all of the muscles and/or bone of the compartment that are involved by the tumor.

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Question 4

Figure 2 shows the radiograph of a 72-year-old woman who reports pain after a fall. History includes several years of increasing thigh pain and limb shortening. Management consisting of an extensive work-up for infection reveals normal laboratory studies, a positive bone scan, and a negative hip aspiration. What is the most likely etiology of this complication?

Hip 2001 Practice Questions: Set 1 (Solved) - Figure 5





Explanation

The patient has a midstem periprosthetic fracture, which commonly results in loosening of the prosthesis. Patients who have a large amount of bone loss may require an allograft with the surgical reconstruction. Although the patient reported a fall, her history is also consistent with preexisting loosening of the prosthesis. Chronic infection has been shown in up to 16% of these fractures; however, the patient's work-up revealed no infection. Garbuz DS, Masri BA, Duncan CP: Periprosthetic fractures of the femur: Principles of prevention and management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 237-242. Bethea JS III, DeAndrade JR, Fleming LL, Lindenbaum SD, Welch RB: Proximal femoral fractures following total hip arthroplasty. Clin Orthop 1982;170:95-106.

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Question 5

A 3-year-old boy has a rigid 40-degree lumbar scoliosis that is the result of a fully segmented L5 hemivertebra. All other examination findings are normal. Management should consist of

Pediatrics 2004 Practice Questions: Set 1 (Solved) - Figure 16





Explanation

Near complete correction and rebalancing of the spine can be achieved by hemivertebral resection that may be done as either a simultaneous or a staged procedure in the young patient. This eliminates the problem of future progression and possible development of compensatory curves. Nonsurgical management is not indicated in congenital scoliosis. Convex hemiepiphyseodesis is best suited for patients younger than age 5 years who have a short curve caused by fully segmented hemivertebrae that correct to less than 40 degrees with the patient supine. Hemiepiphyseodesis and isolated posterior fusion are not indicated. Bradford DS, Boachie-Adjei O: One-stage anterior and posterior hemivertibral resection and arthrodesis for congenital scoliosis. J Bone Joint Surg Am 1990;72:536-540.

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Question 6

A 35-year-old woman who is a recreational runner reports posterior knee pain and tightness in the knee with flexion during running. She denies any history of trauma. Examination reveals normal patellar glide and tilt and no patellar apprehension. Range of motion is 5 degrees to 120 degrees, and quadriceps function and knee ligamentous examination are normal. Radiographs are normal. An MRI scan is shown in Figure 18. What is the most likely diagnosis?

Sports Medicine 2007 Practice Questions: Set 3 (Solved) - Figure 8





Explanation

Ganglia involving the cruciate ligaments have been recently reported as a cause of knee pain that interferes with knee flexion and extension. The symptoms are poorly localized in this patient and not along the medial joint line, making the diagnosis of a torn medial meniscus less likely. In addition, the MRI findings do not show a significant medial meniscal lesion. A Baker's cyst is usually posteromedial and extends posterior to the interval between the medial head of the gastrocnemius and semimembranosus. MRI scans show a fluid-filled lesion with an increased signal on T1- and T2-weighted images. A lipoma would be bright on the T1-weighted image only. Deutsch A, Veltri DM, Altchek DW, et al: Symptomatic intraarticular ganglia of the cruciate ligaments of the knee. Arthroscopy 1994;10:219-223.

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Question 7

Where is the underlying defect in a rhizomelic dwarf with the findings shown in Figure 5?

Pediatrics 2007 Practice Questions: Set 1 (Solved) - Figure 13





Explanation

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

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Question 8

An 8-year-old boy has had pain and swelling around the right knee for the past 4 weeks. He recalls bumping it about 4 weeks ago. He has no pain in other joints, and denies any fevers, chills, or other symptoms. A radiograph is shown in Figure 13. Laboratory studies show a WBC count of 9,700/mm3, an erythrocyte sedimentation rate of 18 mm/h, and a C-reactive protein level of 3.7 mg/L. What is the next most appropriate step in management?

Pediatrics Board Review 2007: High-Yield MCQs (Set 2) - Figure 3





Explanation

The history and laboratory findings are consistent with osteomyelitis of the patella. The radiograph reveals bone destruction in the patella; therefore, the next most appropriate step is open biopsy and debridement of the site. Aspiration of the knee joint may be needed to rule out septic arthritis prior to patellar debridement. With this amount of bone destruction, surgical debridement is helpful to obtain cultures and to remove necrotic material. Administering antibiotics without any prior culture increases the risk of negative cultures later and a potentially incorrect choice of antibiotic. A neoplasm should be included in the differential. It would be inappropriate to initiate chemotherapy and radiation therapy without a biopsy-confirmed diagnosis. A bone scan is likely to demonstrate uptake, but radiographs have already localized the abnormality to the patella. Morrisy RT: Bone and joint sepsis, in Morrissy RT, Weinstein SL (eds): Lovell and Winter's Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 466-470.

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Question 9

Which of the following procedures is considered most appropriate in patients with rheumatoid arthritis?

Hip 2001 Practice Questions: Set 1 (Solved) - Figure 23





Explanation

Synovectomy of the knee prior to loss of articular cartilage has been shown to consistently relieve pain in patients with rheumatoid arthritis. Partial knee replacement will not arrest the process of joint destruction. Osteotomy of the hip has not been found to be a successful procedure in patients with rheumatoid arthritis. Hip arthrodesis should not be considered because of the multiarticular involvement in patients with rheumatoid arthritis. Core decompression of the hip has not been shown to save the femoral head because the necrosis appears to occur simultaneously with the inflammatory joint process. Granberry WM, Brewer EJ Jr: Early surgery in juvenile rheumatoid arthritis, in Calundruccio RA (ed): Instructional Course Lectures XXIII. St Louis, MO, CV Mosby, 1974, pp 32-37.

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Question 10

A 28-year-old man has had a 2-year history of progressive lateral ankle pain. History reveals that he underwent a triple arthrodesis at age 13 for a tarsal coalition. The pain has been refractory to braces, custom inserts, and nonsteroidal anti-inflammatory drugs. Weight-bearing radiographs of the ankle and foot are shown in Figures 3a through 3d. Surgical management should include which of the following?





Explanation

The patient has a valgus-supination triple arthrodesis malunion. Weight-bearing radiographs show excessive residual valgus through the subtalar joint, producing lateral subfibular impingement, and residual forefoot abduction and midfoot supination through the talonavicular joint, lateralizing the weight-bearing forces through the foot. The deformity is best managed with a medial displacement calcaneal osteotomy and transverse tarsal derotational osteotomy. Ankle arthroscopy and lateral ligament reconstruction are indicated in the event of ligament instability. Tendon transfer, lateral column lengthening, and heel cord lengthening are used for treatment of adult flatfoot from posterior tibial tendon insufficiency. Ankle arthrodesis and ankle arthroplasty are not indicated in this patient because the lateral ankle symptoms are the result of the underlying deformity in the hindfoot, the patient is young, and the ankle joint is relatively normal. Haddad SL, Myerson MS, Pell RF IV: Clinical and radiographic outcome of revision surgery for failed triple arthrodesis. Foot Ankle Int 1997;18:489-499.

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Question 11

When using a two-incision approach for open reduction and internal fixation of a Hawkins III talar fracture-dislocation involving the talar neck and body, what anatomic structure must be preserved to optimize outcome?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 22





Explanation

A Hawkins III fracture-dislocation generally presents with posteromedial displacement with the deltoid ligament intact. Therefore, the only remaining blood supply is the deltoid branch of the artery of the tarsal canal originating from the posterior tibial artery. Often, the medial malleolus is fractured, assisting in reduction and visualization of fracture reduction. If the medial malleolus is intact, a medial malleolus osteotomy allows visualization of the reduction without compromising the last remaining blood supply to the talus. Mulfinger GL, Trueta J: The blood supply of the talus. J Bone Joint Surg Br 1970;52:160-167.

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Question 12

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

Hip & Knee Reconstruction 2007 Practice Questions: Set 1 (Solved) - Figure 15





Explanation

Retrieval studies have shown that the debris particles produced by metal-on-metal articulations in total hip arthroplasty are several orders of magnitude smaller and may be up to 100 times more numerous than those found with metal-on-polyethylene articulations. Davies AP, Willert HG, Campbell PA, et al: An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements. J Bone Joint Surg Am 2005;87:18-27.

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Question 13

What is the most important feature in choosing an outcome instrument to assess shoulder disorders?





Explanation

There has been a recent increase in the use of outcome instruments to document and measure effects of treatment of medical conditions, including shoulder disorders. The most important feature of an instrument is whether it actually measures what it purports to measure; this is defined as its validity. Leggin BG, Iannotti JP: Shoulder outcome measurement, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999, p 1027.

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Question 14

Which of the following findings is most prognostic for the ability of a young child with cerebral palsy to walk?

Pediatrics 2007 Practice Questions: Set 1 (Solved) - Figure 15





Explanation

Several studies have shown that sitting ability by age 2 years is highly prognostic of walking. Molnar and Gordon reported that children not sitting independently by age 2 years had a poor prognosis for walking. Wu and associates reported that children sitting without support by age 2 years had an odds ratio of 26:1 of walking compared with those unable to sit. This was far higher than the odds ratios for cerebral palsy location, motor dysfunction, crawling, creeping, scooting, or rolling. Molnar GE, Gordon SU: Cerebral palsy: Predictive value of selected clinical signs for early prognostication of motor function. Arch Phys Med Rehabil 1976;57:153-158.

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Question 15

Mutations of what gene are associated with the subsequent development of osteosarcoma?





Explanation

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

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Question 16

A 58-year-old man reports a 2-month onset of groin pain with no history of trauma. Examination reveals that range of motion of the hip is mildly restricted, and he has pain with both weight bearing and at rest. An MRI scan is shown in Figure 20. Treatment should consist of

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 8





Explanation

The MRI findings show highly increased signal through the entire femoral head and neck on STIR imaging, diagnostic of transient osteoporosis of the femoral head. This disease entity can be seen in middle-aged men, and should be treated nonsurgically. The natural history is that of self-resolution. Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.

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Question 17

A high school athlete reports the sudden onset of low back pain while performing a dead lift. Examination reveals a lumbar paraspinal spasm and a positive straight leg raising test. The deep tendon reflexes, motor strength, and sensation in the lower extremeties are normal. The radiographs are normal. If symptoms persist for more than a few weeks, management should consist of





Explanation

In adolescents, a lumbar herniated disk is characterized by a paucity of clinical findings; a positive straight leg raising test may be the only consistent positive finding. This may result in a long period of nonsurgical management that fails to provide relief. Activities that place a significant shear load on the lumbar spine, such as the dead lift, are associated with an increased risk of central disk herniation. When an adolescent who lifts weights has a history of low back pain that fails to respond to a short period of active rest, an MRI scan is the study of choice to evaluate for a lumbar herniated disk. Epstein JA, Epstein NE, Marc J, Rosenthal AD, Lavine LS: Lumbar intervertebral disk herniation in teenage children: Recognition and management of associated anomalies. Spine 1984;9:427-432.

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Question 18

A 13-year-old girl with Down syndrome has bilateral chronic patellar dislocations. She denies knee pain. She is able to straighten her knees and walks with a symmetric but awkward gait. She does not flex her knees in midstance. Examination reveals that the patellae cannot be brought into a reduced position. Management should consist of

Pediatrics Board Review 2004: High-Yield MCQs (Set 2) - Figure 15





Explanation

Chronic dislocation of the patella is occasionally seen in patients with Down syndrome. In early childhood, patellar realignment may restore stability of the patellae. In later childhood, bony changes in the patellar groove interfere with stability, even if surgical realignment is performed. Realignment can also lead to increased knee pain postoperatively. In asymptomatic patients who are able to extend their knees, continued observation is the management of choice. Dugdale TW, Renshaw TS: Instability of the patellofemoral joint in Down syndrome. J Bone Joint Surg Am 1986;68:405-413.

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Question 19

What is the most common location of osteosarcoma?

Basic Science 2005 Practice Questions: Set 3 (Solved) - Figure 1





Explanation

The most common location of osteosarcoma is the knee area (50% to 55%), followed by the proximal humerus and iliac wing. The most commonly involved long bone is the femur (40% to 45%), followed by the tibia (15% to 25%). Within these bones, tumors are typically adjacent to the epiphyses in most patients. The flat bones of the pelvis and spine are less frequently involved. Malawer MM, Sugarbaker PH, Malawer M: Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Kluwer Academic Publishers, 2001.

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Question 20

Which of the following is a true statement regarding thoracic disk herniations?





Explanation

Symptomatic herniations of the thoracic spine are much less common than those of the cervical or lumbar region. They tend to occur most commonly during the third to fifth decades of life and although they can be found at all levels, they are most common in the lower third near the thoracolumbar region. Posterior laminectomy and disk excision has the highest rate of neurologic deterioration and is not recommended. Multiple studies have shown that herniated thoracic disks can be found at one or more levels in 40% of asymptomatic individuals. Shah RP, Grauer JN: Thoracoscopic excision of thoracic herniated disc, in Vaccaro AR, Bono CM (eds): Minimally Invasive Spine Surgery. New York, NY, Informa Healthcare, 2007, pp 73-80.

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Question 21

A newborn with bilateral talipes equinovarus undergoes serial manipulation and casting. What is the primary goal of manipulation?

Pediatrics 2004 Practice Questions: Set 1 (Solved) - Figure 17





Explanation

Manipulative treatment and casting of talipes equinovarus has become popular because of disappointing surgical results and enthusiasm for the Ponseti method of manipulation. In this technique, the primary goal is to rotate the foot laterally around a talus that is held fixed by the manipulating surgeon's hands. While the navicular may be rotated anterolaterally with this technique, the primary focus is on the calcaneus. The calcaneus is rotated laterally and superiorly, not translated. Some dorsiflexion of the calcaneus can be obtained by manipulation, but the primary focus is on the rotational relationship of the talus and calcaneus, not the degree of calcaneal dorsiflexion. Ponseti IV: Common errors in the treatment of congenital clubfoot. Int Orthop 1997;21:137-141.

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Question 22

A 16-year-old football player sustains a direct blow to the anterior aspect of his flexed right knee. Examination reveals a contusion over the anterior tibial tubercle and a small effusion. MRI scans are shown in Figures 33a through 33c. What is the most likely diagnosis?





Explanation

The MRI scans show disruption of the fibers of the PCL. Patients sustaining an isolated acute PCL injury can present with only minimal discomfort and have full range of motion. When examination reveals a contusion over the tibial tubercle and discomfort with the posterior drawer examination, with or without instability, a possible injury to the PCL should be considered. In acute injuries, the reported accuracy of MRI imaging for diagnosing PCL tears ranges from 96% to 100%. Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging. Philadelphia, PA, WB Saunders, 1997, pp 699-700. Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.

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Question 23

Where is the watershed zone for tarsal navicular vascularity?

Foot & Ankle 2006 Practice Questions: Set 1 (Solved) - Figure 21





Explanation

The central one third has been established as the watershed zone by angiographic studies, and has been borne out in clinical conditions involving the navicular, such as stress fractures and osteonecrosis. These findings account for the susceptibility to injury at this level. Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 239-242.

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Question 24

A 27-year-old man sustained a gunshot wound to the lumbar spine and undergoes an exploratory laparotomy. An injury to the cecum is identified and treated. Management should now include

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





Explanation

Gunshot wounds to the spine present relatively little risk of infection in most cases. When there has been an injury to the colon, the risk of infection can be minimized with a 7-day course of broad-spectrum antibiotics. Fragment removal is not indicated. Roffi RP, Waters RL, Adkins RH: Gunshot wounds to the spine associated with a perforated viscus. Spine 1989;14:808-811.

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Question 25

A 26-year-old woman is seen in the emergency department with an intra-articular distal tibia fracture and a fibular fracture (pilon). The patient, her husband, and three small children have recently immigrated to the United States from Mexico. The husband and wife have both been in a migrant labor camp but have no immediate relatives in the States. What factor is most important when considering her recommended care and treatment?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 6





Explanation

With documented use of a competent interpreter, informed consent should not be an issue. In Hispanic families, the husband often makes the ultimate decision regarding proceeding with surgery; however, he would not be expected to withhold recommended treatment. Hispanics may have a higher risk of comorbidities, but you do not expect this to be a significant concern with this patient. Claustrophobia and some fear of the unfamiliar may make additional imaging studies more difficult to arrange, but not impossible. The real concern is that with no extended family and three small children, the postoperative demand on the patient could significantly jeopardize her ability to comply with weight-bearing restrictions and overall ambulatory demands. Discharge planning and appropriate help may be paramount for a good outcome.

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Question 26

Figures 45a and 45b show the radiographs of a 14-year-old boy who sustained a distal radius fracture while playing hockey. After 1 year the patient is asymptomatic. Follow-up and comparison radiographs and an MRI scan are shown in Figures 45c and 45d. What is the next most appropriate step in management?





Explanation

The patient sustained a growth plate fracture of the distal radius and ulna. Although treated with closed reduction and casting, the follow-up radiographs demonstrate shortening of the radius in comparison to the ulna, and the MRI scan confirms thinning of the distal radius growth plate and bony bars consistent with a growth arrest. At this time, the discrepancy in length is too minor to consider lengthening of the radius; in addition, excision of a physeal bar with minimal growth potential is not likely to restore the gross discrepancy. Ulnar styloid fractures are rarely symptomatic and do not require treatment in the asymptomatic patient. Closure of the distal ulna growth plate will prevent further discrepancy between the radius and ulna. Vanheest A: Wrist deformities after fracture. Hand Clin 2006;22:113-120.

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Question 27

A 47-year-old woman has had left medial clavicle pain for the past 6 months. History is remarkable for mediastinal non-Hodgkin's lymphoma, treated with mantel radiation 22 years ago. A radiograph, CT scan, MRI scan, and a biopsy specimen are shown in Figures 68a through 68d. What is the most likely diagnosis?





Explanation

Radiation-associated sarcomas typically occur at least 5 years following radiation therapy, in the radiation therapy field, and with different histology than the original disease. The radiograph shows a lytic destructive lesion of the medial clavicle. The radiographic differential could include any of the above etiologies. The CT and MRI scans show this same reaction with extension into the adjacent soft tissue and periosteal reaction. These findings eliminate a degenerative process or radiation-induced osteonecrosis but do not distinguish between a neoplastic and infectious process. A PET scan showed marked uptake in the distal clavicle, which is more consistent with a malignant neoplastic process than a reactive process, like that of an infection. These findings, combined with the cellular atypia and bone formation on the biopsy specimen, confirm the diagnosis of radiation-associated sarcoma. In this older patient, radiation-associated sarcoma appears in an unusual location secondary to her previous radiation treatment in that region, which can occur 3 to 50 years after previous radiation therapy. Shaheen M, Deheshi BM, Riad S, et al: Prognosis of radiation-induced bone sarcoma is similar to primary osteosarcoma. Clin Orthop Relat Res 2006;450:76-81.

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Question 28

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





Explanation

Flexor hallucis longus tendinitis is a common cause of posterior ankle pain in dancers. It tends to be more posteromedial and is characterized by a clicking or catching sensation posteromedially with motion of the great toe. A painful os trigonum typically causes more posterolateral ankle pain and may occur after an ankle sprain or plantar flexion injury where there may be a fracture of the os trigonum. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 249-261.

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Question 29

When harvesting an iliac crest bone graft from the posterior approach, what anatomic structure is at greatest risk for injury if a Cobb elevator is directed too caudal?





Explanation

If a Cobb elevator is directed caudally while stripping the periosteum over the iliac wing, it will encounter the sciatic notch. Although this puts the sciatic nerve at risk, the first structure encountered is the superior gluteal artery. Because it is tethered at the superior edge of the notch, it is very vulnerable to injury and can then retract inside the pelvis, making it difficult to obtain hemostasis. The inferior gluteal artery exits the sciatic notch below the piriformis and is more protected. The cluneal nerves are at risk only if the incision extends too anteriorly, and the sacroiliac joint can be entered while harvesting the graft. Banwart JC, Asher MA, Hassanein RS: Iliac crest bone graft harvest donor site morbidity: A statistical evaluation. Spine 1995;20:1055-1060.

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Question 30

Figure 43 shows the lateral radiograph of a patient who underwent anterior cruciate ligament reconstruction. Based on the tunnel placement shown in the radiograph, evaluation of postoperative knee range of motion will most likely show

Sports Medicine Board Review 2001: High-Yield MCQs (Set 4) - Figure 16





Explanation

The radiograph shows the correct tibial tunnel and anterior femoral tunnel; therefore, range of motion will most likely show loss of flexion. Brown CH Jr, Carson EW: Revision anterior cruciate ligament surgery. Clin Sports Med 1999;18:109-171.

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Question 31

A 21-year-old man has had posterior neck discomfort for the past 6 months. A whole-body bone scan and a cervical single-photon emission CT reveal increased activity at the C7 spinous process. MRI reveals multifocal involvement of the spinous process lamina and facet of C7. A CT-directed needle biopsy reveals osteoblastoma. What is the best course of action?





Explanation

En bloc excision is the recommended treatment of osteoblastoma. Treatment should consist of en bloc removal of the lamina, facet, and spinous process. Facet removal would necessitate fusion. Radiation therapy is not recommended. Intralesional curettage has a high rate of recurrence. Bridwell KH, Ogilvie JW: Primary tumors of the spine, in Bridwell KH, DeWald RL (eds): The Textbook of Spinal Surgery. Philadelphia, PA, JB Lippincott, 1991, vol 2, pp 1143-1174.

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Question 32

Figures 4a and 4b show the radiographs of a 32-year-old man who has right groin pain with activity or prolonged standing. Which of the following factors would not prohibit consideration of acetabular liner exchange and grafting of the defects?





Explanation

Polyethylene particles generated as mechanical wear debris can be phagocytized by macrophages and enter a metabolically active state that releases cytokines, causing periprosthetic bone resorption. Significant osteolysis can occur in the pelvis with a porous-coated cementless socket without loosening of the component. If the acetabular component is modular, well positioned, well-designed with a good survivorship record, and remains undamaged after liner removal, the polyethylene liner can be exchanged and the lytic defects can be debrided and bone grafted. This implant is well positioned, has a good survivorship record, a good locking mechanism, and is modular. The hip arthroplasty needs to be aseptic for consideration of liner exchange. Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA: Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am 1997;79:1628-1634.

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Question 33

A healthy 16-year-old boy has had increasing pain in the right knee for the past 3 months. Examination reveals warmth and swelling around the distal femur. Radiographs and an MRI scan are shown in Figures 51a through 51c, and a biopsy specimen is shown in Figure 51d. What is the most likely diagnosis?





Explanation

The radiographs show a bone-producing lesion in the distal femoral metaphysis in this case of classic osteosarcoma presenting in the most common location, the distal femur. The coronal MRI scan reveals a marrow-occupying lesion with extension into the soft tissues. The histology shows osteoid production by pleomorphic cells consistent with an osteosarcoma. Ewing's sarcoma is a bone tumor characterized by uniform small blue cells on histology. Rhabdomyosarcoma is the most common childhood soft-tissue sarcoma. Osteomyelitis has an inflammatory appearance on histology. Malignant fibrous histiocytoma of bone has a lytic radiographic appearance and a pleomorphic storiform pattern without osteoid on histology. Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 179.

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Question 34

A 38-year-old woman with metastatic thyroid carcinoma has had increasing pain in the left hip for the past 3 months. An AP radiograph and coronal T1-weighted MRI scan are shown in Figures 28a and 28b. Management should consist of





Explanation

The radiograph and MRI scan reveal a lytic lesion in the left femoral neck region that extends to the lesser trochanter. Although external beam radiation and radioactive iodine infusion may be helpful in controlling the local disease, the patient is at high risk for femoral neck fracture given the location of the lesion. Prophylactic surgery is indicated; therefore, the treatment of choice is a cemented bipolar hemiarthroplasty. The use of a compression hip screw and side plate or an intramedullary nail has a high likelihood of failure with disease progression. Postoperative treatment with radiation therapy and bisphosphonates is also indicated. Mirels H: Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop 1989;249:256-264. Swanson KC, Pritchard DJ, Sim FH: Surgical treatment of metastatic disease of the femur. J Am Acad Orthop Surg 2000;8:56-65.

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Question 35

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 36

Figure 39 shows the sagittal T1-weighted MRI scan of a 27-year-old man who twisted his knee 2 weeks ago. The arrow is pointing to

Anatomy 2002 Practice Questions: Set 3 (Solved) - Figure 21





Explanation

The arrow identifies a transverse dark line that represents primary trabeculae of the physeal scar. A similar finding is seen in the proximal tibia. These lines may persist indefinitely. They do not represent ongoing growth, an abnormally open physeal plate, a stress fracture, or Looser's line (fatigue fracture in osteomalacia).

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Question 37

A 12-year-old girl has had progressive left knee pain for the past 4 months. She reports that the pain is unrelated to activity, and she has no history of fever or recent infections. Examination reveals full range of motion of the knee but tenderness along the medial joint line. Plain radiographs and MRI scans are shown in Figures 39a through 39d. A biopsy specimen of the lesion is shown in Figure 39e. Treatment should include





Explanation

The lesion is a chondroblastoma. The plain radiographs show a well-defined radiolucent lesion in the distal femoral epiphysis of a skeletally immature patient. The margins are well defined, suggesting a benign growth. The epiphysis is an unusual location for bone tumors, except for chondroblastomas. Of all chondroblastomas, 95% are located within the epiphysis. The MRI scans show a punctate appearance that is commonly seen in cartilage lesions. The biopsy specimen shows a chondroid lesion with polygonal chondrocytes. These findings are consistent with a chondroblastoma. The natural history of chondroblastomas is for continued growth and bone destruction if left untreated. Treatment should consist of curettage, with or without the use of physical or chemical adjuvants, and bone grafting.

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Question 38

A 17-year-old high school gymnast who has peripatellar knee pain has been unable to practice on a consistent basis for the past 3 years. She denies any specific injury events. Physical therapy for modalities, quadriceps strengthening, and hamstring stretching provide temporary relief. A trial of patellar taping significantly reduces her pain. Examination reveals an 15-degree Q angle, moderate lateral facet tenderness, negative patellar apprehension, and the inability to evert the patella. Radiographs show a moderate lateral patellar tilt. Treatment should now consist of





Explanation

The patient has patellofemoral stress and a tight lateral retinaculum that has failed to respond to nonsurgical management; therefore, the most appropriate treatment includes an arthroscopic lateral retinacular release. A patellar restraining brace may aggravate the peripatellar pain by increasing pressure on the lateral facet. There is no evidence of patellar instability or significant malalignment; therefore, medial retinacular repair or a tibial tubercle transfer is not indicated. A modified Maquet tibial tubercle elevation would be considered only for significant patellofemoral arthrosis. Gambardella RA: Techical pitfalls of patellofemoral surgery. Clin Sports Med 1999;18:897-903.

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Question 39

A 37-year-old man pulled his hamstring playing softball 3 weeks ago. The patient had not noted any mass prior to his injury. MRI scans of the posterior thigh are shown in Figures 4a and 4b. Figure 4c shows the biopsy specimen from a needle biopsy. What is the most likely diagnosis?





Explanation

Malignant fibrous histiocytoma (MFH) is the most common soft-tissue sarcoma. MFH typically presents as a large mass, deep to the fascia with heterogeneous signal on MRI. The MRI scans show a heterogeneous lesion in the posterior thigh. There is significant high signal uptake on the T2-weighted image. The histology shows malignant histiocytic cells with marked atypia and pleomorphism. Histology of a hematoma would show only old hemorrhage and some granulation tissue. Lipoma and liposarcoma are both seen as a fat-containing lesion on histology. No significant fat tissue is seen in this histologic specimen. Histology of myositis ossificans would show bone formation. Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 219-276.

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Question 40

What radiographic measurement is best used to assess the adequacy of deformity correction for the patient shown in Figure 22?

Pediatrics Board Review 2004: High-Yield MCQs (Set 2) - Figure 31





Explanation

Developmental coxa vara develops in early childhood and results in a progressive decrease in the proximal femoral neck-shaft angle with growth. The characteristic radiographic features are seen in this patient and include a decreased neck-shaft angle, a more vertical position of the physeal plate, and a triangular metaphyseal fragment in the inferior femoral neck, surrounded by an inverted radiolucent Y pattern. The main goal of surgery is to correct the varus angulation into a more normal range. Valgus overcorrection is preferred. A recent study emphasized the importance of adequately correcting the Hilgenreiner physeal angle to less than 38 degrees to minimize the risk of recurrent angulation. No study has documented the use of any of the other listed radiographic measurements to the outcome of treating developmental coxa vara. Carroll K, Coleman S, Stevens PM: Coxa vara: Surgical outcomes of valgus osteotomies. J Pediatr Orthop 1997;17:220-224.

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Question 41

Figures 36a and 36b show the MRI scans of a 15-year-old girl who has had pain and recurrent hemarthrosis in the knee for the past year. Plain radiographs are normal. What is the most likely diagnosis?





Explanation

In pediatric patients who have pain and recurrent hemarthrosis in the knee, hemangioma is often seen as an internal derangement of the knee, and long delays in diagnosis are common. An MRI scan is noninvasive and will best aid in diagnosis. In this patient, the MRI scan shows a hemangioma with no evidence of meniscal injury or discoid meniscus. Hemophilia is unlikely because the patient is female. The presence of hemarthrosis makes JRA an unlikely diagnosis.

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Question 42

Figures 10a and 10b show the radiographs of an athletic 9-year-old boy who has activity-related anterior knee pain with intact active knee extension. Examination reveals tenderness to palpation over the inferior pole of the patella. There is no effusion or ligamentous instability. Initial management should consist of





Explanation

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

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Question 43

Figure 1 shows the radiograph of an 11-year-old boy who stubbed his great toe while playing soccer barefoot. He is able to walk home despite a small amount of bleeding at the nail fold. Management should consist of

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





Explanation

Great toe fractures through the physis should be considered open fractures if there is bleeding at the nail fold. Treatment should include irrigation and debridement and appropriate antibiotics. Immobilization with a cast is usually sufficient for treatment of the fracture. Noonan KJ, Saltzman CL, Dietz FR: Open physeal fractures of the distal phalanx of the great toe: A case report. J Bone Joint Surg Am 1994;76:122-125.

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Question 44

What is the most appropriate orthotic management for the lesion shown in Figure 6?

Foot & Ankle 2000 Practice Questions: Set 1 (Solved) - Figure 12





Explanation

The figure shows an intractable plantar keratosis (IPK). The keratoma usually forms beneath a bony prominence. This can occur under the sesamoids, most commonly the tibial sesamoid, or under the fibular condyle of a prominent metatarsal head. The initial treatment of an IPK consists of paring down the callused lesion and placing a metatarsal pad proximal to the lesion to provide posting to unload the bony prominence.

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Question 45

What is the most likely cause of the lesion shown in Figures 35a and 35b?





Explanation

The most common cause of myositis ossificans is contusion. Certain regions, including the quadriceps and brachialis, are more commonly affected. The mechanisms of development have not been clearly established. Beiner JM, Jokl P: Muscle contusion injuries: Current treatment options. J Am Acad Orthop Surg 2001;9:227-237.

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Question 46

Turf toe typically involves injury to which of the following structures of the great toe?





Explanation

The term turf toe includes a range of injuries of the capsuloligamentous complex of the first metatarsophalangeal joint with or without osteochondral fracture of the first metatarsal head or one of the sesamoids. The mechanism of injury is hyperextension. Clanton TO, Butler JE, Eggert A: Injuries to the metatarsophalangeal joints in athletes. Foot Ankle 1986;7:162-176.

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Question 47

A 4-year-old girl sustains an isolated spiral femoral fracture after falling from her tricycle. Management should consist of

Trauma 2006 Practice Questions: Set 1 (Solved) - Figure 12





Explanation

Immediate spica casting is ideal for younger children with uncomplicated femoral fractures that are the result of relatively low-energy injury. Surgical stabilization of pediatric femoral fractures is most commonly performed in children who are older than age 6 years or in children with other factors associated with their femoral fracture, such as concomitant head injury, open fracture, floating knee, severe comminution, or vascular injury. Flynn JM, Skaggs DL, Sponseller PD, et al: The surgical management of pediatric fractures of the lower extremity. Instr Course Lect 2003;52:647-659. Sponseller PD: Surgical management of pediatric femoral fractures. Instr Course Lect 2002;51:361-365. Wright JG: The treatment of femoral shaft fractures in children: A systematic overview and critical appraisal of the literature. Can J Surg 2000;43:180-189.

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Question 48

A 6-year-old African-American boy with sickle cell disease has had pain and limited use of his right arm for the past 3 days. History reveals that he sustained a humeral fracture approximately 3 years ago. A lateral radiograph is shown in Figure 25. Based on these findings, a presumptive diagnosis of chronic osteomyelitis is made. What are the two most likely organisms?

Pediatrics 2004 Practice Questions: Set 3 (Solved) - Figure 3





Explanation

The risk of Salmonella osteomyelitis is much greater in patients with sickle cell disease than the general population. The exact reason for this increased risk is still unclear, but it appears to be associated with an increased incidence of gastrointestinal microinfarcts and abscesses. Both Staphylococcus aureus and Salmonella have been mentioned as the most prevalent causative organisms. Piehl FC, David RJ, Prugh SI: Osteomyelitis in sickle cell disease. J Pediatr Orthop 1993;13:225-227. Givner LB, Luddy RE, Schwartz AD: Etiology of osteomyelitis in patients with major sickle hemoglobinopathies. J Pediatr 1981;99:411-413. Epps CH Jr, Bryant DD III, Coles MJ, Castro O: Osteomyelitis in patients who have sickle-cell disease: Diagnosis and management. J Bone Joint Surg Am 1991;73:1281-1294.

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Question 49

Figure 25 shows the CT scan of an adult patient who has neck pain following a motor vehicle accident. What is the most likely diagnosis?

Anatomy Board Review 2005: High-Yield MCQs (Set 2) - Figure 25





Explanation

If the atlanto-dens interval is greater than 3 mm in an adult, a transverse ligament rupture usually is suspected. The atlanto-dens interval can be seen with CT or in lateral radiographs of the upper cervical spine. Transverse ligament rupture can occur as an isolated entity or in association with an odontoid or a Jefferson's fracture. Patients with this type of injury usually require fusion. Dickman CA, Greene KA, Sonntag VK: Injuries involving the transverse atlantal ligament: Classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery 1996;38:44-50.

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Question 50

Figure 47 shows a transverse MRI scan of a patient's left shoulder. The findings reveal which of the following abnormalities?

Anatomy Board Review 2002: High-Yield MCQs (Set 4) - Figure 9





Explanation

The MRI scan shows a defect in the posterior aspect of the humeral head, commonly referred to as a Hill-Sachs lesion. This is an impaction fracture of the humeral head that occurs during anterior shoulder dislocation. The abnormality on this image is an irregularity of the posterior humeral head; the humeral head otherwise has a homogenous appearance. The coracoid, subscapularis, and posterior labrum are normal. Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 47-63.

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Question 51

Figures 5a and 5b show the radiographs of a 45-year-old patient. What is the most likely diagnosis?





Explanation

Glenoid dysplasia is an uncommon anomaly that usually has a benign course but may result in shoulder pain, arthritis, or multidirectional instability. Shoulder pain and instability often improve with shoulder strengthening exercises. 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.

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Question 52

An 18-year-old man was in a motor vehicle accident and sustained a closed head injury, right displaced scapular body and glenoid fractures, a right proximal humeral fracture, fractures of ribs one through three, facial fractures, and bilateral pubic rami fractures with minimal displacement. He has a systolic blood pressure of 80/40 mm Hg despite fluid resuscitation. A radiograph is shown in Figure 17. Spiral CT does not identify any thoracic or abdominal injuries. What is the next most appropriate step in management?

Trauma Board Review 2006: High-Yield MCQs (Set 2) - Figure 12





Explanation

The patient has sustained high-energy upper extremity and chest injuries. He continues to remain hemodynamically unstable with no obvious thoracic or abdominal injury responsible for bleeding. The pelvic fracture is unlikely to be causing significant bleeding. A scapulothoracic dissociation and possible disruption of one of the great vessels of the upper extremity should be considered. Evaluation of peripheral pulses or blood pressure indices bilaterally in the upper extremities is a simple way to evaluate the need for further work-up. If there is any discrepancy or further concern, angiography of the involved extremity is necessary. Althausen PL, Lee MA, Finkemeier CG: Scapulothoracic dissociation: Diagnosis and treatment. Clin Orthop 2003;416:237-244.

References:

Question 53

Figure 36 shows the radiograph of a 28-year-old man who injured his shoulder in a motocross race. Management should consist of

Sports Medicine Board Review 2004: High-Yield MCQs (Set 4) - Figure 6





Explanation

Fractures of the distal one third of the clavicle have a high incidence of delayed union (45% to 67%) and nonunion (22% to 33%) with nonsurgical management. Surgical stabilization with tension band techniques or a combination of plate and screw techniques is indicated, especially in young, active patients. In this patient, significant displacement of the fracture implies injury to the coracoclavicular ligaments with a higher risk of delayed union or nonunion. Various surgical treatments have been recommended, but the use of smooth wires is not indicated because of the potential for hardware migration. Jupiter JB, Ring D: Fractures of the clavicle, in Ianotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott, Williams and Wilkins, 1999, pp 709-736.

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Question 54

A 40-year-old unrestrained passenger reports chest wall pain after a motor vehicle accident. Which of the following structures is most important in preventing the injury shown in Figure 33?

Upper Extremity 2008 Practice Questions: Set 3 (Solved) - Figure 23





Explanation

Through cadaveric study, Spencer and associates measured anterior and posterior translation of the sternoclavicular joint. The study demonstrated that the posterior sternoclavicular joint capsule is the most important structure for preventing both anterior and posterior translation of the sternoclavicular joint. Gilot GJ, Wirth MA, Rockwood CA: Injuries to the sternoclavicular joint, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott, Williams and Wilkins, 2006, vol 2, pp 1373-1374.

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Question 55

A patient with a left-sided C6-7 herniated nucleous pulposis would likely have which of the following constellation of findings?





Explanation

A C6-7 herniation affects the C7 root. The C7 root has the middle finger as its predominant sensory distribution. Its motor function is the triceps, wrist extension, and finger metacarpophalangeal extension. The reflex is the triceps. Magee D: Principles and concepts, in Orthopedic Physical Assessment, ed 3. Philadelphia, PA, WB Saunders, 1997, pp 1-18.

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Question 56

A 6-month-old child is seen in the emergency department with a spiral fracture of the tibia. The parents are vague about the etiology of the injury. There is no family history of a bone disease. In addition to casting of the fracture, initial management should include





Explanation

Unwitnessed spiral fractures should raise the possibility of child abuse, especially prior to walking age. With nonaccidental trauma being considered in the differential diagnosis, a skeletal survey is indicated to determine if there are other fractures in various stages of healing. Kempe CH, Silverman FN, Steele BF, et al: The battered-child syndrome. JAMA 1962;181:17-24.

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Question 57

When using highly cross-linked ultra-high molecular weight polyethylene as an articulating surface for total knee arthroplasty, what property of the material raises concern?





Explanation

The decreased mobility of the polymer chains from cross-linking leads to decreased volumetric wear but also to decreases in ductility and fatigue resistance. Stresses at the knee are higher and varied in the point of application, leading to the concern for fatigue resistance and fracture.

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Question 58

An inverted radial reflex is associated with





Explanation

An inverted radial reflex is a hypoactive brachioradialis reflex in combination with involuntary finger flexion. It is a spinal cord "release" sign and is associated with upper motor neuron pathology as seen in cervical stenosis with myelopathy. Radiculopathy is characterized by a diminished reflex but no finger flexion. Peripheral neuropathy is not associated with any reflex change. Parsonage-Turner syndrome is an idiopathic brachial neuritis. Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 1998, p 762.

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Question 59

A patient with no history of patellar instability sustains a traumatic lateral patellar dislocation. What structure most likely has been torn?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 9





Explanation

Any of the above structures may be involved in a lateral patellar dislocation. However, biomechanic studies have found that the medial patellofemoral ligament is the major soft-tissue static restraint of lateral patellar displacement, providing at least 50% of this function. Desio SM, Burks RT, Bachus KN: Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998;26:59-65. Conlan T, Garth WP Jr, Lemons JE: Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am 1993;75:682-693.

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Question 60

A patient undergoes the procedure shown in Figure 19. An important part of this procedure is preservation of what wrist ligament?

Anatomy Board Review 2008: High-Yield MCQs (Set 2) - Figure 10





Explanation

Proximal row carpectomy is a salvage wrist procedure that yields a surprisingly stable construct. This has been attributed to two factors: 1) the congruency of the head of the capitate in the lunate fossa (this articulation is less congruent than the native lunate/lunate fossa relationship, but surprisingly stable), and 2) preservation of the radioscaphocapitate ligament, the most radial of the palmar extrinsic ligaments, which prevents ulnar subluxation after proximal row carpectomy.

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Question 61

After humeral head replacement for four-part fractures, what is the most commonly reported difficulty?

Shoulder 2002 Practice Questions: Set 1 (Solved) - Figure 25





Explanation

Results show that patients who underwent humeral head replacement for fracture almost routinely report pain relief, but functional reports vary. The most commonly reported difficulty is the use of weight in the overhead position with wide variation in active elevation. Factors found to affect active elevation include age, humeral offset, greater tuberosity positioning, and four-part (as compared with three-part) fractures. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD: Functional outcome after humeral head replacement for acute three- and fourth-part proximal humeral fractures. J Shoulder Elbow Surg 1995;4:81-86.

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Question 62

What type of brace is shown in Figures 22a and 22b?





Explanation

The figures show a Charcot restraining orthotic walker (CROW). This brace has been used as a customized total contact fit removable brace to maintain foot alignment as the patient evolves from Eichenholz stage 1 to Eichenholz stage 3 Charcot arthropathy. Mehta JA, Brown C, Sargeant N: Charcot restraint orthotic walker. Foot Ankle Int 1998;19:619-623.

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Question 63

What are the most common portals for arthroscopic surgery of the ankle?

Anatomy 2005 Practice Questions: Set 1 (Solved) - Figure 2





Explanation

The most commonly used portals are the anterolateral, anteromedial, and posterolateral portals. They have been shown to be the safest areas for portal placement, allowing no penetration of neurovascular structures. All the other portals involve placing another structure at risk. The anterocentral portal is close to the deep peroneal nerve and anterior tibular artery. The trans-Achilles portal is not recommended because of its limited utility and potential to injure the Achilles tendon. The posteromedial portal is too close to the posterotibial artery and nerve, the flexor hallucis longus and flexor digitorum longus tendons, and the branches of the calcaneal nerve. Stetson WB, Ferkel RD: Ankle arthroscopy: I. Technique and complications. J Am Acad Orthop Surg 1996;4:17-23.

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Question 64

A 40-year-old woman reports the atraumatic onset of severe knee pain and swelling after undergoing an uncomplicated elective cholecystectomy 1 week ago. She denies any history of diabetes mellitus or HIV but has had occasional episodes of mild knee pain and swelling that have always responded to nonsteroidal anti-inflammatory drugs. Radiographs are shown in Figures 5a and 5b. A knee aspiration yields a WBC count of 35,000/mm3. The aspirate should also yield which of the following findings?





Explanation

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

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Question 65

A 15-year-old boy has hindfoot pain and very limited subtalar motion. A CT scan reveals a talocalcaneal coalition involving 40% of the middle facet. He has no degeneration of the posterior subtalar facet. Following failure of nonsurgical management, treatment should consist of





Explanation

The CT scan is an important test to help determine the extent of involvement of the talocalcaneal facet in a talocalcaneal coalition. In a young patient with no arthritis and joint involvement of less than 50%, resection of the coalition and fat pad interposition has been shown to be successful. A calcaneal osteotomy does not address the coalition. Subtalar arthroereisis has been used for treatment of a flexible flatfoot; tarsal coalition patients have a rigid-type flatfoot deformity. Sullivan JA: The child's foot, in Morrissy RT, Weinstein SL (eds): Lovell and Winter's Pediatric Orthopaedics, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 2, pp 1077-1135.

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Question 66

Familial (Leiden) thrombophilia is of importance in joint arthroplasty because of an abnormality in the clotting cascade. Which of the following statements best describes the condition?





Explanation

Factor V Leiden is a disease caused by an abnormality of factor V in which a single amino acid substitution of glutamine for arginine in the protein C cleavage region leads to decreased inactivation of factor V and thus a greater tendency to form clots. More than half of all individuals with Factor V Leiden will develop deep venous thrombosis in the presence of a single additional risk factor such as long bone fracture or total joint arthroplasty.

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Question 67

Injury to which of the following structures has been reported following iliac crest bone graft harvest?

Spine Surgery 2000 Practice Questions: Set 1 (Solved) - Figure 5





Explanation

Injury to the lateral femoral cutaneous nerve and the ilioinguinal nerve have both been described with an anterior iliac crest bone graft harvest. The lateral femoral cutaneous nerve may be injured from retraction after elevating the iliacus muscle or from direct injury when the nerve actually courses over the crest. A posterior crest harvest can injure the superior gluteal artery if a surgical instrument violates the sciatic notch. Injury to the inferior gluteal artery has not been described; it leaves the pelvis below the piriformis muscle belly and should not be at risk even with a violation of the sciatic notch. Injury to the ilioinguinal nerve has been reported from vigorous retraction of the iliacus muscle after exposing the inner table of the anterior ilium. Cluneal nerve injury may occur with posterior crest harvest, particularly if the skin incision is horizontal or extends more than 8 cm superolateral from the posterior superior iliac spine. Kurz LT, Garfin SR, Booth RE Jr: Iliac bone grafting: Techniques and complications of harvesting, in Garfin SR (ed): Complications of Spine Surgery. Baltimore, MD, Williams and Wilkins, 1989, pp 323-341.

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Question 68

A 28-year-old man underwent open reduction and internal fixation of a closed, displaced, intra-articular calcaneal fracture 8 weeks ago. Examination now reveals that the lateral wound is red and draining purulent material. Cultures obtained from the wound grow out Staphylococcus aureus. Radiographs show early healing of the fracture. What is the next most appropriate step in management?

Foot & Ankle Board Review 2006: High-Yield MCQs (Set 2) - Figure 23





Explanation

Intravenous antibiotics alone will not adequately treat this infection. At 8 weeks after surgery, the hardware must be removed because Staphylococcus aureus is a virulent microbe. VAC therapy alone is not adequate without debridement and hardware removal, but it may play a role in postoperative wound care. Calcanectomy is a salvage procedure for calcaneal osteomyelitis or recalcitrant heel ulceration. Benirschke SK, Kramer PA: Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 2004;18:1-6. Lim EV, Leung JP: Complications of intra-articular calcaneal fractures. Clin Orthop 2001;391:7-16.

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Question 69

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





Explanation

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

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Question 70

Figure 38a shows the radiograph of a 12-year-old boy who underwent a reamed intramedullary nailing for a closed femoral shaft fracture. One year after rod removal, he reports groin pain. A current radiograph is shown in Figure 38b. The findings are most likely the result of





Explanation

Osteonecrosis of the femoral head is a known complication from the use of rigid intramedullary nails for femoral fractures in adolescents. When the nails are placed through the piriformis fossa, the lateral ascending vessels of the femoral neck may be injured, resulting in osteonecrosis of the femoral head in 1% to 2% of patients. Rigid reamed nails placed into the piriformis fossa are contraindicated in children with open growth plates because the physis is a barrier to blood supply and the ligamentum teres does not provide sufficient vascularity. Alternative fixation methods for femoral fractures in adolescents include external fixation and open reduction and internal fixation. Nailing through the tip of the trochanter may decrease the incidence of this serious complication. Letts M, Jarvis J, Lawton L, et al: Complications of rigid intramedullary rodding of femoral shaft fractures in children. J Trauma 2002;52:504-516. Stans AA, Morrissy RT, Renwick SE: Femoral shaft fracture treatment in patients age 6 to 16 years. J Pediatr Orthop 1999;19:222-228. Buckley SL: Current trends in the treatment of femoral shaft fractures in children and adolescents. Clin Orthop 1997;338:60-73.

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Question 71

A 17-year-old football player is injured during a play and reports abdominal pain that is soon followed by nausea and vomiting. What organ has most likely been injured?

Sports Medicine 2007 Practice Questions: Set 1 (Solved) - Figure 28





Explanation

The spleen is the most common organ injured in the abdomen as the result of blunt trauma. It is also the most common cause of death because of an abdominal injury. The liver is the second most commonly injured organ. Injury to the other organs is rare. The diagnosis can be made with CT. Treatment ranges from observation to splenectomy, depending on the severity of injury. Green GA: Gastrointestinal disorders in the athlete. Clin Sports Med 1992;11:453-470.

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Question 72

When performing a total knee arthroplasty using modular components, what is the minimum recommended thickness of an ultra-high molecular weight polyethylene insert for a tibial component?

Hip 2004 Practice Questions: Set 1 (Solved) - Figure 17





Explanation

Polyethylene wear has been identified as a major contributor to failure of total knee implants, of which thickness is an important factor. Several studies have shown that the minimum thickness should be 6 to 8 mm. While Wright and Bartel have shown that 6 to 8 mm has been recommended as the minimum thickness of an ultra-high molecular weight polyethylene insert for a tibial component in total knee arthroplasty, more recent work by Meding and associates and Worland and associates has verified the clinical efficacy of 4 mm of polyethylene in compression-molded anatomic graduated nonmodular components. Bartel DL, Bicknell VL, Wright TM: The effect of conformity, thickness, and material on stresses in ultra-high molecular weight components for total joint replacement. J Bone Joint Surg Am 1986;68:1041-1051. Wright TM, Bartel DL: The problem of surface damage in polyethylene total knee components. Clin Orthop 1991;273:261-263. Meding JB, Ritter MA, Faris PM: Total knee arthroplasty with 4.4 mm of tibial polyethylene: 10-year followup. Clin Orthop 2001;388:112-117.

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Question 73

A 65-year-old man has chronic Achilles insertional tendinitis that is refractory to nonsurgical management. A radiograph is shown in Figure 9. Preoperative counseling should include a discussion of the realistic duration of postoperative recovery. You should inform the patient that his expected recovery will last

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 27





Explanation

An older patient with calcaneal enthesopathy may take a year or more to recover after tendon debridement and calcaneal ostectomy. Young patients, and those with purely tendon pathology, may recover more quickly. McGarvey WC, Palumbo RC, Baxter DE, et al: Insertional Achilles tendinitis: Surgical treatment through a central tendon splitting approach. Foot Ankle Int 2002;23:19-25.

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Question 74

Figure 48 shows an MRI scan of the knee. The arrow is pointing to what structure?

Anatomy Board Review 2005: High-Yield MCQs (Set 4) - Figure 12





Explanation

The arrow points to the biceps femoris, which is inserted onto the fibula. The biceps femoris lies at the posterolateral aspect of the thigh. The semimembranosus and the semitendinous lie at the posterior medial aspect of the thigh. Gray H: Anatomy of the Human Body. Philadelphia, PA, Lea and Febiger, 1918, 2000.

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Question 75

A 28-year-old woman has had pain in her hand and mild swelling of the little finger for the past 2 months. A radiograph is shown in Figure 41a, and the biopsy specimen is shown in Figures 41b and 41c. What is the most likely diagnosis?





Explanation

The radiographic appearance shows a slightly expansile lesion in the proximal phalanx of the fifth digit typical of an enchondroma. There is a stippled appearance within the bone and no evidence of cortical destruction. The biopsy reveals a cartilage lesion with basophilic cytoplasm. There are some hypercellular areas but no evidence of pleomorphism. Enchondromas in the tubular bones of the hand are usually more cellular than their counterparts in the femur and humerus and should not be considered malignant. No other lesions are noted in the radiograph, so a diagnosis of Ollier's disease cannot be made. An osteochondroma is a benign surface cartilage tumor. Brown tumor and osteomyelitis can be differentiated from enchondroma based on the histology. Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 225.

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Question 76

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 77

A previously healthy 65-year-old woman has a closed fracture of the right clavicle after falling down the basement stairs. Examination reveals good capillary refill in the digits of her right hand. Radial and ulnar pulses are 1+ at the right wrist compared with 2+ on the opposite side. In the arteriogram shown in Figure 36, the arrow is pointing at which of the following arteries?

Upper Extremity 2008 Practice Questions: Set 3 (Solved) - Figure 28





Explanation

The axillary artery commences at the first rib as a direct continuation of the subclavian artery and becomes the brachial artery at the lower border of the teres major. The arteriogram reveals a nonfilling defect in the third portion of the artery just distal to the subscapular artery. The complex arterial collateral circulation in this region often permits distal perfusion of the extremity despite injury.

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Question 78

Which of the following factors is most likely to be associated with prolonged survival of total knee arthroplasty?





Explanation

In a survivorship study of 9,200 total knee arthroplasties, Rand and Ilstrup identified four independent variables associated with a significantly lower risk of failure: primary total knee arthroplasty, diagnosis of rheumatoid arthritis, age of 60 years or older, and use of a condylar prosthesis with a metal-backed tibial component. Other clinical studies report the use of a posterior stabilized prosthesis to be comparable to a total condylar prosthesis with retained posterior cruciate ligament. Rand JA, Ilstrup DM: Survivorship analysis of total knee arthroplasty: Cumulative rates of survival of 9200 total knee arthroplasties. J Bone Joint Surg Am 1991;73:397-409. Stern SH, Insall JN: Posterior stabilized prosthesis: Results after follow-up of nine to twelve years. J Bone Joint Surg Am 1992;74:980-986.

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Question 79

A healthy 25-year-old man sustains a grade IIIB open tibial fracture. Following appropriate debridement, irrigation, and stabilization with an external fixator, the soft-tissue injury is shown in Figure 30. What is the most appropriate definitive soft-tissue coverage procedure?

Trauma 2006 Practice Questions: Set 3 (Solved) - Figure 8





Explanation

This is a very large near circumferential defect with posterior as well as anterior skin and muscle injury. Bone is exposed. The posterior muscles cannot be rotated since they are part of the zone of injury. The bone and other poorly vascularized areas of this wound would not accept a skin graft. The best chance for limb salvage will be to obtain soft-tissue coverage with a free tissue transfer using the latissimus dorsi. Mathes SJ, Nahai F: Vascular anatomy of muscle: Classification and applications, in Mathes SJ, Nahai F (eds): Clinical Application for Muscle and Musculocutaneous Flaps. St Louis, MO, CV Mosby, 1982, p 20.

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Question 80

A 5-year-old girl has had a low-grade fever, right hip and buttock pain, and a right-sided limp for the past 5 days. Examination shows diffuse tenderness and extreme pain on range of motion of the hip. Laboratory studies show a peripheral WBC count of 13,500/mm3 and an erythrocyte sedimentation rate of 55 mm/h. A radiograph is shown in Figure 46a, and an axial postgadolinium T1-weighted MRI scan with fat suppression and an axial T2-weighted fast spin echo MRI scan are shown in Figures 46b and 46c. What is the most likely diagnosis?





Explanation

MRI findings of acute osteomyelitis include a decrease in the normally high signal intensity of bone marrow on T1-weighted imaging; however, a postgadolinium T1-weighted image with fat suppression will show osteomyelitis as a bright marrow signal compared to the surrounding fat. Osteomyelitis is also brighter than normal fat on T2-weighted imaging. There is no rim-enhancing lesion suggesting an abscess, although myositis is seen in the obturator internus and short external rotators. The clinical scenario and imaging studies do not support the diagnosis of septic hip, eosinophilic granuloma, or pelvic fracture. Dormans JP, Drummond DS: Pediatric hematogenous osteomyelitis: New trends in presentation, diagnosis and treatment. J Am Acad Orthop Surg 1994;2:333-341.

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Question 81

A female cross-country runner has an insidious onset of right groin pain. Radiographs of the right hip reveal a tension-side stress fracture. History reveals that she was treated for a "foot" fracture 1 year ago. In addition to performing internal fixation of the femoral neck, which of the following should be obtained?





Explanation

Stress fractures in female long distance runners are frequently associated with the Female Athletic Triad. The triad consists of osteoporosis, amenorrhea, and altered eating habits. A thorough menstrual history, including age of menarche, history of amenorrhea, and use of oral contraceptives, is imperative. Amenorrhea leads to osteoporosis and predisposes the athlete to fractures. An MRI of the hip is not necessary because a fracture is evident on the radiograph. Serum calcium levels are normal in osteoporosis, a family history would be noncontributory, and it is highly unlikely that a contralateral hip radiograph will yield useful information. Bennell KL, Malcolm SA, Thomas SA, et al: Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-818.

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Question 82

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 83

A 44-year-old man who sustained an elbow dislocation 3 months ago now reports pain and restricted elbow motion. Radiographs are shown in Figures 27a and 27b. Management should consist of





Explanation

The treatment of choice for an ankylosed chronically dislocated elbow is surgical reduction. Open reduction with application of an external fixator provides excellent results for this complex problem. Radial head arthroplasty is indicated for a radial head fracture that cannot be reconstructed. Attempts at closed reduction will be unsuccessful and should not be attempted in a stiff elbow. In chronic dislocations, direct reinsertion of injured ligaments is not feasible because of soft-tissue contracture. Jupiter J, Ring D: Treatment of unreduced elbow dislocation with hinged external fixation. J Bone Joint Surg Am 2002;84:1630-1635.

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Question 84

A 43-year-old soccer player who had knee pain following a twisting injury underwent an arthroscopic meniscectomy 6 months ago. He continues to report posterior knee pain. Examination reveals soft-tissue fullness and tenderness just above the popliteal fossa, trace knee effusion, full range of knee motion, no instability, and negative meniscal signs. Radiographs show some mild medial joint space narrowing but no other bony changes. What is the next most appropriate step in management?





Explanation

The phenomenon of tumors misdiagnosed as athletic injuries has been termed "sports tumors." Lewis and Reilly presented a series of 36 patients who initially were thought to have a sports-related injury but ultimately were diagnosed with a primary bone tumor, soft-tissue tumor, or tumor-like condition. Muscolo and associates presented a series of 25 tumors that had been previously treated with an intra-articular procedure as a result of a misdiagnosis of an athletic injury. Initial diagnoses included 21 meniscal lesions, one traumatic synovial cyst, one patellofemoral subluxation, one anterior cruciate ligament tear, and one case of nonspecific synovitis. The final diagnoses were a malignant tumor in 14 patients and a benign tumor in 11 patients. The authors noted that oncologic surgical treatment was affected in 15 of the 25 patients. The most frequent causes of erroneous diagnosis were initial poor quality radiographs and an unquestioned original diagnosis despite persistent symptoms. Persistent symptoms warrant further diagnostic studies, not additional treatment such as physical therapy, corticosteroid injection, or an unloader brace. Although a bone scan may be helpful in this case and confirm arthrosis of the medial compartment, the suspicion of a soft-tissue mass makes MRI the imaging modality of choice. Muscolo DL, Ayerza MA, Makino A, et al: Tumors about the knee misdiagnosed as athletic injuries. J Bone Joint Surg Am 2003;85:1209-1214.

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Question 85

A corset-type brace may help reduce symptoms during an episode of acute low back pain as the result of





Explanation

Although there is no significant alteration in motion with a corset, studies have shown a decrease in intradiskal pressure. Nachemson A, Morris JM: In vivo measurements of intradiscal pressure: Discometry, a method for determination of pressure in the low lumbar disc. J Bone Joint Surg Am 1964;46:1077-1092.

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Question 86

What type of thoracolumbar spinal injury is associated with an increased risk of neurologic deterioration following admission to the hospital?





Explanation

Gertzbein's Scoliosis Research Society Morbidity and Mortality report noted that neurologic deterioration developed in approximately 16% of patients who were hospitalized with fracture-dislocations of the thoracolumbar spine, a particular concern with rotational burst fractures (AO type C). Patients with standard burst fractures and Chance fractures had a markedly lower incidence of neurologic involvement and tended to remain neurologically stable. Gertzbein SD: Neurologic deterioration in patients with thoracic and lumbar fractures after admission to the hospital. Spine 1994;19:1723-1725.

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Question 87

A 10-year-old boy with severe hemophilia A (factor VIII) sustained an injury to his right forearm 2 hours ago when a classmate fell on his arm during a scuffle. Examination reveals moderate swelling in the forearm, decreased sensation in the distribution of the median and ulnar nerves, and pain on passive extension of the fingers. What is the most appropriate sequence of treatment?





Explanation

The patient has severe hemophilia with a volar forearm hemorrhage and an emerging compartment syndrome. Therefore, it is critical to normalize the clotting deficiency as the first step in treatment. In a patient who has a factor VIII level of less than 1% and no inhibitors to factor VIII, transfusion with 4 unit/kg will typically raise the factor VIII level to 100%. Continuous transfusion can then be used to maintain this level. Compartment pressures can be safely measured after infusion of factor VIII. Because the hemorrhage is of limited duration and any surgery is considered serious in a patient with hemophilia, the compartment pressure should be measured before making a decision regarding a fasciotomy. However, it is important to note that the use of factor VIII concentrates allows both emergency and elective surgery provided that adequate hematology backup is available. Splinting the elbow and wrist in flexion reduces the pressure in the volar compartments, protects the forearm from further trauma, and makes the patient more comfortable. Greene WB: Diseases related to the hematopoietic system, in Morrissy RT, Weinstein SL (eds): Lovell & Winter's Pediatric Orthopaedics, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 345-391. Greene WB, McMillan CW: Nonsurgical management of hemophilic arthropathy, in Barr JS (ed): Instructional Course Lectures 38. Park Ridge, Ill, American Academy of Orthopaedic Surgeons, 1989, pp 367-381.

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Question 88

Acral metastases are most commonly seen in what type of carcinoma?





Explanation

Metastatic lesions to bone are usually located in the axial and proximal appendicular skeleton. Metastases below the elbow and knee are rare, but when they do occur they are most commonly from lung carcinoma. Hayden RJ, Sullivan LG, Jebson PJ: The hand in metastatic disease and acral manifestations of paraneoplastic syndromes. Hand Clin 2004;20:335-343.

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Question 89

The dorsal digital cutaneous nerve of the great toe shown in Figure 8 is a branch of what nerve?

Anatomy 2005 Practice Questions: Set 1 (Solved) - Figure 21





Explanation

The dorsal digital cutaneous nerve of the great toe is a branch of the medial branch of the superficial peroneal nerve. The deep peroneal nerve supplies the first web space. McMinn RMH, Hutchings RT, Logan BM: Color Atlas of Foot and Ankle Anatomy. Weert, Netherlands, Wolfe Medical Publications, 1982, p 50.

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Question 90

A 45-year-old tennis player undergoes surgery for chronic lateral epicondylitis. After returning to play, he notes increasing lateral elbow pain with mechanical catching and locking. Examination shows positive supine posterolateral rotatory instability. What ligament has been injured?





Explanation

The patient has sustained an iatrogenic injury to the lateral ulnar collateral ligament. This injury has been reported after lateral approaches to the elbow. The orbicular, annular, and lateral radial collateral ligaments have a much less important role in lateral elbow stability. The anterior band of the ulnar collateral ligament is on the medial side of the elbow and is important for valgus stability. O'Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.

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Question 91

An 8-year-old girl has had a painless enlarging mass of insidious onset in the left thigh for the past 3 weeks. Her mother denies any history of trauma, fever, or disease. Examination reveals a nontender, mobile mass in the left medial thigh. Her gait is normal. Figures 25a through 25d show the frog-lateral radiograph, the axial and coronal T1-weighted MRI scans, and the axial T2-weighted MRI scan. Biopsy results reveal a nonrhabdomyosarcoma soft-tissue sarcoma. The most appropriate treatment should consist of





Explanation

In childhood, the more common soft-tissue sarcomas are rhabdomyosarcoma, synovial sarcoma, and fibrosarcoma. Rhabdomyosarcoma, treated with radiation therapy and chemotherapy, is a round cell tumor and is inconsistent with this patient's histologic findings. Synovial sarcoma can be monophasic or biphasic with both spindle and epithelial-like cells and is associated with the characteristic reciprocal chromosomal translocation of t(x:18)(p11;q11) which is not found in fibrosarcoma. Synovial sarcoma also can be associated with cystic loculated areas best seen in a T2-weighted MRI scan. Nonrhabdomyosarcoma childhood soft-tissue sarcomas are treated with surgical excision in conjunction with chemotherapy and/or radiation therapy. The histology reveals no inflammatory cells to suggest an abscess; therefore, antibiotics and drainage are unnecessary. The MRI scans clearly show a mass of soft tissue and no bone involvement; therefore, proximal femoral resection is not appropriate. Serial observation is not appropriate because of the history of enlargement and insidious onset. Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St Louis, MO, Mosby Year Book, 1995, p 757.

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Question 92

Figure 27 shows the radiograph of a 26-year-old man who sustained a closed head injury and a closed elbow dislocation 6 weeks ago. Examination reveals 65 degrees to 115 degrees of flexion, and intensive physical therapy has resulted in no improvement. A decision regarding the timing of surgical correction of the contracture should be based on

Shoulder 2002 Practice Questions: Set 3 (Solved) - Figure 2





Explanation

The patient has heterotopic ossification, a more common finding in patients who have sustained head injuries. Treatment will require removal of the heterotopic bone and anterior and posterior capsulectomies. The main concern about timing is the possible recurrence of heterotopic bone. While an extended wait was once thought necessary, this is no longer true. The timing is based on the time since injury and evidence of bone maturation on plain radiographs. A sharp marginal demarcation of the new bone and a trabecular pattern within it are usually present 3 to 6 months after onset, indicating that it is safe to proceed with surgical excision. It is not necessary to wait more than 6 months. Bone scan results are not good indicators because they may remain "hot" for long periods of time. The levels of alkaline phosphatase and serum calcium-phosphorus product do not need to be measured.

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Question 93

A 16-year-old boy with spastic quadriplegic cerebral palsy has been referred for evaluation and management of scoliosis. His parents report increasing problems with sitting balance, positioning, and hygiene because of the deformity. The radiograph shown in Figure 46 reveals a lordoscoliosis of 105 degrees with marked pelvic obliquity. Attempts at correcting the pelvic obliquity on supine bending radiographs show significant rigidity. Management should consist of

Pediatrics Board Review 2001: High-Yield MCQs (Set 4) - Figure 1





Explanation

Spinal stabilization is the treatment of choice in patients with severe scoliosis who have progressive positioning, sitting balance, and/or hygiene problems despite maximal nonsurgical management. Pelvic rigidity and marked frontal plane deformity necessitate anterior and posterior procedures so as to maximize correction and fusion. Weinstein SL (ed): The Pediatric Spine: Principles and Practice. New York, NY, Raven Press, 1994, pp 977-997.

References:

Question 94

A 25-year-old woman has had continuous pain after falling on her outstretched wrist 12 weeks ago. A current radiograph is shown in Figure 11. Management should consist of

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 30





Explanation

The patient has a scaphoid fracture with cystic resorption of the distal aspect of the midthird of the scaphoid. This fracture is unlikely to heal without intervention. Percutaneous pinning, closed manipulation, and bone grafting will not restore alignment. Treatment requires restoration of scaphoid length, bone grafting, and internal fixation to obtain healing with normal alignment. Cooney WP, Linscheid RL, Dobyns JH, Wood MB: Scaphoid nonunion: Role of anterior interpositional bone grafts. J Hand Surg Am 1988;13:635-650. Fernandez DL: A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg Am 1984;9:733-737. Stark HH, Rickard TA, Zemel NP, Ashworth CR: Treatment of ununited fractures of the scaphoid by illiac bone grafts and Kirschner-wire fixation. J Bone Joint Surg Am 1988;70:982-991.

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Question 95

A 58-year-old woman is seen in the emergency department after falling at home. History reveals that she underwent right total knee arthroplasty 2 years ago. Radiographs are shown in Figures 56a and 56b. What is the most appropriate treatment?





Explanation

The radiographs show an oblique periprosthetic distal femoral fracture. Of the options listed, open reduction and internal fixation is the most appropriate surgical option because a well-fixed, posterior stabilized closed box femoral component is present. Nonsurgical methods are not favored because of the highly displaced, unstable fracture pattern and prolonged immobility. Revision with a stemmed component is an option but would sacrifice more bone stock in this younger patient. Moran MC, Brick GW, Sledge CB, et al: Supracondylar femoral fracture following total knee arthroplasty. Clin Orthop 1996;324:196-209. Raab GE, Davis CM III: Early healing with locked condylar plating of periprosthetic fractures around the knee. J Arthroplasty 2005;20:984-989.

References:

Question 96

A soccer player who sustained a twisting injury to the right ankle while making a cut is unable to bear weight and has diffuse tenderness over the anterior and lateral aspects of the ankle. Examination also shows a positive squeeze test. Plain radiographs and a stress radiograph are shown in Figures 26a through 26c. Radiographs of the leg and knee are normal. What is the most appropriate management?





Explanation

The mechanism of injury, physical examination, and radiographs indicate a "high" ankle sprain with disruption of the distal tibiofibular ligaments and interosseous membrane. These injuries typically involve pronation and external rotation forces. In addition, recovery is significantly delayed, often requiring 6 to 8 weeks to heal. Radiographs obtained months after recovery often show calcification within the distal syndesmosis, which is not typically symptomatic. This patient has gross instability, resulting in a high incidence of chronic diastasis and subluxation leading to impaired function. Treatment should consist of reduction and stabilization with a transsyndesmotic screw because this injury demonstrates a widened syndesmosis. Boytim MJ, Fisher DA, Neumann L: Syndesmotic ankle sprains. Am J Sports Med 1991;19:294-298.

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Question 97

A 26-year-old professional rodeo bull rider sustained a grade III midshaft femoral fracture after being thrown from his bull. He underwent closed interlocking intermedullary nailing with a titanium rod, and his recovery was uneventful. Prior to returning to competition, the patient must

Sports Medicine Board Review 2004: High-Yield MCQs (Set 2) - Figure 5





Explanation

While it is recommended that a patient gain full range of motion, pain-free function, and symmetric strength prior to returning to vigorous activities, it is absolutely essential that radiographs of the fracture site reveal a circumferential external bridging callus to prevent refracture. This is particularly important for comminuted femoral fractures with various sized fragments. It is also recommended that a return to rodeo riding be postponed for at least 1 year. Brumback RJ, Ellison TS: Intermedullary nailing of femoral stress fractures. J Bone Joint Surg Am 1992;74:106-112. Bucholz RW, Jones A: Fractures of the shaft of the femur. J Bone Joint Surg Am 1991;73:1561-1566.

References:

Question 98

What assay most directly assesses gene expression at the posttranslational level?





Explanation

Gene expression at the posttranslational level refers to proteins, as opposed to DNA or RNA. The only assay above that targets protein expression directly is the Western blot. Standard PCR is amplification of targeted DNA segments, regardless of whether or not they are actively expressed. Real-time PCR, Northern blot, and microarray expression profile analysis all quantify RNA as a means to determine posttranscriptional gene expression. Brinker MR: Cellular and molecular biology, immunology, and genetics in orthopaedics, in Miller MD (ed): Review of Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2001, pp 81-94.

References:

Question 99

A 21-year-old woman sustained a minimally displaced traumatic spondylolisthesis of C2 (Hangman's fracture) after striking the windshield with her forehead during a motor vehicle accident. Management should consist of

Trauma Board Review 2000: High-Yield MCQs (Set 2) - Figure 7





Explanation

According to the classification of Levine and Edwards, a type I Hangman's fracture is minimally displaced without angulation and represents a stable injury. Good clinical success has been achieved with nonsurgical management consisting of use of a rigid collar until the patient reports pain relief, followed by quick mobilization.

References:

Question 100

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





Explanation

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

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