Orthopedic Board Review MCQs: Mock Exam Set #158 (100 Questions)

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

A 52-year-old woman underwent open reduction and internal fixation for radial and ulnar shaft fractures 2 months ago. In a second fall she refractured her forearm and required revision surgery with bone grafting. One month after the second operation she notes erythema, swelling, and drainage from the volar radial incision. In addition to antibiotic treatment, management should consist of

A 63-year-woman has an elbow flexion contracture. History reveals that she underwent three previous surgeries to remove a malignant fibrous histiocytoma of the forearm. An MRI scan reveals a locally recurrent tumor at the site of the previous surgery. Which of the following is considered the most predictive factor for local recurrence?

A 19-year-old man who sustained a spinal cord injury in a motor vehicle accident 3 days ago has 5/5 full strength in the deltoids and biceps bilaterally, 4/5 strength in wrist extension bilaterally, 1/5 triceps function on the right side, and 2/5 triceps function on the left side. The patient has no detectable lower extremity motor function. Based on the American Spinal Injury Association's classification, what is the patient's functional level?

Figures 36a and 36b show the radiographs of a 3-year old child who has a congenital upper extremity deformity. Which of the following features would be a major contraindication to a centralization procedure?

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

An obese patient undergoing total knee arthroplasty is at increased risk for which of the following complications?

A 35-year-old man has had a mass on the bottom of his foot for the past 6 months. He reports that initially the mass was exquisitely painful but now is minimally tender. Examination reveals a 2.5- x 2.0-cm firm, noncompressible, nonmobile mass contiguous with the plantar fascia in the distal arch. The mass is particularly prominent with passive dorsiflexion of the ankle and toes. What is the best course of action?

Which of the following substances is least likely to affect the success of bone union after lumbar arthrodesis?

Which of the following conditions precludes performing a tendon transfer?

An 83-year-old woman with a long history of her foot slowly and progressively "turning out" now reports significant ankle pain. History reveals that she has significant cardiac disease and exercise-induced angina. Examination reveals a deficiency in the posterior tibial tendon; however, the hindfoot remains moderately supple. Radiographs reveal a valgus tilt of the tibiotalar joint and early arthrosis. What is the most appropriate orthotic management?

Which of the following best describes the mechanical response of the inferior glenohumeral ligament to repetitive subfailure strains?

Figure 8a shows the clinical photograph of an 83-year-old woman who has an enlarging left forearm mass. MRI scans are shown in Figures 8b and 8c. What is the next most appropriate step in management?

Radiographs of a 15-year-old girl with knee pain reveal a radiopaque lesion of the distal femoral metaphysis and epiphysis with a small associated soft-tissue mass. A biopsy specimen shows osteoid and pleomorphic cells with multiple mitotic figures. Staging studies show no other sites of disease. Treatment should consist of

A 24-year-old woman fell from a horse and landed on her outstretched right arm. Radiographs reveal an elbow dislocation with a type II coronoid fracture and a nonreconstructable comminuted radial head fracture. What is the most appropriate management?

A 25-year-old construction worker lands on his outstretched hand in a fall. The position of his wrist at the time of impact causes a force that leads to hyperextension, ulnar deviation, and intercarpal supination. Radiographs are shown in Figures 48a and 48b. What type of injury pattern is shown?

Which of the following is considered an inherent problem in using the distal oblique shortening (Weil) metatarsal osteotomy for dorsal metatarsophalangeal subluxation?

The fracture shown in Figure 50 is most reliably treated with what form of fixation?

A 72-year-old woman has had progressively increasing pain in the right knee for the past 6 months. She denies any trauma and has no pain in any other joints, but she notes occasional swelling in the knee and a catching sensation. Figures 31a and 31b show the plain radiographs and Figure 31c shows the MRI scan. Treatment should consist of

A 55-year-old woman with a history of untreated idiopathic scoliosis has had neurogenic claudication for the past several months. MRI reveals spinal stenosis at L2-L3, L3-L4, and L4-L5. Radiographs show a 45-degree lumbar curve from T10 to L4, with a degenerative spondylolisthesis at L4-L5. Laminectomy at the stenotic levels and stabilization of the deformity are planned. Which of the following is NOT considered an absolute indication for extending the fusion to the sacrum, rather than stopping at L5?

Figure 14 shows the AP radiograph of a patient who underwent prosthetic arthroplasty 8 years ago and has now become symptomatic again over the past 18 months. A WBC count and erythrocyte sedimentation rate are within normal limits, and aspiration of the glenohumeral joint yields a negative Gram stain and cultures. Which of the following procedures will most likely provide the best pain relief and function?

A 66-year-old man reports a 2-week history of worsening low back and leg pain. He reports that his pain is aggravated by lying down and relieved by standing and walking. He notes that he has been losing weight recently and that his pain has been awakening him during the night. His medical history is significant for hypertension, coronary artery disease, and prostate cancer. His physical examination is essentially unremarkable. Lumbar radiographs are within normal limits. What is the most appropriate management for this patient?

Thoracic disk herniations are most frequently found in what area of the spine?

Figure 16 shows the radiograph of an otherwise healthy 62-year-old woman who fell. Management should consist of

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

A 72-year-old man injured his right shoulder after tripping over a chair leg. Radiographs obtained in the emergency department reveal an isolated anterior dislocation. After successful closed reduction, the patient has recurrent anterior instability and is unable to elevate the arm. What is the most likely cause of the recurrent instability?

A 23-year-old man sustains a unilateral jumped facet with an isolated cervical root injury in a motor vehicle accident. Acute reduction results in some initial improvement of his motor weakness. Over the next 48 hours, examination reveals ipsilateral loss of pain and temperature sensation in his face, limbs, and trunk, as well as nystagmus, tinnitus, and diplopia. What is the most likely etiology for these changes?

In revision total hip arthroplasty, an acetabular reconstruction cage is best indicated for which of the following patterns of bone loss?

A 28-year-old anesthesia resident has aching pain in his dominant right forearm after injuring it while playing basketball 1 week ago. He reports that he is unable to perform regional anesthesia that requires manipulation of a needle. Examination reveals that he is unable to flex the interphalangeal joint of the thumb, and flexion of the distal interphalangeal joint of the index finger is weak. Management should consist of

What is the mechanism of action of an intramuscular injection of botulinum type A toxin in reducing spasticitiy?

What is the recommended treatment of a skeletally immature 12-year-old boy who has an anterior cruciate ligament-deficient knee?

An otherwise healthy 45-year-old woman reports the onset of severe right leg pain. Figure 20a shows an axial MRI scan of the L4-5 level, and Figure 20b shows a sagittal view with the arrow at the L4-5 level. What nerve root is the most likely source of her pain?

A patient is scheduled to undergo total knee arthroplasty (TKA) following failure of nonsurgical management. History reveals that she underwent a patellectomy as a teenager as the result of a motor vehicle accident. Examination reveals normal ligamentous stability. For the most predictable outcome, which of the following implants should be used?

Which of the following primary prognostic factors best predicts the outcome of the knee lesion shown in Figure 22?

A 45-year-old woman has had intense pain in her foot for the last 3 days. She also reports a mild fever and difficulty with shoe wear. Examination reveals a swollen, slightly erythematous warm foot with tenderness at the great toe metatarsophalangeal joint and pain with passive motion of the joint. An AP radiograph is shown in Figure 13. Which of the following will best aid in determining a definitive diagnosis?

Which of the following choices best describes the fracture pattern shown in Figures 2a through 2c?

Figures 18a and 18b show the radiographs of a 13-year-old baseball player who sustained a patellar dislocation with an associated lateral femoral condyle fracture. What ligament is attached to this fragment?

A 100-lb 9-year-old boy has a closed midshaft transverse femoral fracture. The oblique fracture is shortened by 3 cm with a 10-degree varus angulation. Surgical management consists of intramedullary, retrograde flexible titanium nailing. To optimize fracture stability, the surgeon should

Which of the following benign bone lesions can develop lung metastases?

A 53-year-old patient is seen in the emergency department after sustaining a fall onto her left hip. A current radiograph is shown in Figure 40. What is the best treatment option?

A Trendelenburg gait is most likely to be seen in association with

What is the relative amount of type II collagen synthesis in disease-free adult articular cartilage compared to developing teenagers?

The anticoagulant effect of the low-molecular-weight heparins (LMWH) is mediated by the binding affinity of antithrombin III to which of the following coagulation factors?

A 28-year-old woman fell on her right wrist while rollerblading 2 days ago. She was seen in the emergency department at the time of injury and was told she had a sprain. Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. Standard wrist radiographs are normal. What is the next most appropriate step in management?

A 20-year-old football player has repeated episodes of heat cramps during summer training sessions. A deficiency of what electrolyte is most responsible for heat cramps?

Sacral fractures are most likely to be associated with neurologic deficits when they involve what portion of the sacrum?

Figure 16 shows the clinical photograph of a 3-month-old infant with a foot deformity that has been nonprogressive since birth. Examination reveals that the deformity corrects actively and with passive manipulation. There is no associated equinus. Management should consist of

Figure 30 shows an axial T1-weighted MRI scan of a patient's right shoulder. The arrows are pointing to what normal structure?

Figure 22 shows the radiograph of a 7-year-old boy who underwent retrograde elastic nailing of a femoral shaft fracture. What is the most common problem following this procedure?

A 73-year-old man is scheduled to have mature heterotopic bone resected from around his left total hip arthroplasty. The optimal management for prophylaxis against the return of heterotopic bone postoperatively is radiation therapy that consists of

Figures 5a and 5b show the radiographs of a 56-year-old man who was seen in the emergency department following a twisting injury to his left ankle. Examination in your office 3 days later reveals marked swelling and diffuse tenderness to palpation about the ankle and leg. What is the next most appropriate step in management?

A 50-year-old woman has a painful hallux valgus and a painful callus beneath the second metatarsal head. A radiograph is shown in Figure 46. To correct these problems, treatment of the great toe deformity should consist of

What is the most common presenting sign or symptom in an adult with lumbar pyogenic infection?

Which of the following tumors is most likely to present with a pathologic fracture in a child?

A 32-year-old woman sustained an injury to her left upper extremity in a motor vehicle accident. Examination reveals a 2-cm wound in the mid portion of the dorsal surface of the upper arm and deformities at the elbow and forearm; there are no other injuries. Her vital signs are stable, and she has a base deficit of minus 1 and a lactate level of less than 2. Radiographs are shown in Figures 9a and 9b. In addition to urgent debridement of the humeral shaft fracture, management should include

What is the most common secondary malignancy arising in pagetic bone?

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

An 11-year-old boy stepped on a nail and sustained a puncture to the right forefoot 6 days ago. He was wearing tennis shoes at the time of injury. Treatment in the emergency department consisted of local debridement and tetanus prophylaxis; a radiograph was negative for foreign body, chondral defect, or fracture. He was discharged with a 3-day prescription of amoxicillin and clavulanate. The patient now has increasing pain and tenderness at the puncture site. What is the best course of action?

Which of the following is considered the treatment of choice for a 3-cm chondroblastoma of the distal femoral epiphysis with no intra-articular extension?

An 18-month-old infant with myelomeningocele and rigid clubfeet has grade 5 quadriceps and hamstring strength, but no muscles are functioning below the knee. What is the best treatment option for the rigid clubfeet?

An 18-month-old boy with obstetric brachial plexus palsy is being evaluated for limited right shoulder motion. Physical therapy for the past 6 months has failed to result in improvement of the contracture. Which of the following studies is necessary prior to any shoulder reconstruction?

What nerve is most at risk during placement of the anterolateral portal in elbow arthroscopy?

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

Figures 1a through 1c show the radiograph and MRI scans of a 16-year-old patient who has a painful hip. Examination reveals a significant limp, limited abduction and internal rotation, and severe pain with internal rotation and adduction. A biopsy specimen is shown in Figure 1d. What is the deposited pigment observed in this condition?

A baseball pitcher has intractable posterior and superior shoulder pain. The arthroscopic view seen in Figure 25 shows no Bankart or Hill-Sachs lesion and a negative drive-through sign. There are no signs of ligamentous laxity, but active compression and anterior slide tests are positive. Treatment should consist of

What additional percentage of energy expenditure above baseline is required for ambulation after an above-the-knee amputation?

An 18-year-old man sustained a knife injury to his midback, with the entry wound 2 cm to the left of the midline. He has been diagnosed with a hemicord transection. Neurologic examination will most likely reveal left-sided loss of

When an adult hip is surgically dislocated for relief of femoro-acetabular impingment, what is the risk of postoperative iatrogenic osteonecrosis?

A 4-year-old child was born with bilateral congenital radial clubhands. Which of the following associated conditions is a contraindication to centralization of the hands on the ulna?

A 35-year-old man who snowboards sustained the injury shown in Figures 4a through 4c. What is the mechanism of injury?

The view from an anterosuperior portal of the right shoulder shown in Figure 12 reveals which of the following findings?

Which of the following best characterizes bone mineralization?

A 47-year-old man sustained a degloving injury over the pretibial surface and anterior ankle region in a motor vehicle accident. After debridement and irrigation, there is inadequate tissue for closure of the exposed anterior tibial tendon and tibia. Prior to definitive soft-tissue coverage, management should consist of

It has been shown that bisphosphonate-based supportive therapy (pamidronate or zoledronate) reduces skeletal events (onset or progression of osteolytic lesions) both in patients with multiple myeloma and in cancer patients with bone metastasis. The use of biphosphonate therapy has been associated with

Figure 38 shows the radiograph of a 75-year-old woman who has had right shoulder pain, difficulty sleeping on the affected arm, and difficulties performing activities of daily living for the past 6 weeks. Initial nonsurgical management includes analgesics, a subacromial cortisone injection, and gentle range-of-motion exercises. However, these modalities have failed to provide relief, and the patient reports that she is unable to elevate her arm. Her pain is worse and she would like the most reliable treatment method for pain relief and functional improvement. What is the best surgical treatment?

A 19-year-old man was struck by a car and is seen in the emergency department with a grade IIIC open distal tibia and fibula fracture. Examination reveals that the toes are cool and dusky with a sluggish capillary refill. Angiography reveals a lesion in the posterior tibial artery amenable to repair. There is no sensation on the plantar aspect of the foot, and he is unable to flex his toes. A clinical photograph and radiograph are shown in Figures 2a and 2b. What is the next most appropriate step in management?

A 40-year-old woman has had sciatic pain on the left side for the past 8 weeks. She reports that the pain radiates to her posterior thigh, lateral calf, and into the dorsum of her left foot. Neurologic examination shows weakness of the left extensor hallucis longus. Axial T2-weighted MRI scans through L4-L5 are shown in Figure 14. Management should consist of

A study is being designed to compare the effectiveness of an antibiotic. The choice of the number of patients (ie, the sample size) depends on several factors. What type of calculation assesses the potential of the study to successfully address the effectiveness of the antibiotic?

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?

When performing surgery on a patient with insertional Achilles tendinitis and a Haglund's deformity, how much of the Achilles tendon insertion can be safely detached without having to consider reattachment with bone anchors?

A 58-year-old man with type 1 diabetes mellitus is seen in the emergency department and he reports a 3-day history of a red swollen foot but no history of trauma. Examination reveals that the skin is intact, and the patient has discomfort with passive range of motion at the ankle, hindfoot, and midfoot joints. He denies any fever. Laboratory studies show a WBC count of 7,800/mm3, an erythrocyte sedimentation rate of 40 mm/h, a C-reactive protein level of 23, and a serum glucose of 100. A radiograph and MRI scans are shown in Figures 16a through 16c. What is the next most appropriate step in management?

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?

The acceleration of an object under the influence of a force depends directly on the mass of the object. The angular acceleration of an object under the influence of a moment depends directly on the

A 10-year-old soccer player has bilateral heel pain and reports that the pain is worse during and immediately after sports. Examination reveals that the calcaneal tuberosities are painful to palpation bilaterally. What is the most likely diagnosis?

After making a tackle, a football player is found prone and unconscious without spontaneous respirations. Initial management should consist of

Creatine is currently being used by athletes as a dietary supplement in an attempt to enhance performance. What is the physiologic basis for its use?

Bleeding is encountered while developing the internervous plane between the tensor fascia lata and the sartorius during the anterior approach to the hip. The most likely cause is injury to what artery?

A 35-year-old patient has right hip pain. Figures 34a and 34b show the coronal MRI scan and the biopsy specimen. What is the most likely diagnosis?

A 60-year-old right hand-dominant women fell on her outstretched arm and sustained an anterior shoulder dislocation. The shoulder is reduced in the emergency department and she is seen for follow-up 1 week later wearing a sling. Examination reveals that she has significant difficulty raising her arm in forward elevation and has excessive external rotation compared to the contralateral shoulder. What is the next most appropriate step in management?

A follow-up examination of a patient 6 weeks after knee surgery reveals a range of motion from 5 degrees to 55 degrees of flexion. Which of the following statements best summarizes the role of manipulation under anesthesia for this patient?

Which of the following statements best describes the outcome of the routine use of continuous passive motion (CPM) machines after total knee arthroplasty (TKA)?

A 28-year-old woman has a moderate hallux valgus deformity and a prominence of the medial eminence. She can participate in all activities and reports that she could wear 3-inch heels in the past, but she now notes medial eminence pain even while wearing a soft leather flat shoe with a cushioned sole. She requests recommendations regarding surgical correction. Examination reveals a 1-2 intermetatarsal angle of 10 degrees. A clinical photograph and radiograph are shown in Figures 13a and 13b. What is the best course of action?

What structure is marked Q in the diagram of the brachial plexus shown in Figure 22?

A 67-year-old patient seen in the emergency department reports the acute onset of pain and is unable to ambulate. History reveals that the patient underwent surgical treatment for a periprosthetic femoral fracture 6 months ago. A radiograph is shown in Figure 41. What is the best treatment option at this time?

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

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

Figure 36 shows the radiograph of a 14-year-old boy who has been treated in the past for Perthes' disease with an abduction brace. He now has hip pain that limits his activity, and nonsteroidal anti-inflammatory drugs have failed to provide relief. What is the most appropriate treatment?

Figure 33 shows the MRI scan of a 55-year-old woman who has had a 6-week history of back and leg pain. Which of the following clinical scenarios is most consistent with the MRI scan findings at L4-L5?

A 55-year-old woman with a long history of low back and left lower extremity pain has failed to respond to exhaustive nonsurgical management. MRI scans show bulging and degeneration at L3-4 and L4-5 as well as a normal disk at L2-3 and L5-S1. She undergoes provocative lumbar diskography at L3-4, L4-5, and L5-S1. Post-diskography axial CT images of L3-4 and L4-5 are shown in Figures 6a and 6b, respectively. The injections at L3-4 and L4-5 produce no pain. The injection at L5-S1 produces 10/10 concordant back pain with radiation to the lower extremity. What is the most appropriate recommendation at this time?

Decreased activity of which of the following proteins may be predictive of an aggressive soft-tissue sarcoma?