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

Orthopedic Surgery Board Review: Mock Exam Set #262 (100 High-Yield MCQs)

27 Apr 2026 103 min read 91 Views
AAOS Trauma MCQs: Board Prep Part 9

Key Takeaway

This page provides 100 high-yield orthopedic surgery multiple-choice questions (MCQs) designed for ABOS, OITE, and FRCS board exam preparation. As Mock Exam Set #262, it offers comprehensive practice across all subspecialties, helping surgeons master key concepts and excel in their board certifications.

Comprehensive 100-Question Exam


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Question 1

A 37-year-old man has had isolated chronic knee swelling for the past 6 months. He denies any history of specific trauma. Examination reveals a large effusion with a stable knee, but the remainder of the examination is normal. Plain radiographs are unremarkable. An MRI scan reveals a large effusion without meniscal injury. An arthroscopic image of the suprapatellar pouch is shown in Figure 23. What is the most likely diagnosis?

Sports Medicine 2004 Practice Questions: Set 3 (Solved) - Figure 2





Explanation

The history and physical examination are consistent with a monoarticular joint condition but not typical of joint sepsis. The arthroscopic appearance of brownish proliferative synovium is typical of PVNS. PVNS is a monoarticular synovial disease of unknown etiology and is treated with total synovectomy. The proliferative synovitis is not consistent with chondromalacia. Synovial cell sarcoma is an extracapsular disease. Rheumatoid arthritis typically is polyarticular, and the synovial appearance is not associated with hemosiderin deposition. Flandry FC, Hughston JC, Jacobson KE, Barrack RL, McCann SB, Kurtz DM: Surgical treatment of diffuse pigmented villonodular synovitis of the knee. Clin Orthop 1994;300:183-192.

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Question 2

A 47-year-old woman has an asymptomatic pelvic mass that was discovered on routine gynecologic examination. A radiograph, CT scan, MRI scan, and biopsy specimen are shown in Figures 7a through 7d. Metastatic work-up is negative. Treatment should consist of





Explanation

The imaging studies show a chondrosarcoma; therefore, surgical treatment is indicated. There is no role for intralesional treatment of an exophytic lesion, particularly in the pelvis. Even obtaining a biopsy specimen risks intrapelvic contamination, although many surgeons would still perform a biopsy prior to a resection to confirm the diagnosis. Chondrosarcoma is considered resistant to both radiation therapy and chemotherapy; therefore, radiation therapy generally is not used except for unresectable lesions. Chemotherapy would be used only for metastatic disease or in patients with high-grade chondrosarcoma. The grade would not be known until after resection, and in this patient, the histology slide showed a grade I neoplasm. Chemotherapy would not be used preoperatively because a cartilage tumor is unlikely to shrink, and in this patient, the lesion is resectable. Springfield DS, Gebhardt MS, Mcguire MH: Chondrosarcoma: A review. J Bone Joint Surg Am 1996;78:141-149.

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Question 3

Subluxation caused by rheumatoid arthritis is most commonly seen at what level of the cervical spine?

Spine Surgery 2000 Practice Questions: Set 1 (Solved) - Figure 2





Explanation

Approximately 65% of cervical subluxations occur at C1-C2. Of these, 50% are anterior, with the remainder being lateral and posterior. The second most common type is basilar invagination, occurring in 40% of patients. The third most common type is subaxial, occurring in 20% of patients with rheumatoid arthritis. Subluxation at more than one level is common. Boden S, Clark CR: Rheumatoid arthritis of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, p 693. Boden SD, Dodge LD, Bohlman HH, Rechtine GR: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.

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Question 4

The tibiofibular overlap used to diagnose syndesmotic diastasis on an AP view is most commonly measured between the





Explanation

The tibiofibular overlap is measured between the medial border of the fibula and the lateral border of the anterior tibial tubercle. Plain radiographic assessment of the distal tibiofibular syndesmosis requires AP and mortise views. The following criteria have been used as the normal limits in adults: a talocrural angle of + or - 83 degrees with up to 5 degrees of normal difference between both sides, a medial clear space of less than 4 mm, a talar tilt of less than 2 mm, a tibiofibular clear space of less than 5 mm, a tibiofibular overlap of greater than or equal to 0 mm, and a talar subluxation that is a subjective assessment of congruity of the tibial articular surface and the talar dome; any incongruity is abnormal. It has been recommended to obtain the first three measurements on the mortise view and the other three on the AP view. Wuest TK: Injuries to the distal lower extremity syndesmosis. J Am Acad Orthop Surg 1997;5:172-181.

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Question 5

Figure 26 shows the radiograph of an otherwise healthy Caucasian 5-year-old boy who has a painless limp. What is the best treatment option?

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





Explanation

The prognosis of Legg-Perthes disease in children younger than age 6 years is good. There is no indication that surgical treatment will improve the outcome. Range-of-motion exercises to prevent contracture may be helpful. Herring JA, Kim HT, Browne R: Legg-Calve-Perthes disease: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004;86:2121-2134.

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Question 6

A 17-year-old patient sustained a closed calcaneal fracture when he jumped off of a roof 2 years ago, and he underwent nonsurgical management at the time of injury. The patient now reports lateral hindfoot pain that is worse with weight-bearing activities. Anti-inflammatory drugs and orthoses have failed to provide relief. Coronal and sagittal CT scans are shown in Figures 36a and 36b. What is the best course of action?





Explanation

The CT scans show evidence of a lateral wall blowout and malunion without significant arthrosis of the subtalar joint. In a young patient, it is preferable to avoid a fusion and allow residual motion by performing an exostectomy that decompresses the lateral subtalar joint and peroneal tendons. Chandler JT, Bonar SK, Anderson RB, et al: Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures. Foot Ankle Int 1999;20:18-24.

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Question 7

Figure 13a shows the radiograph of a 9-year-old girl who sustained complete transverse fractures of the radial and ulnar shafts while in-line skating. A manipulative closed reduction is performed, and the result is seen in Figure 13b. What is the next most appropriate step in management?





Explanation

Bayonet apposition of the radius and ulnar shafts is quite acceptable, as long as the angulation is less than 10 degrees. The rotation must be acceptable as well. This patient went on to full healing, with full supination and pronation of the forearm and no cosmetic deformity. Price CT, Scott DS, Kurzner ME, Flynn JC: Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-712.

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Question 8

The peroneus tertius is a commonly used landmark for arthroscopic portal placement. What is the function of this tendon?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 36





Explanation

The peroneus tertius, although absent in 10% of the population, originates on the distal third of the extensor surface of the fibula and inserts onto the base of the fifth metatarsal, possibly extending to the fascia over the fourth interosseous space. The muscle is located in the anterior compartment of the leg and is innervated by the deep peroneal nerve. The tendon produces dorsiflexion and eversion when walking and can be used as an insertion point during tendon transfers to assist dorsiflexion. This tendon is peculiar to humans and is a proximally migrated deep extensor of the fifth toe. Joshi SD, Joshi SS, Athavale SA: Morphology of the peroneus tertius muscle. Clin Anat 2006;19:611-614. Williams PL, Bannister LH, Berry MM, et al (eds): Gray's Anatomy, ed 38. London, Churchill Livingston, 1995, p 883.

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Question 9

Which of the following complications may occur subsequent to resurfacing hip arthroplasty for osteonecrosis of the hip but not after total hip arthroplasty?





Explanation

Advocates of resurfacing hip arthroplasty cite preservation of the proximal femoral bone stock as the main advantage of this procedure over total hip arthroplasty. Fracture of the retained femoral neck has been reported following resurfacing arthroplasty. The exact etiology of the latter is unknown. Technical errors, such as notching of the femoral neck or possibly disruption of the blood supply to the femoral head during extensive soft-tissue exposure, may result in femoral neck fracture. Gabriel JL, Trousdale RT: Stem fracture after hemiresurfacing for femoral head osteonecrosis. J Arthroplasty 2003;18:96-99.

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Question 10

A 68-year-old man embarks on a 24-week strength training program. He trains at 80% of his single repetition maximum for both the upper and lower extremities. Which of the following changes can be anticipated?





Explanation

Consistent, long-term exercise training in older athletes has proven very beneficial in reversing both endurance and strength losses that traditionally have been seen with aging. This patient's program will lead to a significant increase in the strength, cross-sectional area, and capillary density of the trained muscles. No major changes in aerobic capacity are anticipated. Strength improvements of up to 5% per day, similar to those for younger athletes, have been identified in this population in one study. Kirkendall DT, Garrett WE Jr: The effects of aging and training on skeletal muscle. Am J Sports Med 1998;26:598-602.

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Question 11

A 28-year-old painter has had increasing pain in his hand and forearm after sustaining a paint injection wound to the tip of his left index finger 24 hours ago. Management should consist of

Trauma Board Review 2000: High-Yield MCQs (Set 2) - Figure 12





Explanation

The clinical presentation soon after injury may be surprisingly innocuous, but all high-pressure injection injuries of various materials are best treated by emergent surgical debridement of all foreign material from the flexor tendon sheath as well as the subcutaneous tissues. Subsequent hospital admission, IV antibiotics, and possible repeat debridements usually are necessary. The use of antibiotics alone is inadequate treatment of this severe injury. Pinto MR, Turkula-Pinto LE, Cooney WP, Wood MB, Dobyns JH: High-pressure injection injuries of the hand: Review of 25 patients managed by open wound technique. J Hand Surg Am 1993;18:125-130. Urbaniak JR, Evans JP, Bright DS: Microvascular management of ring avulsion injuries. J Hand Surg Am 1981;6:25-30. Tsai TM, Manstein C, DuBou R, Wolff T, Kutz JE, Kleinert HE: Primary microsurgical repair of ring avulsion amputation injuries. J Hand Surg Am 1984;9:68-72. Kay S, Werntz J, Wolff T: Ring avulsion injuries: Classification and prognosis. J Hand Surg Am 1989;14:204-213.

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Question 12

A 7-year-old boy has a limp with pain and tenderness over the distal right femur. Radiographs are shown in Figures 5a and 5b. Based on these findings, what is the best course of action?





Explanation

The patient has a nonossifying fibroma, and the symptoms suggest that there is significant weakening of the cortex and/or microfracture; therefore, biopsy, curettage, and bone grafting is the treatment of choice. Based on the size of the lesion and the presence of symptoms, observation is likely to result in pathologic fracture. A biopsy will further weaken the bone unless combined with curettage and bone grafting. Radiation therapy is not used in the treatment of nonossifying fibroma and is rarely used in any benign condition affecting skeletally immature individuals. Steroid injection has been used in the treatment of unicameral bone cysts and in Langerhan's cell histiocytosis but not for nonossifying fibroma. Dormans, JP, Pill SG: Fractures through bone cysts: Unicameral bone cysts, aneurysmal bone cysts, fibrous cortical defects, and nonossifying fibromas. Instr Course Lect 2002;51:457-467.

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Question 13

What normal tissue has a low signal intensity (appears black) on both T1- and T2-weighted images?

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





Explanation

Tendons, cortical bone, ligaments, menisci, and fibrous tissue will show low signal intensity (SI) on both T1- and T2-weighted images. Fat-containing tissues, such as subcutaneous fat and bone marrow, will show high SI on T1-weighted images and low SI on T2-weighted images. Tissues with high water content, such as joint fluid, intervertebral disk, and edema, will show low SI on T1-weighted images and high SI on T2-weighted images. Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 65-70.

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Question 14

Figure 17 shows the radiograph of a 25-year-old professional football player who has superior shoulder pain that prevents him from sports participation. History reveals that he sustained a shoulder injury that was treated with closed reduction and temporary pinning 3 years ago. The best course of action should be

Shoulder Board Review 2002: High-Yield MCQs (Set 2) - Figure 4





Explanation

The radiograph shows a complete acromioclavicular separation. Because the patient is a professional athlete who is unable to participate, surgery is indicated. Chronic separations, especially those with previous trauma from joint pinning, should be treated with resection of the distal clavicle and stabilization to the coracoid. Some type of biologic reconstruction of the coracoclavicular ligaments is generally recommended. Open repair of the ligaments is generally not possible in such a delayed fashion. Screw fixation alone will not provide a lasting solution as the screws usually need to be removed, leaving no fixation in place. Reconstruction using the coracoacromial ligament is generally recommended with coracoclavicular fixation to protect the repair while it heals. Nuber GW, Bowen MK: Disorders of the acromioclavicular joint: Pathophysiology, diagnosis and management, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999.

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Question 15

A 17-year-old girl who initially presented as a child with multiple skeletal lesions, café-au-lait spots, and precocious puberty now has bone pain. A recent bone scan reveals multiple areas of increased scintigraphic uptake, including bilateral proximal femurs. A radiograph is shown in Figure 19. Besides activity modification, what is the next best line of treatment for decreasing her pain?

Basic Science 2008 Practice Questions: Set 1 (Solved) - Figure 70





Explanation

McCune-Albright syndrome is the combination of polyostotic fibrous dysplasia, café-au-lait lesions, and endocrine dysfunction. The most common endocrine presentation is precocious development of secondary sexual characteristics. Compared with bone lesions in patients without polyostotic disease, the skeletal lesions in patients with the syndrome tend to be larger, more persistent, and associated with more complications. Bisphosphonate therapy has been shown in several studies to decrease the pain associated with the skeletal lesions of fibrous dysplasia. DiCaprio MR, Enneking WF: Fibrous dysplasia: Pathophysiology, evaluation and treatment. J Bone Joint Surg Am 2005;87:1848-1864.

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Question 16

A neurologic injury at T11-L2 with loss of bowel and bladder control is best described as what syndrome?

Spine Surgery Board Review 2000: High-Yield MCQs (Set 2) - Figure 15





Explanation

Conus medullaris syndrome describes isolated loss of bowel and bladder function, usually at T12-L1 but can include T11-L2. In central cord syndrome, lower extremity motor function is better than upper extremity function. Cauda equina syndrome generally involves injury at the lumbar levels, with some degree of lower extremity motor loss. Posterior cord syndrome is characterized by preservation of motor function below the level of injury and position/vibratory sensory loss. In anterior cord syndrome, the lower extremity findings include loss of light touch, sharp/dull, and temperature sensations below the level of injury, as well as motor function. Apple DF Jr: Spinal cord injury rehabilitation, in Rothman RH, Simeone FA (eds): The Spine, ed 3. Philadelphia, PA, WB Saunders, 1992, Chapter 31.

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Question 17

A 23-year-old baseball pitcher who has diffuse pain along the posterior deltoid reports pain during late acceleration and follow-through. Examination of his arc of motion from external rotation to internal rotation at 90 degrees of shoulder abduction reveals a significant deficit in internal rotation when compared to the nonthrowing shoulder. Initial management should consist of

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 3





Explanation

Loss of internal rotation is common among overhead throwers and tennis players. Posterior capsular stretching can improve symptoms when accompanied by rest and gradual resumption of throwing. To avoid a false impression of improvement, cortisone injection is not recommended. Pitching through pain can cause further damage to the labrum and capsule. A sling and external rotator strengthening will not improve internal rotation. Kibler WB: Biomechanical analysis of the shoulder during tennis activities. Clin Sports Med 1995;14:79-85.

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Question 18

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





Explanation

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

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Question 19

A 34-year-old man sustained a tibial fracture in a motorcycle accident. What perioperative variable is associated with the greatest relative risk for reoperation to achieve bone union?





Explanation

In a recent analysis of 200 patients with tibial fractures, Bhandari and associates attempted to identify variables that were predictive of reoperation. The variables in the study were type of injury (fracture pattern), degree of open injury, mechanism of injury, cortical bone contact, postoperative complications, polytrauma, anti-inflammatory drug use, nail insertion technique (reamed versus nonreamed), smoking history, alcohol use, diabetes mellitus, peripheral vascular disease, age, disability status pre-injury, gender, surgeon, time to surgery, steroid use, phenytoin use, antibiotic use, anticoagulant use, and type of fixation used. Three variables were statistically significant predictors of reoperation to achieve bone union in the first postinjury year: transverse fracture pattern, open fracture, and cortical contact of 50% or less. Using these three variables, four reoperation risk groups were identified based on the number of these three variables present: 0, 1, 2, or 3. The risk for reoperation was 0%, 18%, 47%, and 94%, respectively. The authors concluded that these statistics can provide prognostic information to patients and help identify those high-risk patients where early intervention to achieve union is indicated. In addition, the data highlights the significance of achieving cortical contact at the time of initial fixation.

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Question 20

A 16-year-old high school student undergoes a routine preparticipation physical examination at the beginning of the school year. Examination reveals marked laxity of both shoulders but only mild generalized laxity in other joints. The load and shift test allows for anterior humeral translation to the glenoid rim and posterior humeral translation beyond the glenoid rim. The sulcus sign is present. What is the next most appropriate step in management?





Explanation

This patient has shoulder laxity without apprehension. Because there is a wide range of normal laxity in asymptomatic shoulders, the physician should inform the student of these findings, recommend shoulder strengthening exercises, and allow unrestricted sports participation unless symptoms develop. Harryman DT, Sidles JA, Harris SL, Matsen FA III: Laxity of the normal glenohumeral joint: A quantitative in vivo assessment. J Shoulder Elbow Surg 1992;1:66-76. Hawkins RJ, Bokor RJ: Clinical evaluation of shoulder problems, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, p 186. McFarland EG, Campbell G, McDowell J: Posterior shoulder laxity in asymptomatic athletes. Am J Sports Med 1996;24:468-471.

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Question 21

The main advantage of surgical repair of an acute Achilles tendon rupture, when compared with nonsurgical management, is reduced

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





Explanation

The literature supports similar clinical outcomes after surgical and nonsurgical methods. The chief difference lies in the complications between the groups. Surgical patients experience more wound problems but a significantly lower rerupture rate. Although suturing the tendon allows earlier mobility, the tendon healing time is unchanged. Nonsurgical methods are less expensive to provide. Maffulli N: Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81:1019-1036. Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U: Operative versus nonoperative treatment of Achilles tendon rupture: A prospective randomized study and review of the literature. Am J Sports Med 1993;21:791-799.

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Question 22

The spring ligament of the foot connects what two bones?





Explanation

The spring ligament is also known as the calcaneonavicular ligament and connects the calcaneus to the navicular. This ligament supports the talar head and is an important anatomic supporting structure of the medial longitudinal arch of the foot. Choi K, Lee S, Otis JC, et al: Anatomical reconstruction of the spring ligament using peroneus longus tendon graft. Foot Ankle Int 2003;24:430-436.

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Question 23

A 26-year-old rugby player injured his foot when tackled from behind. Radiographs are seen in Figures 35a through 35c. What is the most appropriate treatment?





Explanation

The patient has a ligamentous Lisfranc injury. Diastasis seen between the bases of the second metatarsal and medial cuneiform is pathognomonic for a rupture of the Lisfranc's ligament. This injury is best treated surgically with either open reduction and internal fixation or possibly closed manipulation and percutaneous screw fixation if anatomic alignment can be achieved closed. Pin fixation has been shown to be inferior to screw fixation due to the length of time that fixation is required for adequate ligament healing. Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries of the tarsometatarsal joint. Orthop Clin North Am 2001;32:11-20.

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Question 24

What is the major difference in outcome following open reduction and internal fixation (ORIF) of the tibial plafond at 2 to 5 days versus 10 to 20 days?

Trauma Board Review 2006: High-Yield MCQs (Set 2) - Figure 13





Explanation

Long-term outcomes following tibial plafond fractures treated with ORIF are satisfactory in most patients despite a high incidence of posttraumatic osteoarthritis. If ORIF is delayed until 10 to 20 days following injury, the major difference in outcomes is fewer complications associated with wound healing. Ankle strength, pain, range of motion, and the development of arthritis are equal regardless of the time until fixation. Sirkin M, Sanders R, DePasquale T, et al: A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 1999;13:78-84.

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Question 25

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





Explanation

Traditional surgeries for anterior cruciate ligament-deficient knees carry the potential risk of premature physeal closure in young athletes. Therefore, most surgeons are reluctant to recommend intra-articular reconstruction using bone tunnels with bone-patellar tendon-bone autografts or hamstring tendons. The current recommendation for young athletes is activity modification, rehabilitation, and functional bracing until the patient is near skeletal maturity. At that time, for the very symptomatic patient, the treatment of choice is intra-articular repair of the anterior cruciate ligament. If a skeletally immature patient continues to have instability despite rehabilitation and bracing, a modification of the femoral tunnel to the over-the-top position will not place the lateral femoral physis at risk for premature closure and deformity. A centrally placed tibial tunnel will minimize the risk of angular deformity and minimize limb-length discrepancy if physeal arrest occurs. Barry P: Anterior cruciate ligament injuries, in Andrews JR, Timmerman LA (eds): Diagnostic and Operative Arthroscopy. Philadelphia, Pa, WB Saunders, 1997, p 358. McCarroll JR, Shelbourne KD, Porter DA, Rettig AC, Murray S: Patellar tendon graft reconstruction for midsubstance anterior cruciate ligament rupture in junior high school athletes: An algorithm for management. Am J Sports Med 1994;22:478-484. Nottage WM, Matsuura PA: Management of complete traumatic anterior cruciate ligament tears in the skeletally immature patient: Current concepts and review of the literature. Arthroscopy 1994;10:569-573.

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Question 26

A 62-year-old patient with rheumatoid arthritis has had pain and instability of the elbow following total elbow replacement 2 years ago. A complete work-up, including aspiration and cultures, is negative. Figures 9a and 9b show the AP and lateral radiographs. Treatment should consist of





Explanation

The patient has aseptic loosening of the original semiconstrained prosthesis and significant proximal ulnar bone destruction; therefore, the treatment of choice is revision arthroplasty using a semiconstrained design. Although orthotic stabilization could be used, it will not provide long-term pain relief. Resection arthroplasty after removal of the components may lead to painful instability. Elbow arthrodesis would be difficult with the bone stock loss and is not considered the best option. Two main contraindications to the use of an unconstrained prosthesis are significant bone loss and previous use of a hinged or semiconstrained prosthesis. An ulnar allograft could be combined with the use of a semiconstrained long-stemmed ulnar prosthesis as a treatment modification. Ewald FC, Simmons ED Jr, Sullivan JA, et al: Capitellocondylar total elbow replacement in rheumatoid arthritis: Long-term results. J Bone Joint Surg Am 1993;75:498-507.

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Question 27

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





Explanation

It has been proposed that an imbalance in the proteolytic cascade involving matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) may play a role in the development or progression of malignancy. TIMP activity has been shown to be weak or nonexistent and MMP activity to be high in patients with soft-tissue sarcoma. The level of vascular endothelial growth factor is shown to be a negative prognostic indicator because the expression of this factor is associated with angiogenesis and aggressive growth of many tumors including Ewing' s sarcoma and chondrosarcoma. Stromelysin is a type of MMP. The biology of cytokines in malignancy is complex. A low level of interleukin-1 is not known to be associated with high-grade tumors.

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Question 28

What type of cementless femoral fixation results in the highest rate of distal femoral osteolysis?

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





Explanation

Despite the relatively few problems with porous-coated cementless stems, stress shielding and thigh pain do occur. One design feature of proximally coated stems that has been associated with a higher incidence of distal osteolysis is the presence of noncircumferential proximal porous coating. Tapered, modular with sleeve, and hydroxyapatite proximally porous-coated stems have all performed well. Fully porous-coated straight stems have a high survivorship rate as well. Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 175-180. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.

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Question 29

A 32-year-old football coach has had a 4-month history of increasing right wrist pain, particularly during blocking exercises, and he reports significant pain with range of motion and gripping activities. He denies any history of trauma. Examination reveals dorsal wrist tenderness and boggy fullness over the dorsum of the wrist. No erythema is noted. Grip strength is 60% compared with the opposite side. Radiographs are shown in Figures 5a and 5b. What is the most likely diagnosis?





Explanation

The patient has Kienbock's disease (osteonecrosis of the lunate), which presents with boggy synovitis of the wrist, decreased range of motion, and often normal radiographs. The patient's radiographs reveal small fragments from the lunate, with increased density in the lunate body. While a traumatic event may precede the patient's pain, often an insidious increase in pain is found. Repetitive trauma has been suggested as a possible cause. This disease process is classically associated with an ulnar-negative variant. An MRI scan, revealing a low-intensity signal in the lunate, is the best diagnostic tool for early Kienbock's disease. Green DP, Hotchkiss RN, Pederson WC: Green's Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, pp 837-848.

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Question 30

What is the treatment of choice for the injury shown in Figures 20a through 20c?





Explanation

The radiographs show multiple carpometacarpal dislocations. Reduction is often obtainable but difficult to maintain. Internal fixation is required to maintain the reduction, preferably with Kirschner wires. Closed reduction and percutaneous pinning is preferred by some surgeons. Others recommend open reduction to remove irreconstructable osteochondral fragments from the individual joints and to ensure correct reduction of the carpometacarpal joints. Kirschner wires are removed at 6 to 8 weeks. Prokuski LJ, Eglseder WA Jr: Concurrent dorsal dislocations and fracture-dislocations of the index, long, ring, and small (second to fifth) carpometacarpal joints. J Orthop Trauma 2001;15:549-554.

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Question 31

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?





Explanation

The patient will continue to have pain secondary to the ankle arthrosis with both the UCBL and the molded articulated ankle-foot orthosis. The total contact orthotic does not provide enough hindfoot control to support the progressive collapse of the ankle into valgus positioning. A molded leather gauntlet will not only control tibiotalar motion but also control hindfoot motion and allow support of the longitudinal arch.

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Question 32

Figures 45a and 45b show the radiographs of a 40-year-old woman with rheumatoid arthritis who is unable to straighten her ring and little fingers. Examination reveals that the fingers can be passively corrected, but she is unable to actively maintain the fingers in extension. Management should consist of





Explanation

The patient has extensor tendon ruptures at the level of the wrist that are the result of synovitis at the distal radioulnar joint (Vaughn-Jackson syndrome). Extensor indius proprius transfer appropriately matches strength and excursion of the ruptured extensor digiti quinti and extensor digitorum communis tendons. An extensor tenosynovectomy with distal radioulnar joint resection decreases the synovitis, which if left untreated may cause additional tendon ruptures. Radial head resection is used for posterior interosseous nerve compression secondary to radial head synovitis, and in this patient only two fingers are involved, which rules out this diagnosis. Dynamic splinting is not indicated for ruptured tendons. Metacarpophalangeal arthroplasties and imbrication of the sagittal bands are used for metacarpophalangeal arthritis and extensor tendon subluxation. If this was the problem, the patient should be able to maintain the fingers in extension after they are passively extended. Total wrist arthrodesis prevents the tenodesis effect, thus limiting effective tendon excursion and making the proposed transfer less effective. Feldon P, Terrono AL, Nalebuff EA, et al: Rheumatoid arthritis and other connective tissue diseases: Tendon ruptures, in Green DP, Hotchkiss RN, Pederson WC (eds): Green's Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 1669-1684. Moore JR, Weiland AJ, Valdata L: Tendon ruptures in the rheumatoid hand: Analysis of treatment and functional results in 60 patients. J Hand Surg Am 1987;12:9-14.

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Question 33

A 12-year-old girl has had pain in her right knee for 1 month that started as activity-related and progressed to night pain. Radiographs are shown in Figures 16a and 16b, and a biopsy specimen is shown in Figure 16c. What is the recommended treatment?





Explanation

This is a classic appearance for an osteosarcoma. The radiographs reveal a mixed osteolytic and osteoblastic lesion in a skeletally immature patient in the distal right femoral metaphysis. The pain pattern with progressive symptoms leading to the presence of night pain is also typical for this condition. The biopsy specimen reveals pleomorphic cells and the presence of osteoid. The current standard of care in the treatment of osteosarcoma is neoadjuvant chemotherapy followed by surgical resection or amputation followed by additional postoperative chemotherapy. Osteosarcoma is not radiosensitive. 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 10-year-old boy has had a prominent scapula for the past year. He reports crepitus and aching over the area, but only when he is active. A radiograph and CT scans are shown in Figures 37a through 37c. What is the most likely diagnosis?





Explanation

The findings are typical for an osteochondroma. It is found as an outgrowth of bone and cartilage from those bones that arise from enchondral ossification. It may be flat, verrucous, or with a long stalk and cauliflower-like cap. Osteochondromas can become symptomatic secondary to irritation of the adjacent musculature. They cease to proliferate when epiphyseal growth ceases.

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Question 35

Figure 42 shows the radiograph of a 12-year-old boy who has a limp and pain in the left hip with athletic activity. Examination reveals decreased abduction and internal rotation of the left hip, with pain at the extremes of motion and a 1-cm limb-length discrepancy. Management should consist of

Pediatrics 2001 Practice Questions: Set 3 (Solved) - Figure 25





Explanation

The radiograph shows changes that are most consistent with Legg-Calve Perthes disease. Valgus extension osteotomy is the salvage procedure of choice in patients with late symptomatic Perthes disease with severe joint incongruity. Prerequisites for valgus extension osteotomy include an adequate range of hip adduction and proof of improved congruity in the new position. Total hip arthroplasty is not a good alternative in the young patient. Varus osteotomy would further shorten the extremity and place a flattened portion of the femoral head in the acetabulum. A prerequisite of the innominate osteotomy is a congruent reduction. Skaggs DL, Tolo VT: Legg-Calve-Perthes disease. J Am Acad Orthop Surg 1996;4:9-16.

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Question 36

Which of the following methods of meniscal repair has the highest load to failure strength?





Explanation

Numerous experimental studies have shown that vertical suture techniques are superior to all of the other noted methods. In fact, vertical sutures have been shown to be twice as strong as several of these techniques. DeHaven KE: Meniscus repair. Am J Sports Med 1999;27:242-250. Dervin GF, Downing KJ, Keene GC, McBride DG: Failure strengths of suture versus biodegradable arrow for meniscal repair: An in vitro study. Arthroscopy 1997;13:296-300.

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Question 37

A 22-year-old woman reports a 4-year history of worsening low back and left lower extremity pain following a motor vehicle accident. Management consisting of physical therapy, chiropractic manipulation, and interventional pain management, including sacroiliac joint injections and epidural steroid injections, has failed to provide relief. A sagittal T2-weighted MRI scan is shown in Figure 8. No nerve root compression is seen on axial images. She is currently working and lives with her fiancé. She smokes half a pack of cigarettes per day and reports depression on her health history. She is being maintained on narcotic analgesics and is having increasing difficulty performing her activities of daily living secondary to pain. What is the most appropriate management at this time?

Spine Surgery 2009 Practice Questions: Set 1 (Solved) - Figure 27





Explanation

The MRI scan reveals a rudimentary disk at the L5-S1 level, suggesting transitional anatomy. There is a posterior disk bulge at L3-4. At L4-5, there is disk desiccation and loss of disk height, with a posterior disk bulge and a high intensity zone in the posterior annulus, suggesting an annular tear. While these and similar radiographic findings have been associated with the severity of a patient's pain, they are also commonly found in cross-sectional studies of asymptomatic subjects. Carragee and associates found 59% of symptomatic patients undergoing diskography have high intensity zones as compared to 25% of asymptomatic subjects of a similar patient profile. Diskographic injections provoked pain in disks with high intensity zones approximately 70% of the time whether the individual was previously symptomatic or not. This patient's non-specific pain pattern does not require further work-up as she is not a surgical candidate. Carragee EJ, Paragioudakis SJ, Khurana S: 2000 Volvo Award winner in clinical studies: Lumbar high-intensity zone and discography in subjects without low back problems. Spine 2000;25:2987-2992. Pneumaticos SG, Reitman CA, Lindsey RW: Diskography in the evaluation of low back pain. J Am Acad Orthop Surg 2006;14:46-55. Brox JI, Sorensen R, Friis A, et al: Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913-1921.

References:

Question 38

A 40-year-old man has a painless mass around his left ankle. He notes minimal growth over the past year. An MRI scan is shown in Figure 73a, and biopsy specimens are shown in Figures 73b and 73c. What is the most likely diagnosis?





Explanation

The biopsy specimen is a low-power view of a soft-tissue sarcoma with a biphasic pattern of epithelial cells and fibrous spindle cells that are typical of a synovial sarcoma. A deep, painless soft-tissue mass greater than 5 cm in size is suspicious for a sarcoma. The imaging in this patient is indeterminate and the patient requires a biopsy for an accurate diagnosis. The biopsy reveals a tumor with a biphasic appearance consistent with a synovial sarcoma. These tumors are slow growing, occur primarily in the lower extremities, and are found in a younger demographic population compared to malignant fibrous histiocytoma and liposarcoma. They can occur in a biphasic pattern with clumps of epithelial cells and fibrous spindle cells or in a monophasic pattern. Synovial sarcomas stain positively for keratin. Keratin is positive in nearly all biphasic types and in many tumors of the monophasic fibrous type. Sixty percent of these tumors are found in the lower extremity. The area around the knee is the most common location, followed by the ankle and foot. Epithelioid and clear cell sarcomas are found associated with tendon sheaths of the hand and feet and are generally smaller in size. Epithelioid sarcoma may resemble granulomatous inflammation histologically; clear cell sarcoma is composed of nests of clear cells with occasional multinucleated giant cells. Pigmented villonodular synovitis is found within the synovium and is characterized by a villous histologic appearance with hemosiderin-laden macrophages. Malignant fibrous histiocytoma has a storiform histologic pattern with an abundance of pleomorphic cells. Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St Louis, MO, Mosby, 1995, p 757.

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Question 39

The therapeutic effect of etanercept in the treatment of rheumatoid arthritis is primarily mediated through





Explanation

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

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Question 40

Which of the following best describes the relationship of the anterior tibial artery and dorsalis pedis artery to the extensor hallucis longus (EHL) tendon as they progress from the level of the ankle to the dorsum of the foot?





Explanation

At the ankle level, the anterior tibial artery lies medial to the EHL tendon. The artery becomes the dorsalis pedis after crossing onto the dorsum of the foot. At this point, the artery lies lateral to the tendon. Resch S: Functional anatomy and topography of the foot and ankle, in Myerson M (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 1, pp 25-49.

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Question 41

Figure 44 shows the radiograph of a 65-year-old man who underwent a revision arthroplasty to remove a loose, cemented femoral stem. When planning the postoperative restrictions, the surgeon should be aware that

Hip & Knee Reconstruction 2007 Practice Questions: Set 3 (Solved) - Figure 19





Explanation

The transfemoral approach, also known as the extended trochanteric osteotomy, is an important technique to master for revision hip surgery. When performed correctly, it allows excellent exposure of the femoral canal and aids in exposure of the acetabulum. As demonstrated in the study cited, however, it markedly reduces the torque that the composite can withstand without failure. This type of basic science study is important to guide postoperative rehabilitation.

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Question 42

Which of the following infectious organisms may be associated with underlying malignancy?





Explanation

Evidence implicates an association, albeit unexplained, between Clostridium septicum infection and malignancy, particularly hematologic or intestinal malignancy. The malignancy is often at an advanced stage, compromising survival of the patients. A bowel portal of entry is postulated for most patients. In the absence of an external source in the patient with clostridial myonecrosis or sepsis, the cecum or distal ileum should be considered a likely site of infection. Increased awareness of this association between Clostridium septicum and malignancy, and aggressive surgical treatment, may result in improvement in the present 50% to 70% mortality rate. Other organisms associated with malignancy include group Clostridium streptococci that are occasionally associated with upper gastrointestinal malignancies. Schaaf RE, Jacobs N, Kelvin FM, et al: Clostridium septicum infection associated with colonic carcinoma and hematologic abnormality. Radiology 1980;137:625-627.

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Question 43

A newborn with myelomeningocele has no movement below the waist and has bilateral hips that dislocate with provocative flexion and adduction. What is the best treatment option for the hip instability?

Pediatrics Board Review 2007: High-Yield MCQs (Set 2) - Figure 18





Explanation

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

References:

Question 44

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

Sports Medicine 2004 Practice Questions: Set 3 (Solved) - Figure 16





Explanation

The patient has a distal biceps rupture. While the distal biceps contributes to elbow flexion, its main function is forearm supination. Baker BE, Bierwagen D: Rupture of the distal tendon of the biceps brachii: Operative versus non-operative treatment. J Bone Joint Surg Am 1985;67:414-417. D'Arco P, Sitler M, Kelly J, et al: Clinical, functional, and radiographic assessments of the conventional and modified Boyd-Anderson surgical procedures for repair of distal biceps tendon ruptures. Am J Sports Med 1998;26:254-261.

References:

Question 45

What is the most accurate description of the relationship between gender and knee loading during landing while playing basketball?





Explanation

Ford and associates studied 81 high school basketball players and found that females landed with greater total valgus knee loading and a greater maximum valgus knee angle than male athletes. Hewett and associates reported in a study of 205 female athletes that those with increased dynamic valgus and high abduction loads were at increased risk of anterior cruciate ligament injury. Hewett TE, Myer GD, Ford KR, et al: Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: A prospective study. Am J Sports Med 2005;33:492-501.

References:

Question 46

A characteristic genetic translocation has been noted in which of the following tumors?

Basic Science 2002 Practice Questions: Set 1 (Solved) - Figure 16





Explanation

There have been no characteristic gene translocations or rearrangements noted in osteosarcoma, chondrosarcoma, neurofibrosarcoma, or epithelioid sarcoma. In contrast, Ewing's sarcoma has been noted to have a consistent genetic translocation t(11:22). Brockstein BE, Peabody TD, Simon MA: Soft tissue sarcomas, in Vokes EE Golomb HM (eds): Oncologic Therapies. New York, NY, Springer-Verlag, 1999, pp 925-952.

References:

Question 47

Figure 17 shows the AP radiograph of a 75-year-old man with right hip pain. The femoral component is loose. The mechanism of loosening is most likely secondary to

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 5





Explanation

The femoral construct shown in the radiograph has failed to produce ingrowth of the stem. The stem has subsided and rotated. Impingement of the trochanter did not occur until after the stem subsided. There is no evidence of osteolysis or third-body wear debris from the cerclage wire. A larger femoral stem needs to be implanted to achieve rigid fixation. Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 217-238.

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Question 48

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





Explanation

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

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Question 49

Figures 11a and 11b show the radiographs of a 50-year-old man who was struck by a car. Treatment should consist of





Explanation

The patient has a displaced femoral neck fracture. Although the treatment remains controversial, most clinicians advocate either a closed or open reduction in younger active patients. Achieving an anatomic reduction is necessary to avoid loss of reduction, nonunion, or osteonecrosis. An acceptable reduction may have up to 15 degrees of valgus angulation and 10 degrees of posterior angulation. Parallel multiple screws or pins are the most common method of internal fixation. Prosthetic replacement is generally reserved for older and less active individuals. Callaghan JJ, Dennis DA, Paprosky WG, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 97-108.

References:

Question 50

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

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





Explanation

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

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Question 51

A patient who underwent open reduction and internal fixation of an olecranon fracture 2 months ago now reports painless limitation of motion. Examination reveals a well-healed incision and a flexion-extension arc from 40 degrees to 80 degrees. The patient has been performing home exercises. Radiographs are shown in Figures 26a and 26b. What is the most appropriate treatment?





Explanation

The radiographs do not show an articular malunion. Treatment is directed at the soft-tissue contracture and should begin with formal physical therapy and static progressive splinting. Radiation therapy is effective in the perioperative period and is indicated when ectopic bone formation is a concern. Morrey BF: The posttraumatic stiff elbow. Clin Orthop Relat Res 2005;431:26-35.

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Question 52

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





Explanation

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

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Question 53

A 20-year-old college athlete is seen for follow-up after sustaining an injury at football practice 2 days ago. He reports that he tackled a player and felt neck pain and numbness in both arms. The numbness resolved within seconds, but his neck remains painful and stiff. He denies any history of neck pain or injury. Examination reveals limited neck motion. The neurologic examination and radiographs are normal. MRI scans of the cervical spine are shown in Figure 34. During counseling, the patient, his family, and his coach should be informed that he has an acute cervical disk herniation and cannot play

Spine Surgery Board Review 2000: High-Yield MCQs (Set 4) - Figure 8





Explanation

A player who has an acute cervical disk herniation should not be allowed to return to play until the acute phase is over. Certain players with large herniations may require surgery before returning to play to eliminate the risk of disk-related stenosis and cord compression. Morganti C, Sweeney CA, Albanese SA, Burak C, Hosea T, Connolly PJ: Return to play after cervical spine injury. Spine 2001;26:1131-1136.

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Question 54

A 28-year-old man was shot in the foot with a .22 caliber handgun approximately 2 hours ago. Examination reveals an entrance wound dorsally and a plantar exit wound. The foot is neurovascularly intact. Radiographs reveal a nondisplaced fracture of the third metatarsal. Soft-tissue management for this injury should consist of





Explanation

The patient has sustained a low-velocity, low-caliber gunshot wound to the foot. Because the injury occurred within a period of 8 hours, this is classified as a type I wound. Several studies support the use of surface debridement, cleansing, and sterile dressings as the treatment of choice. More aggressive measures are reserved for high-velocity injuries and shotgun injuries. Brettler D, Sedlin ED, Mendes DG: Conservative treatment of low velocity gunshot wounds. Clin Orthop 1979;140:26-31. Hampton OD: The indications for debridement of gunshot bullet wounds of the extremities in civilian practice. J Trauma 1961;1:368-372.

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Question 55

A 68-year-old man had a 3-year history of shoulder pain that failed to respond to nonsurgical management. Examination reveals forward elevation to 120 degrees and external rotation to 30 degrees. True AP and axillary radiographs and an axial CT scan are shown in Figures 1a through 1c. What management option would lead to the best long-term results?





Explanation

The radiographs and CT scan reveal osteoarthritis with posterior subluxation and posterior bone loss. Total shoulder arthroplasty with reaming of the high side to neutralize the glenoid surface has been shown to yield better results than hemiarthroplasty. The amount of bone loss in this patient does not require posterior glenoid augmentation. Reverse total shoulder arthroplasty is indicated for rotator cuff tear arthropathy; therefore, it is not applicable. Arthroscopic debridement has yielded poor results with advanced osteoarthritis and posterior subluxation. Results from glenoid osteotomy have been variable and glenoid osteotomy is not indicated with associated osteoarthritis. Iannotti JP, Norris TR: Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2003;85:251-258.

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Question 56

A 28-year-old man reports knee stiffness, swelling, and a constant ache that is worse with activity. Examination reveals an effusion, global tenderness, and warmth to the touch. Flexion is limited to 110 degrees. Figures 48a through 48d show sagittal T1-weighted, sagittal T2-weighted, axial T1-weighted fat-saturated gadolinium, and axial gradient echo MRI scans. Based on these findings, what is the most likely diagnosis?





Explanation

The MRI scans show multiple low-signal intensity lesions scattered throughout the knee, extending posteriorly inferior to the tibial plateau. The low-signal intensity on both the T1- and T2-weighted images, the modest vascularity noted on the gadolinium image, and the "blooming" noted on the gradient echo image (ferrous-laden tissue) are all strongly suggestive of diffuse PVNS. Whereas synovial chondromatosis can present as diffuse masses in the knee, they present as nodule masses that have low T1- and high T2-weighted signal characteristics. Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, WB Saunders, 2002, pp 4241-4252.

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Question 57

Following reconstruction of the anterior cruciate ligament (ACL), which of the following rehabilitation exercises has the greatest potential to harm the graft?





Explanation

Isometric quadriceps contraction between 15 and 30 degrees of flexion creates significant strain in the ACL and potential damage to the reconstructed graft. Isolated quadriceps contraction with knee flexion of greater than 60 degrees, hamstring contraction at any angle of knee flexion, and active knee motion between 35 and 90 degrees of flexion create substantially less strain in the properly implanted ACL graft. Beynnon BD, Gleming BC, Johnson RL, Nichols CE, Renstrom PA, Pope MH: Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med 1995;23:24-34.

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Question 58

A 2-year-old boy has complete absence of the sacrum and lower lumbar spine. What is the most likely long-term outcome if no spinal pelvic stabilization is performed?

Pediatrics 2007 Practice Questions: Set 1 (Solved) - Figure 14





Explanation

Without stabilization, progressive kyphosis will develop between the spine and pelvis. The kyphosis progresses to the point that the child must use his or her hands to support the trunk, and therefore is unable to use his or her hands for other activities. Neck extension contracture does not usually develop. Neurologic deficit, including sexual dysfunction, is generally present at birth and static. Tachdjian MO: The spine: Congenital absence of the sacrum and lumbosacral vertebrae (lumbosacral agenesis), in Wickland EH Jr (ed): Pediatric Orthopaedics, ed 2. Philadelphia, PA, WB Saunders, 1990, vol 3, p 2228.

References:

Question 59

Figure 48 shows the initial AP chest radiograph of a 21-year-old motorcycle rider who sustained multiple injuries after striking a telephone pole at high speed. What is the most significant radiographic finding leading to a diagnosis?

Shoulder Board Review 2002: High-Yield MCQs (Set 4) - Figure 13





Explanation

Scapulothoracic dissociation is a rare, violent traumatic injury in which the scapula is torn away from the chest wall but the skin remains intact. Massive swelling and ecchymosis are common. Neurovascular injury is the rule with possible subclavian or axillary artery disruption and severe partial or complete brachial plexus paralysis. The diagnosis is made on a nonrotated chest radiograph that shows significant lateral displacement of the medial scapular border from the sternal notch. A right midshaft clavicular fracture is present but is not considered the most significant finding. Ebraheim NA, An HS, Jackson WT, et al: Scapulothoracic dissociation. J Bone Joint Surg Am 1988;70:428-432. Ebraheim NA, Pearlstein SR, Savolaine ER, et al: Scapulothoracic dissociation. J Orthop Trauma 1987;1:18-23. Sampson LN, Britton JC, Eldrup-Jorgensen J, et al: The neurovascular outcome of scapulothoracic dissociation. J Vasc Surg 1993;17:1083-1088.

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Question 60

Sudden cardiac death in the young athlete is most frequently caused by

Sports Medicine 2001 Practice Questions: Set 1 (Solved) - Figure 19





Explanation

Hypertrophic cardiomyopathy is the leading cause of sudden cardiac death in athletes, accounting for 40% of reported cases. Most athletes have no previous symptoms, and sudden death may be the first clinical manifestation. The prevalence of hypertrophic cardiomyopathy in the general population is 1 in 500, with a mortality rate of 2% to 4% in young adults. Athletes with active myocarditis should not engage in sports for up to 6 months, and although they may be at risk for the development of chronic cardiomyopathy, it is rarely a cause of sudden cardiac death. Mitral valve prolapse with an accompanying systolic murmur is common in the general population, but infrequently a cause of sudden cardiac death. Weakening of the aortic wall associated with Marfan syndrome can result in abrupt rupture of the aorta. This accounts for 3% of sudden cardiac deaths in young athletes. Marfan syndrome usually can be detected on preparticipation screenings by its skeletal and ocular manifestations. Atherosclerotic coronary artery disease is the most common cause of sudden cardiac death in older athletes, accounting for 75% of reported cases. However, it is much less common in the young competitive athlete. Burke AP, Farb A, Virmani R, Goodin J, Smialek JE: Sports-related and non-sports-related sudden cardiac death in young adults. Am Heart J 1991;121:568-575.

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Question 61

What is the effect on knee kinematics following placement of an anterior cruciate ligament (ACL) graft at the 12 o'clock position?





Explanation

Endoscopic ACL reconstructive techniques may result in a vertical graft placement. The reconstructed ligament will resist anterior translation of the tibia but the graft will not restore rotatory stability. Decreased flexion and extension are caused by placement of the femoral tunnel too anterior and posterior, respectively. Impingement of the graft on the femoral notch is caused by anterior placement of the tibial tunnel or inadequate notchplasty. Scopp JM, Jasper LE, Belkoff SM, et al: The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 2004;20:294-299.

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Question 62

A 21-year-old man has had right groin pain for the past year. A radiograph, CT scan, MRI scans, and a biopsy specimen are shown in Figures 50a through 50e. What is the most likely diagnosis?





Explanation

The pathology demonstrates a very cellular chondroid matrix with multinucleated forms, atypia, and myxomatous regions. This is most consistent with a myxoid chondrosarcoma. The radiograph shows a well-circumscribed lesion in the superior and medial aspect of the right acetabulum. The CT and MRI scans confirm these same findings with no evidence of matrix mineralization or significant surrounding edema. Unfortunately, in this location with this appearance, the radiographic differential diagnosis includes all the diagnoses listed. Terek RM: Recent advances in the basic science of chondrosarcoma. Orthop Clin North Am 2006;37:9-14. Donati D, El Ghoneimy A, Bertoni F, et al: Surgical treatment and outcome of conventional pelvic chondrosarcoma. J Bone Joint Surg Br 2005;87:1527-1530.

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Question 63

A 68-year-old man with no significant medical history underwent a total knee arthroplasty 4 years ago. A radiograph is shown in Figure 55. He reports that he had no problems with the knee until 6 weeks ago when he noted the gradual onset of pain following a colonoscopy. Examination reveals a painful, swollen knee. Knee aspiration reveals a WBC count of 40,000/mm3. Management should consist of

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 4) - Figure 14





Explanation

The treatment of choice for a late hematogenous infection is two-stage resection arthroplasty and reimplantation, with parenteral antibiotics prior to reimplantation. This is particularly true when septic loosening has occurred as in this patient. Open irrigation and debridement with polyethylene exchange has been used successfully when the duration of symptoms is 3 weeks or less. Long-term suppressive antibiotics are most commonly used when the patient's medical condition precludes further surgery. Delayed reimplantation has been shown to be superior to immediate reimplantation in multiple studies. Little data support the use of arthroscopic irrigation and debridement. Swanson KC, Windsor RE: Diagnosis of infection after total knee arthroplasty, in Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA, JB Lippincott, 2003, vol 2, pp 1485-1491.

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Question 64

A professional pitcher reports pain localized to the medial aspect of his throwing elbow. History reveals that he was pitching in a playoff game and heard and felt a pop in his elbow. MRI reveals a complete ulnar-sided avulsion of the medial collateral ligament (MCL). Examination reveals valgus instability and ulnar nerve involvement. What recommendations should be made based on the patient's desire to return to sport?





Explanation

Injuries to the MCL usually result from repetitive high valgus stress on the medial aspect of the elbow joint due to overhead throwing or racquet sports. Excessive stresses during the late cocking and acceleration phase of throwing can injure the anterior band of the MCL. Clinically, the injuries may present as chronic or acute, and a pop may be noted in the latter. Associated ulnar nerve involvement is common. Valgus instability is present in about 25% of patients. Patients typically are athletes who participate in throwing and have localized medial elbow pain and tenderness along the course of a ligament that extends from the medial epicondyle of the distal humerus to the sublime tubercle of the ulna. Surgical reconstruction is the procedure of choice in an athlete desiring a return to a high level of throwing. Miller MD, Cooper DE, Warner JJP (eds): Review of Sports Medicine and Arthroscopy. Philadelphia, PA, WB Saunders, 1995, p 230. Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, p 227.

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Question 65

A 58-year-old woman who underwent a successful total hip replacement for degenerative arthritis 8 years ago reports groin pain for the past 6 months. A radiograph of the hip is shown in Figure 32. At revision, severe deficiency of the posterior column is noted. What reconstructive option would be most appropriate for the acetabulum?

Hip Board Review 2001: High-Yield MCQs (Set 4) - Figure 6





Explanation

The radiograph shows medial migration of the cementless acetabular component, strongly suggesting acetabular discontinuity with a combined segmental and cavitary medial deficiency. The treatment of choice is a morcellized or structural graft, supported with a reconstructive cage bridging the pelvic discontinuity, and a cemented cup. Whiteside LA: Selection of acetabular component, in Steinberg ME, Garino JP (eds): Revision Total Hip Arthroplasty. Philadelphia, PA, Lippincott Williams and Wilkins, 1999, pp 209-220.

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Question 66

An otherwise healthy 45-year-old man has a 3-cm subcutaneous mass on his anterior thigh that is presumed to be a lipoma. Removal of the mass is performed in the office of his primary care physician. Pathologic evaluation shows a high-grade malignant fibrous histiocytoma. Staging reveals no evidence of metastatic disease. Management at this time should consist of





Explanation

Resection of a previously excised soft-tissue sarcoma is recommended. Reoperation is recommended after removal of malignant tumors previously believed to be benign, as approximately one half of the patients will have residual tumor in the re-excised specimen. Observation is not indicated in most patients because local recurrence is likely. Radiation therapy alone may result in long-term local control but is felt to be less effective than reoperation. Chemotherapy and radiation therapy alone are not recommended. Wide excision is the most important factor for local disease control. Radiation therapy after surgical re-excision may also decrease the risk of local recurrence. Peabody TD, Monson D, Montag A, Schell MJ, Finn H, Simon MA: A comparison of the prognoses for deep and subcutaneous sarcomas of the extremities. J Bone Joint Surg Am 1994;76:1167-1173. Giuliano AE, Eilber FR: The rationale for planned reoperation after unplanned total excision of soft-tissue sarcomas. J Clin Oncol 1985;3:1344-1348. Lewis JJ, Leung D, Espat J, Woodruff JM, Brennan MF: Effect of resection in extremity soft tissue sarcoma. Ann Surg 2000;231:655-663.

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Question 67

A 30-year-old woman has pain in her right hand. The radiograph, CT scan, and biopsy specimen are seen in Figures 38a through 38c. What is the most likely diagnosis?





Explanation

An enchondroma is the most common primary tumor of the long bones of the hand. The lesion is usually asymptomatic and often is detected when there is a pathologic fracture. Shimizu K, Kotoura Y, Nishijima N, Nakamura T: Enchondroma of the distal phalanx of the hand. J Bone Joint Surg Am 1997;79:898-900.

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Question 68

Figures 49a and 49b show MRI scans of the shoulder. What is the most likely diagnosis?





Explanation

The supraspinatus tendon shows clear detachment and retraction from its greater tuberosity attachment by the absence of the normal dark subacromial signal extending to the attachment on the greater tuberosity. There is no anterior inferior glenoid labral detachment that usually is seen in a Bankart lesion. The acromioclavicular joint shows no evidence of separation. The humeral head is migrated cranially, indicating a chronic rotator cuff tear. Iannotti JP, Zlatkin MB, Esterhai JL, Kressel HY, Dalinka MK, Spindler KP: Magnetic resonance imaging of the shoulder: Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 1991;73:17-29. Seeger LL, Gold RH, Bassett LW, Ellman H: Shoulder impingement syndrome: MR findings in 53 shoulders. Am J Roentgenol 1988;150:343-347.

References:

Question 69

A 40-year-old man with amyloidosis injured his left knee while walking. Figure 17a shows an AP radiograph that was obtained 2 weeks after the injury. The radiograph shown in Figure 17b was obtained after the patient wore a hinged knee brace for 3 months. A clinical photograph is shown in Figure 17c. What is the most likely diagnosis?





Explanation

The patient has a Charcot arthropathy of the knee, which is associated with amyloidosis. The rapid joint destruction shown in the radiographs is most consistent with that diagnosis. Drennan D, Fahey J, Maylahn D: Important factors in achieving arthrodesis of the Charcot knee. J Bone Joint Surg Am 1971;53:1180-1193. Soudry M, Binazzi R, Johanson N, et al: Total knee arthroplasty in Charcot and Charcot like joints. Clin Orthop 1986;208:199-204.

References:

Question 70

When a structure like a long bone is under a bending load, its maximum stress is most dependent on what factor?





Explanation

The maximum stress in a bone occurs at the periosteal surface (the greatest distance from the center of the bone). The magnitude of the stress is equal to the magnitude of the applied moment (M) multiplied by the distance to the surface (roughly the radius of the bone, r) divided by the area moment of inertia (I), so that stress = Mr/I. Of the possible answers, only area moment of inertia of the cross section contains any of these three items. The stress can also depend on the length of the bone, but it cannot be determined without knowing the location at which the bending load is applied, information that was not given in the problem. The type of structural support may influence local stresses where the support contacts the bone, but it has little effect on the maximum stress in the bone. The cross-sectional area is not as important as the area moment of inertia because the stress is not evenly distributed over the cross-section. Plastic modulus is a material property, not a geometric or structural property, and it does not affect stress. Hayes WC, Bouxsein ML: Biomechanics of cortical and trabecular bone: Implications for assessment of fracture risk, in Mow VC, Hayes WC (eds): Basic Orthopaedic Biomechanics, ed 2. New York, NY, Lippincott-Raven, 1997, pp 76-82.

References:

Question 71

A 40-year-old woman with no history of back problems has a symptomatic L4-5 disk herniation with an L5 radiculopathy that has failed to respond to 12 weeks of nonsurgical management. In the preoperative discussion, the surgeon advises the patient that the chance of recurrence of the herniation after successful diskectomy is what percent?





Explanation

The incidence of recurrent disk herniation after a successful diskectomy is approximately 5% to 10%. Indications for surgical diskectomy for a recurrence are the same as for a primary diskectomy. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 685-698.

References:

Question 72

In the anterior forearm approach to the distal radius (Henry approach), the radial artery is located between what two structures?

Anatomy 2005 Practice Questions: Set 1 (Solved) - Figure 30





Explanation

The standard approach to the volar aspect of the distal radius is the Henry approach. Following incision of the skin and subcutaneous tissues, the forearm fascia is incised. The radial artery and venae comitantes lie in the interval between the tendons of the flexor carpi radialis muscle and the brachioradialis muscle. This interval is developed, and the radial artery and veins are retracted in a radial direction. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 118-131.

References:

Question 73

When compared to traditional open repair through a posterior incision, percutaneous Achilles tendon repair clearly results in a reduction of what complication?





Explanation

Prospective studies, including randomized and randomized multicenter reports, have shown that percutaneous or mini-open acute Achilles tendon repair has comparable functional results when compared to traditional open techniques. Calder and Saxby reported one superficial infection out of 46 patients with a mini-open repair; Assal and associates and Cretnik and associates had no wound complications or infections. The other complications have not proved to be less likely with the mini-open or percutaneous technique. Assal M, Jung M, Stern R, et al: Limited open repair of Achilles tendon ruptures: A technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am 2002;84:161-170. Calder JD, Saxby TS: Early, active rehabilitation following mini-open repair of Achilles tendon rupture: A prospective study. Br J Sports Med 2005;39:857-859.

References:

Question 74

What is the most common long-term complication of the fracture shown in Figure 32?

Foot & Ankle 2000 Practice Questions: Set 3 (Solved) - Figure 9





Explanation

The fracture pattern shown in the radiograph involves both a talar neck fracture and a talar body fracture. The body fracture propagates into the subtalar joint, with significant risk for the development of arthritis in that surface even with an anatomic reduction. In addition, Canale and Kelly reported a 25% incidence of malunion of talar neck fractures, with varus angulation occurring most frequently. Of these patients, 50% required a secondary surgical procedure because of the development of degenerative joint disease of the subtalar joint. Canale ST, Kelly FB Jr: Fractures of the neck of the talus: Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 1978;60:143-156.

References:

Question 75

What are the four most common soft-tissue sarcomas to spread via the lymph node system?

Basic Science 2008 Practice Questions: Set 1 (Solved) - Figure 71





Explanation

Soft-tissue sarcomas most frequently metastasize to the lung, but certain histologic types have a predilection for the lymph node system as well. Rhabdomyosarcoma, clear cell sarcoma, epithelioid sarcoma, and synovial sarcoma are four of the most common types to spread in this fashion. Careful evaluation and/or sentinel lymph node biopsy plays a role in disease staging and prognosis. Riad S, Griffin AM, Liberman B, et al: Lymph node metastasis in soft-tissue sarcoma in an extremity. Clin Orthop Relat Res 2004;426:129-134.

References:

Question 76

A 42-year-old man has a symptomatic flatfoot deformity and walks with a slight limp after falling off a scaffold 9 months ago. He also reports that he has had difficulty returning to work. Orthotics have failed to provide relief. Current radiographs are shown in Figures 19a and 19b. To relieve his pain and return the patient to work, treatment should consist of





Explanation

Because the patient has sustained a tarsometatarsal injury with midfoot sag, the treatment of choice is a tarsometatarsal arthrodesis. The cause of his flatfoot deformity is secondary to the tarsometatarsal injury and not from posterior tibialis tendon deficiency. Lateral column lengthening, double arthrodesis, and calcaneal osteotomy are not indicated. Although open reduction and internal fixation may be performed late when arthritis is present, these procedures are less likely to succeed. Komenda GA, Myerson MS, Biddinger KR: Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am 1996;78:1665-1676.

References:

Question 77

Torsional moments about the longitudinal axis of a total hip arthroplasty show what change during stair climbing compared with walking?





Explanation

The magnitudes of out-of-plane loads on a total hip replacement during activities of daily living can be substantial. Bergmann and associates studied these forces about two instrumented hip prostheses. They noted that the torsional moment about the hip during stair climbing is twice as high as during slow walking and that similar moments are generated during slow jogging. Higher loads were noted when the patients stumbled without falling. They also noted that the torsional moments observed in vivo were close to or even exceeded the experimentally determined limits of the torsional strength of implant fixations. Hurwitz DE, Andriacchi TP: Biomechanics of the hip, in Callaghan JJ, Rosenberg AG, Rubash HE (eds): The Adult Hip. Philadelphia, PA, Lippincott Raven, 1998, pp 75-85.

References:

Question 78

A 13-year-old boy injured his knee playing basketball and is now unable to bear weight. Examination reveals tenderness and swelling at the proximal anterior tibia, with a normal neurologic examination. AP and lateral radiographs are shown in Figures 1a and 1b. Management should consist of





Explanation

The patient has a displaced intra-articular tibial tuberosity fracture; therefore, the treatment of choice is open reduction and internal fixation. Periosteum is often interposed between the fracture fragments and prevents satisfactory closed reduction. Fortunately, most patients with this injury are close to skeletal maturity and therefore, growth arrest and recurvatum are unusual. Nondisplaced fractures can be treated with a cast, but displaced fractures are best treated with open reduction and internal fixation. Intra-articular fractures can disrupt the joint surface and are sometimes associated with a meniscal tear; therefore, arthroscopy may be needed at the time of open reduction and internal fixation. McKoy BE, Stanitski CL: Acute tibial tubercle avulsion fractures. Orthop Clin North Am 2003;34:397-403.

References:

Question 79

Figures 10a and 10b show the clinical photograph and MRI scan of a plantar foot lesion. If excisional biopsy is performed, what is the most likely complication?





Explanation

The MRI scan shows plantar fibromatosis. The treatment is usually nonsurgical. If surgery is indicated, wide local excision with excision of the entire plantar fascia is usually indicated. The main problem with simple excision of the lesion is the high chance of recurrence. The other listed complications are those that are a result of the wide local excision. Aluisio FV, Mair SD, Hall RL: Plantar fibromatosis: Treatment of primary and recurrent lesions and factors associated with recurrence. Foot Ankle Int 1996;17:672-678.

References:

Question 80

A 35-year-old woman states that she stepped on a piece of glass 6 months ago and reports numbness and shooting pain along the plantar lateral forefoot. She had previously received steroid injections in the 3 to 4 webspace. Examination reveals mild tenderness along the plantar fascia; no Tinel's sign is noted plantar medially and no Mulder's click is noted distally. An MRI scan is shown in Figure 7. What is the most likely cause of the numbness?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 24





Explanation

The MRI scan reveals a laceration through the abductor hallucis musculature and lateral plantar nerve, producing numbness along its distribution. There is no evidence of a foreign body on the MRI scan. Baxter's nerve, or nerve to the abductor digiti quinti muscle, is the first branch off the lateral plantar nerve and impingement of this nerve typically produces a Tinel's sign along the nerve branch deep to the abductor hallucis muscle. Interdigital neuroma would be suggested by the presence of a Mulder's click. A digital nerve laceration would exhibit isolated numbness more distally. Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop Relat Res 1992;279:229-236.

References:

Question 81

What is the most common benign bone tumor in childhood?





Explanation

The most common benign bone tumor in childhood is a nonossifying fibroma. It is estimated that 30% of children have a nonossifying fibroma. In most patients, the lesion is not identified until a radiograph is obtained for unrelated reasons. Similarly, most identified cases of fibrous cortical defect are not biopsied because the radiographic and clinical presentations are diagnostic. Aboulafia AJ, Kennon RE, Jelinek JS: Benign bone tumors of childhood. J Am Acad Orthop Surg 1999;7:377-388.

References:

Question 82

Figure 52 shows the MRI scan of a 28-year-old baseball pitcher. Examination will most likely reveal which of the following findings?

Anatomy Board Review 2005: High-Yield MCQs (Set 4) - Figure 16





Explanation

A ganglion cyst compressing the suprascapular nerve results in poorly localized pain in the shoulder girdle. Sensation is intact, with weakness of external rotation and abduction. Supraspinatus and infraspinatus atrophy is often noted when viewed from behind. These cysts are typically associated with labral tears. Deltoid weakness is associated with an axillary nerve injury, and scapular winging results from injury to the long thoracic nerve. Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg 2002;11:600-604.

References:

Question 83

A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals that the knee is held in 45 degrees of flexion, and any attempt to actively or passively extend the knee produces pain and muscle spasms. A lateral radiograph is shown in Figure 4. What is the most likely diagnosis?

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 9





Explanation

This is a typical patellar sleeve fracture. The patellar tendon avulses a portion of the distal bony patella, along with the retinaculum and articular cartilage from the inferior pole of the patella. It is common in children between ages 8 and 10 years. Anatomic reduction and repair of the extensor mechanism are mandatory to reestablish full knee extension. Houghton GR, Ackroyd CE: Sleeve fractures of the patella in children: A report of three cases. J Bone Joint Surg Br 1979;61:165-168.

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Question 84

Figures 32a and 32b show the radiographs of a 13-year-old right hand-dominant boy who sustained a closed Salter-Harris type II fracture of the proximal humerus during a hockey game. The shoulder has significant swelling, but is neurovascularly intact. What treatment offers the best chance of reestablishing normal shoulder motion?





Explanation

The patient has a significantly angulated proximal humerus fracture with a high degree of varus angulation, and rotational malalignment is likely. Failure to correct the varus angulation will result in permanent loss of shoulder abduction because the patient's age limits bony remodeling. These fractures are inherently unstable due to the inability to control the proximal fracture alignment. Shoulder spica casts have a high rate of redisplacement after treatment. Adequate open or closed reduction and pin fixation in the operating room optimizes alignment and all but eliminates the chance of redisplacement. Dobbs MB, Luhmann SJ, Gordon JE, et al: Severely displaced proximal humerus epiphyseal fractures. J Pediatr Orthop 2003;23:208-215. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, p 701.

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Question 85

A patient who was involved in a motor vehicle accident 2 weeks ago now reports neck pain. Work-up reveals no evidence of nerve root involvement or acute radiographic abnormality. The patient appears to have a hyperextension soft-tissue injury of the neck (whiplash). What is the best course of treatment at this time?

Spine Surgery Board Review 2000: High-Yield MCQs (Set 2) - Figure 9





Explanation

Early mobilization and resumption of normal activities immediately after neck sprain has been shown to improve functional outcome and decrease subjective symptoms as measured 6 months after injury. Borchgrevink GE, Kaasa A, McDonagh D, Stiles TC, Haraldseth O, Lereim I: Acute treatment of whiplash neck injuries: A randomized trial during the first 14 days after a car accident. Spine 1998;23:25-31.

References:

Question 86

A 29-year-old man undergoes surgery for a grade I isthmic spondylolisthesis at L5. Following surgery, what type of brace will best immobilize the L5-S1 motion segment?





Explanation

The thoracolumbosacral orthosis with thigh extension best immobilizes the lumbosacral junction. Fidler and Plasmans have demonstrated increased motion at the lumbosacral junction with the standard chairback-type brace. Connolly PJ, Grob D: Bracing of patients after fusion for degenerative problems of the lumbar spine: Yes or no? Spine 1998;23:1426-1428.

References:

Question 87

A 45-year-old man who has had recurrent pain and swelling of the left Achilles tendon insertion for the past 10 years reports that physical therapy and activity modification have provided relief in the past. He now has continued pain despite these efforts. He also reports occasional bouts of dysuria that he attributes to a history of prostatitis. He also notes recent eye irritation that he attributes to allergies. A lateral heel radiograph is shown in Figure 33. Which of the following laboratory studies would best aid in diagnosis?

Foot & Ankle 2006 Practice Questions: Set 3 (Solved) - Figure 18





Explanation

Reiter's syndrome is a seronegative spondyloarthropathy characterized most commonly by a triad of asymmetric arthritis, urethritis, and uveitis. Tendon ensethopathies can also be present. It is most often seen in men and is associated with a positive HLA-B27 marker. Rheumatoid arthritis does not usually present with these features; more commonly it causes forefoot pain and synovitis of the metatarsophalangeal joints. A CBC count with differential would be helpful in a situation of possible infection. The urethral swab would help to diagnose a gonococcal infection which can cause a monoarticular septic arthritis. Antiphospholipid antibody is associated with a hypercoaguable state and increased risk of deep venous thrombosis.

References:

Question 88

Figure 9 shows the radiograph of a 75-year-old woman who reports the sudden onset of disabling medial knee pain. What is the most likely diagnosis?

Hip Board Review 2004: High-Yield MCQs (Set 2) - Figure 1





Explanation

Idiopathic osteonecrosis of the medial femoral condyle occurs predominantly in women older than age 60 years. It is characterized by pain centered in the medial anterior aspect of the knee, and onset is sudden. Flattening, sclerosis, and the radiolucent crescent sign are radiographic indicators of osteonecrosis. The radiographs show no narrowing of the joint space or osteophyte formation to indicate osteoarthritis, and there are no loose bodies to indicate synovial osteochondromatosis. A meniscal tear is not consistent with the radiographic findings shown here. Meniscal tears can coexist with osteonecrosis, but the pain is not eliminated merely by partial meniscectomy. Metastatic lesions to the distal femoral epiphysis are exceedingly rare. Urbaniak JR, Jones JP Jr (eds): Osteonecrosis: Etiology, Diagnosis, and Treatment. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 413-418.

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Question 89

A 25-year-old man sustained a head injury after being ejected from his car. Examination reveals a Glasgow Coma Scale score of 7 and a swollen right knee. Clinical examination shows that the knee is very unstable, suggesting tears of the medial collateral and anterior and posterior cruciate ligaments, as well as the posterior lateral corner. What is the most appropriate first step to rule out a vascular injury?





Explanation

A knee dislocation carries the potential for an arterial injury and has always brought up the question of need for arteriography to rule out this limb-threatening injury. However, arteriography has an inherent complication rate that may compromise the general care of the patient. In over 240 published cases with documented knee dislocations that were evaluated for vascular injury by physical examination (without imaging studies), not a single missed injury was reported, for a 100% negative predictive value (0% false-negative rate). This degree of accuracy at excluding major vascular injury is unsurpassed by the results obtained with arteriography but with no risk involved and a marked savings in time, equipment, and costs. Therefore, the most appropriate first step to rule out vascular injury is examination of the pedal pulses. If there is any doubt about an arterial injury, another option is the ankle-brachial index (ABI). If the ABI is greater than 0.9, the chance of arterial injury is again nonexistent. However, a positive physical examination or an ABI of less than 0.9 is not 100% predictive of an arterial injury; therefore, arteriography is recommended. Miranda FE, Dennis JW, Veldenz HC, et al: Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: A prospective study. J Trauma 2002;52:247-252.

References:

Question 90

When performing a gastrocnemius recession, what structure should be protected?





Explanation

When performing a gastrocnemius slide at the tendinous portion of the gastrocnemius insertion, the sural nerve and saphenous vein, which tend to run midline posterior at this level, must be protected and retracted laterally. An anatomic study of the sural nerve at this level localized the nerve superficial to the deep fascia overlying the gastrocnemius in 42.5% of the cases; deep to the superficial fascia in 57.5% of the cases, and directly applied to the gastrocnemius tendon in 12.5% of cases. Pinney SJ, Sangeorzan BJ, Hanen ST Jr: Surgical anatomy of the gastrocnemius resection (Strayer procedure). Foot Ankle Int 2004;25:247-250.

References:

Question 91

A 24-year-old man has right forearm pain after sliding head first into home plate. Examination reveals that the arm is swollen, but there are no neurovascular deficits or skin lacerations. Radiographs reveal a both-bone forearm fracture. The ulna has an oblique fracture with a 30% butterfly fragment, and the radius is comminuted over 75% of its circumference. In addition to reduction and plate fixation of both bones, management should consist of





Explanation

The patient has a both-bone fracture with a comminuted radial shaft. Open reduction and internal fixation of both bones is the treatment of choice. In the past, Chapman and associates recommended bone grafting radial shaft fractures with more than 30% comminution of the circumference. This has remained the recommendation in most textbooks. More recent studies, where modern biologic plating techniques were used, found that the addition of bone graft to comminuted fractures was not necessary because the union rate did not differ from that of nongrafted comminuted fractures. Anderson LD, Sisk TD, Tooms RE, Park WI III: Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am 1975;57:287-297. Chapman MW, Gordon JE, Zissimos AG: Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg Am 1989;71:159-169. Wright RR, Schmeling GJ, Schwab JP: The necessity of acute bone grafting in diaphyseal forearm fractures: A retrospective review. J Orthop Trauma 1997;11:288-294.

References:

Question 92

When comparing surgical and nonsurgical extremities in patients who underwent anterior cruciate ligament (ACL) reconstruction using patellar tendon or hamstrings autografts, isokinetic strength measurements obtained 6 months after the surgery would most likely reveal





Explanation

Follow-up examination at 6 months revealed no statistically significant differences in quadricep or hamstring strength when comparing surgical versus nonsurgical extremities isokinetically. Therefore, the selection of autogenous hamstring or patellar tendon for ACL reconstruction should not be based solely on the assumption of the graft tissue source altering the recovery of quadricep and/or hamstring strength. Carter TR, Edinger S: Isokinetic evaluation of anterior cruciate ligament reconstruction: Hamstring versus patellar tendon. Arthroscopy 1999;15:169-172 Howell SM, Taylor MA: Brace-free rehabilitation, with early return to activity, for knees reconstructed with a double-looped semitendinosus and gracilis graft. J Bone Joint Surg Am 1996;78:814-825.

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Question 93

A 59-year-old woman who underwent a total hip arthroplasty 5 years ago now has recurrent dislocation following bariatric surgery and a weight loss of 200 lb. An attempt at converting to a larger head size and trochanteric advancement has failed. Her components are well aligned. What is the best course of action?

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 1





Explanation

When a patient has well-aligned components and soft-tissue tensioning with a larger femoral head and trochanteric advancement has failed, options are limited. The use of a constrained acetabular liner is the best option in this situation. Goetz and associates and Shrader and associates have demonstrated good results with these implants. Shrader used this device on 109 patients with recurrent instability with a successful outcome in all but 2 patients. Resection arthroplasty is a salvage situation and is not the best option at the present time. A hip abduction brace does not address the soft-tissue laxity. Conversion to a bipolar arthroplasty, although possibly minimizing the incidence of dislocation, will lead to groin pain and migration of the component with diminished functional results. Goetz DD, Capello WN, Callaghan JJ, et al: Salvage of recurrently dislocating hip prosthesis with use of a constrained acetabular component: A retrospective analysis of fifty-six cases. J Bone Joint Surg Am 1998;80:502-509. Shrader MW, Parvizi J, Lewallen DG: The use of constrained acetabular component to treat instability after total hip arthroplasty. J Bone Joint Surg Am 2003;85:2179-2183.

Scientific References

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Question 94

What is the typical MRI signal intensity of bone marrow affected by acute osteomyelitis?

Anatomy 2005 Practice Questions: Set 1 (Solved) - Figure 26





Explanation

The classic MRI findings of osteomyelitis are a decrease in the normally high signal intensity of marrow on T1-weighted images and normal or increased signal intensity on T2-weighted images. This is the result of replacement of marrow fat by inflammatory cells and edema, which causes lower signal intensity than fat on T1-weighted images and higher signal intensity than fat on T2-weighted images. The addition of gadolinium to a T1-weighted sequence reveals increased signal intensity in the hyperemic marrow. Unger E, Moldofsky P, Gatenby R, et al: Diagnosis of osteomyelitis by MR imaging. Am J Roentgenol 1988;150:605-610. Dormans JP, Drummond DS: Pediatric hematogenous osteomyelitis: New trends in presentation, diagnosis and treatment. J Am Acad Orthop Surg 1994;2:333-341.

References:

Question 95

A 37-year-old laborer falls 12 feet and sustains a comminuted tibial plafond fracture. Three years after treatment using standard techniques, what will be the most likely outcome?





Explanation

Two recent studies by Pollak and associates and Marsh and associates have focused on function after high-energy tibial plafond fractures. Findings are unfavorable even when anatomic reduction is performed in the best centers and patients are provided excellent rehabilitation. Function improves up to 2 years after injury, but even basic walking skills remain adversely affected. Virtually all patients have long-term adverse general health effects compared to their gender and age-matched peers. Posttraumatic degenerative arthritis is present in most ankles. Patients should be told early about the long-term prognosis, and early vocational/psychological counseling should be given. Despite these adverse outcomes, only a minority of patients require fusion or arthroplasty. Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.

References:

Question 96

A 67-year-old woman undergoes a revision total shoulder arthroplasty for replacement of a loose glenoid component. Examination in the recovery room reveals absent voluntary deltoid and triceps contraction, weakness of wrist and thumb extension, and absent sensation in the palmar aspect of all fingertips and the radial forearm. The next most appropriate step in management should consist of





Explanation

Neurologic injury after shoulder replacement is relatively uncommon, occurring in 4% of shoulders in one large series. The importance of identifying and protecting the musculocutaneous and axillary nerves cannot be overemphasized; it is especially critical during revision arthroplasty when the normal anatomic relationships have been distorted. The long deltopectoral approach leaving the deltoid attached to the clavicle was found to be significant in the development of postoperative neurologic complications. A correlation was found between surgical time and postoperative neurologic complications, with long surgical times being associated with more neurologic complications. The presumed mechanism of injury is traction on the plexus that occurs during the surgery. A neurologic injury after total shoulder arthroplasty usually does not interfere with the long-term outcome of the arthroplasty itself; it is best managed by protective measures with passive range of motion of the involved extremity. Wirth MA, Rockwood CA Jr: Complications of shoulder arthroplasty. Clin Orthop 1994;307:47-69.

References:

Question 97

During anterior surgery on the cervical spine, at what level would the lateral dissection of the longus coli muscle most likely cause Horner's syndrome?

Spine Surgery 2000 Practice Questions: Set 1 (Solved) - Figure 10





Explanation

The sympathetic chain approaches the lateral border of the longus coli muscle at C6 and is more vulnerable to injury at this level. Injury to the chain will cause Horner's syndrome, usually seen as unilateral ptosis.

References:

Question 98

A 26-year-old man is brought to the emergency department unresponsive and intubated after being found lying on the side of the road. He has a Glasgow Coma Scale score of 6. A chest tube has been inserted on the right side of the chest for a pneumothorax. An abdominal CT scan reveals a small liver laceration and minimal intraperitoneal hematoma. A pneumatic antishock garment (PASG) is on but not inflated. He has bilateral tibia fractures. A pelvic CT scan shows an anterior minimally displaced left sacral ala fracture and left superior and inferior rami fractures. He has received 2 L of saline solution and 4 units of blood but remains hemodynamically unstable. What is the next most appropriate step in management?

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 34





Explanation

There is no identifiable thoracic, abdominal, or long bone source of ongoing bleeding. The patient has a lateral compression Burgess-Young type I pelvic ring injury. This injury does not increase the pelvic volume because it is not unstable in external rotation. Application of a PASG, a pelvic clamp, or an external fixator may be helpful if the patient has a pelvic injury that is unstable in external rotation or translation but would be of little use in this injury pattern. Persistent hemodynamic instability after administration of 4 units of blood is the decision point where most authors would recommend angiography and embolization. If the pelvis is unstable in external rotation or translation, inflation of the PASG trousers or application of an external fixator is recommended before angiography. Attributing the hemodynamic instability to the head injury before ruling out the pelvis as a source is not indicated. Burgess AR, Eastridge BJ, Young JW, et al: Pelvic ring disruptions: Effective classification system and treatment protocols. J Trauma 1990;30:848-856. Evers BM, Cryer HM, Miller FB: Pelvic fracture hemorrhage: Priorities in management. Arch Surg 1989;124:422-424.

References:

Question 99

A 20-year-old college pitcher reports medial elbow pain after 3 innings of hard throwing. He recalls no injury and reports no pain with light throwing. The examination shown in the clinical photograph in Figure 48 reproduces the elbow pain. What is the most likely diagnosis?

Upper Extremity Board Review 2008: High-Yield MCQs (Set 4) - Figure 21





Explanation

The milking test, as seen in the photograph, elicits pain when a tear is present in the medial collateral ligament. Complete rupture is possible but unlikely when there is no history of trauma and the patient is able to throw pain-free for several innings. Subluxation of the ulnar nerve and triceps tendon subluxation present as a painful snapping over the medial aspect of the elbow. Williams RJ III, Urquhart ER, Altchek DW: Medial collateral ligament tears in the throwing athlete. Instr Course Lect 2004;53:579-586.

References:

Question 100

An elite skier training for the Olympics sustains an isolated traumatic dislocation of the peroneal tendons that have spontaneously reduced. The games are 9 months away and the athlete does not want to miss them. Treatment should consist of

Foot & Ankle 2006 Practice Questions: Set 1 (Solved) - Figure 26





Explanation

Most of these injuries occur in young, active patients. Success rates for nonsurgical management are only marginally better than 50%. The treatment of choice is early surgery for patients who desire a quick return to a sport or active lifestyle. Subluxation of the peroneal tendons leads to longitudinal tears over time. McLennan JG: Treatment of acute and chronic luxations of the peroneal tendons. Am J Sports Med 1980;8:432-436.

References:

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