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

100 Orthopedic Surgery MCQs: Board Review Mock Exam Set #495

27 Apr 2026 105 min read 102 Views
AAOS Sports Medicine MCQs: Board Prep Part 2

Key Takeaway

This page offers 100 high-yield orthopedic surgery multiple-choice questions for ABOS, OITE, and FRCS board review. Mock Exam Set #495 helps surgeons master exams by practicing across Sports Medicine, Trauma, Spine, and Pediatrics, ensuring comprehensive preparation for certification tests.

Comprehensive 100-Question Exam


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Question 1

A 19-year-old football player who sustained three traumatic anterior shoulder dislocations underwent surgery to repair a Bankart lesion. Nine months after surgery, examination reveals stability, elevation to 150 degrees, external rotation to 0 degrees with the elbow at his side and to 50 degrees at 90 degrees of abduction, and internal rotation to T12. If his range of motion does not improve, he is at most risk for





Explanation

Loss of external rotation can lead to degenerative joint disease following an anterior stabilization procedure. A tight anterior capsule will prevent internal impingement. Risk of thoracic outlet syndrome should not be increased. Subscapularis detachment is a risk following open anterior repair; however, a gain in external rotation would be noted. In time, this patient's shoulder may show increased posterior glenohumeral wear but should not have symptoms of recurrent subluxation unless multidirectional instability is present. Hawkins RJ, Angelo RL: Glenohumeral osteoarthrosis: A late complication of the Putti-Platt repair. J Bone Joint Surg Am 1990;72:1193-1197.

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Question 2

A 39-year-old woman fell onto her flexed elbow and sustained a comminuted displaced radial head and neck fracture. Radiographs confirm concentric reduction of the ulnohumeral joint. Examination reveals pain with compression of the radius and ulna at the wrist. What is the best treatment for the radial head fracture?





Explanation

Patients with comminuted radial neck and head fractures and associated wrist pain have a significant injury to the elbow and forearm. Nonsurgical management is an option, but initial casting will result in stiffness and early range of motion is likely to be unsuccessful secondary to pain. Surgical treatment with open reduction and internal fixation, although possible, is technically demanding and results are unpredictable with comminuted fractures. Excision alone in the face of wrist pain may lead to radial shortening. The treatment of choice is excision and metallic radial head arthroplasty. Silastic implants have been associated with synovitis and wear debris. Furry KL, Clinkscales CM: Comminuted fractures of the radial head: Arthroplasty versus internal fixation. Clin Orthop 1998;353:40-52.

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Question 3

What is a common clinical finding in patients with severe hypercalcemia secondary to bony metastasis?





Explanation

Increased levels of calcium are known to cause anorexia, nausea, vomiting, dehydration, muscle weakness, polyuria, and polydipsia. Treatment may include hydration, saline diuresis, and bisphosphonates.

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Question 4

A 28-year-old professional dancer reports a 3-month history of progressive pain in the posterior aspect of the left ankle. Her symptoms are worse when she assumes the en pointe position. Examination reveals tenderness to palpation at the posterolateral aspect of the ankle posterior to the peroneal tendons which is made worse with passive plantar flexion. There is no nodularity, fluctuance, or tenderness of the Achilles tendon. The neurovascular examination is unremarkable. A lateral radiograph and MRI scan are shown in Figures 16a and 16b, respectively. Management should consist of





Explanation

The imaging studies reveal findings typical of the os trigonum syndrome. This condition results from inflammation between the os trigonum and the adjacent talus. The symptoms of posterior ankle pain are exacerbated by plantar flexion, which stresses the fibrous union between these two bones. Definitive management of the high-level athlete involves excision of the os trigonum from a medial approach, although arthroscopic excision has also been described. The os trigonum is not an intra-articular structure; therefore, ankle arthroscopy is neither diagnostic nor therapeutic. Abramowitz Y, Wollstein R, Barzilay Y, et al: Outcome of resection of a symptomatic os trigonum. J Bone Joint Surg Am 2003;85:1051-1057. Mouhsine E, Crevoisier X, Leyvraz P, et al: Post-traumatic overload or acute syndrome of the os trigonum: A possible cause of posterior ankle impingement. Knee Surg Sports Traumatol Arthrosc 2004;12:250-253.

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Question 5

A 62-year-old man with a long history of ankylosing spondylitis has neck pain after lightly bumping his head on the wall. Examination reveals neck pain with any attempted motion; the neurologic examination is normal. Plain radiographs show extensive ankylosis of the cervical spine and kyphosis but no fracture. What is the next most appropriate step in management?





Explanation

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

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Question 6

A football player sustains a traumatic anterior inferior dislocation of the shoulder in the last game of the season. It is reduced 20 minutes later in the locker room. The patient is neurologically intact and has regained motion. If the patient undergoes arthroscopic evaluation, what finding is seen most consistently?

Upper Extremity Board Review 2008: High-Yield MCQs (Set 2) - Figure 12





Explanation

In an acute first-time dislocation, arthroscopy has been shown to reveal a Bankart lesion in most shoulders. The classic finding of labral detachment from the anterior inferior glenoid along with occasional hemorrhage within the inferior glenohumeral ligament is the most common sequelae of a traumatic anterior inferior dislocation. Acute treatment, if chosen, is repair of the labral tissue back to the glenoid plus or minus any capsular plication to address potential plastic deformation of the glenohumeral ligament. Acute treatment of a patient sustaining a first-time dislocation remains controversial. The potential indications may be patients whose dislocation occurs at the end of a season and when the desire to minimize risk of future instability outweighs the risks of surgical intervention. Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306-311. DeBerardino TM, Arciero RA, Taylor DC, et al: Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes: Two- to five-year follow-up. Am J Sports Med 2001;29:586-592.

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Question 7

What is the primary intracellular signaling mediator for bone morphogenetic protein (BMP) activity?





Explanation

BMPs signal through the activation of a transmembrane serine/threonine kinase receptor that leads to the activation of intracellular signaling molecules called SMADs. There are currently eight known SMADs, and the activation of different SMADs within a cell leads to different cellular responses. The other mediators are not believed to be directly involved with BMP signaling. Lieberman J, Daluiski A, Einhorn TA: The role of growth factors in the repair of bone: Biology and clinical applications. J Bone Joint Surg Am 2002;84:1032-1044. Li J, Sandell LJ: Transcriptional regulation of cartilage-specific genes, in Rosier RN, Evans C (eds): Molecular Biology in Orthoapedics, Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 21-24.

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Question 8

The relocation test is most reliable for diagnosing anterior subluxation of the glenohumeral joint when

Shoulder 2002 Practice Questions: Set 1 (Solved) - Figure 11





Explanation

The relocation test is most accurate when true apprehension is produced with the arm in combined abduction and external rotation and then relieved when posterior pressure is placed on the humeral head. Pain with this test is a less specific response and may occur with other shoulder disorders such as impingement.

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Question 9

A 14-year-old competitive gymnast has had activity-related low back pain for the past month. Examination reveals no pain with forward flexion, but she has some discomfort when resuming an upright position. She also has pain with extension and lateral bending of the spine. The neurologic examination is normal. Popliteal angles measure 20 degrees. AP, lateral, and oblique views of the lumbar spine are negative. What is the next most appropriate step in management?





Explanation

Symptoms of activity-related low back pain, physical findings of pain with extension, lateral bending, and resuming an upright position, and relative hamstring tightness are consistent with spondylolysis. While the initial diagnostic work-up should include plain radiographs of the lumbosacral spine, the findings may be negative because it can take weeks or months for the characteristic changes to become apparent. SPECT has been a useful adjunct in the diagnosis of spondylolysis when plain radiographs are negative. Since the patient's pain is activity related and she is otherwise healthy, evaluation for infection is not indicated. Because the neurologic examination is normal, electromyography, nerve conduction velocity studies, and MRI are not indicated. CT can be used in those instances in which SPECT and bone scans are negative. Ciullo JV, Jackson DW: Pars interarticularis stress reaction, spondylolysis, and spondylolisthesis in gymnasts. Clin Sports Med 1985;4:95-110. Collier BD, Johnson RP, Carrera GF, et al: Painful spondylolysis or spondylolisthesis studied by radiography and single photon emission computed tomography. Radiology 1985;154:207-211. Jackson DW, Wiltse LL, Cirincione RT: Spondylolysis in the female gymnast. Clin Orthop 1976;117:68-73.

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Question 10

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

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





Question 11

A 32-year-old runner has pain in the medial arch that radiates into the medial three toes. He reports the presence of pain only when running. Examination reveals normal hindfoot alignment. There is a weakly positive Tinel's sign over the posterior tibial nerve. Tenderness is noted with palpation over the plantar medial area in the vicinity of the navicular tuberosity. What is the most likely diagnosis?





Explanation

The examination findings reveal that there is specific involvement of the medial plantar nerve by the distribution of the pain medially. The symptoms exclude the possibility of plantar fasciitis and anterior tibial tendinitis. Sinus tarsi syndrome would produce anterolateral symptoms rather than medial symptoms. Rask MR: Medial plantar neurapraxia (jogger's foot): Report of three cases. Clin Orthop 1978;134:193-195. Murphy PC, Baxter DE: Nerve entrapment of the foot and ankle in runners. Clin Sports Med 1985;4:753-763.

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Question 12

A 25-year-old competitive skier sustains a twisting injury to the right ankle while skiing. She is unable to continue the activity secondary to severe lateral ankle pain. Examination reveals ecchymosis and fullness over the lateral malleolus with pain and weakness on active ankle dorsiflexion and external rotation. There is no medial-sided pain. Neurovascular examination is normal. An AP radiograph and MRI scan are shown in Figures 17a and 17b, respectively. Management should consist of





Explanation

The MRI scan shows a dislocated peroneus brevis tendon with disruption of the peroneal retinaculum. This injury is commonly seen in skiers and is the result of peroneal contraction with the ankle everted and dorsiflexed. Nonsurgical management is rarely successful; therefore, repair of the peroneal retinaculum is the treatment of choice. Eckert WR, Davis EA Jr: Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976;58:670-672. Murr S: Dislocation of the peroneal tendons with marginal fracture of the lateral malleolus. J Bone Joint Surg Br 1961;43:563-565.

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Question 13

Figure 34 shows the standing AP radiograph of a 2-year-old girl who has a left bowleg deformity. Her mother states that she first noticed the problem when the child began walking at age 10 months, and the deformity has worsened over the past 6 months. Examination reveals a definite lateral thrust of the knee during the stance phase of gait. Management should consist of

Pediatrics 2001 Practice Questions: Set 3 (Solved) - Figure 10





Explanation

Infantile tibia vara is a developmental condition characterized by a varus angulation of the proximal end of the tibia that is caused by a growth disturbance of the proximal medial physis. In a study of 42 affected extremities in 24 children younger than age 3 years, it was found that daytime ambulatory brace treatment favorably altered the natural history of tibia vara. Another study of 27 patients with stage II Langenskiöld disease found a success rate of 70% (improved alignment without the need for osteotomy) using brace treatment. These authors also noted that children with unilateral disease were more likely to obtain correction of the deformity compared with those with bilateral disease. In this patient, observation is not warranted because untreated tibia vara has a significant risk for progressive worsening. Osteotomy is best reserved for those patients who, despite bracing, do not show satisfactory clinical and radiographic improvement by age 4 years. Elevation of the medial tibial plateau is a treatment option for older patients who have more advanced disease. An MRI scan would not provide any useful clinical information at this time. Zionts LE, Shean CJ: Brace treatment of early infantile tibia vara. J Pediatr Orthop 1998;18:102-109. Richards BS, Katz DE, Sims JB: Effectiveness of brace treatment in early infantile Blount's disease. J Pediatr Orthop 1998;18:374-380.

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Question 14

What anatomic site is considered at highest risk for pathologic fracture?

Basic Science Board Review 2002: High-Yield MCQs (Set 2) - Figure 29





Explanation

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

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Question 15

Initial postoperative management after repair of an acute rotator cuff tear includes





Explanation

In the immediate postoperative period following repair of an acute rotator cuff tear, passive forward elevation and external rotation should be performed within the safe zone determined at surgery. Early active range of motion (prior to tendon healing), internal rotation behind the back, and resistive exercises increase the risk of rupture of the repair. Iannotti JP: Full-thickness rotator cuff tear: Factors affecting surgical outcome. J Am Acad Orthop Surg 1994;2:87-95.

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Question 16

A 15-year-old boy has a mass at the knee. Radiographs show an aggressive tumor involving the proximal tibia, and biopsy findings reveal a high-grade osteosarcoma. Staging studies show that the tumor impinges on the neurovascular bundle. The tumor enlarges during preoperative chemotherapy. Management should now consist of

Pediatrics 2007 Practice Questions: Set 1 (Solved) - Figure 26





Explanation

Limb salvage procedures have become the usual treatment for even high-grade osteosarcomas. However, tumors associated with pathologic fracture, tumors encasing the neurovascular bundle, and tumors that enlarged during preoperative therapy and are adjacent to the neurovascular bundle require amputation.

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Question 17

Which of the following substances makes up the majority by weight of the extracellular matrix for articular cartilage?





Explanation

The extracellular matrix consists of water, proteoglycans, and collagen. Water makes up the majority (approximately 65% to 80%) of wet weight; 95% of the collage is type II with much smaller amounts of other collagens, including types IV, VI, IX, X, and XI. The exact functions of these other collagens are unknown, but they are believed to be important in matrix attachment and stabilization of the diameter of collagen fibrils. Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 444-445.

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Question 18

A 72-year-old woman who is right hand-dominant has severe pain in the right shoulder that has failed to respond to nonsurgical management. She reports night pain and significant disability. Examination reveals 30 degrees of active forward elevation. An AP radiograph is shown in Figure 27. Which of the following treatment options will provide the best functional improvement?

Upper Extremity 2008 Practice Questions: Set 3 (Solved) - Figure 9





Explanation

The patient has end-stage rotator cuff tear arthropathy. The radiograph shows complete proximal humeral migration (acromiohumeral interval of 0 mm), severe glenohumeral arthritis, and acetabularization of the acromion. In addition, she has "pseudoparalysis" with active elevation of only 30 degrees. Reverse shoulder arthroplasty affords her the best opportunity for pain relief and functional improvement. The other procedures have mixed results but typically are better for pain relief than they are for functional gains. Frankle M, Siegal S, Pupello D, et al: The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am 2005;87:1697-1705.

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Question 19

Figures 4a through 4c show the clinical photographs and radiographs of a 12-month-old boy who has progressive difficulty wearing shoes because of the length of the second toe, as well as width of the forefoot. Management should consist of





Explanation

The patient has macrodactyly involving the second ray, with significant enlargement of the width and height of the foot. The radiographs show widening of the interval between the first and second metatarsal and between the second and third metatarsal. With this degree of involvement, amputation of the second ray with excision of the overgrowth of affected soft tissue provides the most consistent desired reduction in foot size. A threaded Steinmann pin should be inserted across the remaining metatarsals until healing has occurred. Patients with macrodactyly should be examined to exclude neurofibromatosis type 1 and Klippel-Trenaunay-Weber syndrome.

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Question 20

What is the most likely type of pathology seen in Figure 16?

Spine Surgery Board Review 2000: High-Yield MCQs (Set 2) - Figure 23





Explanation

The figure shows the missing pedicle or "winking owl" sign that is characteristic of tumor involvement of the cortical bone of the pedicle. None of the other pathologic processes commonly gives this radiographic picture. Thinned, but not missing pedicles, have been described as a normal variant. McLain R, Weinstein J: Tumors of the spine, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 1173.

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Question 21

An otherwise healthy 16-year-old dancer reports a 1-month history of leg pain. AP and lateral radiographs of the distal femur are shown in Figures 67a and 67b. What is the next most appropriate step in management?





Explanation

The radiographs show a very ill-defined, aggressive, moth-eaten bony destruction involving the distal left femoral diaphysis just above the metaphyseal junction. The differential diagnosis includes Ewing's sarcoma, osteosarcoma, lymphoma of bone, eosinophilic granuloma, osteomyelitis, and others. MRI would further define the lesion, and soft-tissue and intramedullary extension. There is aggressive periosteal reaction in the posteromedial aspect of the adjacent lesion with some multilayered components in the distal interface of the periosteum. The lateral radiograph shows cortical penetration and irregular periosteal reaction of the posterior margin, suggesting some posterior soft-tissue extension at this site as well. Gebhardt MC, Ready JE, Mankin HJ: Tumors about the knee in children. Clin Orthop Relat Res 1990;255:86-110.

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Question 22

A 34-year-old woman has had painful snapping and popping in the elbow since falling while in-line skating 6 months ago. The popping also occurs when she pushes off with her hands to rise from a seated position. Initial radiographs were normal, and she was told that she had sprained her elbow. Examination reveals few findings except that she is very apprehensive when the forearm is forcefully supinated with the elbow extended or partially flexed. A radiograph taken in that position is shown in Figure 24. Treatment should consist of

Shoulder Board Review 2002: High-Yield MCQs (Set 2) - Figure 25





Explanation

The radiograph reveals posterolateral rotatory subluxation of the radiohumeral and ulnohumeral joints. The space between the ulna and trochlea is enlarged, particularly posteriorly at the olecranon. These findings are diagnostic of posterolateral rotatory instability, which causes recurrent subluxation and reduction as the elbow is flexed from an extended and supinated position with valgus load. The posterolateral rotatory instability apprehension test was performed on this patient and the result was positive. The lateral pivot-shift test causes a clunk as the elbow reduces but is more difficult to perform, even under general anesthesia. The patient does not have isolated subluxation of the radial head, although these findings can be mistakenly diagnosed as such. The radial head is normally shaped and does not represent a congenital dislocation. There are no findings here to suggest osteochondritis dissecans or loose bodies. O'Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446. Burgess RC, Sprague HH: Post-traumatic posterior radial head subluxation: Two case reports. Clin Orthop 1984;186:192-194.

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Question 23

Figure 3 shows the AP radiograph of a patient with diabetes mellitus who has knee pain. A semiconstrained knee prosthesis was used in this patient to prevent which of the following complications?

Hip & Knee Reconstruction 2007 Practice Questions: Set 1 (Solved) - Figure 8





Explanation

The radiographic appearance of the joint is highly suspicious for neuropathic joint (Charcot's joint). Evidence of bone loss on both the tibial and the femoral sides may necessitate the use of metal and/or bone augments. Patients with a neuropathic joint often have excellent range of motion, and postoperative stiffness is not a problem. The main problem with these patients is instability that occurs secondary to ligamentous laxity. Use of a semiconstrained prosthesis prevents the latter complication. Parvizi J, Marrs J, Morrey BF: Total knee arthroplasty for neuropathic (Charcot) joints. Clin Orthop 2003;416:145-150.

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Question 24

A 35-year-old man sustained the closed injury shown in Figure 52 in his dominant extremity. Neurologic function is normal. Treatment should consist of

Upper Extremity 2008 Practice Questions: Set 5 (Solved) - Figure 6





Explanation

Functional bracing has been demonstrated to have a very high rate of healing without any functional limitations in a large series of patients. Surgery is reserved for "floating elbows," open injuries, neurovascular injuries, and those fractures that go on to nonunion. Sarmiento A, Zagorski JB, Zych GA, et al: Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-486.

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Question 25

A 46-year-old woman who was involved in a motor vehicle accident reports a 4-month history of right-sided lower back pain and pain radiating into the right thigh. The patient underwent an extensive 3-month course of physical therapy and now is dependent on narcotic medication for pain control. Epidural injection therapy has failed to improve her symptoms. Examination is significant for weakness of hip flexion in the seated position and for decreased sensation to light touch in the medial anterior thigh region. Straight leg raise is negative, but the femoral stretch test reproduces anterior thigh pain. A CT myelogram image, at L3-L4, is shown in Figure 3. What is the most appropriate management at this time?

Spine Surgery 2009 Practice Questions: Set 1 (Solved) - Figure 14





Explanation

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

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Question 26

Figures 42a and 42b show the radiographs of a 52-year-old man who sustained a fall from a motorcycle 6 months ago and now reports pain and stiffness in his left shoulder. What is the most reliable treatment to improve function and comfort of the shoulder?





Explanation

Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult. Gerber C, Lambert SM: Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376-382. Spencer EE Jr, Brems JJ: A simple technique for management of locked posterior shoulder dislocations: Report of two cases. J Shoulder Elbow Surg 2005;14:650-652. Sperling JW, Pring M, Antuna SA, et al: Shoulder arthroplasty for locked posterior dislocation of the shoulder. J Shoulder Elbow Surg 2004;13:522-527. Hawkins RJ, Neer CS II, Pianta RM, et al: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.

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Question 27

Vertebral fractures are common in the thoracolumbar spine. What is the most important factor that determines the strength of the cancellous bone in the vertebral body?





Explanation

Cancellous bone strength and stiffness are determined primarily by the apparent density (the amount of bone per unit volume). Strength varies approximately as the square of the density, and stiffness as the cube of the density; therefore, these are very strong relationships. Cancellous bone strength also depends on the mineral content, the rate of loading (it is viscoelastic), the anatomic level, and the trabecular number (an histomorphometry term), but all to a markedly lesser extent than density. Carter DR, Hayes WC: The compressive behavior of bone as a two-phase porous structure. J Bone Joint Surg Am 1977;59:954-962.

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Question 28

A 24-year-old woman was struck by a mini van in a parking lot and sustained a closed segmental tibia fracture that was treated with an intramedullary nail the following morning. Follow-up examinations reveal a slowly progressive clawing of all five toes, a progressive equinocavovarus contracture, and the patient is unable to perform a single heel rise on the affected limb. At 1 year after surgery, the patient now has a 10-degree equinus contracture that is not relieved with knee flexion. Treatment should now consist of





Explanation

This is an example of a missed deep posterior compartment syndrome that typically presents 6 months after the injury with progressive clawing due to necrosis, scarring, and contracture of the posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus. Treatment consists of debridement of necrotic muscle and scar tissue with corresponding tendon excision. After debridement and posterior capsule release, if the equinus is relieved with knee flexion, a gastrocnemius slide may be performed. Otherwise, the lengthening should be at the level of the Achilles tendon. Bracing will not address the claw toes. Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 212-213. Manoli A II, Smith DG, Hansen ST Jr: Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res 1993;292:309-314.

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Question 29

Figures 12a through 12c show the radiographs of a 28-year-old professional baseball player who has ulnar-sided wrist pain and numbness and tingling in the fourth and fifth digits for the past 6 weeks. Management should consist of





Explanation

Hook of the hamate fractures typically occur as a result of direct force from swinging a bat, golf club, or racket. Pain is localized to the hypothenar eminence. The injury is best seen on a carpal tunnel view. CT will confirm the diagnosis. Chronic cases can be associated with neuropathy of the ulnar nerve. Excision of the hook through the fracture site usually yields satisfactory results, allowing the athlete to return to competition. Parker RD, Berkowitz MS, Brahms MA, et al: Hook of the hamate fractures in athletes. Am J Sports Med 1986;14:517-523.

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Question 30

A previously healthy 30-year-old woman has neck pain and bilateral hand and lower extremity tingling with weakness after falling down stairs. She is alert and oriented. Examination reveals incomplete quadriplegia at the C6 level that remains unchanged throughout her evaluation and initial treatment. Radiographs show a bilateral facet dislocation of C6 on C7 without fracture. Attempts at reduction with halo cervical traction up to her body weight are unsuccessful. What is the next most appropriate step?

Spine Surgery Board Review 2006: High-Yield MCQs (Set 2) - Figure 4





Explanation

A facet dislocation that cannot be reduced in an alert, awake patient with some preservation of cord function requires MRI to evaluate the disk prior to a reduction under anesthesia. The presence or absence of a disk herniation must be assessed, as this factor may influence the method of reduction. Vaccaro AR, Falatyn SP, Flanders AE, et al: Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine 1999;24:1210-1217. Fardon DF, Garfin SR, Abitbol J (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 247-262. Eismont FJ, Arena MJ, Green BA: Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets. J Bone Joint Surg Am 1991;73:1555-1560.

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Question 31

A 56-year-old woman has a painful mass on the bottom of her left foot, and orthotic management has failed to provide relief. Examination reveals that the mass is contiguous with the plantar fascia. An MRI scan shows a homogenous nodule within the plantar fascia. Resection of the tumor is shown in the clinical photograph in Figure 39. What type of cell is most likely responsible for the formation of this tumor?

Foot & Ankle Board Review 2006: High-Yield MCQs (Set 4) - Figure 10





Explanation

The history, examination, and surgical findings are most consistent with plantar fibromatosis. Plantar fibromatosis is a benign tumor of the plantar fascia that consists chiefly of fibromyoblasts. These cells produce excessive collagen and are similar to the cells found in the palmar fascia of patients with Dupuytren's contracture of the hand. The myocyte, synovial cell, and osteocyte all produce their respective individual tissue types but do not contribute to the formation of a plantar fibromatosis. The T-cell is an important immunologic cell that is most affected in patients with HIV.

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Question 32 High Yield

A 30-year-old man caught his dominant little finger on the straps of his windsurfing board 10 days ago. He reports swelling about the distal phalanx and has difficulty completely extending the distal interphalangeal joint. A radiograph is shown in Figure 47. What is the most appropriate treatment for this injury?

General Orthopedics Board Review 2026: High-Yield MCQs (Set 2) - Figure 26





Detailed Explanation

The radiograph reveals a "bony mallet injury." As the distal phalanx is not volarly subluxated, extension splinting, similar to a classic mallet injury without bony involvement, is appropriate. If there is volar subluxation associated with a large bony fragment, surgical intervention is appropriate. Baratz ME, Schmidt CC, Hughes TB: Extensor tendon injuries, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green's Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 192.

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Question 33

A 12-year-old girl sustains an acute injury to the right elbow in a fall. An AP radiograph is shown in Figure 5. Nonsurgical management will most likely result in

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





Explanation

The patient has a significantly displaced medial epicondyle fracture. The only absolute indication for surgical treatment is irreducible incarceration in the joint. Nonsurgical management usually results in a painless nonunion with good elbow function and little elbow instability. Prolonged immobilization should be avoided to prevent stiffness. Tardy ulnar nerve palsy and cubitus varus are not complications of medial epicondyle fractures. Chamber HG, Wilkins KE: Part IV: Apophyseal injuries of the distal humerus, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 801-812.

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Question 34

A 52-year-old woman has bicompartmental osteoarthritis following patellectomy. Treatment should consist of





Explanation

The patient has extensive degenerative changes in both the medial and lateral compartments within the knee; therefore, arthroscopic debridement or an osteotomy will not be helpful. A patellar arthroplasty will not address the medial and lateral compartments. Because the extensor mechanism provides a significant amount of anteroposterior stability, a posterior cruciate-substituting total knee arthroplasty is the treatment of choice for this patient. Martin SD, Haas SB, Insall JN: Primary total knee arthroplasty after patellectomy. J Bone Joint Surg Am 1995;77:1323-1330.

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Question 35

A 25-year-old man is unresponsive at the scene of a high-speed motor vehicle accident and remains obtunded. Initial evaluation in the emergency department reveals a left-sided femoral shaft fracture and a right-sided humeral shaft fracture. The cervical spine remains immobilized in a semi-rigid cervical collar, and the initial AP and lateral radiographs obtained in the emergency department are unremarkable. What is the most appropriate management at this time?





Explanation

Clearance of the cervical spine can be difficult in the obtunded or unresponsive patient. Various trauma series have been reported to detect up to 95% of cervical fractures but only when ideal imaging views have been obtained, which is not often possible in the unresponsive or uncooperative patient. Passively performed cervical flexion-extension under live fluoroscopy has been suggested but is not without inherent risk in the potentially unstable cervical spine. CT of the cervical spine has gained acceptance for the evaluation of these patients given the excellent evaluation of the osseous anatomy and for the common availability in most emergency departments. Sanchez and associates, using a protocol to evaluate for cervical spine injuries after blunt trauma, were able to detect 99% of cervical fractures with 100% specificity. Chiu WC, Haan JM, Cushing BM, et al: Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: Incidence, evaluation, and outcome. J Trauma 2001;50:457-463. Sanchez B, Waxman K, Jones T, et al: Cervical spine clearance in blunt trauma: Evaluation of a computed tomography-based protocol. J Trauma 2005;59:179-183.

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Question 36

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

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





Explanation

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

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Question 37

The safest surgical approach to the insertion of the tibial posterior cruciate ligament uses the interval between which of the following muscles?

Anatomy 2005 Practice Questions: Set 1 (Solved) - Figure 5





Explanation

Burks and Schaffer described an approach to the tibial insertion of the posterior cruciate ligament that uses the interval between the semimembranosus and the medial gastrocnemius. The medial gastrocnemius muscle is retracted laterally and protects the neurovascular bundle. This approach is used to repair an avulsion of the posterior cruciate ligament tibial attachment or for performing a posterior cruciate ligament tibial inlay reconstruction. Berg EE: Posterior cruciate ligament tibial inlay reconstruction. Arthroscopy 1995;8:95-99.

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Question 38

Which of the following surgical techniques is associated with an increased incidence of patellar complications after total knee arthroplasty?





Explanation

Surgical technique in patellar resurfacing has been found to be one of the critical factors in the success or failure of total knee arthroplasty. Theoretically, metal-backed patellar components are an excellent way of evenly distributing joint forces from the polyethylene button to bone (similar to the tibial component). However, despite this theoretical advantage, metal-backed patellae have been associated with a higher failure rate. Some of the observed problems include poor bone ingrowth, peg failure, dissociation of the metal plate and polyethylene button, and component fracture. Because of these factors, all-polyethylene patellae have proved to be the standard if patellar resurfacing is attempted. Medialization of the patellar component, a symmetrically thick patella, and external rotation of the femoral and tibial components improve patellar tracking. 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 323-337.

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Question 39

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 40

Figure 39 shows the AP radiograph of a 62-year-old man with degenerative osteoarthritis secondary to trauma. History reveals that he underwent total elbow arthroplasty 3 years ago. He continues to report instability and constant pain. A complete work-up, including aspiration and cultures, is negative. Treatment should consist of removal of the components and

Shoulder 2002 Practice Questions: Set 3 (Solved) - Figure 19





Explanation

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

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Question 41

A young active patient with a complete isolated posterior cruciate ligament (PCL) tear undergoes a double bundle PCL reconstruction. The tensioning pattern of the anterolateral (AL) and posteromedial (PM) bundles most likely to reproduce the most normal knee kinematics would be to tension





Explanation

During flexion and extension of the normal knee, the AL bundle of the PCL is taut in flexion, and the PM bundle is taut when the knee is near extension. The AL bundle is approximately two times larger at its midsubstance, stiffer, and has a higher ultimate load than the PM bundle. In vitro testing has demonstrated that by tensioning the AL bundle at 90 degrees of flexion and the PM bundle at 0 degrees of flexion, essentially normal knee kinematics are restored. Tensioning the AL bundle at 45 degrees of flexion and the PM bundle at 0 degrees of flexion would result in increased laxity with flexion at 90+ degrees. Tensioning the AL bundle at 90 degrees of flexion and the PM bundle at 45 degrees of flexion would result in increased laxity near extension. Harner CD, Janaushek MA, Kanamori A, Yagi M, Vogrin T, Woo SL: Biomechanical analysis of a double-bundle posterior cruciate ligament reconstruction. Am J Sports Med 2000;28:144-151.

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Question 42

In the upright standing position, approximately what percent of the vertical load is borne by the lumbar spine facet joints?

Spine Surgery 2000 Practice Questions: Set 1 (Solved) - Figure 35





Explanation

Direct measurement and finite element modeling results show that approximately 20% of the vertical load is borne by the posterior structures of the lumbar spine in the upright position. Adams MA, Hutton WC: The effect of posture on the role of the apophyseal joints in resisting intervertebral compressive forces. J Bone Joint Surg Br 1980;62:358-362.

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Question 43

Sterilization of ultra-high molecular weight polyethylene by gamma irradiation in air will degrade its wear performance because of

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 16





Explanation

Gamma irradiation has long been used as a sterilization method for polyethylene. Exposure to gamma irradiation causes breakage of the chemical bonds in the polyethylene, and oxidation will occur if the material is subsequently exposed to air. The amount of oxidation and decrease in wear performance is also related to the length of time that the gamma-irradiated polyethylene is exposed to oxygen. Collier JP, Sutula LC, Currier BH, et al: Overview of polyethylene as a bearing material: Comparison of sterilization methods. Clin Orthop 1996;333:76-86. McKellop H, Shen FW, Lu B, et al: Effect of sterilization method and other modifications on the wear resistance of acetabular cups made of ultra-high molecular weight polyethylene: A hip-simulator study. J Bone Joint Surg Am 2000;82:1708-1725.

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Question 44

A 10-year-boy has had thigh pain for the past several months. He denies any history of trauma. Examination reveals no soft-tissue mass, and mild tenderness. Figures 33a and 33b show the plain radiograph and MRI scan, and the biopsy specimens are shown in Figures 33c and 33d. What is the most likely diagnosis?





Explanation

The diagnosis is eosinophilic granuloma. The plain radiograph and MRI scan show a lesion in the midshaft of the femur. There is no soft-tissue mass. There is reactive bone about the lesion that suggests a less aggressive tumor. The histology reveals eosinophils in an otherwise bland cellular background with no evidence of mitotic figures or malignant cells to suggest sarcoma. The diagnostic elements are the amphophilic (ie, pale purple) histiocytes with cigar-shaped nuclei, some of which have linear longitudinal grooves. There is no histologic evidence of infection. Lymphoma of bone would be an unusual occurrence in this age group, and the histology is not consistent with that diagnosis.

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Question 45

A patient with deficient anteroinferior bone stock undergoes a Latarjet procedure that transfers a portion of the coracoid to the glenoid rim and secures it with two screws. After surgery, the patient reports numbness on the anterolateral forearm. To verify the diagnosis, what muscle should be tested for strength?

Shoulder Board Review 2002: High-Yield MCQs (Set 2) - Figure 24





Explanation

A Latarjet procedure is similar to a Bristow procedure, but with the Latarjet procedure a larger portion of the coracoid is transferred to the scapular neck at the anteroinferior glenoid. As in a Bristow procedure, if the fragment is pulled or twisted during the dissection or during fixation, the musculocutaneous nerve can be injured. With loss of biceps function, elbow flexion and forearm supination will be weaker. Ho E, Cofield RH, Balm MR, Hattrup SJ, Rowland CM: Neurologic complications of surgery for anterior shoulder instability. J Shoulder Elbow Surg 1999;8:266-270. Boardman ND 3rd, Cofield RH: Neurologic complications of shoulder surgery. Clin Orthop 1999;368:44-53.

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Question 46

Which of the following statements best describes synovial fluid?





Explanation

Synovial tissue is composed of vascularized connective tissue that lacks a basement membrane. Two cell types (type A and type B) are present: type B cells produce synovial fluid. Synovial fluid is made of hyaluronic acid and lubricin, proteinases,and collagenases. It is an ultrafiltrate of blood plasma added to fluid produced by the synovial membrane. It does not contain erythrocytes, clotting factors, or hemoglobin. It lubricates articular cartilage and provides nourishment via diffusion. Synovial fluid exhibits non-Newtonian flow characteristics. The viscosity coefficient is not a constant, the fluid is not linearly viscous, and its viscosity increases as the shear rate decreases.

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Question 47

Examination of a 28-year-old woman reveals a moderate hallux valgus deformity and a prominence of the medial eminence. She reports that she can participate in all activities, wear 3-inch heels with minimal discomfort, and walk in a 1-inch heel with no pain. However, she is concerned that the deformity will get worse and requests recommendations regarding surgical correction. What is the best course of action?





Explanation

Because the patient is essentially asymptomatic, the most appropriate course of action is observation. Prophylactic hallux valgus surgery is not medically indicated. Steroid injection would only risk infection, as well as joint and capsule damage. There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity. Special shoe wear or an extra-depth shoe is not necessary and is unlikely to be accepted by the patient. Donley BG, Tisdel CL, Sferra JJ, Hall JO: Diagnosing and treating hallux valgus: A conservative approach for a common problem. Cleve Clin J Med 1997;64:469-474.

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Question 48

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





Explanation

Sodium deficiency is the cause of heat cramps. It is the principle electrolyte of sweat and is readily lost during training, especially in warmer temperatures. The condition can be avoided by adding extra table salt to food and maintaining good hydration before and after sports activities. Salt tablets are to be avoided when a patient has heat cramps because the high soluble load will cause gastric irritation. Bergeron MF, Armstrong LE, Maresh CM: Fluid and electrolyte losses during tennis in the heat. Clin Sports Med 1995;14:23-32.

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Question 49

A 27-year-old woman reports the acute atraumatic onset of burning pain in her right shoulder followed a week later by significant weakness and the inability to abduct her shoulder. One week prior to this incident she had recovered from a flu-like syndrome. Examination reveals full passive motion of the shoulder and the inability to actively raise the arm. Sensation in the right upper extremity is normal. Cervical spine examination is normal. Radiographs of the shoulder and cervical spine are normal. What is the most likely diagnosis?

Upper Extremity Board Review 2008: High-Yield MCQs (Set 2) - Figure 34





Explanation

The patient has symptoms and examination findings of acute brachial neuritis which is often a diagnosis of exclusion. The recent viral flu-like symptoms have shown a correlation with the development of this disorder. The acute, severe shoulder weakness excludes calcific tendinitis, impingement, and poliomyelitis. A normal cervical spine examination makes cervical disk disease unlikely. Turner JW, Parsonage MJ: Neuralgic amyotrophy (paralytic brachial neuritis). Lancet 1957;2:209-212.

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Question 50

Figures 2a and 2b show the radiographs of a 72-year-old man with aseptic loosening of the tibial component of his total knee arthroplasty. Optimal management should include





Explanation

The radiographs show massive subsidence of the lateral side of the tibia with severe tibial bone loss and a fractured proximal fibula. Reconstruction should consist of a large metal or bony lateral tibial augmentation, and a stem long enough to bypass the defect is required. The femoral and tibial components are articulating without any remaining polyethylene medially; therefore, the femoral component is damaged and needs revision. The insertions of the lateral ligaments are absent, thereby rendering the lateral side of the knee predictably unstable. Also, the large valgus deformity compromises the medial collateral ligament. The posterior cruciate ligament is also likely to be deficient with this much tibial bone destruction. The patient requires a posterior stabilized femoral component at the minimum, and possibly a constrained femoral component. Retention of the femoral component, even though it may be well-fixed, jeopardizes the outcome. Lotke PA, Garino JP: Revision Total Knee Arthroplasty. New York, NY, Lippincott-Raven, 1999, pp 137-250. Insall JN, Windsor RE, Scott WN, et al: (eds): Surgery of the Knee, ed 2. New York, NY, Churchill Livingstone, 1993, pp 935-957.

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Question 51

An 82-year-old man is seen in consultation after being admitted for a fall from ground level. There was no loss of consciousness and the patient recalls striking his head and sustaining a hyperextension-type injury to the cervical spine. Examination reveals an 8-cm head laceration with only mild axial neck tenderness. He has generalized weakness throughout the upper extremities and maintained motor function of the lower extremities. There are no obvious sensory deficits, and the bulbocavernous reflex and deep tendon reflexes are maintained. What is the most appropriate diagnosis at this time?





Explanation

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

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Question 52

Pain associated with a proximal medial tibial osteochondroma in a 10-year-old patient is most commonly the result of





Explanation

Pain secondary to an osteochondroma is usually from soft-tissue irritation and bursal formation. This is particularly common for proximal medial tibia osteochondromas that irritate the pes anserine tendons. Malignant degeneration into a chondrosarcoma rarely occurs, is usually associated with multiple hereditary exostoses, and usually occurs after skeletal maturity. Borges AM, Huvos AG, Smith J: Bursa formation and synovial chondrometaplasia associated with osteochondromas. Am J Clin Pathol 1981;75:648-653.

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Question 53

When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?





Explanation

As the chance of success of lumbosacral fusion increases with the stiffness and rigidity of the construct, fixation and stiffness improve with fixation into both the upper sacrum and the ilium. In a review of individuals treated with long constructs to the pelvis for adult scoliosis, Islam and associates reported that the rate of pseudarthrosis was significantly lower with sacral and iliac fixation compared with sacral fixation alone or iliac fixation alone. Iliac screws provide significant fixation anterior to the instantaneous axis of rotation for flexion and extension, as well as provides resistance to lateral bending and rotational forces. Numerous biomechanical studies support the concept of increasing biomechanical stabilization with increased fixation from the sacrum to the ilium. Islam NC, Wood KB, Transfeldt EE, et al: Extension of fusions to the pelvis in idiopathic scoliosis. Spine 2001;26:166-173. O'Brien N, et al: Sacral pelvic fixation and spinal deformity, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 601-614.

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Question 54

A 9-year-old girl reports progressive right knee pain. Radiographs are shown in Figures 59a and 59b. Work-up reveals no other sites of disease. Low- and high-power photomicrographs are shown in Figures 59c and 59d. What is the most appropriate treatment?





Explanation

This classic case of osteosarcoma illustrates the typical radiographic and histologic characteristics of this disease. The radiographs show an aggressive-appearing lesion of the distal femur. The lesion has both lytic and blastic areas. Periosteal reaction is present in the form of a Codman's triangle. The radiographs are highly suggestive of osteosarcoma. The photomicrographs show malignant spindle cells that produce osteoid, thus confirming the diagnosis of osteosarcoma. Treatment of osteosarcoma is multimodal including multi-agent chemotherapy and surgery (wide resection or amputation). Bacci G, Ferrari S, Bertoni F, et al: Long-term outcome for patients with nonmetastatic osteosarcoma of the extremity treated at the Instituto Ortopedico Rizzoli according to the Instituto Ortopedico Rizzoli/osteosarcoma-2 protocol: An updated report. J Clin Oncol 2000;18:4016-4037. Bielack SS, Kempf-Bielack B, Delling G, et al: Prognostic factors in high-grade osteosarcoma of the extremities or trunk: An analysis of 1,702 patients treated on neoadjuvant cooperative osteosarcoma study group protocols. J Clin Oncol 2002;20:776-790.

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Question 55

What complication is frequently associated with the Weil lesser metatarsal osteotomy (distal, oblique) in the treatment of claw toe deformities?





Explanation

Weil osteotomies are useful in achieving shortening of a lesser metatarsal with preservation of the distal articular surface. The osteotomy is oriented from distal-dorsal to proximal-plantar; therefore, proximal displacement of the distal fragment is associated with plantar (not dorsal) displacement as well. Plantar displacement can result in the intrinsics acting dorsal to the center of the metatarsophalangeal joint and the development of an extended or "floating toe." Nonunion, osteonecrosis, and inadequate shortening are infrequent complications associated with the Weil lesser metatarsal osteotomy. Trnka HJ, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int 2001;22:47-50.

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Question 56

A 20-year-old collegiate football player sustains an injury to his left foot 3 weeks before the start of the fall season. Examination reveals localized tenderness over the lateral midfoot and normal foot alignment. Radiographs are shown in Figures 28a through 28c. What is the treatment of choice?





Explanation

Due to the relatively high incidence of delayed union and nonunion associated with this mildly displaced Jones-type fracture, and the temporal proximity to his playing season, intramedullary screw fixation is the treatment of choice in this collegiate athlete to best ensure healing and expedite his return to football. If nonsurgical management were elected, application of a non-weight-bearing short leg cast would be appropriate since a higher likelihood of healing is expected with it versus a short leg walking cast. The risk of recurrent fracture of fractures that heal with nonsurgical management has reportedly been high (approximately 30%). Quill GE: Fractures of the proximal fifth metatarsal. Orthop Clin North Am 1995;26:353-361. Torg JS, Balduini FC, Zelko RR, et al: Fractures of the base of the fifth metatarsal distal to the tuberosity: Classification and guidelines for nonsurgical and surgical management. J Bone Joint Surg Am 1984;66:209-214.

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Question 57

Figures 25a and 25b show the radiograph and MRI scan of a 48-year-old man who reports increasing unsteadiness in his gait and hand clumsiness. Examination reveals a positive Hoffmann's reflex bilaterally, positive clonus, and a spastic gait. Management should consist of





Explanation

The patient has a congenitally small spinal canal with secondary multilevel degenerative changes causing stenosis and cord compression across multiple segments, including directly posterior to the vertebral bodies. A multilevel diskectomy may address the cord compression at the disk level, but not posterior to the bodies, and most likely would be inadequate. The patient has significant stenosis distal to C5, necessitating a more extensive surgical approach than simply C3-C5. Because the patient's cervical lordosis is preserved, a posterior procedure such as laminoplasty or laminectomy would allow the cord to fall away from the anterior pathology and afford decompression. Cervical myelopathy does not tend to resolve, and there is a significant risk for progression; therefore, surgical management usually is recommended. Edwards CC II, Riew KD, Anderson PA, et al: Cervical myelopathy: Current diagnostic and treatment strategies. Spine J 2003;3:68-81.

Scientific References

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Question 58

A 32-year-old man sustains a forceful inversion injury while playing soccer. Examination reveals tenderness in the lateral hindfoot and midfoot region with associated ecchymosis and swelling. Radiographs show proximal migration of the os peroneum. Active eversion is still present. These findings indicate disruption of the





Explanation

The os peroneum is an accessory ossicle located within the peroneus longus tendon. It is typically located at the level of the cuboid groove in the lateral hindfoot and midfoot region. Proximal migration of the os peroneum indicates disruption of the peroneus longus tendon and is an important clue to diagnosis. This unusual condition can cause chronic lateral ankle pain, and surgical repair may be indicated. Active eversion indicates that the peroneus brevis is clinically intact. Disruption of the extensor digitorum brevis, plantar fascia, or syndesmosis would have no effect on the position of the os peroneum. Thompson FM, Patterson AH: Rupture of the peroneus longus tendon: Report of three cases. J Bone Joint Surg Am 1989;71:293-295.

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Question 59

In Figure 14, the primary fracture line in a calcaneal fracture is best depicted by which of the following schematics?

Trauma Board Review 2000: High-Yield MCQs (Set 2) - Figure 5





Explanation

The schematic labeled A best depicts the primary fracture line in a calcaneal fracture. The primary fracture line in an axial-loading fracture of the calcaneus occurs from superior-lateral to inferior-medial. This fracture line separates the calcaneus into sustentacular and tuberosity fragments and typically enters the subtalar joint through the posterior facet. Although additional fracture lines typically occur, the primary fracture line is almost always present. If surgical reduction is planned, reducing the primary fracture is always a key step. Macey LR, Benirschke SK, Sangeorzan BJ, Hansen ST: Acute calcaneal fractures: Treatment option and results. J Am Acad Orthop Surg 1994;2:36-43.

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Question 60

A 22-year-old skier reports painful range of motion in the left thumb after falling forward on his outstretched hand while holding his ski pole. Examination of the left thumb reveals increased AP laxity and 45 degrees of valgus laxity at the metacarpophalangeal (MCP) joint. Examination of the right thumb shows 25 degrees of valgus laxity at the MCP joint. Radiographs are normal. Management should consist of





Explanation

The patient has a complete tear of the ulnar collateral ligament as defined by MCP joint laxity of greater than 30 degrees (or 15 degrees greater laxity compared with the opposite side). Primary repair is the treatment of choice because displacement of the ligament superficial to the adductor aponeurosis (Stener lesion) must be corrected. Any volar plate injury can be addressed during repair of the ulnar collateral ligament.

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Question 61

Figures 13a and 13b show the preoperative radiographs of a 60-year-old woman who is scheduled to undergo total knee arthroplasty under epidural anesthesia. Postoperatively she reports a burning sensation on the dorsum of her foot despite the administration of IV analgesics through a patient-controlled analgesia (PCA) pump. Management should now include





Explanation

The patient has a significant flexion contracture and valgus deformity; therefore, the risk of peroneal nerve injury is increased. Idusuyi and Morrey noted that epidural anesthesia also increases the risk of peroneal nerve injury. The initial symptom can be a burning sensation on the foot, followed by pain and then motor weakness. Initial management should consist of release of the dressings and knee flexion. Idusuyi OB, Morrey BF: Peroneal nerve palsy after total knee arthroplasty: Assessment of predisposing and prognostic factors. J Bone Joint Surg Am 1996;78:177-184.

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Question 62

A 52-year-old woman with a 2-year history of a flexible (stage II) adult-acquired flatfoot deformity has failed to respond to nonsurgical management consisting of immobilization, custom orthotics, nonsteroidal anti-inflammatory drugs, and physical therapy. The patient is unable to perform a single limb heel rise. Weight-bearing radiographs are shown in Figures 30a through 30c. What is the most appropriate surgical correction?





Explanation

The patient has an atypical adult flatfoot deformity. The radiographs reveal forefoot abduction, mild loss of calcaneal pitch, and marked plantar flexion sag through the naviculocuneiform joint. The inability to perform a single limb heel rise indicates that the posterior tibial tendon is nonfunctional; however, the deformity remains flexible. In this patient, surgical treatment should include a tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening. Because a substantial portion of the deformity stems from the naviculocuneiform joint in this instance, tendon transfer and lateral column lengthening alone provide insufficient deformity correction. Triple arthrodesis and heel cord lengthening is best reserved for fixed flatfoot deformities. Soft-tissue procedures alone are associated with a high failure rate, as are attempted tendon repairs. Greisberg J, Assal M, Hansen ST Jr, et al: Isolated medial column stabilization improves alignment in adult-acquired flatfoot. Clin Orthop Relat Res 2005;435:197-202.

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Question 63

What is the most common complication requiring reoperation after dorsal plating for a distal radius fracture?





Explanation

The most common complication of dorsal plating is extensor tenosynovitis, which often causes pain and is a frequent reason for hardware removal. Other less frequent complications include loss of reduction and extensor tendon ruptures, with flexor tendon ruptures occuring to an even lesser degree. Rozental TD, Beredjiklian PK, Bozentka DJ: Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Joint Surg Am 2003;85:1956-1960.

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Question 64

A 64-year-old man has had increasing pain in the left hip for the past 6 months. A radiograph and MRI scan are shown in Figures 25a and 25b. Biopsy specimens are shown in Figures 25c and 25d. What is the recommended treatment?





Explanation

The radiograph shows a lytic lesion in the left periacetabular area consistent with chondrosarcoma. A large soft-tissue mass is present along with extension through the supra-acetabular region and pubic ramus. The histology shows a hypercellular lesion infiltrating through the bony trabeculae with a basophilic cytoplasm. This is classified as a grade 2 chondrosarcoma. The treatment of a pelvic chondrosarcoma is wide resection via either an internal hemipelvectomy or amputation. Chondrosarcoma requires surgical resection for control and does not traditionally respond to chemotherapy or external beam irradiation therapy. Pring M, Weber, KL, Unni KK, et al: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg 2001;83:1630-1642.

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Question 65

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





Explanation

Patients born with bilateral radial clubhands may have difficulty getting their hands to their mouth. The centralization procedure would take away that ability if there is a lack of elbow flexion. Green DP, Hotchkiss RN, Pederson WC: Green's Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 344-349.

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Question 66

The essential lesion responsible for posterolateral rotatory instability of the elbow is disruption of the





Explanation

Posterolateral rotatory instability (PLRI) of the elbow represents a three-dimensional injury pattern of rotational displacement of the ulna from the trochlea and the radius from the capitellum. The ulna supinates (externally rotates) past its normal limit and the radiocapitellar joint subluxates posterolaterally, permitting the coronoid process to slide beneath the trochlea. In cadaver studies, the lateral ulnar collateral ligament has been shown to be the essential lesion responsible for PLRI. The medial collateral ligament (of which the anterior bundle is the most important) is the primary restraint to valgus instability. The posterolateral capsule and radial collateral ligament may be disrupted in a complete posterolateral dislocation but are not essential injuries for PLRI. The primary function of the annular ligament is to stabilize the proximal radioulnar joint. O'Driscoll SW, Jupiter JB, King GJW, Hotchkiss RN, Morrey BF: The unstable elbow. J Bone Joint Surg Am 2000;82:724-738. Olsen BS, Sojbjerg JO, Dalstra M, Sneppen O: Kinematics of the lateral constraints of the elbow. J Shoulder Elbow Surg 1996;5:333-341.

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Question 67

A 65-year-old man has a painful and often audible crepitus after undergoing a total knee arthroplasty 8 months ago. His symptoms are reproduced with active extension of about 30 degrees. Examination reveals no effusion or localized tenderness, a stable knee, and a range of motion of 5 degrees to 120 degrees. Radiographs are shown in Figures 37a and 37b. Management should consist of





Explanation

This is a typical presentation of the patellar clunk syndrome. The syndrome usually follows implantation of a posterior stabilized prosthesis. It is thought to be the result of femoral component design and altered extensor mechanics. The condition usually resolves with arthroscopic debridement of the suprapatellar fibrous nodule. Arthrotomy or revision is seldom warranted. Beight JL, Yao B, Hozack WJ, Hearn SL, Booth RE Jr: The patellar "clunk" syndrome after posterior stabilized total knee arthroplasty. Clin Orthop 1994;299:139-142.

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Question 68

A 38-year-old man has an enlarging left paraspinal soft-tissue mass. Based on the MRI scans and biopsy specimens shown in Figures 32a through 32e, what is the most likely diagnosis?





Explanation

Fibromatosis is a benign but aggressive fibrous lesion that principally arises from the connective tissue of muscle and the overlying fascia. The peak incidence is between the ages of 25 and 35 years. Most patients have a deep-seated, firm, poorly circumscribed mass that has grown insidiously and causes little or no pain. MRI is helpful in diagnosing the lesion and in assessing the extent of disease prior to surgical intervention. Histologically, the lesion is poorly circumscribed and infiltrates the surrounding tissue. The lesion appears bland with uniform spindle cells separated by abundant collagen, with little or no cell-to-cell contact. Despite its bland microscopic appearance, the tumor frequently behaves in an aggressive manner. These lesions do not metastasize but have a high incidence of recurrence. Treatment options consist of surgical resection, radiation therapy, chemotherapeutic protocols, hormone modulation, and/or anti-inflammatory medications. Weiss SW, Goldblum JR, Enzinger FM: Enzinger and Weiss's Soft Tissue Tumors, ed 4. Philadelphia, PA, Elsevier, 2001, pp 309-337.

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Question 69

A 5-year-old boy has a deformity of his right arm after falling from a jungle gym. A radiograph is shown in Figure 37. Management should consist of

Trauma 2006 Practice Questions: Set 3 (Solved) - Figure 18





Explanation

Monteggia fractures in children must be recognized. Early appropriate treatment is much easier than delayed reconstruction for a missed radial head dislocation. In younger children, attempts should be made to reduce the ulna fracture and radial head dislocation with traction and manual manipulation. Anterior Monteggia fractures are the most common, and in this variety the radius is much better stabilized in elbow flexion. Posterior Monteggia fractures are less common and may be managed in elbow extension. Closed reduction is much more successful in younger children; ulnar fixation with a rod or plate may be needed in older patients with unstable fractures. Annular ligament repair is rarely needed in the acute fracture. Wilkins KE: Changes in the management of Monteggia fractures. J Pediatr Orthop 2002;22:548-554. Kay RM, Skaggs DL: The pediatric Monteggia fracture. Am J Orthop 1998;27:606-609.

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Question 70

A 50-year-old electrician who is right-hand dominant has had right shoulder pain and stiffness after sustaining an electric shock 2 months ago. An AP radiograph obtained at the time of injury was considered negative, and the patient was diagnosed with a shoulder sprain. The patient now reports continued shoulder pain and restricted motion. AP and axillary radiographs and a CT scan are shown in Figures 41a through 41c. Management should consist of





Explanation

Open reduction and transfer of the subscapularis and lesser tuberosity into the humeral head defect is the treatment of choice for chronic posterior dislocations in which the articular defect consists of 20% to 40% of the articular surfaces. Closed reduction can be used if the dislocation is recognized early and the articular defect is less than 20% of the articular surface. Humeral arthroplasty is reserved for patients with an articular defect that is greater than 45% to 50% of the head. Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.

Scientific References

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Question 71

A 23-year-old woman reports right knee pain and fullness. The pain is worse with activity but also present at rest. Radiographs are shown in Figures 20a and 20b. What is the most likely diagnosis?





Explanation

The radiographs reveal a predominantly lytic, destructive lesion of the distal femur, although there is a hint of some blastic change as well. The lesion has violated the cortex, and there is mineralization outside the cortex laterally. The lateral radiograph suggests a soft-tissue density. These aggressive changes on radiographs in this age group are strongly suggestive of osteosarcoma. Sanders TG, Parsons TW: Radiographic imaging of musculoskeletal neoplasia. Cancer Control 2001;8:221-231.

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Question 72

The wear resistance of ultra-high molecular weight polyethylene can be improved by exposing the polymer to high-energy radiation (eg, gamma or electron beam), followed by a thermal treatment. What is one detrimental side effect of this process?





Explanation

Highly cross-linked polyethylene has gained widespread acceptance for joint arthroplasty components because of reported experimental and early clinical accounts of significant reductions in wear. Cross-linking is increased by imparting additional energy into the polymer (above that conventionally used for sterilization). The thermal treatments after cross-linking stabilize the material against oxidative degradation by quenching free radicals and also reduce the elastic modulus. One disadvantage of the increased cross-linking is a reduction in toughness that makes the polyethylene more susceptible to crack initiation and propagation. The reduced toughness raises concerns for gross component fracture and fracture at stress concentrations that can arise with the locking mechanisms used to secure polyethylene inserts into metallic backings. Nonconsolidated polyethylene particles have been associated with increased subsurface density secondary to oxidative degradation in conventional polyethylene implants. The quenching of free radicals by thermal treatment in highly cross-linked polyethylene should prevent this problem. Collier JP, Currier BH, Kennedy FE, et al: Comparison of cross-linked polyethylene materials for orthopaedic applications. Clin Orthop 2003;414:289-304. Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 203-208.

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Question 73

What is the most frequent late complication of cementless fixation in total knee arthroplasty?

Hip 2004 Practice Questions: Set 1 (Solved) - Figure 25





Explanation

The incidence of osteolysis, particularly around fixation screws in the tibia, can be as high as 30%. Stable femoral component fixation is generally maintained. Infection, subluxation of the patella, and stiffness can occur with either cemented or cementless fixation. Peters PC, Engh GA, Dwyer KA, Vinh TN: Osteolysis after total knee arthroplasty without cement. J Bone Joint Surg Am 1992;74:864-876.

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Question 74

Figure 16 shows the radiograph of a 56-year-old man who has neck pain after a rollover accident on his lawnmower. The injury appears to be isolated, and he is neurologically intact. Management of the fracture should consist of

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





Explanation

The radiograph shows a type IIa Hangman's fracture, and the classic treatment is halo vest immobilization. Traction should be avoided in type IIa injuries because of the risk of overdistraction. A lesser form of immobilization such as a hard collar or a Minerva jacket can be used for nondisplaced (type I) fractures. Surgery generally is reserved for type III fractures (includes C2-3 facet dislocation), or extenuating circumstances such as multiple trauma or other fractures of the cervical spine that require surgical stabilization. Levine AM, Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985;67:217-226.

Scientific References

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Question 75

The vascularity of the digital flexor tendons is significantly richer in what cross-sectional region?





Explanation

The vascularity of the dorsal portion of the digital flexor tendons is considerably richer than the volar portion. The other regions are not preferentially more vascular. Hunter JM, Scheider LH, Makin EJ (eds): Tendon Surgery in the Hand. St Louis, MO, Mosby, 1987, pp 91-99.

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Question 76

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

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





Explanation

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

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Question 77

A 12-year-old girl with juvenile rheumatoid arthritis (JRA) has had chronic pain and synovitis about the knee that is now well-controlled medically. Examination reveals 20 degrees of valgus at the knee. Knee range of motion shows 10 degrees to 90 degrees of flexion. Treatment should consist of





Explanation

Children with JRA frequently have valgus in association with hypervascularity because of chronic inflammation. This is normally caused by overgrowth of the medial femoral epiphysis. Staple hemiepiphyseodesis, if done early, can reverse the deformity. Osteotomy is usually unnecessary at this age, and there is a risk of stiffness of the knee following the procedure. Synovectomy may be helpful but will not prevent or correct a deformity.

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Question 78

What is the most common complication following surgical fixation of a distal humeral fracture?

Upper Extremity Board Review 2005: High-Yield MCQs (Set 2) - Figure 30





Explanation

In most series, elbow stiffness is the most common complication and can be overcome by achieving stable fixation and initiating early motion after surgery. All of the other complications are seen but to a lesser degree than elbow stiffness. Sanders RA, Raney EM, Pipkin S: Operative treatment of bicondylar intra-articular fractures of the distal humerus. Orthopedics 1992;15:159-163.

References:

Question 79

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

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





Explanation

Similar to the action of a force, a moment tends to angularly accelerate an object in a manner proportional to a quantity related to the mass of the object. The concept of a more massive object requiring a larger force to cause the same straight line acceleration is straightforward. The concept for changing angular velocity is similar but not identical. The proportional constant between the moment and the resulting angular acceleration is the mass moment of inertia, which depends not only on the mass of the object, but also its distribution. The unit of mass moment of inertia is obtained by multiplying the mass of the object by the square of the distance between an equivalent location of the center of rotation of the object and an equivalent location of the center of mass. Orthopaedic surgeons can change both the amount of mass carried by a limb and the way that the mass is distributed. For example, in applying a cast to the leg, the physician can affect the mass of the cast by the choice of casting material and by the size of the cast. As the mass moment of inertia of the limb increases (eg, by applying the cast farther down on the leg or using a heavier casting material), the patient will need to exert larger moments to angularly accelerate the leg during gait. Andriacchi T, Natarajan RN, Hurwitz DE: Musculoskeletal dynamics, locomotion, and clinical applications, in Mow VC, Hayes WC (eds): Basic Orthopaedic Biomechanics, ed 2. New York, NY, Lippincott-Raven, 1997, pp 43-47.

References:

Question 80

Which of the following methods most reliably detects mechanical loosening of the hip?





Explanation

Mechanical loosening of the hip is best revealed by serial radiographs of the prosthetic joint. None of the other methods of evaluation is considered reliable in diagnosing mechanical loosening. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 455-492.

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Question 81

Examination of a 12-year-old girl with bilateral anterior knee pain reveals excessive femoral anteversion and excessive external tibial torsion. The patient has no patellofemoral instability. Nonsurgical management consisting of muscle strengthening and nonsteroidal medication has failed to relieve the patient's pain. Treatment should now consist of





Explanation

Children with symptomatic severe torsional malalignment of the lower extremity and patellofemoral pathology show excessive femoral anteversion and external tibial torsion on physical examination and analysis of gait. The functional effect of this torsional malalignment is centered about the knee joint. If nonsurgical management fails to alleviate patellofemoral pain, definitive surgical treatment should consist of corrective osteotomies, including internal rotation of the distal part of the tibia or external rotation of the femur, or both. Patients with surgical correction by osteotomy show an improved gait pattern and appearance of the extremity and a marked decrease in knee pain. External rotation of the distal part of the tibia or internal rotation of the distal part of the femur worsens the torsional malalignment. No additional soft-tissue realignment procedures, including retinacular release or patellar realignment, are required.

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Question 82

The third plantar intrinsic muscle layer of the foot consists of which of the following structures?





Explanation

The plantar intrinsic muscles are divided into four layers with respect to depth from the plantar fascia. They are (from superficial to deep): 1) abductor hallucis, flexor digitorum brevis, abductor digiti minimi; 2) quadratus plantae, lumbricals; 3) flexor digiti minimi, flexor hallucis brevis, adductor hallucis brevis; and 4) dorsal and plantar interosseous muscles. The flexor hallucis brevis and adductor hallucis brevis originate from the midtarsal bones, encompass the sesamoids, and insert into the base of the proximal phalanx. The adductor hallucis brevis consists of two muscle bellies forming a conjoined tendon and inserting into the lateral portion of the proximal phalanx and the lateral sesamoid. The adductor hallucis brevis is stronger than the abductor hallucis brevis, which may contribute to hallux valgus. The flexor digitorum minimi travels under the fifth metatarsal, arising at the base and inserting into the lateral base of the fifth proximal phalanx.

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Question 83

A 27-year-old man was struck by a taxi cab and sustained comminuted right distal third tibia and fibula fractures; treatment consisted of placement of an intramedullary nail in the tibia the following morning. At his 6-month follow-up, he has clawing of all five toes. Examination reveals flexion deformities of the distal and proximal interphalangeal joints that are flexible with plantar flexion and rigid with dorsiflexion. Calluses are present on the dorsum and tip of the toes. Single heel rise is normal. He has a mild equinus contracture (relative to the left leg) that is not relieved with knee flexion. What is the most appropriate treatment option?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 2) - Figure 30





Explanation

This is an example of tethering of the flexor hallucis longus/flexor digitorum longus (FHL/FDL) to the fracture site. Additional time and/or physical therapy and bracing would not be expected to be of benefit. Release of the FHL and FDL from the fracture site or retromalleolar lengthening will address the posttraumatic claw toe deformity and Achilles tendon lengthening will address the mild equinus. Posterior tibial tendon transfer is not appropriate as the patient demonstrates a normal heel rise. Midfoot releases and hallux fusion are also not indicated. Feeny MS, Williams RL, Stephens MM: Selective lengthening of the proximal flexor tendon in the management of acquired claw toes. J Bone Joint Surg Br 2001;83:335-338.

References:

Question 84

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





Explanation

Although thoracic disk herniations have been reported at all levels of the thoracic spine, more than two thirds are found at T9-T12, which is the more mobile lower third of the thoracic region. Belanger TA, Emery SE: Thoracic disc disease and myelopathy, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 855-864.

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Question 85

A 16-year-old female swimmer reports several episodes of atraumatic glenohumeral instability that occur with different arm positions. Examination reveals generalized ligamentous laxity and a positive sulcus sign, and her shoulder can be subluxated both anteriorly and posteriorly. Initial management should consist of

Upper Extremity Board Review 2005: High-Yield MCQs (Set 2) - Figure 31





Explanation

The patient has multidirectional instability (MDI). It has been reported that a high percentage of patients with MDI respond to a properly structured exercise program that is continued for at least 3 to 6 months. If nonsurgical management fails to provide relief, stabilization with an inferior capsular shift procedure has been effective in a high percentage of patients. Unidirectional repairs, such as the Putti-Platt procedure, are unsuitable for correcting MDI. Thermal capsulorrhaphy has been reported to have a very high failure rate (greater than 50%) for treating MDI. Burkhead WZ Jr, Rockwood CA Jr: Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am 1992;74:890-896. Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908. Pollock RG, Owens JM, Flatow EL, et al: Operative results of the inferior capsular shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg Am 2000;82:919-928.

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Question 86

A 22-year-old woman injures her neck in a motor vehicle accident. Examination reveals no sensory or motor function below T8. Radiographs and an MRI scan show a burst fracture at T7. Forty-eight hours later, the bulbocavernosus reflex is present but there is no evidence of motor or sensory recovery in the lower extremities. What is the most likely diagnosis?

Trauma 2009 Practice Questions: Set 1 (Solved) - Figure 25





Explanation

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

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Question 87

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

Basic Science 2008 Practice Questions: Set 1 (Solved) - Figure 61





Explanation

The use of bisphosphonates has been recently associated with the development of osteonecrosis of the jaw. Length of exposure seems to be the most important risk factor for this complication. The type of bisphosphonate may play a role and previous dental procedures may be a precipitating factor. Bisphosphonates are a class of therapeutic agents originally designed to treat loss of bone density (ie, alendronate). The primary mechanism of action of these drugs is inhibition of osteoclastic activity, and it has been shown that these drugs are useful in diseases with propensities toward osseous metastases. In particular, they are effective in diseases in which there is clear upregulation of osteoclastic or osteolytic activity, such as breast cancer and multiple myeloma, and have developed into a mainstay of treatment for individuals with these diseases. Although shown to reduce skeletal events, there has been no improvement in patient survival. Bamias A, Kastritis E, Bamia C, et al: Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: Incidence and risk factors. J Clin Oncol 2005;23:8580-8587. Thakkar SG, Isada C, Smith J, et al: Jaw complications associated with bisphosphonate use in patients with plasma cell dyscrasias. Med Oncol 2006;23:51-56.

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Question 88

When elevating the arm, the ratio of scapulothoracic to glenohumeral motion over the total range of motion is best described as





Explanation

The ratio of scapulothoracic to glenohumeral motion with elevation has been shown to vary depending on what portion of elevation is examined, how much load is on the arm, and the technique used to measure increments of elevation. However, almost every study shows that the ratio of scapulothoracic to glenohumeral motion is 1:2 for the contributions over a full range of elevation to 170 degrees. In the first 30 degrees of elevation, there is significant variability in the ratio, and there may be significant variability up to around 60 degrees. Inman VT, Saunders JR, Abbott LC: Observations of the function of the shoulder joint. Clin Orthop 1996;330:3-12.

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Question 89

A 58-year-old woman with rheumatoid arthritis and a severe hindfoot valgus deformity now reports recurrent lateral ankle pain. Examination reveals pain over the fibula and sinus tarsi, with a valgus hindfoot that is passively correctable. Despite the use of an ankle-foot orthosis, this is the second time this problem has occurred. Radiographs and a clinical photograph are shown in Figures 28a through 28c. What is the next most appropriate step in treatment?





Explanation

Excessive hindfoot valgus can lead to abutment between the calcaneus and fibula. This valgus force can lead to a stress fracture of the distal fibula. Surgery may be required if an insufficiency fracture recurs despite orthotic management. Of the choices listed, a subtalar arthrodesis is most likely to achieve rebalancing of the foot at the level of the deformity. Stephens HM, Walling AK, Solmen JD, Tankson CJ: Subtalar repositional arthrodesis for adult acquired flatfoot. Clin Orthop 1999;365:69-73

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Question 90

A 22-year-old man who sustained a Gustilo-Anderson grade IIIC open fracture of the right tibia and fibula was treated with an immediate open transtibial amputation. After two serial debridements, he underwent wound closure with a posterior myocutaneous soft-tissue flap. What is the preferred method of early rehabilitation?

Foot & Ankle Board Review 2006: High-Yield MCQs (Set 2) - Figure 5





Explanation

There is no evidence that early weight bearing enhances ultimate rehabilitation. At the other extreme, weight bearing should not be delayed for a prolonged period of time. In a young, healthy individual, the rigid plaster dressing appears to be the safest method of protecting the wound during the early postoperative period. If the wound appears to be secure, early partial weight bearing can be safely initiated. Burgess EM, Romano RL, Zettl JH: The Management of Lower Extremity Amputations. Washington, DC, US Government Printing Office, 1969, also at: www.prs-research.org.

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Question 91

A 30-year-old man who sustained a tibial fracture with a peroneal nerve palsy 2 years ago now has a drop foot and weak eversion of the foot. He reports success with stretching exercises, but he catches his toes when his foot tires. Examination reveals that the foot is plantigrade and supple. What is the next most appropriate step in management?

Foot & Ankle 2006 Practice Questions: Set 1 (Solved) - Figure 9





Explanation

The patient has a supple plantigrade foot that would benefit from a drop foot brace to prevent catching of the toes. Tendon transfer should not be considered until the patient has undergone bracing. Achilles tendon lengthening is not necessary because the foot is plantigrade and flexible. Nerve grafting is not indicated because of the length of time the peroneal nerve palsy has been present. Dehne R: Congenital and acquired neurologic disorders, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 552-553.

References:

Question 92

In patients without spondylolisthesis or scoliosis undergoing laminectomy for lumbar spinal stenosis, spinal fusion is generally recommended if





Explanation

With the notable exception of fusion for degenerative spondylolisthesis and scoliosis, there is a paucity of evidence on the indications for spinal fusion in patients undergoing laminectomy for spinal stenosis. However, it is generally recommended that if the spine is destabilized (for example by removal of one complete facet joint or by an iatrogenic pars fracture), spinal fusion should be considered. Although fusion can be considered for a very long laminectomy, a two-level laminectomy does not represent, by itself, a clear indication for the addition of a spinal fusion. The repair of a dural tear and the use of nicotine by the patient play no role in the determination of whether or not to add fusion to a laminectomy procedure. Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 299-409.

References:

Question 93

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





Explanation

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

References:

Question 94

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

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





Explanation

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

References:

Question 95

A 60-year-old woman with a history of breast cancer has progressive paraparesis. The MRI scan is shown in Figure 28. What form of management is most likely to restore or maintain ambulation?

Spine Surgery 2000 Practice Questions: Set 3 (Solved) Figure 2





Explanation

Surgical decompression and stabilization have been shown to be the most effective means of improving neurologic function. Decompression is most reliably done from the side of the compression, which is anterior in this patient. Harrington KD: Metastatic tumors of the spine: Diagnosis and treatment. J Am Acad Orthop Surg 1993;1:76-86.

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Question 96

A 65-year man has right hip pain after a fall. Radiographs reveal a reverse oblique intertrochanteric femoral fracture. Treatment consists of reduction and internal fixation. Which of the following implants is most commonly associated with nonunion and hardware failure?

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





Explanation

Reverse oblique intertrochanteric femoral fractures account for 5% of all intertrochanteric or subtrochanteric fractures. They are uncommon but not rare and will be encountered in practice. The sliding hip screw is associated with the most problems because of its design. When reverse oblique fractures are fixed with a sliding hip screw, the action of the construct causes medial displacement of the distal fragment rather than compression of the proximal and distal fragments. All of the other implants prevent medial displacement of the distal segment. It should not be assumed that simply using one of the other implants is reason for success. There is a significant failure rate for each of these implants with reverse oblique fractures. The implant must be ideally placed and the fracture must be reduced. Haidukewych GJ, Israel TA, Berry DB: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650. Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.

References:

Question 97

A 30-year-old firefighter sustained a longitudinal pulling injury to the arm while attempting to move a heavy object during a fire. Figure 45 shows an MRI scan of the elbow. Initial management should consist of

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





Explanation

Because the MRI scan shows a complete rupture of the distal biceps tendon, the preferred treatment is anatomic repair of the tendon to the radial tuberosity either with the use of suture anchors or transosseous sutures through a two-incision technique. Several studies have documented superior results with anatomic repair of the distal biceps tendon when compared with results of nonsurgical management or repair of the tendon by attachment to the brachialis muscle. Patients undergoing anatomic repair of the distal biceps tendon through a two-incision technique typically regain a functional range of motion and nearly normal strength. D'Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. Am J Sports Med 1993;21:114-119. Boyd JB, Anderson LD: A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Am 1961;43:1041-1043. Morrey BF, Askew LJ, An KN, Dobyns JH: Rupture of the distal tendon of the biceps brachii: A biomechanical study. J Bone Joint Surg Am 1985;67:418-421.

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Question 98

A 26-year-old right hand-dominant man has had right shoulder pain for the past 6 months. History reveals that he was the starting pitcher for his high school team. Activity modification, physical therapy, cortisone injection, and anti-inflammatory drugs have failed to improve his symptoms. He has a positive O'Brien's active compression test. What is the next most appropriate step in the diagnosis of this patient?

Upper Extremity Board Review 2008: High-Yield MCQs (Set 2) - Figure 24





Explanation

MRI-arthrography has been shown to be an accurate technique for assessing the glenoid labrum in patients with suspected labral tears. Often standard MRI technique will not identify labral lesions. The use of MRI-arthrography with an intra-articular injection of gadolinium provides improved visualization of labral lesions. Bencardino and associates demonstrated a sensitivity of 89%, a specificity of 91%, and an accuracy of 90% in detecting labral lesions. SLAP lesions can be visualized on coronal oblique sequences as a deep cleft between the superior labrum and the glenoid that extends well around and below the biceps anchor. Often, contrast will diffuse into the labral fragment, causing it to appear ragged or indistinct. Applegate GR, Hewitt M, Snyder SJ, et al: Chronic labral tears: Value of magnetic resonance arthrography in evaluating the glenoid labrum and labral-bicipital complex. Arthroscopy 2004;20:959-963. Bencardino JT, Beltran J, Rosenberg ZS, et al: Superior labrum anterior-posterior lesions: Diagnosis with MR arthrography of the shoulder. Radiology 2000;214:267-271.

References:

Question 99

What is the most common reason for reoperation in total knee arthroplasty?

Hip 2001 Practice Questions: Set 1 (Solved) - Figure 3





Explanation

Patellar problems currently constitute the largest number of complications after total knee arthroplasty, affecting between 8% and 35% of patients. These problems include patellar instability, fracture, component loosening, surface erosion, and pain. Malalignment, as an isolated reason for revision, is uncommon, yet it contributes to accelerated wear of the components. Joint instability affects up to 6% of patients, and the infection rate in knee arthroplasty is around 1% to 2%. Blasier RB, Matthews LS: Complications of prosthetic knee arthroplasty, in Epps CH (ed): Complications in Orthopaedic Surgery. Philadelphia, PA, JP Lippincott, 1994, pp 1066-1069. Rand JA: The patellofemoral joint in total knee arthroplasty. J Bone Joint Surg Am 1994;76:612-620.

References:

Question 100

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

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





Explanation

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

References:

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