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Comprehensive Master Guide · Medically Reviewed

Orthopedic Board Review: 100 High-Yield MCQs - Set #538

Ace your exams with our Orthopedic Board Review featuring 100 high-yield MCQs. Test your knowledge with our interactive quiz, timer, and score tracking!

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104 min read
Updated: Apr 2026
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Dr. Mohammed Hutaif
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Prof. Dr. Mohammed Hutaif
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Quick Medical Answer

This page provides 100 high-yield orthopedic surgery multiple-choice questions (MCQs) designed for ABOS, OITE, and FRCS board exam preparation. Surgeons can master key concepts across spine, trauma, sports, peds, and adult reconstruction, ensuring comprehensive review and success on their certification exams.

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Question 1

A 40-year-old man has had hip pain with increased activity over the past year. Examination reveals restriction of motion and tenderness with combined hip flexion, adduction, and internal rotation. An AP radiograph is shown in Figure 34. What is the most likely diagnosis?

Anatomy 2008 Practice Questions: Set 3 (Solved) - Figure 12





Explanation

Femoral acetabular impingement (FAI) is a pathologic entity leading to pain, reduced range of motion in flexion and internal rotation, and development of secondary arthritis of the hip. There are two types of FAI: cam impingement and pincher impingement. Cam impingement is seen when a nonspherical femoral head produces a cam effect when the prominent portion to the femoral head rotates into the joint. This mechanism produces shear forces that damage articular cartilage. Radiographs reveal early joint degeneration and flattening of the head neck junction (the so-called "pistol grip deformity") as seen in this image. The pincher type of impingement involves abnormal contact between the femoral head neck junction and the acetabulum, in the presence of a spherical femoral head. Beall DP, Sweet CF, Martin HD, et al: Imaging findings of femoraoacetabular impingement syndrome. Skeletal Radiol 2005;34:691-701.

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Question 2

Figure 26 shows the clinical photograph of a patient who has developed a residual limb ulcer following a traumatic transtibial amputation 2 years ago. What is the preferred treatment to resolve the ulcer?

Foot & Ankle 2009 Practice Questions: Set 3 (Solved) - Figure 4





Explanation

The first step in the treatment of an amputation residual limb (stump) ulcer is local wound care and adjustment of the residual limb-prosthetic interface, as well as adjusting prosthetic alignment. Surgical revision should be undertaken only when prosthetic modification is unsuccessful. Murnaghan JJ, Bowker JH: Musculoskeletal complications, in Smith DG, Michael JW, Bowker JH (eds): Atlas of Amputations and Limb Deficiencies, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 683-700.

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Question 3

A 68-year-old woman stepped on a needle while walking barefoot 10 days ago. She is not certain but thinks it is imbedded in her foot, and she notes local tenderness at the puncture site and drainage. Her primary care physician has been treating her with oral antibiotics. A plain radiograph is shown in Figure 38. What is the best course of action?

Foot & Ankle 2000 Practice Questions: Set 3 (Solved) - Figure 18





Explanation

Based on the radiographic findings, the patient has a metallic foreign body in her foot that is consistent with a needle. She has local infection secondary to the continued presence of the foreign body. CT is not necessary to localize the foreign body as it is adequately visualized on the plain radiographs. The infection cannot be adequately treated until the foreign body is removed. Attempted removal of foreign bodies without proper anesthesia and fluoroscopy frequently results in frustration because of the inability to localize the foreign body. Removal in a surgical suite with proper anesthesia and fluoroscopy is the preferred option. Once the foreign body is removed, the local infection will resolve rapidly. Combs AH, Kernek CB, Heck DA: Orthopedic grand rounds: Retained wooden foreign body in the foot detected by computed tomography. Orthopedics 1986;9:1434-1435.

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Question 4

In children with isolated zone II lacerations of the flexor tendon, poor digital motion is best correlated with





Explanation

In a recent study on restoration of motion following zone I and zone II flexor tendon repairs in children, age was found to have no effect on the results of zone II tendon repairs. Early passive motion offered no better results than immobilization for 3 weeks. Immobilization for more than 4 weeks correlated with poorer results.

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Question 5

Compared to postoperative radiation therapy, preoperative radiation therapy has a higher rate of what complication?

Basic Science 2008 Practice Questions: Set 3 (Solved) - Figure 77





Explanation

Radiation therapy is commonly used as an adjuvant in the treatment of soft-tissue sarcomas, but a controversy exists whether it should be preoperative or postoperative. Radiation therapy can be given prior to or following resection of the tumor. Postoperative radiation is usually given in a higher dose to a larger treatment field. This commonly results in a higher incidence of fibrosis and lymphedema. There is no statistical difference in local recurrence rate between the two radiation treatment plans. Neuropathy is more commonly a complication of chemotherapy. Preoperative radiation therapy has been shown to have a higher wound complication rate than postoperative radiation. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.

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Question 6

Which of the following acetabular cup designs has shown the greatest survivorship at 10 years in patients younger than age 60 years?





Explanation

Poor survivorship of cemented sockets in young patients has lead to the development of a variety of cementless designs. Of these, smooth metal-backed sockets have not performed as well as porous-coated designs. Threaded metal-backed sockets showed a 6% to 25% revision rate secondary to aseptic loosening at a mean follow-up of 4.5 to 6 years. Despite some early failed designs, cementless porous-coated metal-backed sockets have shown the best survivorship in long-term studies. Smith SE, Harris WH: Total hip arthroplasty performed with insertion of the femoral component with cement and the acetabular component without cement: Ten to thirteen-year study. J Bone Joint Surg Am 1997;79:1827-1833.

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Question 7

A 16-year-old girl sustained the injury shown in Figure 7a. CT scans are shown in Figures 7b through 7d. The results of treatment of this injury have been shown to most correlate with which of the following factors?





Explanation

The patient has a very low T-type acetabular fracture; however, the head is not congruent under the dome so surgical reduction is necessary. The anterior and posterior columns are displaced and will move independent from each other. The extended iliofemoral is the only approach allowing for visualization and reduction of each column. A combined anterior and posterior approach may also be used. The timing of surgery should be within the first 3 weeks of injury to optimize chances of obtaining an accurate reduction because this is an important factor in determining outcome. Letournel E, Judet R (eds): Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer-Verlag, 1991.

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Question 8

A relative contraindication for anteromedial tibial tubercle transfer for patellar instability is arthrosis in what portion of the patella?





Explanation

Anteromedial displacement of the tibial tubercle unloads the distal and lateral facets of the patella and shifts the forces to the proximal and medial facets. Therefore, if findings indicate arthrosis predominately in the medial and proximal areas of the patella, this is considered a relative contraindication because it may accentuate arthritic symptoms. Fulkerson JP: Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin Orthop 1983;177:176-181. Bellemans J, Cauwenberghs F, Witvrouw E, et al: Anteromedial tibial tubercle transfer in patients with chronic anterior knee pain and a subluxation-type patellar malalignment. Am J Sports Med 1997;25:375-381.

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Question 9

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





Explanation

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

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Question 10

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





Explanation

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

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Question 11

The anterolateral (Watson-Jones) approach to the hip exploits the intermuscular interval between the

Anatomy Board Review 2005: High-Yield MCQs (Set 2) - Figure 14





Explanation

The Watson-Jones approach to the hip uses the intermuscular interval between the gluteus medius and the tensor fascia lata. This is not a true internervous plane, as both muscles are supplied by the superior gluteal nerve. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, pp 316-332.

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Question 12

What malignant disease most commonly develops in conjunction with chronic osteomyelitis?

Basic Science Board Review 2005: High-Yield MCQs (Set 2) - Figure 15





Explanation

The most common malignant disease to arise in conjunction with chronic osteomyelitis is squamous cell carcinoma particularly in patients with a long-standing draining sinus tract. Dell PC: Hand, in Simon MA, Springfield D (eds): Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott-Raven, 1998, pp 405-420.

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Question 13

An adult patient has an 8- x 4- x 10-cm soft-tissue mass located within the adductor compartment of the thigh. Staging studies should consist of

Basic Science 2002 Practice Questions: Set 1 (Solved) - Figure 47





Explanation

The appropriate staging studies should consist of MRI and a radiograph of the primary lesion and CT of the chest. MRI is superior to CT for soft-tissue imaging. CT may be useful for evaluating the cortex of bone for invasion by tumor. Bone scans are not commonly used because soft-tissue sarcomas rarely metastasize to bone. CT of the abdomen and pelvis is not typically ordered except for possible liposarcoma. With liposarcoma, there may be a synchronous or metastatic retroperitoneal liposarcoma. Demetri GD, Pollock R, Baker L, et al: NCCN sarcoma practice guidelines: National Comprehensive Cancer Network. Oncology (Huntingt) 1998;12:183-218.

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Question 14

The MRI findings shown in Figure 51 would most likely create which of the following signs and symptoms?

Anatomy Board Review 2005: High-Yield MCQs (Set 4) - Figure 15





Explanation

The MRI scan shows a far lateral disk herniation. With the L4-5 disk, a far lateral herniation abuts the left L4 nerve root. The findings would be consistent with those of a left L4 radiculopathy and would include pain or a sensory deficit on the anteromedial aspect of the knee, diminished patellar tendon reflex, and quadriceps weakness, perhaps making it difficult to walk up and down stairs. Fardin DF, Garfin SR (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 329.

References:

Question 15

A 39-year-old man has had persistent right shoulder pain for the past 6 months. A formal physical therapy program has failed to provide relief, and an injection several months ago provided only short-term relief. Examination reveals a positive Neer and Hawkins test. There is no instability and the neurovascular examination is normal. Arthroscopy reveals a partial rotator cuff tear on the bursal side measuring 60% of the tendon thickness. What is the next most appropriate step in management?

Upper Extremity 2008 Practice Questions: Set 1 (Solved) - Figure 18





Explanation

Although arthroscopic debridement with or without subacromial decompression is a reasonable response, the patient has positive impingement signs. Several recent studies regarding the surgical treatment of partial rotator cuff tears have demonstrated good to excellent results after repair of tears involving more than 50% of the tendon thickness. This was shown specifically for bursal-sided tears and joint-side tears. Biceps tenotomy is not indicated in a young patient. Matava MJ, Purcell DB, Rudzki JR: Partial-thickness rotator cuff tears. Am J Sports Med 2005;33:1405-1417.

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Question 16

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





Explanation

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

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Question 17

A 10-lb, 2-oz infant who was born via a difficult breech delivery 12 hours ago is now being evaluated for hip pain. Although the infant is resting comfortably, examination reveals that the patient is not moving the right lower extremity and manipulation of the right hip causes the infant to cry. The Galeazzi sign is positive. An AP radiograph of the pelvis shows proximal and superior migration of the right proximal femoral metaphysis. What is the most likely diagnosis?





Explanation

Transphyseal fractures of the proximal femur at birth are more likely to occur in large newborns after a difficult delivery. At rest, the patients are comfortable and show a pseudoparalysis; however, passive motion of the lower extremity results in discomfort. Teratologic hip dislocations will have a positive Galeazzi sign, but are not painful. Development of a septic hip would be unlikely within 12 hours postpartum. Congenital coxa vara is typically painless. Postpartum ligamentous laxity might account for a positive Ortolani sign, but is painless. Weinstein JN, Kuo KN, Millar EA: Congenital coxa vara: A retrospective review. J Pediatr Orthop 1984;4:70-77.

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Question 18

What is the most common MRI appearance of a malignant soft-tissue sarcoma?

Basic Science 2005 Practice Questions: Set 1 (Solved) - Figure 10





Explanation

The classic MRI appearance of a soft-tissue sarcoma is a well-defined heterogeneous mass deep to the fascia. MRI has greatly enhanced our ability to identify and characterize soft-tissue masses. In many patients, MRI is diagnostic and may obviate the need for biopsy. In other patients, it may indicate with high probability that the mass is malignant and consideration for referral can be made. A common misconception is that sarcomas are infiltrative; therefore, physicians mistakenly exclude the diagnosis of a sarcoma based on a well-defined mass seen on MRI. However, sarcomas grow centrifugally with balloon-like expansion compressing surrounding normal tissue; as such, they appear well defined. Many benign soft-tissue masses such as lipomas are similarly well defined. However, MRI is especially useful in identifying fat. Lipomas appear to be homogeneous masses with fat signal characteristics on all sequences. Ill-defined soft-tissue masses include infection, trauma, and desmoid tumors. Heterogeneity is not unique to malignant tumors but is a characteristic of soft-tissue sarcomas. Bancroft LW, Peterson JJ, Kransdorf MJ, Nomikos GC, Murphey MD: Soft tissue tumors of the lower extremities. Radiol Clin North Am 2002;40:991-1011. Berquist TH, Ehman RL, King BF, et al: Value of MR imaging in differentiating benign from malignant soft-tissue masses: Study of 95 lesions. Am J Roentgenol 1990;155:1251-1255.

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Question 19

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

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





Explanation

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

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Question 20

A patient with degenerative osteoarthritis of the sternoclavicular (SC) joint reports constant pain, discomfort, and marked prominence and instability of the SC joint following medial clavicle resection. Which of the following procedures is most likely to produce these signs and symptoms?





Explanation

Medial clavicle excision alone can be associated with postoperative instability of the clavicle. The clavicle should be stabilized to the first rib by reconstructing the costoclavicular ligament if it is torn or if the resection is lateral to its clavicular insertion. Therefore, care must be taken to resect only that part of the clavicle that is medial to the costoclavicular ligament. Adequate protection for vital structures that lie posterior to the medial end of the clavicle must be provided. Bremner RA: Nonarticular noninfected subacute arthritis of the sternoclavicular joint. J Bone Joint Surg Br 1959;41:749-753.

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Question 21

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





Explanation

Surgical decompression is unnecessary in a patient with no neurologic deficit and canal compromise of less than 50%. A compression deformity of less than 50% and kyphosis of less than 30 degrees may be successfully treated with a TLSO extension brace. Deformity in this range will reliably heal with minimal risk for late deformity or residual pain. Although some studies suggest 6 weeks of bed rest as treatment, early mobilization and bracing is preferred. Hartman MB, Chrin AM, Rechtine GR: Nonoperative treatment of thoracolumbar fractures. Paraplegia 1995;33:73-76. Chow GH, Nelson BJ, Gebhard JS, Brugman JL, Brown CW, Donaldson DH: Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracing and early mobilization. Spine 1996;21:2170-2175.

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Question 22

A 28-year-old man sustained a shoulder dislocation 2 years ago. It remained dislocated for 3 weeks and required an open reduction. He now reports constant pain and has only 60 degrees of forward elevation and 10 degrees of external rotation. He desires to return to some sporting activities. An AP radiograph and intraoperative photograph (a view of the humeral head through a deltopectoral approach) are shown in Figures 31a and 31b. What is the best treatment option to decrease pain and improve function?





Explanation

The radiograph and intraoperative photograph show osteonecrosis with near complete head loss/collapse. A stemmed implant is more appropriate in this patient because there is very little bone to support a resurfacing implant. In a younger patient, a glenoid implant should be delayed as long as possible because of the eventual need for revision secondary to glenoid loosening and wear, especially in a young active male. The hemiarthroplasty may be converted to a total shoulder arthroplasty in the future. Levy O, Copeland SA: Cementless surface replacement arthroplasty of the shoulder: 5- to 10-year results with the Copeland mark-2 prosthesis. J Bone Joint Surg Br 2001;83:213-221.

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Question 23

A 30-year-old patient has acetabular dysplasia and moderate secondary osteoarthrosis. Which of the following studies will best help predict the success of periacetabular osteotomy?





Explanation

Improvement in the appearance of the hip joint on functional radiographic evaluation (abduction/adduction views) has been shown to be predictive of outcome following joint preserving surgery. CT and MRI findings have not been shown to be predictive of outcome.

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Question 24

A 7-year-old boy has had low back pain for the past 3 weeks. Radiographs reveal apparent disk space narrowing at L4-5. The patient is afebrile. Laboratory studies show a WBC count of 9,000/mm3 and a C-reactive protein level of 10 mg/L. A lumbar MRI scan confirms the loss of disk height at L4-5 and reveals a small perivertebral abscess at that level. To achieve the most rapid improvement and to lessen the chances of recurrence, management should consist of





Explanation

The patient has diskitis. Administration of IV antibiotics speeds resolution and minimizes recurrence. Bed rest and cast immobilization have been successfully used to treat this disorder but can be associated with prolonged recovery and frequent recurrence, even when oral antibiotics are administered. A perivertebral abscess seen in association with this condition usually resolves without surgery. Ring D, Johnston CE II, Wenger DR: Pyogenic infectious spondylitis in children: The convergence of discitis and vertebral osteomyelitis. J Pediatr Orthop 1995;15:652-660.

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Question 25

A 7-year-old boy sustains an acute injury to the distal radial metaphysis, along with a completely displaced Salter-Harris type I fracture of the ulnar physis, as shown by the arrows in Figure 12. After satisfactory reduction of both injuries, what is the major concern?

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 31





Explanation

While injury of the distal radial metaphysis is a rather common occurrence, the incidence of physeal arrest is only about 4% to 5% of patients. While injury of the distal physis of the ulna is rare, the incidence of physeal arrest is greater than 50% in fractures of this structure. These patients need to be followed closely both clinically and radiographically to look for the signs of distal ulnar/physeal arrest such as loss of the prominence of the ulna and ulnar deviation of the hand. Radiographically, progressive shortening of the ulna is observed. Nelson OA, Buchanan JR, Harrison CS: Distal ulnar growth arrest. J Hand Surg Am 1984;9:164-170.

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Question 26

Which of the following has been associated with a decreased rate of glenoid component radiolucent lines?





Explanation

According to a recent study, cemented pegged glenoid components had fewer radiolucent lines initially and at 2-year follow-up when compared to a cemented keeled design. Curve-backed designs have also shown fewer radiolucent lines when compared to flat-backed designs. Oversizing the glenoid can lead to impaired rotator cuff function and decreased range of motion. An off-centered glenoid can lead to early loosening. Gartsman GM, Elkousy HA, Warnock KM, et al: Radiographic comparison of pegged and keeled glenoid components. J Shoulder Elbow Surg 2005;14:252-257. Szabo I, Buscayret F, Edwards TB, et al: Radiographic comparison of flat-back and convex-back glenoid components in total shoulder arthroplasty. J Shoulder Elbow Surg 2005;14:636-642.

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Question 27

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

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





Explanation

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

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Question 28

During a posterior approach to the glenoid with retraction as shown in Figure 33, care should be taken during superior retraction to avoid injury to which of the following structures?

Trauma 2006 Practice Questions: Set 3 (Solved) - Figure 11





Explanation

During a posterior approach to the shoulder for either a scapular fracture, glenoid fracture, or posterior shoulder pathology, the interval between the teres minor and infraspinatus is split. Excessive superior retraction on the infraspinatus, or excessive dissection superomedially under the infraspinatus muscle and tendon can cause injury to the suprascapular nerve and/or artery. During dissection in this interval, the axillary artery and axillary nerve are well protected. A branch of the circumflex scapular artery ascends between the teres minor and infraspinatus muscle, but it is at risk during dissection on the scapula in the mid portion of the interval and not during superior retraction. The profunda brachii artery is not present in this interval. Jerosch JJ, Greig M, Peuker ET, et al: The posterior subdeltoid approach: A modified access to the posterior glenohumeral joint. J Shoulder Elbow Surg 2001;10:265-268. Judet R: Surgical treatment of scapular fractures. Acta Orthop Belg 1964;30:673-678.

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Question 29

A 62-year-old man has cervical myelopathy with no evidence of cervical radiculopathy. MRI reveals stenosis at C4-5 and C5-6 with severe cord compression. Examination will most likely reveal which of the following findings?

Spine Surgery 2000 Practice Questions: Set 1 (Solved) - Figure 20





Explanation

Cervical myelopathy involves compression of the spinal cord and presents as an upper motor neuron disorder. Patients commonly have extremity spasticity and problems with ambulation and balance. Hoffman's sign is often present and is elicited by suddenly extending the distal interphalangeal joint of the middle finger; reflexive finger flexion represents a positive finding. The extremities are usually hyperreflexic with myelopathy. With cervical radiculopathy (lower motor neuron disorder), reflexes are hyporeflexic, and patients report pain along a dermatomal distribution. A hyperactive jaw jerk reflex indicates pathology above the foramen magnum or in some cases, systemic disease. Flaccid paraparesis suggests a lower motor neuron problem. Sachs BL: Differential diagnosis of neck pain, arm pain and myelopathy, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 741-742.

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Question 30

Which of the following factors are considered prognostic of survival in patients with soft-tissue sarcomas?





Explanation

The factors that are independently prognostic of patient survival are tumor size, tumor grade, and tumor depth (ie, subfascial versus superficial). These factors are the basis for the American Joint Committee on Cancer staging criteria. Patient age and neurovascular invasion are not prognostic. Surgical margin is prognostic for local recurrence but not conclusively for patient survival or metastasis. Metastatic disease is also predictive of survival. Cheng EY, Thompson RC Jr: New developments in the staging and imaging of soft-tissue sarcomas. Instr Course Lect 2000;49:443-451.

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Question 31

An adult patient has a closed humeral fracture that was treated nonsurgically and a concomitant radial nerve injury. Six weeks after injury, electromyography shows no evidence of recovery. Management should now consist of





Explanation

In patients with radial nerve injuries with closed humeral fractures, it has been reported that 85% to 95% spontaneously recover. Based on this premise, most surgeons favor expectant management of these injuries. Even if there is no evidence of recovery at 6 weeks, repeat electromyography at 12 weeks is advocated. If there is no clinical or electromyographic signs of recovery at 6 months, exploration is recommended. If the nerve is in continuity at the time of exploration, nerve action potentials are useful in helping determine the need for neurolysis, excision, and grafting, or if excision and repair is the best option. Pollock FH, Drake D, Bovill EG, et al: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.

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Question 32

A patient undergoes a simple excision of a 3-cm superficial mass in the thigh at another institution. The final pathology reveals a leiomyosarcoma, without reference to the margins. What is the recommendation for definitive treatment?

Basic Science Board Review 2008: High-Yield MCQs (Set 2) - Figure 50





Explanation

Treatment of patients with unplanned excision of soft-tissue sarcomas is challenging. If the margins are positive or unclear, the patient is best managed with repeat excision of the tumor bed, and radiation therapy if the repeat excision does not yield wide margins. In patients with no detectable tumor on physical examination or imaging after unplanned excision, some studies have shown that up to 35% of patients will have residual disease and a poorer local recurrence rate (22% versus 7%). Therefore, whenever feasible, a reexcision of the tumor bed is recommended.

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Question 33

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





Explanation

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

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Question 34

A 7-year-old boy sustained a 2-cm laceration to the anterior aspect of his left knee after falling on a rock. Examination reveals that the joint surface is not visible through the wound. Radiographs show no evidence of a foreign body or free air in the joint. Management should consist of

Pediatrics Board Review 2004: High-Yield MCQs (Set 2) - Figure 30





Explanation

The possibility of an open joint injury should be considered in any patient who has a small periarticular laceration. Failure to promptly diagnose and treat such injuries may lead to septic arthritis. The diagnosis of an open joint is easily made when there is visible communication of the joint through the traumatic wound, or when intra-articular air is present on a radiograph. In the absence of these findings, the diagnosis of an open joint may be established by the saline load test, in which a volume of saline is injected into the joint under sterile conditions. If fluid extravasates through the traumatic wound, the diagnosis of an open joint is established. Voit and associates used a saline load test in 50 patients with periarticular lacerations suggestive of joint penetration. When they compared the clinical prediction of whether or not the laceration had penetrated the joint and the test results, the authors reported a false-positive clinical result in 39% of patients and a false-negative clinical result in 43%. The authors concluded that the saline load test was valuable in evaluating periarticular lacerations. Voit GA, Irvine G, Beals RK: Saline load test for penetration of periarticular lacerations. J Bone Joint Surg Br 1996;78:732-733.

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Question 35

A 42-year-old man who is right-hand dominant injured his right shoulder when he fell from a ladder onto his outstretched arm 1 hour ago. Radiographs reveal a two-part greater tuberosity anterior fracture-dislocation. Initial management should consist of





Explanation

Greater tuberosity anterior fractures associated with anterior glenohumeral dislocations respond very well to closed methods in the majority of patients. Closed reduction of the glenohumeral joint often anatomically reduces the greater tuberosity into its cancellous bed, without the need for open fixation or cuff repair. Once closed reduction of the joint is performed, tuberosity displacement and joint articulation should be evaluated radiographically with AP and scapular lateral views as well as an axillary view. The axillary view will not only definitively show the joint articulation but also demonstrate posterior displacement of the greater tuberosity missed on the AP and lateral views. If no or minimal (5 mm) displacement is found, then nonsurgical management consisting of a sling and gentle passive range-of-motion exercises can be instituted. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

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Question 36

Figure 2 shows the lateral radiograph of an 8-year-old boy who sustained an acute injury to the elbow after falling down the stairs. Management should consist of

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 4





Explanation

The patient has a flexion-type olecranon fracture, and the integrity of the extensor mechanism is disrupted. With this degree of displacement, closed reduction and extension casting would not be adequate. The strongest construct is an oblique screw across the fracture site, with a tension band. Healing is rapid in this age group; therefore one of the heavy absorbable sutures can be used as the tension band. Two parallel pins with the stainless steel tension band wire (AO technique) can be used but requires wire dissection for removal. Once the fracture is healed, the single screw can be removed easily with only a small incision. The presence of the screw, across the apophysis, has not been shown to produce any significant growth disturbance. Use of a large intramedullary screw would not be advisable because of the small size of the proximal fragment. Murphy DF, Greene WB, Gilbert JA, Dameron TB Jr: Displaced olecranon fractures in adults: Biomechanical analysis of fixation methods. Clin Orthop 1987;224:210-214.

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Question 37

There is increasing concern about the ethical relationship of orthopaedists to the orthopaedic equipment industry. Which of the following describes the most appropriate relationship?

Hip & Knee Reconstruction 2007 Practice Questions: Set 3 (Solved) - Figure 2





Explanation

It is appropriate for orthopaedic surgeons to have relationships with industry as long as the relationship is for the good of the patient and no "quid pro quo" intent exists. A grant to cover registration at a CME event is appropriate but travel and hotel for a spouse is not. For orthopaedists who are faculty at a meeting sponsored by industry, it is appropriate for travel and expenses to be covered for that faculty member. Care must be exercised that the faculty member contributes in an amount appropriate for the expenses paid. The faculty member must ensure that information presented is unbiased and based on reasonable data and opinion. Consulting agreements should spell out specifically the duties of the agreement and payment should be appropriate for the time spent. There should be a defined work product for the consulting. Agreements that are thinly veiled payments for use of a company's products must be avoided. In all cases, the agreements must stand up to public scrutiny. Restricted grants for specific industry-sponsored programs aimed at residents are not appropriate. Unrestricted grants intended for attendance at approved CME courses are appropriate. Dinners at which information is presented about topics that can aid in patient care are appropriate as long as the expense is reasonable ($100 or less/person) and the guest list includes individuals who can use the information in a patient case. Clearly a "premium" dinner for office staff to review new surgical instrumentation would not pass this test.

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Question 38

Which of the following malignant tumors most commonly contains soft-tissue calcifications seen on radiographs or CT?

Basic Science Board Review 2008: High-Yield MCQs (Set 2) - Figure 21





Explanation

Focal calcifications causing small radiopacities are found in 15% to 20% of synovial sarcomas. Their irregular contours differentiate them from the phleboliths found in a benign hemangioma. Ewing's sarcoma, clear cell sarcoma, and malignant fibrous histiocytoma do not commonly have calcifications within the lesions. Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St Louis, MO, Mosby, 1995, p 761.

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Question 39

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

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





Explanation

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

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Question 40

A 59-year-old construction worker who is right-hand dominant has had right shoulder pain for the past 9 months with no history of injury. Nonsurgical management consisting of two cortisone injections, physical therapy for 3 months, and nonsteroidal anti-inflammatory drugs has failed to provide lasting relief. Examination reveals tenderness over the acromioclavicular (AC) joint and over the subacromial bursa. He has positive Neer and Hawkins impingement signs and AC joint pain with adduction of the shoulder. Radiographs are shown in Figures 36a and 36b. An MRI scan reveals an intact rotator cuff. Management should now consist of





Explanation

Because the patient has clinical and radiographic signs of AC arthritis and subacromial impingement, the treatment of choice is anterior acromioplasty and distal clavicle excision. Arthroscopic acromioplasty alone would not address the AC arthritis. The rotator cuff is intact; therefore, rotator cuff repair is not indicated. An open Mumford procedure would address the AC arthritis only and not the impingement symptoms. Immobilization might lead to stiffness of the shoulder and is not recommended for treating impingement.

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Question 41

A 17-year-old high school football player injures his right ankle during a game. Examination reveals swelling and a closed ankle deformity, with normal foot circulation and sensation. Radiographs are shown in Figures 10a and 10b. In addition to closed reduction, management should include





Explanation

The examination and radiographs reveal a closed fracture-dislocation of the ankle with tibiofibular diastasis. Immediate fixation of the medial malleolus and plating of the fibula are indicated. If residual tibiofibular diastasis occurs with lateral translation of the fibula after plating, a syndesmotic screw is placed to stabilize the syndesmosis. Ankle fracture-dislocations associated with a proximal fibular fracture (Maisonneuve fracture) require syndesmotic fixation, but the fibula is not plated. Unstable ankle fractures require surgical treatment. If swelling is severe (fracture blisters, loss of skin wrinkling), a compressive splint is applied and surgery is delayed for 5 to 7 days. Browner BD, Jupiter JB, Levine AM, Trafton PG: Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992, pp 1887-1957.

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Question 42

The postoperative neurologic prognosis of a patient who has a tumor that is compressing the spinal cord and causing a neurologic deficit depends primarily on the





Explanation

The tumor biology, location, and pretreatment neurologic status are the best predictors of a patient's postoperative neurologic prognosis. Between 60% to 90% of patients who are ambulatory at the time of diagnosis will retain this ability after treatment. Location is important in that less space is available for the cord in the thoracic spine. Lesions located in vascular watershed regions may disrupt the vascular supply of the cord. Weinstein JN: Differential diagnosis and surgical treatment of primary benign and malignant neoplasms, in Frymoyer JW (ed): The Adult Spine: Principles and Practice. New York, NY, Raven Press, 1991, vol 1, pp 829-860.

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Question 43

A 22-year-old professional ballet dancer reports a 3-month history of posterior ankle pain that occurs when she changes from a flat foot to pointe (hyperplantar flexed position). Examination does not elicit the pain with forced passive plantar flexion. A radiograph is shown in Figure 8. What is the most likely cause of the pain?

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





Explanation

The most common causes of posterior ankle pain in ballet dancers are flexor hallucis longus tenosynovitis and os trigonum syndrome. Flexor hallucis longus tenosynovitis differs from a symptomatic os trigonum by the absence of pain with forced plantar flexion and the presence of pain with resisted plantar flexion of the great toe. The pain is often felt in the posterior ankle and can be associated with a snapping or triggering sensation. Os trigonum syndrome commonly occurs in ballet dancers who perform in a position of extreme plantar flexion. The pain occurs from entrapment of the os trigonum between the posterior portion of the talus and calcaneus. Hamilton WG, Geppert MJ, Thompson FM: Pain in the posterior aspect of the ankle in dancers: Differential diagnosis and operative treatment. J Bone Joint Surg Am 1996;78:1491-1500.

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Question 44

An 8-year-old boy reports progressive difficulty with walking. Examination reveals muscle weakness, with proximal groups more affected than distal muscles. Deep tendon reflexes are within normal limits. Laboratory studies show a creatine kinase level of 7,200 IU. Based on these findings, what is the most likely diagnosis?

Pediatrics Board Review 2004: High-Yield MCQs (Set 2) - Figure 29





Explanation

Patients with Becker muscular dystrophy have an abnormality in dystrophin, but unlike patients with Duchenne muscular dystrophy, some dystrophin is present. As a result, the progression of muscle weakness is slower, with the diagnosis typically made after age 8 years. Similar to patients with Duchenne muscular dystrophy, patients with Becker muscular dystrophy have pseudohypertrophy of the calves, markedly increased creatine kinase levels, and X-linked transmission of the condition. In addition, these patients are more prone to cardiomyopathy; a condition that should be carefully evaluated if any surgery is required. Patients with spinal muscular atrophy also have proximal muscle weakness, but the onset of weakness occurs earlier in childhood. These patients also have absent deep tendon reflexes and fasciculations, but pseudohypertrophy is absent and creatine kinase levels are normal. Patients with Emery-Dreifuss dystrophy may have a similar clinical picture to Becker's muscular dystrophy, but pseudohypertrophy is absent and creatine kinase levels are only mildly elevated. In addition, neck extension, elbow flexion, and ankle equinus contractures develop at an early age. Limb girdle dystrophy is a group of progressive muscular dystrophies that is not associated with pseudohypertrophy or a significant elevation of creatine kinase levels. Guillain-Barre syndrome is a condition associated with results from postinfectious demyelination of the peripheral nerve. These patients have the acute onset of weakness, hypotonia, and areflexia; creatine kinase levels are normal. Sussman MD: Muscular dystrophy, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1573-1583.

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Question 45

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 46

What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered?

Spine Surgery Board Review 2009: High-Yield MCQs (Set 2) - Figure 29





Explanation

The injury shown is a fracture-dislocation and it is highly unstable. In addition to this concern, spinal epidural hematomas have a much higher incidence in people with ankylosing spondylitis following knee fracture. It is felt to be due to disrupted epidural veins, with hypervascular epidural soft tissue in the setting of a rigid spinal canal. Patients with ankylosing spondylitis may have other significant comorbidities, especially cardiac and pulmonary, and these should be carefully assessed. Ludwig S, Zarro CM: Complications encountered in the management of patients with ankylosing spondylitis, in Vaccaro AR, Regan JJ, Crawford AH, et al (eds): Complications of Pediatric and Adult Spine Surgery. New York, NY, Marcel Dekker, 2004, pp 279-290.

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Question 47

A 70-year-old golfer has pain in her dominant shoulder. She reports that initially the pain was at night but now she is unable to play. Examination reveals weakness in external rotation and shoulder abduction. Radiographs reveal the humeral head articulating with a thin acromion. Management should consist of

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 12





Explanation

Chronic rotator cuff tears should be nonsurgically managed initially with a strengthening program. A cortisone injection may reduce inflammation. Surgery is reserved for patients who continue to have pain and lose sleep despite the use of physical therapy. Blood tests for infection or inflammation are nonspecific. Arthroscopy may play a role, but surgical replacement is reserved for advanced cases. Bokor DJ, Hawkins RJ, Huckell GH, et al: Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop 1993;294:103-110.

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Question 48

A 14-year-old girl has a painful hallux valgus deformity that has not responded to shoe modifications. Figure 21 shows a standing AP radiograph. What is the most appropriate surgical procedure?

Pediatrics 2007 Practice Questions: Set 3 (Solved) - Figure 1





Explanation

The radiograph reveals an increased first-second intermetatarsal angle and a congruent metatarsophalangeal joint with an abnormal distal metatarsal articular angle. Correction of both of these abnormalities requires a proximal and distal first metatarsal osteotomy. Coughlin M: Juvenile bunions, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby, 1993, pp 297-339.

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Question 49

A 45-year-old man reports right shoulder pain with overhead activities only. Figures 47a through 47d show the radiographs, bone scan, and MRI scan of a lesion of the proximal shoulder. What is the most appropriate treatment?





Explanation

The figures show a lesion of the proximal humerus consistent with an enchondroma. The lesion is calcified on the radiographs. There is no cortical destruction, significant endosteal scalloping, or soft-tissue mass. The bone scan shows mild uptake in the area of the proximal humerus, and the T2-weighted MRI scan shows a lesion with high uptake, suggesting a lesion with high water content. A CT scan could also be obtained to rule out bone destruction or periosteal reaction. Pain with overhead activities is likely related to the rotator cuff. A biopsy is unlikely to add information because of inherent difficulties interpreting low-grade cartilaginous lesions. Curettage and grafting and en bloc resection are excessive treatments for a benign lesion that is apparently asymptomatic. Observation with a follow-up radiograph in 3 to 6 months is appropriate. Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.

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Question 50

Figure 1 shows the radiograph of a patient who underwent a total knee revision with a posterior stabilized mobile-bearing prosthesis and now has recurrent knee dislocations. What is the most likely cause?

Hip & Knee Reconstruction 2007 Practice Questions: Set 1 (Solved) - Figure 2





Explanation

The patient has a posterior stabilized total knee revision, and the femoral component has dislocated over the tibial polyethylene cam/post. This usually indicates a loose flexion gap, or "flexion instability." A loose flexion gap can occur due to undersizing of the femoral component, anteriorization of the femoral component, excessive distal augmentation of the distal femur, or collateral ligament insufficiency, especially if combined with posterior capsular insufficiency. Isolated laxity of the extension gap (with a well-balanced flexion gap) causes varus/valgus instability, but it rarely causes the femoral component to "jump" the tibial cam of a posterior stabilized tibial insert. Malrotation of the components may cause patellar instability or a rotational instability of the tibiofemoral joint but should not cause a frank posterior dislocation of the tibia, unless combined with other errors of balancing. Although a mobile-bearing total knee arthroplasty may be more sensitive to errors in balancing than a fixed-bearing total knee arthroplasty, this complication does not reflect a faulty prosthetic design. 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 339-365. Lotke PA, Garino JP: Revision Total Knee Arthroplasty. New York, NY, Lippincott-Raven, 1999, pp 173-186, 227-249.

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Question 51

A 78-year-old patient undergoing revision total knee arthroplasty has bone loss throughout the knee at the time of revision. A distal femoral augment is used to restore the joint line. One month after surgery, the patient reports pain and is unable to ambulate. A lateral radiograph is shown in Figure 34. What is the most likely etiology of this problem?

Hip & Knee Reconstruction 2007 Practice Questions: Set 3 (Solved) - Figure 7





Explanation

Instability is a leading cause of failure following total knee arthroplasty. Instability can present as global instability, extension gap (varus/valgus) instability, or flexion gap (anterior/posterior) instability. Treatment options are numerous based on the exact pathology. The radiograph reveals anterior/posterior instability with dislocation consistent with flexion gap instability. A loose flexion gap can allow the femoral component to ride above the tibial cam post mechanism, resulting in dislocation. Distal femoral augments treat extension gap instability, whereas tibial augments can treat both flexion and extension gap instability. Posterior condyle augments at the distal femur can also be used to treat flexion gap instability. Flexion gap instability is further aggravated by extension mechanism incompetence. Note the excessively thin patella on the lateral radiograph. Pagnano MW, Hanssen AD, Lewallen DG, et al: Flexion instability after primary cruciate retaining total knee arthroplasty. Clin Orthop 1998;356:39-46. McAuley J, Engh GA, Ammeen DJ: Treatment of the unstable total knee arthroplasty. Inst Course Lect 2004;53:237-241.

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Question 52

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 53

Storage of musculoskeletal allografts by cryopreservation is achieved by





Explanation

Cryopreservation uses chemicals to remove cellular water and controlled rate freezing to prevent ice crystal formation. The tissue is procured, cooled to wet ice temperature for quarantine, and then stored in a container with cryoprotectant solution of dimethyl sulfoxide or glycerol which displaces the cellular water. The controlled rate freezing is then done to prevent ice crystal formation. Fresh allografts are not frozen in order to maintain maximum cellular viability, and this process limits the shelf life of osteochondral allografts. Freeze-drying involves replacement of water in the tissue with alcohol to a moisture level of 5% and then uses a vacuum process to remove the alcohol from the tissue. Preparation of fresh frozen grafts involves freezing the graft twice and packaging the tissue without solution at minus 80 degrees C. American Association of Tissue Banks: Standards for Tissue Banking. MacLean, VA, American Association of Tissue Banks, 1999. Vangsness CT Jr, Triffon MJ, Joyce MJ, et al: Soft tissue allograft reconstruction of the human knee: A survey of the American Association of Tissue Banks. Am J Sports Med 1996;24:230-234.

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Question 54

Which of the following mechanisms is considered the most common cause of failure of osteoarticular allografts used for articular reconstruction?

Hip 2001 Practice Questions: Set 1 (Solved) - Figure 18





Explanation

Mechanical loosening and infection can occur as complications after surgery, but the most common cause of osteoarticular allograft failure is graft collapse during revascularization. Clinical rejection because of an immune response is an unusual means of failure. Meyers MH, Akeson W, Convery FR: Resurfacing of the knee with fresh osteochondral allograft. J Bone Joint Surg Am 1989;71:704-713.

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Question 55

A 64-year-old man who was involved in a high-speed motor vehicle accident 6 weeks ago has been in the ICU with a closed head injury. Examination reveals that his range of motion for external rotation to the side is -30 degrees. Radiographs are shown in Figures 28a and 28b. What is the most likely diagnosis?





Explanation

The patient has a posterior shoulder dislocation. The AP radiograph shows overlapping of the humeral head on the glenoid. The scapular Y view shows his humeral articular surface posterior to the glenoid. The posterior shoulder dislocation is frequently missed because the patient is comfortable in the "sling" position with the arm adducted and internally rotated across the abdomen. The marked restriction in external rotation on examination raises the suspicion of a posterior dislocation, adhesive capsulitis, or glenohumeral osteoarthritis. The posterior dislocation is diagnosed based on the radiographic findings. An axillary view or CT is recommended to better evaluate the dislocation. Robinson CM, Aderinto J: Posterior shoulder dislocations and fracture-dislocations. J Bone Joint Surg Am 2005;87:639-650.

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Question 56

In the treatment of all magnitudes of bunionette deformities, what is the most common complication associated with lateral condylectomy of the fifth metatarsal head?





Explanation

When a lateral condylectomy alone is performed for all bunionette deformities, a high recurrence rate is expected. Lateral condylectomy should be used alone when the primary deformity is an enlarged lateral condyle of the fifth metatarsal head. In cases with significant divergence of the fifth metatarsal shaft in relationship to the fourth metatarsal shaft or with lateral bowing of the distal fifth metatarsal shaft, the lateral fifth metatarsal prominence will not be effectively reduced and recurrent symptoms and deformity are expected. Transfer metatarsalgia and/or dislocation of the metatarsophalangeal joint can infrequently occur with excessive metatarsal head excision. Arthrosis of the metatarsophalangeal joint has not been frequently reported. Coughlin MJ, Mann RA: Keratotic disorders of the plantar skin, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby-Year Book, 1993, pp 413-465. Kelikian H: Deformities of the lesser toe, in Kelikian H (ed): Hallux Valgus, Allied Deformities of the Forefoot and Metatarsalgia. Philadelphia, PA, WB Saunders, 1965, pp 327-330.

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Question 57

Outcome measures should have established psychometric properties of reliability, validity, and responsiveness. Reliability refers to which of the following?





Explanation

The recent JBJS article by Kocher and associates defines the different psychometric properties that are used in outcome measures. Reliability is a measure of how reproducible a test is. This can be interobserver reliability (ie, reliability between people), or intraobserver reliability (ie, reliability for the same person doing the outcome measure at different occasions).

Scientific References

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Question 58

If a laminectomy for spinal stenosis is performed, which of the following is an indication for concomitant arthrodesis at that level?

Spine Surgery 2006 Practice Questions: Set 1 (Solved) - Figure 30





Explanation

A prospective randomized study of patients with degenerative spondylolisthesis and spinal stenosis by Herkowitz and Kurz showed significantly improved clinical outcomes in patients who also received a lumbar arthrodesis. Patients with a laminectomy at an adjacent level do not have improved outcomes with an arthrodesis. Minimal lumbar scoliosis does not require arthrodesis. Arthrodesis is indicated in cases where there is removal of more than 50% of the facets bilaterally but not with an associated foraminal stenosis. Herkowitz HN, Kurz LT: Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 1991;73:802-807.

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Question 59

Figure 13 shows the radiographs of a 56-year-old woman who has pain and varus knee deformity after undergoing total knee arthroplasty 8 years ago. Aspiration and studies for infection are negative. During revision surgery, management of the tibial bone loss is best achieved by

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





Explanation

Massive bone loss encountered in revision total knee arthroplasty remains a significant challenge. Recent reports have shown high success rates using structural allograft to reconstruct massive bone defects. Custom and hinged prostheses in this setting are no longer favored. The defect shown is segmental and is too large to be filled with cement or iliac crest bone graft. Mow CS, Wiedel JD: Structural allografting in revision total knee arthroplasty. J Arthroplasty 1996;11:235-241. Engh GA, Herzwurm PJ, Parks NL: Treatment of major defects of bone with bulk allografts and stemmed components during total knee arthroplasty. J Bone Joint Surg Am 1997;79:1030-1039.

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Question 60

Where is the watershed zone for tarsal navicular vascularity?

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





Explanation

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

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Question 61

With a full-thickness articular cartilage injury, the body's healing response produces cartilage mainly composed of what type of collagen?





Explanation

With a full-thickness articular cartilage injury, a healing response is initiated with hematoma, stem cell migration, and vascular ingrowth. This response produces type I collagen and resultant fibrous cartilage rather than desired hyaline cartilage as produced by chondrocytes. This repair cartilage has diminished resiliency, stiffness, poor wear characteristics, and the predilection for arthritis. Type I collagen is also found in the annulus of intervertebral disks, tendon, bone, meniscus, and skin. Type II is found in articular cartilage and nucleus pulposus of intervertebral disks. Type III is found in skin and blood vessels, type IV is found in basement membranes, and type X is found in the calcified layer of cartilage. Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 19-28.

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Question 62

A 12-month-old boy has right congenital fibular intercalary hemimelia with a normal contralateral limb. A radiograph of the lower extremities shows a limb-length discrepancy of 2 cm. All of the shortening is in the right tibia. Assuming that no treatment is rendered prior to skeletal maturity, the limb-length discrepancy will most likely





Explanation

Many congenital limb deficiencies and bowing deformities result in growth retardation. If unilateral, a gradually progressive limb-length discrepancy will result; however, the proportional lengths of the lower extremities will remain at a relatively constant ratio. For example, if the right foot is at the level of the left knee at birth, this will still be true at maturity. This concept can be useful for early prediction of limb-length discrepancy by using a "multiplier method," as described by Paley and associates. This method can facilitate early treatment decisions, such as the need for amputation, without having to wait for serial scanography measurements. Paley D, Bhave A, Herzenberg JE, et al: Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am 2000;82:1432-1446.

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Question 63

Figures 26a through 26c show the MRI scans of a 47-year-old man who underwent arthroscopic shoulder surgery 6 months ago and continues to have pain despite a prolonged course of rehabilitation. Management should now consist of





Explanation

The MRI scans show an os acromiale of the mesoacromion type. This represents an unfused acromial apophysis. Pain is thought to be caused by either motion at the site or downward displacement of the anterior aspect of the acromion onto the rotator cuff, causing impingement. Most patients can be treated nonsurgically as they are usually asymptomatic. In those patients with persistent symptoms of pain and tenderness over the acromion, surgery consisting of rigid internal fixation and bone grafting has yielded satisfactory results. Excision may be a viable treatment option for the preacromion type. Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20. Warner JP, Beim GM, Higgins L: The treatment of symptomatic os acromiale. J Bone Joint Surg Am 1998;80:1320-1326.

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Question 64

It is important to avoid which of the following exercises in the immediate postoperative period after humeral head replacement for an acute four-part fracture?

Shoulder 2002 Practice Questions: Set 1 (Solved) - Figure 6





Explanation

It is critical to withhold active range of motion of the shoulder within the first 6 weeks after arthroplasty for acute fracture to prevent tuberosity avulsion. When radiographic and clinical findings show that the tuberosities are healed, active motion may be instituted, usually at 6 to 8 weeks. Immediate passive range-of-motion exercises, including external rotation with a stick, pendulum, and passive elevation, should begin within the limits of the repair on the day of surgery to prevent stiffness. Hartstock LA, Estes WJ, Murray CA, et al: Shoulder hemiarthroplasty for proximal humerus fractures. Orthop Clin North Am 1998;29:467-475.

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Question 65

Examination of a 9-year-old girl who injured her left elbow in a fall reveals tenderness and swelling localized to the medial aspect of the elbow. Motor and sensory examinations of the hand are normal, and circulation is intact. A radiograph is seen in Figure 28. Management should consist of

Pediatrics 2004 Practice Questions: Set 3 (Solved) - Figure 7





Explanation

Avulsion fractures of the medial epicondyle are caused by a valgus stress applied to the immature elbow and usually occur in children between the ages of 9 and 14 years. Long-term studies have shown that isolated fractures of the medial epicondyle with between 5 to 15 mm of displacement heal well. Brief immobilization (1 to 2 weeks) in a long arm cast or splint yields results similar to open reduction and internal fixation. Fibrous union of the fragment is not associated with significant symptoms or diminished function. Surgical excision of the fragment yielded the worst results in one study and should be avoided. Open reduction is best reserved for those injuries in which the medial epicondylar fragment becomes entrapped in the elbow joint during reduction and cannot be extracted by closed manipulation. Farsetti P, Potenza V, Caterini R, Ippolito E: Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am 2001;83:1299-1305.

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Question 66

Which of the following statements about hoarseness due to vocal cord paralysis after anterior cervical diskectomy and fusion is most accurate?





Explanation

It has been traditionally taught that a left-sided approach to the anterior cervical spine is associated with a lower incidence of injury compared to the right-sided approach. This is due in part to the anatomic differences in the path the recurrent laryngeal nerve (RLN) takes on the right as compared to the left. Both nerves ascend in the tracheoesophageal groove after branching off the vagus nerve in the upper thorax. The left-sided RLN loops around the aortic arch and stays relatively medial as compared to the right-sided RLN which loops around the right subclavian artery and is somewhat more lateral at this point, and therefore is theoretically more vulnerable as it ascends toward the larynx before becoming protected in the tracheoesophageal groove. Furthermore, the variant of a nonrecurrent inferior laryngeal nerve branching directly off the vagus nerve at the level of the midcervical spine is much more common on the right than the left. Despite this reasoning, there has been no clinical evidence to suggest that laterality of approach for anterior cervical surgery makes any difference in the incidence of vocal cord paralysis. Furthermore, two recent studies have shown that the incidence of RLN injury and vocal cord paralysis is equal with either side of approach. Beutler WJ, Sweeney CA, Connolly PJ: Recurrent laryngeal nerve injury with anterior cervical spine surgery risk with laterality of surgical approach. Spine 2001;26:1337-1342.

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Question 67

A 45-year-old man undergoes an anterior cervical diskectomy and fusion at C5-6 and C6-7 with instrumentation. During the first postoperative visit at 1 week, the patient reports difficulty swallowing and mild anterior cervical tightness. The anterior wound is benign and the patient denies any dyspnea or shortness of breath. A postoperative radiograph is seen in Figure 25. What is the most appropriate management at this time?

Spine Surgery 2009 Practice Questions: Set 3 (Solved) - Figure 12





Explanation

The radiograph shows significant prevertebral soft-tissue swelling following a two-level anterior cervical diskectomy and fusion. The incidence of dysphagia 2 years after anterior cervical spine surgery is 13.6%. Risk factors for long-term dysphagia after anterior cervical spine surgery include gender, revision surgeries, and multilevel surgeries. The use of instrumentation, higher levels, or corpectomy versus diskectomy did not significantly increase the prevalence of dysphagia. Lee and associates demonstrated that while dysphagia after anterior cervical spine surgery is a common early finding, it generally decreases significantly by 6 months with nonsurgical management. A minority of patients experience moderate or severe symptoms by 6 months after the procedure. Female gender and multiple surgical levels have been identified as risk factors for the development of postoperative dysphagia. Lee MJ, Bazaz R, Furey CG, et al: Risk factors for dysphagia after anterior cervical spine surgery: A two-year prospective cohort study. Spine J 2007;7:141-147.

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Question 68

A 47-year-old woman has a painful bunion of the right foot, and shoe wear modifications have failed to provide relief. Examination reveals a severe hallux valgus with dorsal subluxation of the second toe. Radiographs are shown in Figures 14a and 14b. The most appropriate management should include





Explanation

The radiographs do not show significant arthrosis of the hallux metatarsophalangeal joint; therefore, arthrodesis is unnecessary. Orthotics will not correct the deformity. A distally based osteotomy will not achieve sufficient correction of the incongruity of deformity, and a Keller resection is not indicated in the younger population. The treatment of choice is a proximal metatarsal osteotomy with second toe correction.

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Question 69

Figures 12a and 12b show the radiographs of a 56-year-old man with diabetes mellitus who has had left foot swelling with no pain for the past several weeks. He denies any history of trauma. Examination reveals warmth, moderate swelling, no tenderness, and mild pes planus with standing. Pulses are palpable, and his sensory examination is grossly intact to light touch. Standing radiographs are shown in Figures 12c and 12d. What is the most likely diagnosis?





Explanation

The radiographs show tarsometatarsal joint subluxation without fragmentation. The clinical history and delay in presentation with the radiographic findings suggest a neuropathic or Charcot arthropathy involving the midfoot area. Intact sensory examination to light touch is not diagnostic for an intact peripheral neurologic system; monofilament testing is a more accurate office baseline examination for the presence of sensory peripheral neuropathy. With an acute traumatic Lisfranc fracture-dislocation, a history of a traumatic event is necessary, and radiographic abnormalities are expected, although nonstanding radiographs still may be misleading. Acquired pes planus due to posterior tibial tendon rupture may have negative nonstanding radiographs. Standing radiographs may reveal pes planus. However, intermetatarsal disruption is not expected as seen in a Lisfranc abnormality. Localized osteomyelitis of the foot without a penetrating injury or cutaneous ulceration is extremely unlikely and does not fit with the clinical picture described. An isolated metatarsal stress fracture would show osseous irregularity without the instability pattern pictured. Brodsky JW: The diabetic foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 895-969.

References:

Question 70

Passive glycation of articular cartilage results in





Explanation

Passive glycation of articular cartilage occurs over decades. One of the consequences of this glycation appears to be the stiffening of collagen. This phenomenon appears to be associated with an increased collagen degradation and development of osteoarthrosis. Passive glycation also results in a relatively yellow appearance. Passive glycation does not directly influence chondrocyte proliferation. DeGroot J, Verzijl N, Wenting-van Wijk MJ, et al: Accumulation of advanced glycation end products as a molecular mechanism for aging as a risk factor in osteoarthritis. Arthritis Rheum 2004;50:1207-1215.

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Question 71

Examination of the shoulder seen in Figure 52 shows atrophy and tenderness of the infraspinous fossa and profound weakness in external rotation. The supraspinous fossa shows normal muscle bulk. What is the most likely cause of this condition?

Shoulder Board Review 2002: High-Yield MCQs (Set 4) - Figure 18





Explanation

Compression of the suprascapular nerve by a ganglion cyst is a well-documented cause of pain and weakness in the shoulder. Isolated involvement of the infraspinatus indicates that the area of entrapment is at the spinoglenoid notch and not the suprascapular notch. The majority of ganglion cysts found in the shoulder are related to tears of the labrum. When such a compressive lesion is found, decompression can be accomplished through either an open or arthroscopic approach. Several authors have shown the value of arthroscopy in the treatment of this condition. It has been shown that it is technically possible to decompress a paralabral ganglion cyst using arthroscopy; this method is usually followed by repair of the torn labrum. Alternatively, arthroscopic repair of the labrum can be performed and the cyst may be aspirated at the time of surgery. Open cyst excision through a posterior approach is also an acceptable method of treatment. Schickendantz MS, Ho CP: Suprascapular nerve compression by a ganglion cyst: Diagnosis by magnetic resonance imaging. J Shoulder Elbow Surg 1993;2:110-114. Thompson RC, Schneider W, Kennedy T: Entrapment neuropathy of the inferior branch of the suprascapular nerve by ganglia. Clin Orthop 1982;166:185-187.

References:

Question 72

A 65-year-old man has a painful right hip mass that has been growing for several years. A radiograph, CT scan, and photomicrograph are shown in Figures 56a through 56c. What is the most appropriate treatment?





Explanation

This is a conventional chondrosarcoma. The radiograph and the CT scan show a lesion arising from the inferior pubic ramus with a large soft-tissue mass. Abundant punctate, stippled, or "popcorn-like" calcification is present. The photomicrograph demonstrates hypercellular cartilage. Surgical resection is the only effective treatment. Whereas chemotherapy might play a role in the treatment of a dedifferentiated chondrosarcoma, it has no role in the treatment of a conventional chondrosarcoma. Chondrosarcomas are relatively radioresistant. Donati D, El Ghoneimy A, Bertoni F, et al: Surgical treatment and outcome of conventional pelvic chondrosarcoma. J Bone Joint Surg Br 2005;87:1527-1530. Lee FY, Mankin HJ, Fondren G, et al: Chondrosarcoma of bone: An assessment of outcome. J Bone Joint Surg Am 1999;81:326-338.

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Question 73

Which of the following is considered a potential advantage in prophylaxis for the prevention of deep venous thrombosis associated with the use of low-molecular weight heparin (LMWH) as compared with fixed-dose unfractionated heparin?

Hip Board Review 2001: High-Yield MCQs (Set 2) - Figure 12





Explanation

One possible reason for improved efficacy of LMWHs is the relative improved bioavailability compared with that of unfractionated heparin. This is, in part, the result of a more predictable dose response and a longer half-life. There is no alteration of venous flow, and the rate of bleeding complications is the same or slightly higher than that of other prophylactic agents. Colwell CW Jr, Spiro TE, Trowbridge AA: Use of enoxaparin, a low-molecular weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement: A clinical trial comparing efficacy and safety. J Bone Joint Surg Am 1994;76:3-14. Bara L, Billaud E, Kher A, Samama M: Increased anti-Xa bioavailability for a low-molecular weight heparin (PK 10169) compared with unfractionated heparin. Semin Thromb and Hemost 1985;11:316-317.

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Question 74

During the first 2 years of life, which of the following actions is most responsible for increasing structural stability of the physis?





Explanation

The zone of Ranvier provides the earliest increase in strength of the physis. During the first year of life, the zone spreads over the adjacent metaphysis to form a fibrous circumferential ring bridging from the epiphysis to the diaphysis. This ring increases the mechanical strength of the physis. The zone also helps the physis grow latitudinally. In turn, the increased width of the physis helps the physis further resist mechanical forces. The change in shape of the physis to its progressively more undulating form is also a factor in increasing physeal strength, but this occurs over a longer period of time, as the child's activity level increases. The undulations of the physis seen in some growth plates also add to stability but to a lesser extent. The other changes contribute little toward increasing physeal strength. Burkus J, Ogden J: Development of the distal femoral epiphysis: A microscopic morphological investigation of the zone of Ranvier. J Pediatr Orthop 1984;4:661-668.

References:

Question 75

What is the structure indicated by the letter "A" in Figure 21?

Anatomy Board Review 2008: High-Yield MCQs (Set 2) - Figure 13





Explanation

The ligaments shown are the components of the lateral collateral ligament complex, and the structure indicated by the letter "A" is the radial collateral ligament. The lateral ulnar collateral ligament is the structure indicated by the letter "C" and the annular ligament is indicated by the letter "B." The transverse ligament is a component of the medial collateral ligament complex. Morrey BF: Anatomy of the elbow joint, in Morrey BF (ed): The Elbow and Its Disorders. Philadelphia, PA, WB Saunders, 1993, p 30.

References:

Question 76

What is the most common problem seen following epiphysiodesis for limb-length discrepancy?

Pediatrics Board Review 2004: High-Yield MCQs (Set 2) - Figure 24





Explanation

Errors in timing are by far the most common in this technically safe procedure. Incomplete growth arrest has been reported in up to 15% of patients versus timing errors in 61%. Fracture through the site has been reported rarely. Neurovascular and cartilaginous injury are extremely uncommon but always need to be considered when performing surgery in the vicinity of these structures. Blair VP III, Walker SJ, Sheridan JJ, Schoenecker PL: Epiphysiodesis: A problem of timing. J Pediatr Orthop 1982;2:281-284.

References:

Question 77

Which of the following are considered appropriate nonsurgical bracing/orthotic options for a supple adult-acquired flatfoot deformity with forefoot abduction, secondary to posterior tibial tendon insufficiency?

Foot & Ankle Board Review 2006: High-Yield MCQs (Set 2) - Figure 22





Explanation

The initial stages of posterior tibial tendon insufficiency, where the deformity remains supple, may be treated with bracing or an orthotic for pain relief. The Arizona brace was introduced in 1988, and assists in pain relief and deformity correction by minimizing hindfoot valgus alignment, lateral calcaneal displacement, and medial ankle collapse. It is particularly helpful in those patients with advanced disease that cannot tolerate an ankle-foot orthosis. All other choices are incorrect because of the addition of lateral posting, which is not advantageous in valgus deformities. The addition of medial posting to any of the above choices would render them correct alternatives. A heel lift is applicable in Achilles tendon disorders, not posterior tibial tendon disorders. Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int 1996;17:736-741.

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Question 78

What is the most common surgical cause of the foot deformity shown in Figure 9?

Foot & Ankle 2000 Practice Questions: Set 1 (Solved) - Figure 21





Explanation

The radiograph shows a hallux varus deformity. Iatrogenically acquired hallux varus is most often the result of excessive lateral soft-tissue release, sesamoidectomy, or both. It also can be caused by a medial tibial sesamoid subluxation in conjunction with excessive postoperative dressing application, overcorrection of the intermetatarsal angle, or excessive medial eminence resection. Donley BG: Acquired hallux varus. Foot Ankle Int 1997;18:586-592.

References:

Question 79

A 13-year-old boy sustains a valgus stress injury to the knee while playing football, and he is unable to bear weight after the injury. Examination reveals tenderness medially superior to the joint line. The knee is held in flexion, and he has a large effusion and localized medial swelling. Plain radiographs show no obvious fracture. What is the next diagnostic step?





Explanation

In the skeletally mature individual, this mechanism of injury will often result in a sprain of the medial collateral ligament. In skeletally immature patients, the same mechanism can cause a fracture of the distal femoral physis. If the fracture is nondisplaced, the plain radiographs may show only soft-tissue swelling or effusion. While the MRI scan may show edema in the soft tissues on the medial side of the knee and even an abnormality of the physis, stress radiographs provide a quicker and less expensive means of making the diagnosis. Arthroscopy and arthrography would not be helpful in making the diagnosis. Arthroscopy may result in further displacement of the injury. Smith L: Concealed injury to the knee. J Bone Joint Surg Am 1962;44:1659-1660.

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Question 80

Consider the theoretic articulation shown in Figure 11 as femoral and tibial components of a total knee prosthesis in which the components fit like a "roller in trough." Which of the following best describes the articulation?

Hip Board Review 2004: High-Yield MCQs (Set 2) - Figure 7





Explanation

The theoretic total knee components will resist anteroposterior motion by making the femoral component "climb the walls" of the tibial component. As drawn, there is no constraint to medial-lateral translation. The cylinder is not rounded on the edges, so varus-valgus motion will impart load from the cylinder to the trough over a small area, thus having a high contact stress.

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Question 81

What is the average linear wear rate of a conventional, noncross-linked ultra-high molecular weight polyethylene liner used in total hip arthroplasty?





Explanation

Several studies have shown that ultra-high molecular weight polyethylene liners used in total hip arthroplasties wear at a rate of 0.1 to 0.2 mm/yr. The orthopaedic surgeon performing total hip arthroplasties should be aware of the average wear rate so that potential problems can be identified when following patients postoperatively. Callaghan JJ, Albright JC, Goetz DD, Olejniczak JP, Johnston RC: Charnley total hip arthroplasty with cement: Minimum twenty-five year follow-up. J Bone Joint Surg Am 2000;82:487-497.

Scientific References

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Question 82

A 15-year-old boy reports leg pain after being tackled during football practice. Radiographs and a CT scan are shown in Figures 46a through 46c. The patient has a pathologic fracture through what underlying lesion?





Explanation

The images show a lobulated, eccentric, well-marginated lesion that is typical of a nonossifying fibroma. The lesion is slightly expansile, and the CT scan findings show that the lesion is very well marginated and the cortex is disrupted, which is a common finding. None of the characteristics of this lesion is aggressive in nature. Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 69-75.

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Question 83

Which of the following is considered a contraindication to cement injection techniques, such as kyphoplasty or vertebroplasty, in the treatment of osteoporotic compression fractures?





Explanation

When retropulsion of the posterior vertebral wall is present, nothing prohibits the cement from following the path of least resistance into the canal or from pushing a bone fragment further into the canal; most clinicians consider it a contraindication to these techniques. Patient age itself is not a contraindication as long as there are no medical contraindications to surgery. An acute fracture in a patient who remains immobile and hospitalized because of pain may be a good indication for such a technique. Prior compression fracture and older compression fractures are not contraindications, but pain relief may be less predictable. Phillips FM, Pfeifer BA, Leiberman IH, et al: Minimally invasive treatment of osteoporotic vertebral compression fractures: Vertebroplasty and kyphoplasty. Instr Course Lect 2003;52:559-567. Truumees E, Hilibrand A, Vaccaro AR: Percutaneous vertebral augmentation. Spine J 2004;4:218-229.

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Question 84

Evaluation of the percent of necrosis in the resected specimen after preoperative chemotherapy is of prognostic value for what type of sarcoma?





Explanation

To date, only the percent of necrosis after induction chemotherapy in high-grade osteosarcomas seems to be of prognostic value. The value in soft-tissue sarcoma and rhabdomyosarcoma is being evaluated but has not been substantiated. Chondrosarcomas and parosteal osteosarcomas are not treated with chemotherapy. Rosen G, Marcove RC, Caparros B, Nirenberg A, Kosloff C, Huvos AG: Primary osteogenic sarcoma: The rationale for pre-operative chemotherapy and delayed surgery. Cancer 1979,43:2163-2177. Davis AM, Bell RS, Goodwin PJ: Prognostic factors in osteosarcoma: A critical review. J Clin Oncol 1994;12:423-431.

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Question 85

A 21-year-old man has had progressive right knee pain for the past 2 months that is exacerbated with weight-bearing activities. A plain radiograph and an MRI scan are shown in Figures 43a and 43b. A biopsy specimen is shown in Figure 43c. According to the Enneking staging system of tumor classification, the lesion should be classified as what stage?





Explanation

The lesion is an eccentric lytic bone lesion within the epiphyseal-metaphyseal end of the proximal tibia. There is geographic destruction with a "fading border" extending to the articular cartilage. There is no matrix formation or periosteal reaction. The MRI scan shows cortical destruction with extension into the soft tissue. According to the Enneking staging system, benign lesions are stage 1, 2, or 3; malignant lesions are stage I, II, or III. Benign stage 1 lesions are latent; stage 2 are active; and stage 3 are benign aggressive. The histology shows a benign giant cell tumor. Given the cortical breakthrough shown on the MRI scan, the lesion should be classified as stage 3. Enneking WF: Clinical musculoskeletal pathology, in Enneking WF (ed): Appendix A. Gainesville, FL, Storter Publishing, 1986, pp 451-466.

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Question 86

When using the direct lateral (or Hardinge) approach for hip arthroplasty, three muscles are detached from the femur. In addition to the vastus lateralis, they include the





Explanation

This approach is criticized for the episodic limp associated with the muscle detachment and reattachment. Classically, two thirds of the gluteus medius is detached as a sleeve with the vastus lateralis. This exposes the gluteus minimus and the ligament of Bigelow. These must also be detached to allow dislocation of the hip and osteotomy of the femoral neck. The rectus femoris lies medially and anteriorly and does not need to be addressed. The piriformis and obturator internus are exposed during the posterior approach. Neither the gluteus maximus nor tensor fascia lata attach to the anterior femur. The sartorius and iliopsoas are not exposed during this dissection. Hoppenfeld S, deBoer P (eds): Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, pp 333-335.

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Question 87

Which of the following changes of calcium metabolism accompany the loss of bone during menopause?





Explanation

There is a negative change of calcium balance with a decrease in intestinal absorption and an increase in urinary calcium loss. The reduction of intestinal absorption is accompanied by reduced circulating concentrations of total, but not free 1,25-dihydroxyvitamin D. However, estrogen may also directly regulate intestinal calcium resorption independent of vitamin D. Tubular resorption of calcium is higher in the presence of estrogen. Studies of the levels of PTH in the presence of estrogen are controversial. Oh KW, Rhee EJ, Lee WY, et al: The relationship between circulating osteoprotegerin levels and bone mineral metabolism in healthy women. Clin Endocrinol (Oxf) 2004;61:244-249.

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Question 88

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





Explanation

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

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Question 89

A 16-year-old boy has had left knee pain and swelling after sustaining a minor twisting injury while playing basketball 2 weeks ago. Figures 5a through 5e show the radiograph, MRI scans, and biopsy specimens. What is the most likely diagnosis?





Explanation

The imaging studies and histology are most consistent with Ewing's sarcoma. Tuberculosis can show small round blue cells on histology (lymphocytes associated with chronic infection) but would more typically involve the knee joint and periarticular bone. Osteosarcoma and MFH do not have small round blue cells histologically. Sissons HA, Murray RO, Kemp HBS: Orthopaedic Diagnosis. Berlin, Springer-Verlag, 1984, pp 254-256.

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Question 90

A 60-year-old woman has activity-related hip pain after undergoing arthroplasty 5 years ago. She has severe Parkinsonism and denies fevers or chills. Radiographs are shown in Figures 45a and 45b. What is the most likely cause of her pain?





Explanation

The radiographs reveal both cement debonding at the lateral shoulder of the prosthesis and a cement mantle fracture. Both of these indicate a loose femoral component. The radiographs show a stress fracture with reactive bone on the lateral femoral cortex in conjunction with the cement mantle fracture. The acetabular component shows no evidence of loosening. Heterotopic bone usually is not a source of pain when it is Brooker grade I, as in this case. Parkinsonism generally is not associated with hip pain. Harris WH, McCarthy JC, O'Neill DA: Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am 1982;64:1063-1067. Callaghan JJ, Rosenberg AG, Rubash H (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, pp 960, 1228-1229.

References:

Question 91

Up to what time frame are the risks minimized in anterior revision disk replacement surgery?

Spine Surgery Board Review 2009: High-Yield MCQs (Set 2) - Figure 8





Explanation

Revision anterior exposure within 2 weeks of total disk replacement incurs relatively little additional morbidity because adhesion formation is minimal. Surgeons should have a low threshold for revising implants that are clearly dangerously malpositioned or show early migration within this 2-week window. Beyond this time period, a revision strategy must be individualized to the particular clinical situation. A posterior fusion with instrumentation with or without a laminectomy is currently the most effective salvage procedure.

References:

Question 92

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

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





Explanation

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

References:

Question 93

Figure 17 shows the radiograph of an 80-year-old woman who has left groin pain. She underwent a total hip arthroplasty 15 years ago and has no history of hip dislocation; however, she now reports that the pain results in functional impairment. Preoperative findings reveal that the component used has been discontinued, the locking mechanism is poor, and there is no replacement polyethylene available from the company. During surgery, the acetabular component is found to be well fixed, it is in satisfactory position, and adequate access can be obtained through the screw holes in the component to debride the osteolytic cavities. What is the best course of action for revision?

Hip 2004 Practice Questions: Set 3 (Solved) - Figure 5





Explanation

The clinical result in this patient has been good, with no dislocations, suggesting that the components are in reasonably good position. The radiograph and examination at the time of surgery suggest that the acetabular component is well fixed. The surrounding bone of the acetabulum is osteopenic and there would most likely be considerable bone loss if the acetabular component is removed. Access to the osteolytic lesions is possible. Cementing an acetabular component into the retained socket will cause the least amount of bone loss, shorten the procedure, and most likely result in a functional hip. Maloney WJ: Socket retention: Staying in place. Orthopedics 2000;23:965-966.

References:

Question 94

A 25-year-old man has had an insidious onset of left hip pain over the past 11 months. A radiograph, coronal MRI scan, and histopathologic specimens are seen in Figures 2a through 2d. What is the most likely diagnosis?





Explanation

Ewing's sarcoma is the second most common primary sarcoma of bone in children and young adults. It is a malignant round cell tumor with uncertain histogenesis. Sheets of uniform small round blue cells with a high nuclear-to-cytoplasm ratio and the absence of osteoid formation differentiate this histologic diagnosis from the other conditions. Immunohistochemical staining and molecular diagnostic studies are useful to verify the diagnosis.

References:

Question 95

A 13-year-old boy has a mild deformity of the left sternoclavicular joint after being involved in a rollover accident while riding an all-terrain vehicle. Examination in the emergency department reveals that he is hemodynamically stable, and his neurovascular examination is normal. The CT scan shown in Figure 22 was obtained because radiographs were inconclusive. Management should consist of

Upper Extremity Board Review 2005: High-Yield MCQs (Set 2) - Figure 32





Explanation

The CT scan reveals a completely displaced physeal fracture of the medial clavicle with marked posterior displacement of the distal fragment. This fracture pattern is associated with potential injury to the vascular structures of the mediastinum. Reduction should be performed for this fracture and generally can be done closed with shoulder retraction and upward pull on the clavicle with a towel clip. Once reduced, the fracture is relatively stable and typically will heal in good position. Reduction should be performed in the operating room in the event that a vascular injury is detected once compression is removed from the clavicle. Open reduction may be necessary if closed reduction is not possible; however, pinning or ligament reconstruction usually is not necessary. Rockwood CA, Matsen FA (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, p 581.

References:

Question 96

Figures 3a and 3b show the current radiographs of a 59-year-old woman who has pain and deformity after undergoing bunion surgery 1 year ago. Nonsurgical management has failed to provide relief. Treatment should now consist of





Explanation

The hallux varus seen in this patient is most likely the result of a combination of causes. Based on the degenerative changes and the significant shortening of the first metatarsal relative to the second metatarsal, a metatarsophalangeal arthrodesis is the treatment of choice. The other surgical approaches are not expected to provide a satisfactory result. Coughlin MJ, Mann RA: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby-Year Book, 2000, pp 150-269.

References:

Question 97

An otherwise healthy 33-year-old man who works in construction reports a 3-month history of knee pain. Radiographs are shown in Figures 9a and 9b. An axial T1-weighted MRI scan with contrast, an angiogram, and histologies are shown in Figures 9c through 9f. What is the most likely diagnosis?





Explanation

Dedifferentiated parosteal osteosarcoma designates high-grade transformation of conventional low-grade parosteal osteosarcoma. Unlike conventional parosteal osteosarcoma, where wide surgical excision alone is considered adequate treatment, patients with dedifferentiated osteosarcoma are treated with neoadjuvant chemotherapy and wide local resection. Recognition of dedifferentiated areas with angiography can localize the area that should be biopsied and thus render an accurate diagnosis. Percutaneous biopsy of hypervascular areas should prompt the administration of chemotherapy and wide local excision to optimize patient outcome. Sheth DS, Yasko AW, Raymond AK, et al: Conventional and dedifferentiated parosteal osteosarcoma: Diagnosis, treatment, and outcome. Cancer 1996;78:2136-2145.

References:

Question 98

Figure 31 shows the radiograph of an 8-year-old boy who has a swollen forearm after falling out of a tree. Examination reveals that all three nerves are functionally intact, and there is no evidence of circulatory embarrassment. Management should consist of

Trauma 2000 Practice Questions: Set 3 (Solved) - Figure 12





Explanation

The patient has a Bado type IV Monteggia lesion. It involves dislocation of the radial head and fractures of both the radial and ulnar shafts. These fractures are very difficult to manage by closed reduction alone. The radial and ulnar shafts first have to be stabilized surgically to give a lever arm to reduce the radial head. In this age group, intramedullary pins are easy to insert percutaneously and cause less tissue trauma than plates and screws. In these types of injuries, the focus is often on the forearm fracture; the radial head dislocation may not be appreciated as was the case with this patient. Gibson WK, Timperlake RW: Operative treatment of a type IV Monteggia fracture-dislocation in a child. J Bone Joint Surg Br 1992;74:780-781.

References:

Question 99

A 30-year-old man has had intermittent swelling of his right ankle for the past 6 months. He denies any history of trauma. Radiographs reveal osteolytic changes on both sides of the joint. An axial CT scan and a T2-weighted MRI scan are shown in Figures 40a and 40b. He undergoes surgical excision. An intraoperative photograph and a biopsy specimen are shown in Figures 40c and 40d. What is the most likely diagnosis?





Explanation

Pigmented villonodular synovitis often presents with intermittent swelling and minimal pain. It often occurs around joints but may be found around tendon sheaths and bursal linings. Periarticular erosions involving both sides of joints are typical, and multiple joint involvement has been described. Portions of low-signal intensity on T1- and T2-weighted images are characteristic of hemosiderin-laden processes. High-signal content is suggestive of high water content. The combination of low-signal intensity areas in intra-articular lesions with or without osseous destruction is diagnostic of pigmented villonodular synovitis. Aspiration reveals bloody or brownish fluid. The treatment of choice is synovectomy performed arthroscopically or open. Recurrence is common. Walling AK: Soft tissue and bone tumors, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1007-1032.

References:

Question 100

What is the main function of collagen found within articular cartilage?

Sports Medicine 2001 Practice Questions: Set 1 (Solved) - Figure 25





Explanation

The main function of collagen in articular cartilage is to provide the tissue's tensile strength. It also immobilizes proteoglycans within the extracellular matrix. Compressive properties are maintained by proteoglycans. Cartilage metabolism is maintained by the indwelling chondrocytes. The flow of water through the tissue promotes transport of nutrients and provides a source of lubricant for the joint. Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 3-44.

References:

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Chapter 1 56 min

Orthopaedic Board Review: High-Yield Clinical MCQs

Master high-yield orthopaedic surgery concepts with our elite board review MCQs. Covering trauma, pediatrics, oncology,…

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Chapter 2 78 min

Orthopedic Board Review MCQs: High-Yield Clinical Vignettes

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Chapter 3 50 min

Orthopedic Board Review MCQs: High-Yield Case Analysis

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Chapter 4 63 min

High-Yield Orthopedic Board Review MCQs

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Orthopedic Board Review MCQs: Arthroplasty, Spine & Pediatrics | Part 78

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Chapter 6 530 min

Orthopedic Board Review MCQs: Pediatric, Trauma, Knee & Elbow Surgery | Part 80

Ace your OITE and AAOS exams with Part 80 of our Orthopedic Surgery Board Review. Practice 100 verified MCQs on pediatr…

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07
Chapter 7 222 min

Orthopedic Board Review MCQs: Adult Reconstruction, Trauma & Ankle Part 97

Ace your OITE and AAOS exams with Part 97 of our Orthopedic Surgery Board Review. Practice 100 verified MCQs on trauma,…

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08
Chapter 8 414 min

Orthopedic Board Review MCQs: Adult Reconstruction & Trauma - Part 98

Prepare for OITE & ABOS exams with Part 98. Access 100 high-yield, verified MCQs in AAOS/OITE format, covering key clin…

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09
Chapter 9 211 min

Orthopedic Board Review MCQs: Trauma, Sports Medicine & Pediatrics Part 103

Ace your OITE and AAOS exams with Part 103 of Dr. Hutaif's Orthopedic Board Review. Test yourself with 100 high-yield M…

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Dr. Mohammed Hutaif
Medically Verified Content by
Prof. Dr. Mohammed Hutaif
Consultant Orthopedic & Spine Surgeon
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