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AAOS Orthopedic MCQs (Set 1): Spine Disorders, Sports Medicine & Arthroplasty | 2026 Board Review

100 Orthopedic MCQs: Trauma, Spine & Joints | Board Review Set 759

27 Apr 2026 99 min read 92 Views
AAOS General Orthopedics MCQs: Board Prep Part 7

Key Takeaway

This page offers 100 high-yield orthopedic surgery MCQs for ABOS, OITE, and FRCS board exam preparation. Mock Exam Set 759 covers critical topics including trauma, spine, and joints. Surgeons can use these randomized questions to master concepts and confidently prepare for certification.

Comprehensive 100-Question Exam


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Question 1

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





Explanation

By convention when determining the motor level, the key muscle must be at least 3/5. The next most rostral level must be 4/5. Therefore, this patient's functional level is C6.

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Question 2

A 24-year-old man who works at a local oyster and clam farm sustained a laceration on his hand at work. Examination reveals a cellulitic index finger without evidence of tenosynovitis. After appropriate irrigation and debridement, what antibiotic is most appropriate?





Explanation

Injuries involving brackish water and shellfish can have devastating consequences caused by Vibrio vulnificus infections. Patients may have a severe invasive infection, with three main clinical features: primary septicemia, wound infection, and gastroenteritis. Antibiotic administration is crucial because mortality rates of up to 50% have been observed with Vibrio septicemia. The current recommendation is to give a third-generation cephalosporin such as ceftazadime. Chiang SR, Chuang YC: Vibrio vulnificus infection: Clinical manifestations, pathogenesis, and antimicrobial therapy. J Microbiol Immunol Infect 2003;36:81-88.

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Question 3

For patients undergoing a surgical procedure where the risk of requiring a transfusion is less than 10%, the International Committee of Effective Blood Usage suggests

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





Explanation

Recent studies have shown a high rate of waste of autologous blood. Therefore, the Committee does not recommend autologous blood donation for procedures that carry a transfusion risk of 10% or less. Toy P, Beattie C, Gould S, et al: Transfusion alert: Use of autologous blood. National Heart, Lung, and Blood Institute Expert Panel on the use of autologous blood. Transfusion 1992;35:703-711.

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Question 4

The use of knee arthroscopy following total knee arthroplasty is most effective in treating which of the following conditions?





Explanation

Patellar clunk syndrome is associated with certain types of posterior stabilized knee arthroplasties. Arthroscopic resection of the band of inflammatory tissue inferior to the patellar component is effective in treating this condition. Arthroscopic lavage of infected knee arthroplasties is not associated with an acceptable success rate. Diagnostic arthroscopy for nonspecific pain following arthroplasty is not uniformly successful. Patellar component maltracking is frequently associated with component malposition and is not alleviated by an arthroscopic lateral release. Synovitis secondary to polyethylene wear is best treated by exchange of the polyethylene spacer and not arthroscopic synovectomy. Lucas TS, DeLuca PF, Nazarian DG, et al: Arthroscopic treatment of patellar clunk. Clin Orthop 1999;367:226-229.

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Question 5

Which of the following is considered the most accurate test to determine the amount of limb-length discrepancy in a patient with a knee flexion contracture of 35 degrees?





Explanation

Flexion contractures and angular deformities of a limb cause inaccurate limb-length measurement results with most clinical methods. A CT scanogram is more accurate than standard scanograms for determining limb length in patients with knee flexion contractures of 30 degrees or more. The cost and time necessary to complete the examinations are comparable, but the CT scanogram delivers only 20% of the radiation needed for standard scanograms. Aaron A, Weinstein D, Thickman D, Eilert R: Comparison of orthoroentgenography and computed tomography in the measurement of limb-length discrepancy. J Bone Joint Surg Am 1992;74:897-902.

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Question 6

Which of the following muscle tendons inserts just lateral to the long head of biceps tendon on the proximal humerus?





Explanation

The pectoralis major insertion is just lateral to the long head of the biceps tendon. Medial to the biceps is the insertion for the teres major and latissimus dorsi. The short head of the biceps originates on the coracoid process. The subscapularis inserts on the lesser tuberosity just medial to the biceps.

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Question 7

A 21-year-old college student reports hearing a pop and has acute pain laterally over the ankle after twisting it during a recreational basketball game. Examination 1 hour after the injury reveals minimal swelling and ecchymosis. The anterior drawer sign is positive. Radiographs reveal no evidence of a fracture. What is the best course of action?

Foot & Ankle Board Review 2000: High-Yield MCQs (Set 2) - Figure 25





Explanation

Even though the patient has a grade 3 ankle ligament injury, studies have shown that 95% of patients with a grade 3 injury that may include a complete tear of the ligaments will heal successfully with conservative functional management. Extensive diagnostic evaluation with stress radiographs, CT, and MRI is not indicated. Surgical reconstruction is not indicated because of the overwhelming success of conservative management; however, in the few patients where late instability develops, surgical reconstruction offers an excellent outcome. Carne P: Nonsurgical treatment of ankle sprains using the modified Sarmiento brace. Am J Sports Med 1989;17:253-257.

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Question 8

A 70-year-old man underwent primary total knee arthroplasty 3 months ago. Figures 7a and 7b show the radiograph and clinical photograph following incision and drainage of the wound 1 week ago. Aspiration of the joint reveals methicillin-sensitive Staphylococcus aureus. What is the next most appropriate step in management?





Explanation

The overriding factor determining treatment in this case is the appearance of the surgical wound. Based on MacPhearson's work, this "C" wound is best managed with two-stage exchange. The functional outcome is markedly diminished following a knee arthrodesis compared to revision knee arthroplasty. Harwin SF: The diagnosis and management of infected total knee replacement. Seminars Arthroplasty 2002;13:9-22. Goldmann RT, Scuderi GR, Insall JN: 2-stage reimplantation for infected total knee replacement. Clin Orthop 1996;331:118-124.

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Question 9

What neurovascular structure is in closest proximity to the probe in the arthroscopic view of the elbow shown in Figure 50?

Upper Extremity 2008 Practice Questions: Set 5 (Solved) - Figure 4





Explanation

The image shows a view of the radiocapitellar joint from an anterior medial portal. The radial nerve lies on the elbow capsule at the midportion of the capitellum. It is at risk for injury when capsular excision is performed in this region. Field LD, Altchek DW, Warren RF, et al: Arthroscopic anatomy of the lateral elbow: A comparison of three portals. Arthroscopy 1994;10:602-607.

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Question 10

Which of the following is an important factor in performing a proper biopsy?

Basic Science 2008 Practice Questions: Set 3 (Solved) - Figure 6





Explanation

There are a number of important technical details in performing a biopsy. Incisions should always be longitudinal in the extremity. Good hemostasis is important in avoiding contamination from hematoma. The approach should avoid neurovascular structures, and go through a single muscle belly when possible. Although a frozen section should be obtained to ensure adequate viable tissue has been obtained, definitive diagnosis is not necessary at the time of the frozen section. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.

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Question 11

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





Explanation

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

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Question 12

A 25-year-old patient who sustained multiple bilateral rib fractures, a pulmonary contusion, a left nondisplaced transtectal acetabular fracture, and a closed humerus fracture in a motor vehicle accident 2 weeks ago is transferred from another hospital. The humerus fracture has been surgically treated. There are no signs of infection, and the trauma surgeon wants to mobilize the patient as soon as possible. Radiographs are shown in Figures 15a and 15b. Management of the humerus fracture should consist of





Explanation

The radiographs show a distal third humerus fracture that is angulated, rotated, and not rigidly fixed. Rigid fixation is needed because mobilization is highly desirable to improve pulmonary function. The acetabular fracture is through the weight-bearing dome but is nondisplaced. Nonsurgical management of the acetabular fracture requires at least 6 weeks of touchdown weight bearing to minimize the forces across the hip joint. Open reduction and plate fixation would achieve anatomic reduction and immediate mobilization. A single posterolateral 4.5-mm plate or two 3.5-mm plates at 90 degrees are possible alternatives. Immediate weight bearing on a plated humerus fracture with the use of crutches or a walker has been shown to be safe and would allow touchdown weight bearing, protecting the hip. None of the other options would achieve this goal for this distal fracture.

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Question 13

A 3-year-old girl has had wrist pain, a fever, and has refused to move her right wrist for the past 10 days. She has an oral temperature of 102 degrees F (38.7 degree C). Laboratory studies show an erythrocyte sedimentation rate of 50 mm/h, a WBC count of 11,000/mm3, and a left shift. AP and lateral radiographs are shown in Figures 57a and 57b. What is the most likely diagnosis?





Explanation

The most likely diagnosis is acute osteomyelitis. She may also have a septic wrist; however, the lytic lesion in the distal radius has the typical presentation and radiographic appearance of metaphyseal osteomyelitis. In this area of sluggish vascular flow, low oxygen tension, and low pH, bacterial seeding is common and is the usual origin of metaphyseal osteomyelitis. Leukemia and Ewing's sarcoma can present as a lytic lesion with an elevated erythrocyte sedimentation rate, but they are much less common than osteomyelitis and are less focal and more destructive in appearance. Nonossifying fibroma is typically metaphyseal and eccentric; however, it is well circumscribed and uncommon in the upper extremity. Eosinophilic granuloma does not typically present with inflammatory indicies. Dormans JP, Drummond DS: Pediatric hematogenous osteomyelitis: New trends in presentation, diagnosis and treatment. J Am Acad Orthop Surg 1994;2:333-341.

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Question 14

A young man sustains a lumbar strain in an on-the-job motor vehicle accident. Both he and his treating physician feel that he is capable of limited duty with appropriate restrictions shortly after the injury. What term best describes his work status?





Explanation

Because the man is only recently removed from his injury and is judged capable of returning to work with some restrictions, the term that best describes his work status is temporary partial disability.

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Question 15

What nerve is most likely to be injured during the anterior exposure of C2-3?





Explanation

The hypoglossal nerve exits from the ansa cervicalis at approximately the C2-3 level and can be injured during retraction up to the C2 level. The superior laryngeal nerve lies at about C4-5. The facial nerve is much higher. The vagus nerve runs with the internal jugular and carotid much more laterally. The phrenic nerve exits posteriorly. Chang U, Lee MC, Kim DH: Anterior approach to the midcervical spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 45-54.

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Question 16

A knock-out mouse for the Vitamin D receptor has which of the following phenotypes?





Explanation

A knock-out mouse to the Vitamin D receptor would cause loss of vitamin D function, resulting in rickets. Renal failure would not occur; although Vitamin D is converted from 25 (OH) D to 1,25 (OH) D in the kidney, the active hormone acts on the gut and bone. Osteopetrosis can be seen as the phenotype for the c fos knock-out mouse; the Jansen-type metaphyseal dysplasia phenotype results from overactivation of the PTH/PTHrp receptor. Although compensatory hyperparathyroidism would occur, excessive PTH would not be able to rescue the skeletal loss and instead phosphoturia and phosphotasia would result. Glowacki J, Hurwitz S, Thornhill TS, et al: Osteoporosis and vitamin-D deficiency among postmenopausal women with osteoarthritis undergoing total hip arthroplasty. J Bone Joint Surg Am 2003;85:2371-2377.

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Question 17

Figure 40 shows the radiographs of a 2-year-old boy who has a deformed leg. The patient is ambulatory and has no pain. What is the most appropriate management?

Pediatrics Board Review 2007: High-Yield MCQs (Set 4) - Figure 12





Explanation

The patient has a prefractured stage of congenital pseudarthrosis of the tibia and is at risk for fracture. The PTB orthosis may prevent or delay the fracture. Osteotomy is frequently complicated by nonunion. When established nonunion does not respond to intramedullary nailing and bone grafting, vascularized grafting may succeed. Amputation is a salvage procedure. Murray HH, Lovell WW: Congenital pseudarthrosis of the tibia: A long-term follow-up study. Clin Orthop 1982;166:14-20.

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Question 18

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

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





Explanation

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

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Question 19

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





Explanation

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

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Question 20

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 21

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 22

An adult with a distal humeral fracture underwent open reduction and internal fixation. What is the most common postoperative complication?





Explanation

Most patients lose elbow range of motion after open reduction and internal fixation of a distal humeral fracture. Ulnar nerve dysfunction, nonunion, and infection all occur less commonly. Webb LX: Distal humerus fractures in adults. J Am Acad Orthop Surg 1996;4:336-344.

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Question 23

A 26-year-old man has had hand pain and progressive swelling in the knuckle for the past several months. He denies any trauma to the hand. The ring finger metacarpophalangeal joint is tender, and there is loss of motion in the digit. Figure 32a shows the radiograph and Figures 32b through 32d show the T1-weighted, T2-weighted, and gadolinium MRI scans, respectively. What is the most likely diagnosis?





Explanation

The radiograph reveals a subchondral lesion in the metacarpophalangeal joint that is lytic and expansile. The MRI scans show a mass that is moderate in intensity on the T2-weighted image and has some gadolinium uptake. There are no cystic components in this lesion. The subchondral location and expansile nature are highly suggestive of giant cell tumor of bone. A lesion with this appearance might also represent an aneurysmal bone cyst, given the amount of expansion present. Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 113-118.

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Question 24High Yield

A 32-year-old man has a Glasgow Coma Scale score of 8 and an open pelvic fracture. The patient's family reports that he is a Jehovah's Witness. Initial hemodynamic instability has resolved. In the operating room during a washout, the patient's blood pressure becomes unstable. What is the most appropriate action?

Explanation

Certain medical procedures involving blood are specifically prohibited in the belief system of a Jehovah's Witness whereas others are not doctrinally prohibited. For procedures where there is no specific doctrinal prohibition, a Jehovah's Witness should obtain the details from medical personnel and make his or her own decision. Transfusions of allogeneic whole blood or its constituents or preoperative donated autologous blood are prohibited. Other procedures, while not doctrinally prohibited, are not promoted such as hemodilution, intraoperative cell salvage, use of a heart-lung machine, dialysis, epidural blood patch, plasmapheresis, white blood cell scans (labeling or tagging of removed blood returned to the patient), platelet gel, erythropoietin, or blood substitutes. The patient should not be given blood. Plasma expanders should be used first to restore hemodynamic stability. Cell saver blood from an open would is not recommended nor would there likely be enough from an open tibial fracture to salvage. The patient's family may be expressing their own beliefs rather than the patient's beliefs and it would be better to ask the patient when he or she is more alert to determine what procedures they would allow. A consult with the ethics committee will unnecessarily delay an intervention that should restore hemodynamic stability. Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.

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Question 25

A 19-year-old college student reports a 1-week history of wrist pain following an intramural rugby match. A PA radiograph is shown in Figure 6. He denies any prior wrist injury. What is the best course of action?

Trauma 2009 Practice Questions: Set 1 (Solved) - Figure 12





Explanation

The patient has a scaphoid fracture involving the proximal pole. Surgical treatment is recommended for such fractures because of the prolonged period of cast immobilization necessary and the increased risk of delayed union, nonunion, and/or osteonecrosis with nonsurgical management. A cannulated compression screw, inserted in the central scaphoid via a dorsal approach, is biomechanically advantageous and provides greater stability for fracture healing than Kirschner wires. Recently, good outcomes have been reported with arthroscopic-assisted percutaneous fixation of nondisplaced or minimally displaced scaphoid fractures. Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210. Chan KW, McAdams TR: Central screw placement in percutaneous screw scaphoid fixation: A cadaveric comparison of proximal and distal techniques. J Hand Surg Am 2004;29:74-79. Bedi A, Jebson PJ, Hayden RJ, et al: Internal fixation of acute non-displaced scaphoid waist fractures via a limited dorsal approach: An assessment or radiographic and functional outcomes. J Hand Surg Am 2007;32:326-333.

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Question 26

A 30-year-old man who underwent an anterior lumbar diskectomy and fusion at L4-5 and L5-S1 through an anterior retroperitoneal approach 1 month ago now reports he is unable to obtain and maintain an erection. The most likely cause of this condition is





Explanation

Sexual dysfunction is a common condition after extensive anterior lumbar surgical dissection. Erectile dysfunction usually is nonorganic but may be related to parasympathetic injury. The parasympathetic nerves are deep in the pelvis at the level of S2-3 and S3-4 and usually are not involved in the surgical field for anterior L4-5 and L5-S1 procedures. Retrograde ejaculation is the result of injury to the sympathetic chain on the anterior surface of the major vessels crossing the L4-5 level and at the L5-S1 interspace. Erectile function and orgasm are not affected by sympathetic injury. The pudendal nerve is primarily a somatic nerve and is not located in the surgical field. Flynn JC, Price CT: Sexual complications of anterior fusion of the lumbar spine. Spine 1984;9:489-492.

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Question 27

Which of the following types of ultra-high molecular weight polyethylene has been associated with the poorest clinical performance?





Explanation

Numerous studies have documented the poor performance of heat-pressed ultra-high molecular weight polyethylene used in the porous-coated anatomic tibial inserts of both total knee and unicompartmental arthroplasty. The other processing and sterilization methods have not been associated with significantly high failure rates. Wright TM, Rimnac CM, Stulberg SD, et al: Wear of polyethylene in total joint replacements: Observations from retrieved PCA knee implants. Clin Orthop 1992;276:126-134. Landy MM, Walker PS: Wear of ultra-high molecular-weight polyethylene components of 90 retrieved knee prostheses. J Arthroplasty 1988;3:S73-S85.

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Question 28

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 29

A newborn has an anterolateral bow of the tibia and a duplication of the great toe. Which of the following conditions will develop as the infant grows?





Explanation

Anterolateral bowing of the tibia is normally associated with congenital pseudarthrosis of the tibia. This, in turn, is associated with neurofibromatosis. Posterior bowing is more benign and usually corrects spontaneously. However, anterolateral bowing also corrects spontaneously, and the limb-length discrepancy may be the only remaining sequela when associated with duplication of the great toe. Lisch nodules and axillary freckling are pathognomonic findings in neurofibromatosis but would not be expected in this patient because this type of tibial deformity is not associated with neurofibromatosis.

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Question 30

The space available for the cord is an important determinant in neurologic recovery. Recent analysis suggests that the most reliable radiographic predictor for neurologic recovery after surgery in patients with rheumatoid arthritis and paralysis is a preoperative

Spine Surgery Board Review 2000: High-Yield MCQs (Set 2) - Figure 16





Explanation

Boden and associates' recent article presents significant evidence that patients with rheumatoid arthritis, neurologic deterioration, and C1-2 instability are more likely to improve after surgery if the posterior alanto-odontoid interval is greater than 10 mm preoperatively. The accepted safe range for the posterior atlanto-odontoid interval is 14 mm. This measurement is believed to better represent the space available for the cord than the anterior alanto-odontoid interval. Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 273-279. Boden SD, Dodge LD, Bohlman HH, Rechtine GR: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.

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Question 31

Which of the following best describes the relationship of the median nerve to the flexor carpi radialis tendon just proximal to the carpal canal?

Anatomy 2008 Practice Questions: Set 3 (Solved) - Figure 8





Explanation

The median nerve has an intimate association with the palmaris longus and the flexor carpi radialis at the proximal aspect of the carpal canal. The median nerve lies just ulnar and dorsal to the flexor carpi radialis tendon. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 118-131.

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Question 32

What is the second most common primary bone malignancy in children?

Basic Science 2008 Practice Questions: Set 3 (Solved) - Figure 25





Explanation

Ewing's sarcoma is the second most common bone tumor in children with an incidence of three per one million Caucasian children younger than 21 years of age. Ewing's sarcoma is rare in African Americans. Osteosarcoma is the most common bone tumor in children. Rhabdomyosarcoma is the most common soft-tissue sarcoma in children. Fibrosarcoma is a rare primary bone tumor most commonly seen in adults. Adamantinoma is a rare primary bone malignancy also most commonly seen in adults in the tibia. Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 195.

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Question 33

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





Explanation

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

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Question 34

A patient notes pain under the first metatarsophalangeal joint following a soccer injury. The MRI scans shown in Figures 27a and 27b reveal what pathologic finding?





Explanation

The MRI scans show a complete disruption of the sesamoid complex with proximal retraction of the medial sesamoid and high signal originating from the site normally occupied by the plantar plate (metatarsophalangeal ligament). This injury is the result of a hyperextension injury and is a severe variant of a turf toe. Watson TS, Anderson RB, Davis WH: Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin 2000;5:687-713.

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Question 35

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 36

Which of the following prophylactic regimens for the prevention of deep venous thrombosis after knee arthroplasty has received a grade 1A recommendation in favor of its use from the American College of Chest Physicians (ACCP) in the 2004 guidelines?





Explanation

In the 2004 ACCP guidelines, there were three prophylactic regimens that received a grade 1A favorable recommendation. These included low-molecular-weight heparin, warfarin, or fondaparinux, as long as they are used for at least 10 days. If warfarin is used, the target INR should be 2.0 to 3.0, according to the guidelines. Pneumatic compression sleeves have gained popularity in the orthopaedic community but have not received a grade 1A rating from the ACCP at this time. Use of aspirin by itself is discouraged by the ACCP.

References:

Question 37

A 46-year-old man fell 20 feet and sustained the injury shown in Figure 3. The injury is closed; however, the soft tissues are swollen and ecchymotic with blisters. The most appropriate initial management should consist of

Trauma 2006 Practice Questions: Set 1 (Solved) - Figure 6





Explanation

Although this is a fracture of the medial and lateral malleoli, the degree of displacement and comminution of the medial dome indicate that this injury is similar to a pilon fracture. Initial management should consistent of stabilization to allow for soft-tissue healing. The use of temporizing spanning external fixation should be the initial step, followed by limited or more extensive open reduction and internal fixation when the soft-tissue status will allow. Initial placement in either a short or long leg cast does not provide the needed stability and does not allow for care and monitoring of soft tissues. In addition, maintaining reduction of the talus may be very difficult. Immediate open reduction and internal fixation through an injured soft-tissue envelope adds the risk of difficulties with incision healing and a higher risk of deep infection. In the acute setting, a primary ankle fusion through this soft-tissue envelope is not indicated. Marsh JL, Bonar S, Nepola JV, et al: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-1509. Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A randomized, prospective study. J Bone Joint Surg Am 1996;78:1646-1657.

References:

Question 38

What ligament is the primary restraint to applied valgus loading of the knee?





Explanation

The superficial portion of the MCL contributes 57% and 78% of medial stability at 5 degrees and 25 degrees of knee flexion, respectively. The deep MCL and posteromedial capsule act as secondary restraints at full knee extension. The anterior cruciate ligament and PCL also provide secondary resistance to valgus loads.

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Question 39

A 45-year-old woman has had progressive right shoulder pain for the past 6 months. She notes that the pain disrupts her sleep, she has pain at rest that requires the use of narcotic analgesics, and she has limited use of her left shoulder for most activities of daily living. History reveals the use of corticosteroids for systemic lupus erythematosus. Examination shows diminished range of motion. Radiographs of the right shoulder are shown in Figures 4a and 4b. Treatment should consist of





Explanation

Humeral arthroplasty provides excellent pain relief and function for stage IV osteonecrosis with humeral collapse. In late disease with glenoid involvement (stage V), total shoulder arthroplasty is preferred. Some authors have reported satisfactory results with core decompression of the humeral head for early stages of osteonecrosis, but results for stage IV osteonecrosis are less satisfactory when compared with those for humeral arthroplasty. Cruess RL: Steroid-induced avascular necrosis of the head of the humerus: Natural history and management. J Bone Joint Surg Br 1976;58:313-317. LePorte DM, Mont MA, Mohan V, Pierre-Jacques H, Jones LC, Hungerford DS: Osteonecrosis of the humeral head treated by core decompression. Clin Orthop 1998;355:254-260.

References:

Question 40

An otherwise healthy 65-year-old man reports thigh pain of insidious onset. He states that the pain is increased with weight bearing and also occurs at night. He denies any history of cancer. Radiographs are shown in Figures 22a and 22b. A bone scan shows an isolated lesion. CT scans of the chest and abdominal are negative for any other lesions. Initial management should consist of





Explanation

The patient has a solitary lesion that is at high risk for fracture. While metastatic lesions are most common in this age group, a stabilization procedure is contraindicated until results of a biopsy confirm the presence of a metastasis. Because of the lytic lesion and the associated calcification shown on the radiograph, the most likely diagnosis is a chondrosarcoma. Therefore, any type of stabilization procedure with a rod or plate would compromise a wide surgical excision to remove the entire proximal femur. Radiation therapy and chemotherapy are also contraindicated until biopsy results are obtained. Because of these factors, obtaining a frozen section biopsy specimen is considered the next most appropriate step in management. If a metastatic lesion is confirmed on the frozen section, a stabilization procedure could then be performed under the same anesthetic. Therefore, it is important to have a pathologist available at the time of a biopsy. Frassica FJ, Frassica DA, McCarthy EF, Riley LH III: Metastatic bone disease: Evaluation, clinicopathologic features, biopsy, fracture risk, nonsurgical treatment, and supportive management. Instr Course Lect 2000;49:453-459.

References:

Question 41

A 10-year-old girl has been referred for evaluation of a prominence at the lower cervical spine. The patient is asymptomatic, and the examination reveals no evidence of neurologic abnormality. A radiograph and CT scans are shown in Figures 12a through 12c. What is the most likely diagnosis?





Explanation

Tuberculosis is uncommon in the cervical spine but has a relatively greater incidence in young children. In a review of 40 patients with lower cervical spine involvement (C2 to C7), 24 were younger than age 10 years at presentation. In children, the disease is characterized by more extensive involvement with the formation of large abscesses. In older patients with lower cervical tuberculosis, the disease is more localized but is more likely to cause paraplegia. Four-drug antituberculosis therapy should be used. For patients with pain or neurologic dysfunction, anterior excision of diseased bone and grafting are indicated. Whether vertebral body excision and grafting should be done in an asymptomatic 10-year-old child is debatable. The CT scan shows a large "cold" abscess that is partially calcified. Hsu LC, Leong JC: Tuberculosis of the lower cervical spine (C2 to C7): A report on 40 cases. J Bone Joint Surg Br 1984;66:1-5.

References:

Question 42

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 43

A 19-year-old man has had pain and swelling in his left forearm for the past 8 months. Laboratory studies show a mildly elevated WBC count and erythrocyte sedimentation rate. Radiographs are shown in Figures 58a and 58b, a CT scan is shown in Figure 58c, and T1- and T2-weighted MRI scans are shown in Figures 58d and 58e, respectively. A biopsy specimen is shown in Figure 58f. Immunohistochemistry demonstrates that the lesion is negative for leukocyte common antigen (CD34). What is the most common cytogenetic translocation associated with this lesion?





Explanation

The imaging studies show a permeative lytic destructive lesion in the proximal radius with "hair-on-end" periosteal reaction and a large soft-tissue mass most consistent with Ewing's sarcoma. The pathology reveals monotonous sheets of "round blue" cells. This limits the differential diagnosis to primary lymphoma of bone versus Ewing's sarcoma. These are best differentiated by immunohistochemistry, cytogenetics, and flow cytometry. Lymphoma of bone is typically CD34 positive and CD99 negative; whereas, the reverse is true of Ewing's sarcoma, CD34 negative and CD99 positive. The most common cytogenetic translocation with Ewing's sarcoma is 11; 22; 21; 22 and 7; 22 translocations have also been reported in Ewing's sarcomas. The X; 18 translocation is most commonly associated with synovial cell sarcomas; the 12; 22 translocation is most commonly associated with clear cell sarcomas; the 2; 13 translocation is most commonly associated with alveolar rhabdomyosarcomas, and the 12; 16 translocation is most commonly associated with myxoid liposarcomas. Flow cytometry is used to characterize the cell types of lymphomas. Womer R: The cellular biology of bone tumors. Clin Orthop Relat Res 1991;262:12-21. Yamaguchi U, Hasegawa T, Morimoto Y, et al: A practical approach to the clinical diagnosis of Ewing's sarcoma/primitive neuroectodermal tumour and other small round cell tumours sharing EWS rearrangement using new fluorescence in situ hybridisation probes for EWSR1 on formalin fixed, paraffin wax embedded tissue. J Clin Pathol 2005;58:1051-1056.

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Question 44

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

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





Explanation

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

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Question 45

A right-handed 24-year-old woman underwent an arthroscopic Bankart repair for recurrent anterior dislocations 9 months ago. Despite extensive physical therapy for 8 months, the patient has very limited range of motion (elevation to 130 degrees and external rotation to 10 degrees with the arm at the side). Shoulder radiographs are normal. The next step in management should consist of

Shoulder Board Review 2002: High-Yield MCQs (Set 2) - Figure 23





Explanation

Arthroscopic capsular release is an effective means of treating stiffness that is the result of capsular contractures, such as in the case of a tight Bankart repair. Open release allows lengthening of a surgically shortened subscapularis, such as after a tight Putti-Platt repair. Additional physical therapy is unlikely to be effective because 8 months of treatment has failed to result in improvement. Accepting this degree of asymptomatic limited motion is not advisable because of the functional limitations for the patient and the increased risk of postoperative degenerative arthritis. Warner JJ, Allen AA, Marks PH, Wong P: Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 1997;79:1151-1158.

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Question 46

A 70-year-old woman reports anterior knee pain after undergoing an uncomplicated total knee arthroplasty 6 months ago. Examination reveals prepatellar tenderness, with no extensor lag. The radiographs shown in Figures 25a through 25c reveal a well-fixed patellar component. Management should consist of





Explanation

Patellar fractures that occur after a total knee arthroplasty are usually stress fractures. Integrity of the extensor mechanism precludes the need for surgical repair or internal fixation, while stability and fixation of the patellar component determine whether revision is indicated. A cylindrical cast and full weight bearing for 6 weeks is recommended for transverse fractures with an intact extensor mechanism and a stable component. A similar fracture, if vertical, may be treated with earlier motion. Rorabeck CH, Angliss RD, Lewis PL: Fractures of the femur, tibia, and patella after total knee arthroplasty: Decision making and principles of management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 449-458. Hozack WJ, Goll SR, Lotke PA, Rothman RH, Booth RE Jr: The treatment of patellar fractures after total knee arthroplasty. Clin Orthop 1988;236:123-127.

References:

Question 47

An 18-year-old man underwent open reduction and internal fixation of a tibial spine avulsion and a posterolateral corner repair. Two years later, he underwent lateral collateral ligament (LCL) and posterolateral corner reconstruction because of instability. Examination reveals a pronounced lateral varus knee thrust when ambulating. Varus stress in 30 degrees of flexion produces a 10-mm opening that is eliminated in extension. The Lachman's test is 2 mm with a firm end point, and the posterior drawer test is negative. Standing radiographs show widening of the lateral joint space and a 5-degree mechanical varus alignment. What is the most effective course of treatment?





Explanation

The patient has chronic posterolateral instability with a varus knee alignment; therefore, the most effective treatment is a valgus-producing HTO. A repeat soft-tissue reconstruction without correction of the varus alignment will most likely fail. An ACL reconstruction is not indicated with a normal Lachman's test. Physical therapy and bracing will have little effect. Naudie DD, Amendola A, Fowler PJ: Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med 2004;32:60-70.

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Question 48

An 8-year-old boy is diagnosed with acute onset cauda equina syndrome. A radiograph, MRI scans, and a biopsy specimen are shown in Figures 57a through 57d. What is the most appropriate treatment?





Explanation

The findings are consistent with an aneurysmal bone cyst. The MRI scan demonstrates a lesion involving the posterior elements of the vertebrae with fluid-fluid levels and neural compression. Fibrovascular tissue with multinucleated giant cells surrounding a vascular lake is seen on the histology. The most appropriate treatment is a marginal resection of the involved posterior elements. Although the recurrence rate can be as high as 25% to 30%, wide surgical resection could result in permanent neurologic injury and is not necessary. Aspiration and steroid injection have been advocated but would not relieve the nerve compression in this patient. Radiation therapy and chemotherapy are not indicated. Mankin HJ, Hornicek FJ, Ortiz-Cruz E, et al: Aneurysmal bone cyst: A review of 150 patients. J Clin Oncol 2005;23:6756-6762.

References:

Question 49

Which of the following statements best describes why the ulnar nerve is most prone to neuropathy at the elbow?

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





Explanation

The ulnar nerve is more prone to neuropathy than the radial or median nerves for many reasons. It has the greatest longitudinal excursion required to accommodate elbow range of motion, subjecting it to potential traction forces. The dimensions of the entrance of the cubital tunnel change with elbow motion, potentially causing compression in flexion. For these two reasons, the ulnar nerve is subjected to both compression and traction during elbow motion. Although it passes between two muscle heads as it enters the forearm, so do the median and radial nerves. Finally, the vascular supply is adequate because of the anastamoses between the superior ulnar collateral artery, the posterior ulnar recurrent artery, and the inferior ulnar collateral artery. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 369-378. Prevel CD, Matloub HS, Ye Z, Sanger JR, Yousif NJ: The extrinsic blood supply of the ulnar nerve at the elbow: An anatomic study. J Hand Surg Am 1993;18:433-438.

Scientific References

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Question 50

A metal-on-metal bearing used for total hip arthroplasty shows which of the following properties?

Hip & Knee Reconstruction 2007 Practice Questions: Set 1 (Solved) - Figure 3





Explanation

Activity levels do not affect cobalt and chromium ion levels, which are the bulk of serum ion levels. The majority of ions are produced in the run-in period in the first several years. A gradual reduction in ion levels occurs thereafter. The kidneys are responsible for the bulk of clearance from the serum, and to date there is no relationship of cancer to ion levels in the serum.

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Question 51

A 52-year-old man has a stage IIB malignant fibrous histiocytoma of the distal femur. Local treatment should consist of





Explanation

Local control of malignant fibrous histiocytoma of bone typically consists of wide excision. Curettage and bone grafting is a procedure with an intralesional surgical margin, with an unacceptable rate of local recurrence. Prophylactic fixation is considered for patients with metastatic disease. Radiation therapy alone is not adequate for local control of this tumor. Neoadjuvant chemotherapy is often used primarily for systemic tumor control.

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Question 52

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





Explanation

The patient has a transscaphoid dorsal perilunate dislocation. The radiographs clearly define a dorsal dislocation of the capitolunate joint, and the scaphoid fracture component is easily visible on the AP view. A scaphoid fracture alone is an unlikely diagnosis because of the midcarpal dislocation component. The radiocarpal joint is not dislocated because the lunate is sitting in the lunate fossa of the radius. Isolated radiocarpal dislocations are not associated with a midcarpal disruption. While a midcarpal dislocation is a component of a dorsal perilunate dislocation, this diagnosis does not address the scaphoid fracture. A volar lunate dislocation is not seen because the lunate is reduced in the lunate fossa of the distal radius. Volar lunate dislocations are in the spectrum of injury of perilunate dislocations and fracture-dislocations; however, the radiographs show a transscaphoid dorsal perilunate dislocation. Mayfield JK, Johnson RP, Kilcoyne RK: Carpal dislocations: Pathomechanics and progressive perilunar instability. J Hand Surg Am 1980;5:226-241.

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Question 53

The correct starting point for an external fixation half pin placed into the anterior inferior iliac spine (AIIS) is labeled by what letter in Figure 3?

Trauma 2009 Practice Questions: Set 1 (Solved) - Figure 5





Explanation

Half pins placed in the AIIS are an alternative to pins placed in the iliac crest. A strong pillar of bone runs from the AIIS to the posterior iliac crest and less soft tissue is typically present in this area. The starting point is best seen on an obturator outlet view. The obturator outlet view is a combination of the pelvic outlet view and the obturator view of Judet and Letournel. The beam is rotated "over the top" of the patient since the iliac wing is externally rotated as well as cephalad to best visualize this column of bone running from the AIIS to the posterior iliac spine. This corridor of bone will appear as a teardrop. Once the correct view is obtained, the pin should be started at least 2 cm proximal to the hip joint to avoid placing a pin within the hip capsule. Blunt dissection and a guide sleeve should be used to prevent damage to the lateral femoral cutaneous nerve. An iliac oblique view is used after the pin has been partially inserted to make sure the pin is passing superior to the superior gluteal notch, and an obturator inlet view can be used at the completion of the procedure to make sure the pin is contained within the bone for its entire length. Gardner MJ, Nork SE: Stabilization of unstable pelvic fractures with supra-acetabular compression external fixation. J Orthop Trauma 2007;21:269-273. Haidukewych GJ, Kumar S, Prpa B: Placement of half-pins for supra-acetabular external fixation: An anatomic study. Clin Orthop Relat Res 2003;411:269-273.

References:

Question 54

A 45-year-old male karate instructor sustained the injury shown in Figures 40a through 40c while practicing karate. The decision to proceed with surgery depends on which of the following factors?





Explanation

The most important criteria in determining the need for surgery following a nondisplaced or minimally displaced tibial plateau fracture is knee stability to varus/valgus stress. Soft-tissue injury noted on MRI may be addressed at a later time following fracture healing. This fracture pattern is amenable to nonsurgical management. Decisions regarding surgical intervention may be made up to 2 weeks after injury.

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Question 55

A 50-year-old man with metastatic renal cell carcinoma has right hip pain. A radiograph and CT scan are shown in Figures 48a and 48b. The first step in management should consist of





Explanation

These lesions are extremely vascular and can cause uncontrolled intraoperative bleeding; therefore embolization is the appropriate first treatment. Because the radiograph and CT scan show a lytic lesion in the supra-acetabular region that affects the weight-bearing dome and medial wall, the next step in treatment would most likely be a total hip arthroplasty and acetabular reconstruction. Treatment with bisphosphonates and radiation therapy will not prevent an acetabular fracture. Cementoplasty is an emerging technique in which cement is injected percutaneously into a lesion, but no long-term results have been reported. Radiofrequency ablation of bone metastases is also an emerging technique that provides palliative pain control. Layalle I, Flandroy P, Trotteur G, Dondelinger RF: Arterial embolization of bone metastases: Is it worthwhile? J Belge Radiol 1998;81:223-225.

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Question 56

In a patient who has rheumatoid arthritis with acetabular protrusion, what is the best biomechanical position for the cup with respect to the preoperative center of rotation?

Hip 2001 Practice Questions: Set 1 (Solved) - Figure 24





Explanation

Acetabular protrusion in patients with rheumatoid arthritis moves the center of hip rotation medially and posteriorly. Positioning of the acetabular component in a patient with protrusion is best accomplished in the normal (anterior and inferior) position and not in a protruded position. This has been shown both clinically and in a finite-element analysis. Any medial positioning will produce impingement of the prosthesis neck on the rim, and superior placement produces improper hip mechanics. Crowninshield RD, Brand RA, Pedersen DR: A stress analysis of acetabular reconstruction in protrusio acetabuli. J Bone Joint Surg Am 1983;65:495-499.

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Question 57

A 19-year-old soccer player feels a pop in his knee while making a cut and notes the development of an effusion over several hours. Examination reveals medial joint line tenderness, but the knee is stable to manual stress testing of all ligaments. Examination under anesthesia confirms a stable knee. What is the most critical factor in determining healing after repair of the lesion shown in Figure 14?

Sports Medicine Board Review 2004: High-Yield MCQs (Set 2) - Figure 6





Explanation

Numerous clinical and basic science investigations have evaluated meniscal tear characteristics to identify factors that either promote or mitigate against meniscal healing. Complex tears have been noted to heal poorly, while longitudinal tears heal more predictably. Tear length, time from injury to repair, medial versus lateral meniscal tears, and the use of a fibrin clot have not been shown to consistently affect meniscal healing. However, rim width, the distance of the tear site from the peripheral meniscocapsular junction (vascular supply), has been shown to have a significant role in the ability of a meniscus repair to heal. DeHaven KE, Arnoczky SP: Meniscus repair: Basic science, indications for repair, and open repair. Instr Course Lect 1994;43:65-76.

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Question 58

Figures 32a and 32b show the radiographs of an active 13-year-old boy who has persistent left thigh pain and a limp despite a trial of protected weight bearing. Management should consist of





Explanation

The plain radiographs show an eccentric metaphyseal lesion involving a long bone in a skeletally immature patient. The lesion is longer than it is wide, with distinctly lobular outer edges that are sclerotic. These findings are characteristic of a nonossifying fibroma. Small asymptomatic lesions may be followed clinically. Larger lesions that occupy greater than two thirds of the width of the shaft and are located in areas of high mechanical stress such as the femur are more prone to fracture than smaller lesions. Pain is often a sign of impending fracture or the presence of a small fracture that may not be apparent on radiographs. The natural history of the lesion is to resolve over a period of years. The procedure that would allow the patient to return to contact sports is curettage and bone grafting. Intralesional steroid injection has been advocated in the treatment of unicameral bone cysts and eosinophilic granuloma but not nonossifying fibromas. En block resection is not indicated for a benign lesion. Low-dose radiation therapy has been used for eosinophilic granuloma but not for nonossifying fibromas. Walker RN, Green NE, Spindler KP: Stress fractures in skeletally immature patients. J Pediatr Orthop 1996;16:578-584.

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Question 59

A patient with a below-the-knee amputation is being evaluated for a new prosthesis. He wants to improve his ability to walk on uneven surfaces. What modification to the prosthesis can be made to accommodate this request?





Explanation

Changing from a solid keel to a keel with a sagittal split allows an amputee to navigate uneven terrain more easily. Changing the length of the keel affects the responsiveness of the prosthesis but does not address the surface conditions for ambulation. The SACH is not used as frequently anymore, because overload problems to the nonamputated foot have been observed. Koval K (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 31-45.

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Question 60

A 42-year-old man has had left lower extremity pain in an L5 radicular pattern for the past 6 weeks. He denies significant axial low back pain. History reveals that he underwent an L4-5 diskectomy with successful relief of similar pain 5 years ago. Which of the following imaging studies would offer the greatest amount of information?





Explanation

MRI with gadolinium will best identify recurrent herniated nucleus pulposus or other root compression and distinguish scar from recurrent disk. CT is unable to distinguish scar from recurrent disk density, and the addition of myelogram dye can reveal compromise of the thecal sac but cannot distinguish the scar from recurrent disk as the source of compression. Although lateral flexion-extension radiographs may be important to rule out any instability, much of that information can be inferred from the associated disk and adjacent bony changes on MRI. Bone scan techniques may identify subtle stress fractures resulting from previous aggressive facet resection, but low back pain also would be expected. Mirowitz SA, Shady KL: Gadopentetate dimeglumine-enhanced MR imaging of the postoperative lumbar spine: Comparison of fat-suppressed and conventional T1-weighted images. Am J Roentgenol 1992;159:385-389.

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Question 61

What part of the glenoid labrum has the least vascularity?

Upper Extremity 2005 Practice Questions: Set 1 (Solved) - Figure 7





Explanation

The glenoid labrum receives its blood supply from the suprascapular, posterior humeral circumflex, and circumflex scapular arteries. The labral vessels arise from the capsular and periosteal vessels that penetrate the periphery of the labrum. The bone does not appear to be a source of vascularity. The posterior/superior and inferior labrum have a fairly robust vascular supply, whereas the anterior/superior labrum has relatively poor vascularity, which may influence the success of superior lateral repairs.

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Question 62

In a juvenile Tillaux ankle fracture, what ligament causes the displacement of the fracture fragment?





Explanation

The juvenile Tillaux ankle fracture usually occurs because the lateral half of the distal tibial physis remains open. During an external rotational force, the anterior tibiofibular ligament holds the lateral tibial epiphysis, separating it through at the junction of the middle closed physis and lateral open physis.

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Question 63

Figure 25 shows an arthroscopic thermal capsular shrinkage device being used in the anterior inferior quadrant of a patient with a subluxating shoulder. Which of the following neurologic complications is most frequently reported with this technique?

Anatomy Board Review 2002: High-Yield MCQs (Set 2) - Figure 26





Explanation

The axillary nerve lies within millimeters of the anterior inferior capsule. The inferior capsule is of varying thickness, and thermal energy used in shortening the ligament can cause damage to the sensory fibers of the axillary nerve. Clinically, this is manifested as a burnt skin sensation in the axillary nerve distribution area. The motor branch of the axillary nerve is usually spared. The suprascapular nerve and the radial nerve are far from the shrinkage zone. The musculocutaneous nerve, frequently at risk with open procedures, lies well anterior. Fanton GS: Arthroscopic electrothermal surgery of the shoulder. Op Tech Sports Med 1998;6:157-160.

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Question 64

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





Explanation

The patient is showing signs of vertebral artery stroke. The signs of Wallenberg syndrome include those listed above, as well as contralateral loss of pain and temperature sensation throughout the body, an ipsilateral Horner's syndrome, dysphagia, and ataxia. Vertebral artery injuries are not unusual in significant cervical facet injuries. A lesion in the cervical spinal cord is not associated with these symptoms, and an intracranial hemorrhage from trauma is unlikely to present in this manner. Young PA, Young PH: Basic Clinical Neuroanatomy. Baltimore, MD, Williams and Wilkins, 1997, pp 242-243. Hauop JS, et al: The cause of neurologic deterioration after acute cervical spinal cord injury. Spine 2001;26:340-346.

References:

Question 65

A woman injures the metacarpophalangeal (MCP) joint of her thumb while skiing. Examination reveals tenderness along the ulnar aspect of the MCP joint. Radially directed stress of the joint in full extension produces 5 degrees of angulation. When the MCP joint is flexed 30 degrees, a radially directed stress produces 45 degrees of angulation. Radiographs are otherwise normal. Management should consist of





Explanation

Injuries to the ulnar collateral ligament of the MCP joint of the thumb commonly occur in recreational skiers. Historically, this injury has been referred to as "gamekeeper's thumb." The ligament consists of the proper collateral ligament and the more volar accessory collateral ligament. In extension, the accessory ligament is taut, and in flexion, the proper ligament is taut. For a complete tear of the ligament complex to occur, there must be laxity in full extension. Incomplete tears respond well to thumb spica splinting or casting for 2 to 3 weeks and gradual resumption of range of motion. Prolonged immobilization of incomplete injuries leads to higher rates of MCP joint stiffness. Stener B: Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb: A clinical and anatomical study. J Bone Joint Surg Br 1971;44:869.

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Question 66

Figures 57a through 57c show the radiographs of a patient who has pain, discomfort, and a popping sensation localized to the posterior aspect of the knee after undergoing primary left total knee arthroplasty 6 months ago. Examination reveals that the patient is able to ambulate without a limp. There is no significant swelling, erythema, or effusion. Range of motion is 0 degrees to 115 degrees, and a palpable crepitation or snapping is detected at the posterior lateral joint line. What is the most likely diagnosis?





Explanation

Popliteal snapping syndrome represents the most likely diagnosis. Barnes and Scott noted that the popliteus tendon can be a potential source of internal derangement after total knee arthroplasty. They noted that it can be subluxated anteriorly and posteriorly over a retained lateral femoral condyle osteophyte. Allardyce and associates described the condition as a popliteus condition, snapping as it rolls over a retained lateral femoral condylar osteophyte. Patellar clunk syndrome is a distinct syndrome associated with the patella and has been reported in posterior stabilized knees. In addition to crepitation with range of motion, the patella literally snaps or jumps as the knee is taken from flexion to extension. Beight JL, Yao B, Hozack WJ, et al: The patellar "clunk" syndrome after posterior stabilized total knee arthroplasty. Clin Orthop 1994;299:139-142. Barnes CL, Scott RD: Popliteus tendon dysfunction following total knee arthroplasty. J Arthroplasty 1995;10:543-545.

References:

Question 67

Figure 7 shows the radiograph of an 18-year-old hockey player who sustained a shoulder injury during a fall into the side boards. Examination reveals a significant prominence at the acromioclavicular joint. Management should consist of

Sports Medicine 2001 Practice Questions: Set 1 (Solved) - Figure 22





Explanation

The radiograph shows a type V acromioclavicular separation with greater than 100% superior elevation of the clavicle. This finding implies detachment of the deltoid and trapezius from the distal clavicle. Because of severe compromise of function and potential compromise to the overlying skin, surgery is the treatment of choice for type V acromioclavicular separations. During reduction and repair, meticulous repair of the deltotrapezial fascia will also aid in securing the repair. Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:11-18.

References:

Question 68

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

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





Explanation

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

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Question 69

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





Explanation

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

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Question 70

A 6-year-old boy presents with a mass and a lucent lesion involving the tibial shaft as seen in Figure 17a. The mass is mildly tender to palpation. The bone scan is focally hot in the tibia. Biopsy specimens are shown in Figures 17b and 17c. What is the most likely diagnosis?





Explanation

Osteofibrous dysplasia frequently presents at a very young age, usually less than 10 years. In most patients, it involves the anterior cortex of the tibial shaft and minor anterior bowing of the tibia is frequently seen. The lesion is unpredictable in nature, but local recurrence is very high in patients who undergo surgery before 15 years of age. Campanacci M, Laus M: Osteofibrous dysplasia of the tibia and fibula. J Bone Joint Surg Am 1981;63:367-375.

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Question 71

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





Explanation

Curettage and bone grafting typically are the preferred treatment of chondroblastoma, yielding acceptable local recurrence rates of less than 10%. Some surgeons advocate adjuvant therapies such as phenol, liquid nitrogen, or argon beam coagulation. Untreated, these lesions can destroy bone and invade the joint to a significant degree. Large intra-articular lesions may require major joint reconstruction. Wide local excision is rarely required to control the tumor. Radiation therapy is indicated only in unresectable lesions. Springfield DS, Capanna R, Gherlinzoni F, et al: Chondroblastoma: A review of seventy cases. J Bone Joint Surg Am 1985;67:748.

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Question 72

The arrows in the axial T1-weighted MRI scan shown in Figure 25 show which of the following structures?

Anatomy Board Review 2008: High-Yield MCQs (Set 2) - Figure 23





Explanation

The arrows in the figure show the deep branch of the ulnar nerve (more radial) and the superficial branch of the ulnar nerve within Guyon's canal. Guyon's canal is approximately 4 cm long beginning at the proximal extent of the transverse carpal ligament and ends at the aponeurotic arch of the hypothenar muscles. Many structures comprise the boundaries of Guyon's canal. The floor, for example, consists of the transverse carpal ligament, the pisohamate and pisometacarpal ligaments, and the opponens digiti minimi. Within Guyon's canal, the ulnar nerve bifurcates into the superficial and deep branches. The ulnar artery is immediately adjacent and radial to the ulnar nerve. The median nerve is visualized within the carpal tunnel, and the palmar cutaneous branch is more radial to Guyon's canal and volar to the carpal tunnel. The radial and ulnar digital nerves to the little finger are branches off of the superficial branch of the ulnar nerve distal to its emergence from Guyon's canal. The ulnar artery is the round structure located radial to the branches of the ulnar nerve within Guyon's canal. Adjacent to the ulnar artery are two small veins. The dorsal cutaneous branch of the ulnar nerve branches from the ulnar nerve in the distal forearm, well proximal to Guyon's canal. The common digital artery to the fourth web branches from the superficial palmar arch distal to Guyon's canal. The hook of the hamate is clearly seen in the figure, orienting the observer to the ulnar side of the wrist. Gross MS, Gelberman RH: The anatomy of the distal ulnar tunnel. Clin Orthop Relat Res 1985;196:238-247.

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Question 73

A 38-year-old left hand-dominant bodybuilder reports ecchymosis in the left axilla and anterior brachium after sustaining an injury while bench pressing 3 weeks ago. Coronal and axial MRI scans are shown in Figures 16a and 16b. What treatment method yields the best long-term results?





Explanation

The MRI scans show a rupture of the sternocostal portion of the pectoralis major tendon. This is the most common site of rupture and bench pressing is the most common etiology. Surgical repair yields better functional outcomes and patient satisfaction for tears not only at the tendon/bone interface but also at the myotendinous junction. Bak K, Cameron EA, Henderson IJ: Rupture of the pectoralis major: A meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc 2000;8:113-119.

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Question 74

A 2-week-old infant has had diminished movement of the right upper extremity since birth. Examination reveals weakness of shoulder abduction and external rotation, elbow flexion, and forearm supination. Both pupils are equally round and responsive to light. The remainder of the examination is normal. Radiographs of the upper limb show a healing middle-third clavicle fracture. Management should consist of





Explanation

The patient has a classic Erb's palsy with weakness of the muscles innervated by the fifth and sixth cervical roots. Horner syndrome, a poor prognostic indicator for recovery, is absent in this infant. All infants with brachial plexus birth palsies initially should be monitored for spontaneous recovery during the first 3 to 6 months of life. During this period of observation, glenohumeral motion, especially external rotation, should be maintained. Many infants will begin to show recovery within the first 6 to 8 weeks after birth and continue on to normal function. The timing of microsurgery is controversial. A recent study found that the outcome of microsurgical repair in patients who had no recovery of biceps function within 3 months after birth was similar compared to those who had recovery of biceps function between 3 and 6 months and no microsurgical repair. The author concluded that microsurgical repair was effective in improving function in those infants who had no evidence of recovery of biceps function within the first 6 months of life. Waters PM: Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy. J Bone Joint Surg Am 1999;81:649-659.

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Question 75

A 62-year-old man has a severe pes planus and pain in the hindfoot. Radiographs show advanced degenerative changes at the talonavicular and subtalar joints with good preservation of the ankle joint. What is the most appropriate surgical procedure to alleviate his pain?





Explanation

Once degenerative changes have occurred, soft-tissue procedures are not indicated. Triple arthrodesis is the treatment of choice for adult-acquired flatfoot. Isolated fusion of the subtalar or talonavicular joint will not be sufficient to correct the problem. Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 269-282.

References:

Question 76

What measure of physiologic status best evaluates whether an injured patient is fully resuscitated and best predicts that perioperative complications will be minimized following definitive stabilization of long bone fractures?

Trauma Board Review 2006: High-Yield MCQs (Set 2) - Figure 33





Explanation

Serum lactate levels can be used to evaluate the effectiveness of the resuscitation of patients who have multiple injuries. Even after resuscitation, patients may have occult hypoperfusion as defined by a serum lactate level of greater than 2.5 mmol/L. The studies referenced indicate that these patients are at increased risk of perioperative complications such as organ failure or adult respiratory distress syndrome if definitive surgical fixation of the orthopaedic injuries is pursued prior to correction of the occult hypoperfusion. The other markers may be an indication of current physiology but have not been correlated with perioperative risks. Blow O, Magliore L, Claridge JA, et al: The golden hour and silver day: Detection and correction of occult hypoperfusion within 24 hours improves outcomes from major trauma. J Trauma 1999;47:964-977. Crowl A, Young JS, Kahler DM, et al: Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. J Trauma 2000;48:260-267.

References:

Question 77

What is the best surgical approach for the scapular fracture shown in Figure 46?

Shoulder Board Review 2002: High-Yield MCQs (Set 4) - Figure 10





Explanation

Indications for open reduction of glenoid intra-articular fractures include those fractures with a 5-mm articular surface displacement or when the humeral head is subluxated with the fracture fragment. Kavanaugh and associates and Leung and Lam have shown that the posterior approach with plate fixation is best for most glenoid fractures, including the Ideberg type II fracture shown here. The anterior approach is best used for anterior rim and transverse fractures. Kavanagh BF, Bradway JK, Cofield RH: Open reduction and internal fixation of displaced intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am 1993;75:479-484. Leung KS, Lam TP: Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle. J Bone Joint Surg Am 1993;75:1015-1018.

References:

Question 78

A 58-year-old woman with a history of severe asthma and long-term prednisone use reports a progression of chronic shoulder pain for the past 6 months. Radiographs and MRI scans are shown in Figures 30a through 30d. What is the most likely diagnosis?





Explanation

The patient has osteonecrosis of the humeral head. The radiographs show increased density in the superior subchondral region of the humeral head. The MRI scans reveal a central collapse of the humeral head. The patient's history of severe asthma and long-term prednisone use predisposes her to this condition. The MRI scans show no evidence of a full- or partial-thickness rotator cuff tear. Without a history of fevers, chills, or other systemic signs or symptoms, there is no indication of septic arthritis. The radiographs do not reveal periarticular erosions, commonly seen in rheumatoid arthritis. Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 871-874.

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Question 79

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





Explanation

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

References:

Question 80

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.

References:

Question 81

Figure 53 shows the arteriogram of a 45-year-old man who has severe vasculitis. What do the findings show?

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





Explanation

The arterial supply to the hand is abundant and normally duplicated. The deep palmar arch as shown in this arteriogram typically receives its primary contribution from the radial artery which travels deep to the first dorsal compartment tendons and then returns to the volar aspect of the palm through the first web space. The superficial palmar arch receives its supply from the ulnar artery and is not visualized in this patient.

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Question 82

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

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





Explanation

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

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Question 83

Of the following factors, which is considered the most important prognostic indicator in soft-tissue sarcomas?

Basic Science Board Review 2002: High-Yield MCQs (Set 2) - Figure 20





Explanation

Histologic grade, the presence or absence of metastatic disease, and tumor size are important prognostic factors. Of the available choices, however, the size of the sarcoma is the most important prognostic indicator. A tumor size of greater than 5 cm is a more important prognostic factor than tumor location. Patients with sarcomas that measure 5 cm or less have nearly identical 3-year survival rates regardless of whether the tumor is subcutaneous or deep. Histologic grade (high versus low) is an important factor. However, histologic subtype frequently is not as important a factor as tumor size.

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Question 84

What is the most common foot and ankle deformity in patients with arthrogryposis?





Explanation

Clubfoot (talipes equinovarus) in patients with arthrogryposis is a rigid and resistant deformity. However, multiple studies document limited success with nonsurgical management. Manipulation and casting are generally a preliminary treatment before surgery; successful correction will most like require a talectomy. Guidera KJ, Drennan JC: Foot and ankle deformities in arthrogryposis multiplex congenita. Clin Orthop 1985;194:93-98. Handelsman JE, Badalamente MA: Neuromuscular studies in clubfoot. J Pediatr Orthop 1981;1:23-32.

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Question 85

The lesion seen in Figure 4 is most likely the result of metastases from what solid organ?

Basic Science 2005 Practice Questions: Set 1 (Solved) - Figure 12





Explanation

The primary carcinoma most likely to metastasize distal to the elbow and knees is lung carcinoma. Renal cell carcinoma can also metastasize to distal sites. Most metastatic bone disease occurs in the vertebral bodies, pelvis, and proximal long bones. Simon MA, Bartucci EJ: The search for the primary tumor in patients with skeletal metastases of unknown origin. Cancer 1986;58:1088-1095.

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Question 86

A 64-year-old man with a history of diabetes mellitus underwent open reduction and internal fixation of a displaced ankle fracture 8 weeks ago. Examination now reveals recent onset erythema, warmth, and swelling of the midfoot. Radiographs are shown in Figures 23a through 23d. What is the most likely reason for the swelling of the foot?





Explanation

A Charcot flare in adjacent joints is not uncommon in patients with neuropathy who undergo surgery or other trauma. Venous thrombosis would present with swelling of the entire leg, while infection would present earlier in the postoperative period. The radiographs are pathognomonic of Charcot arthropathy, not an unrecognized fracture or gout. A compartment syndrome this late after injury is extremely rare, and there would be no bony distraction associated with compartment syndrome.

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Question 87

A 12 1/2-year-old boy reports intermittent knee pain and limping that interferes with his ability to participate in sports. He actively participates in football, basketball, and baseball. He denies any history of injury. Examination shows full range of motion without effusion. Radiographs reveal an osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. MRI scans are shown in Figures 14a and 14b. Initial treatment should consist of





Explanation

This skeletally immature patient has a small OCD lesion that appears stable, and he has not undergone any treatment. Therefore, a trial of immobilization until pain resolves is the best initial choice. Thereafter, cessation of sport activities for 4 to 6 months may allow healing of the lesion. Surgical treatment of juvenile OCD lesions is reserved for unstable lesions, patients who have not shown radiographic evidence of healing and are still symptomatic after 6 months of nonsurgical management, or patients who are approaching skeletal maturity. Good results with stable in situ lesions that have failed to respond to nonsurgical management have been reported with both transarticular and retroarticular drilling. Results after excision alone are poor at 5-year follow-up, and it is unclear if microfracture will improve the long-term outcome. Mosaicplasty may be the next best option for patients who remain or become symptomatic after excision of the fragment and microfracture. Wall E, Von Stein D: Juvenile osteochondritis dissecans. Orthop Clin North Am 2003;34:341-353.

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Question 88

The major benefit of irrigation with a castile soap solution over irrigation with bacitracin solution for the treatment of the open fracture shown in Figure 42 can be seen in which of the following outcomes?

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 23





Explanation

The mainstay of early treatment of open fractures includes irrigation and debridement. Prior to the development of antibiotics, this was traditionally accomplished with some form of detergent irrigation. Antibiotic irrigation has been in favor more recently but has mixed scientific results related to its use. Results of at least one major study show the use of a nonsterile liquid soap additive (castile soap) is at least as effective as the use of bacitracin with regards to the rate of postoperative infection and fracture healing, and shows a significant decrease in problems with soft-tissue healing.

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Question 89

A 50-year-old woman reports a burning sensation on the plantar aspect of her left forefoot, distal to the metatarsal heads between her third and fourth digits. Palpation of the third web space recreates her symptoms. Which of the following will most accurately aid in confirming a diagnosis?





Explanation

The diagnosis of an interdigital neuroma is best made by a thorough history and careful physical examination. Radiographs are helpful in excluding other pathologic processes such as a metatarsal stress fracture. MRI and ultrasound have both been reported to aid in the diagnosis of an interdigital neuroma. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 145-151.

References:

Question 90

A patient who underwent closed reduction of the hips as an infant now reports pain. An abduction internal rotation view shows an incongruous joint. Based on the findings shown in Figure 3, what is the most appropriate type of pelvic osteotomy for the right hip?

Pediatrics 2007 Practice Questions: Set 1 (Solved) - Figure 8





Explanation

Pelvic osteotomies that redirect hyaline cartilage over the femoral head offer the potential for long-term preservation of the hip; however, salvage procedures such as the Chiari osteotomy are indicated in patients without a concentrically reducible hip. Ito and associates reported that moderate dysplasia and moderate subluxation without complete obliteration of the joint space and a preoperative center-edge angle of at least minus 10 degrees are desirable selection criteria. Ohashi H, Hirohashi K, Yamano Y: Factors influencing the outcome of Chiari pelvic osteotomy: A long-term follow-up. J Bone Joint Surg Br 2000;82:517-525.

References:

Question 91

Based on the findings seen in the posteroanterior radiograph of the wrist shown in Figure 17, which of the following structures is torn?

Anatomy Board Review 2002: High-Yield MCQs (Set 2) - Figure 8





Explanation

The radiograph shows widening between the scaphoid and lunate. The normal variance is up to 5 mm. Although several ligaments may be torn, the scapholunate interosseous ligament must be torn for this widening to occur. Cooney WP, Linscheid RL, Dobyns JH: The Wrist: Diagnosis and Operative Treatment. St Louis, MO, Mosby-Year Book, 1998, vol 1, pp 503-506.

References:

Question 92

Epithelioid sarcoma most commonly occurs in which of the following anatomic locations?





Explanation

Epithelioid sarcoma is a rare soft-tissue sarcoma that most commonly arises in the hand or upper extremity, and it is frequently misdiagnosed as an infection or granuloma. It tends to have a higher incidence of lymph node metastasis than other soft-tissue sarcomas. The mainstay of treatment is wide surgical excision, even if amputation is necessary. Gupta TD, Chaudhuri P (eds): Tumors of the Soft Tissues, ed 2. Stamford, CT, Appleton and Lange, 1998, p 475.

References:

Question 93

A 43-year-old woman has had pain in the left hip for the past 2 months. A radiograph, CT scan, MRI scan, and biopsy specimens are shown in Figures 16a through 16e. What is the most likely diagnosis?





Explanation

The imaging studies are consistent with a chondrosarcoma. The radiograph shows a radiolucent lesion in the pelvis, and there are stippled calcifications on the CT scan. The histology shows a low-grade cellular hyaline cartilage neoplasm with stellate, occasionally binucleated chondrocytes. Enchondroma has a more benign histologic appearance.

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Question 94

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





Explanation

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

References:

Question 95

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





Explanation

Calcaneal apophysitis (Sever's disease) is a common cause of heel pain in children who are active in sports. The symptoms are most commonly bilateral and will often respond to a gastrocnemius-soleus complex stretching program. In addition, rest, anti-inflammatory drugs, and heel pads for the shoe may be prescribed. There is no effect on the long-term growth of the calcaneus. Micheli LJ, Ireland ML: Prevention and management of calcaneal apophysitis in children: An overuse syndrome. J Pediatr Orthop 1987;7:34-38.

References:

Question 96

A 46-year-old woman has bilateral groin pain, with more severe pain on the left side than on the right side. Figures 44a and 44b show a radiograph and a T1-weighted MRI scan. What is the most likely diagnosis?





Explanation

The radiograph reveals bilateral patchy sclerosis of the femoral heads without evidence of collapse. The MRI scan shows bilateral head involvement with a common serpentine-like low-intensity signal of the superior femoral head that is common to osteonecrosis. Changes confined to the femoral head effectively exclude rheumatoid arthritis and osteoarthritis. Resnick D (ed): Diagnosis of Bone and Joint Disorders, ed 4. Philadelphia, PA, WB Saunders, 2002, vol 4, pp 3160-3162.

References:

Question 97

What is the most common neurologic complication following an anterior cervical diskectomy and fusion?





Explanation

The recurrent laryngeal nerve provides innervation to the vocal cords and was the most common neurologic injury reported in a series of 36,000 patients. The nerve is felt to be more vulnerable during a right-sided approach because of its anatomic course. A recent study has also suggested a role for increased endotracheal cuff pressures in this nerve injury. Flynn TB: Neurologic complications of anterior cervical interbody fusion. Spine 1982;7:536-539.

References:

Question 98

A 15-year-old diver has had persistent, activity-related low back pain for the past 2 months. He denies any history of trauma. Examination reveals that the pain is localized to the lumbosacral junction, and there are no radicular symptoms. The pain is worse with back extension. Neurologic examination is normal, as are AP, lateral, and oblique radiographs of the lumbosacral spine. Further evaluation should include





Explanation

Spondylolysis may develop as a stress fracture resulting from repetitive hyperextension during athletic activities. In young people, the pars interarticularis is thin, the neural arch has not yet reached maximum strength, and the intravertebral disk is less resistant to shear. While clinical symptoms may lead to the suspicion of spondylolysis, radiographic confirmation may be difficult in early cases. Plain radiographs may be negative initially, and the plain MRI scan may not offer good visualization of the pars. A bone scan with SPECT is very sensitive initially. CT scans with regular axial and reverse-gantry angled cuts may help determine the type of fracture and the course of treatment. Congeni J, McCulloch J, Swanson K: Lumbar spondylolysis: A study of natural progression in athletes. Am J Sports Med 1997;25:248-253.

Scientific References

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Question 99

A full-term newborn has webbing at the knees, rigid clubfeet, a Buddha-like posture of the lower extremities, and no voluntary or involuntary muscle action at and below the knees. Radiographs of the spine and pelvis reveal an absence of the lumbar spine and sacrum. What maternal condition is associated with this diagnosis?





Explanation

The history, physical examination, and radiographic findings are consistent with type IV sacral agenesis or caudal regression syndrome. These children are born with no lumbar spine or sacrum. The T12 vertebra is often prominent posteriorly. Popliteal webbing and knee flexion contractures are common with this diagnosis. There is a higher incidence of this diagnosis when the mother has diabetes mellitus. Maternal drug abuse and alcoholism can produce phenotypically unique children but without the findings described here. Maternal idiopathic scoliosis is not associated with caudal regression syndrome. Chan BW, Chan KS, Koide T, et al: Maternal diabetes increases the risk of caudal regression caused by retinoic acid. Diabetes 2002;51:2811-2816.

References:

Question 100

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

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





Explanation

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

References:

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