Orthopedic Board Review MCQs (2026 Edition) - Part 1

_Propionibacterium acnes (P. acnes) has emerged as the most likely cause of infection associated with shoulder arthroplasty. A gram-positive, aerotolerant anaerobic rod that lives in the skin, not on the skin, it is more difficult to diagnose and treat than more conventional organisms. As an anaerobe, it does not create pus, but rather a turbid fluid, and is associated with humeral stem loosening when a clinically significant infection is present. P. acnes remains sensitive to most antibiotics, and, although some resistance to clindamycin has been reported, highly resistant strains have not yet evolved._
_P. acnes often remains a diagnostic challenge. Conventional tests measuring C-reactive protein, sedimentation rate, Interleukin-6, and white cell counts are not highly accurate. Even aspiration and culture of the affected joint is not reliable. Cultures should be kept at least 2 weeks to avoid false-negative results with slow-growing organisms. Some investigators have advocated diagnostic arthroscopy with biopsy as another diagnostic alternative._
Treatment of shoulder replacements infected with _P. acnes_ is evolving. For shoulders associated with low clinical suspicion for infection but an unexpected positive culture result, treatment can be 1-stage reconstruction without an extended course of intravenous antibiotics. Most commonly, an infected shoulder arthroplasty is treated with a 2-stage reconstruction similar to that seen in the setting of hip and knee arthroplasty.
RECOMMENDED READINGS
23. Kelly JD 2nd, Hobgood ER. Positive culture rate in revision shoulder arthroplasty. Clin Orthop Relat Res. 2009 Sep;467(9):2343-8. doi: 10.1007/s11999-009-0875-x. Epub 2009 May 12. PubMed PMID:
[19434469/. ](http://www.ncbi.nlm.nih.gov/pubmed/19434469)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19434469)
24. Dodson CC, Craig EV, Cordasco FA, Dines DM, Dines JS, Dicarlo E, Brause BD, Warren RF. Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. J Shoulder Elbow Surg. 2010 Mar;19(2):303-7. doi: 10.1016/j.jse.2009.07.065. Epub 2009 Nov 1. PubMed PMID:
[19884021/. ](http://www.ncbi.nlm.nih.gov/pubmed/19884021)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19884021)
25. Grosso MJ, Sabesan VJ, Ho JC, Ricchetti ET, Iannotti JP. Reinfection rates after 1-stage revision shoulder arthroplasty for patients with unexpected positive intraoperative cultures. J Shoulder Elbow Surg. 2012 Jun;21(6):754-8. doi: 10.1016/j.jse.2011.08.052. Epub 2012 Feb 3. PubMed PMID:
[22305921/. ](http://www.ncbi.nlm.nih.gov/pubmed/22305921)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22305921)
26. [Pottinger P, Butler-Wu S, Neradilek MB, Merritt A, Bertelsen A, Jette JL, Warme WJ, Matsen FA 3rd. Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening. J Bone Joint Surg Am. 2012 Nov 21;94(22):2075-83. doi: 10.2106/JBJS.K.00861.](http://www.ncbi.nlm.nih.gov/pubmed/23172325)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23172325)

The image depicts the medial ulnar collateral ligament of the elbow. This ligament is the primary restraint to valgus forces at the elbow. It is commonly injured in baseball pitchers. Pain with resisted wrist flexion would suggest medial epicondylitis. Pain with resisted wrist extension would suggest lateral epicondylitis. Lateral elbow pain and varus instability would suggest posterolateral rotatory instability.

Figure A is an AP radiograph demonstrating a displaced femoral neck fracture. Active older patients who present with a displaced femoral neck fracture should
be treated with total hip arthroplasty (THA).
Displaced femoral neck fractures can present a challenge to treat. In younger patients with good bone stock a closed vs. open reduction and internal fixation should be attempted. For active older patients a total hip arthroplasty is the best option, especially if there is pre-existing arthritis in the injured hip. THA provides the best function with the least pain and less need for repeat surgery (compared to hemiarthroplasty). For low-demand or debilitated patients, for patients older than age 80, or for those who can not reliably follow hip precautions a hemiarthroplasty provides the lowest risk of dislocation, and thus would be the treatment of choice.
Macaulay et al. present a prospective randomized trial of patients with femoral neck fractures treated with THA vs hemiarthroplasty. They found that functional outcomes and patient satisfaction were higher in the THA group without significant increased risk of complications. Inclusion criteria required patients to be over age 50, be a community ambulator, and were excluded for presence of dementia.
Abboud et al. retrospectively reviewed patients treated with THA for osteoarthritis and compared them to patients treated with THA for a femoral neck fracture. They found no significant difference between the two groups for outcomes or complications.
Figure A is an AP radiograph demonstrating a displaced femoral neck fracture. Incorrect Answers:
Answer 2: Parkinsons dementia presents an increased risk for dislocation and
would make a hemiarthroplasty a more suitable choice.
Answer 3: According to AAOS guidelines, age greater than 80 and low demand status is an indication for hemiarthroplasty
Answer 4: Hepatic encephalopathy would raise concern for the ability to follow hip precautions and presents an increased risk for dislocation. Thus a hemiarthroplasty would be a better choice.
Answer 5: For a young male laborer a closed vs open reduction and internal fixation should be attempted rather than an arthroplasty.

The MRI scan shows a posterior horn medial meniscus root avulsion with bony edema at the tibial root insertion. The radiograph shows no significant degenerative changes. If left untreated, posterior meniscal
root tears lead to progressive degenerative changes as a result of the altered tibiofemoral contact pressures and areas. Nonsurgical treatment including injections, physical therapy, and unloader braces are more _appropriate in the older patient with pre-existing advanced degenerative changes._

- Proximal avulsion of the lateral ulnar collateral ligament

The radiographs reveal a fractured malunited, shortened fibula with deltoid
instability.Corrective osteotomy with fibular lengthening has shown positive results. Nonsurgical management in an active, healthy patient will lead to rapid deterioration of the ankle joint. Without evidence of arthritis, a joint-sacrificing procedure should not be used.

---

The patient has a surgical neck fracture with medial calcar comminution. In patients where this cannot be anatomically reconstructed to provide cortical support, a fibular allograft can be used to prevent varus collapse. A “push” screw can be seen in Figure 3, which was used to medialize the graft into a biomechanically favorable position for this fracture pattern. Although the allograft theoretically provides the other benefits listed, they are not the primary indication for this injury.

This injury is a type III supracondylar humerus fracture with posterolateral displacement. The area of ecchymosis is anteromedial, corresponding to the proximal spike of the humeral metaphysis. The brachial artery is likely tented over this spike, leading to diminished perfusion. The median nerve also resides in this area, and any neurological deficit is likely in its most vulnerable fibers, those of the anterior interosseous nerve (AIN). The AIN contains no sensory fibers, and its motor function involves flexion of both the thumb IP joint and the index distal IP joint.
First dorsal web space anesthesia and an inability to extend the fingers would indicate radial nerve neuropraxia, which would be more likely with posteromedially displaced fractures and lead to anterolateral ecchymosis. Finger abduction is controlled by the ulnar nerve, which most often is injured in flexion injuries and iatrogenically by medially placed pins.

Figure 56

This patient demonstrates scapholunate dissociation with an associated dorsal intercalated segment instability deformity. Chronic scapholunate ligament tears lead to scapholunate advanced collapse (SLAC) wrist. Watson and Ballet describe SLAC wrist as having a predictable progression of arthritic changes, starting at the radial styloid, progressing to the radioscaphoid joint, and advancing to the lunocapitate joint. Some authors have described the radiolunate joint as being affected in very late-stage _SLAC wrist._

Exercises must be the first treatment for this patient because he is too mature for brace treatment.
Brace treatment is not indicated for someone of this skeletal maturity. Surgery is not indicated unless the patient fails conservative treatment.

The avulsed fragment represents the origin of the rectus femoris from the anterior inferior iliac spine and the brim of the acetabulum. Avulsion of the anterior inferior iliac spine is much less common than avulsion of the anterior superior iliac spine with its origin of the sartorius. The origin of the gluteus minimus is from the outer cortex of the iliac wing and has not been reported as a source of bony avulsion. The hip capsule is composed of the ischiofemoral and pubofemoral ligaments, in addition to the iliofemoral ligament. The pelvic attachment of the ischiofemoral ligament is from the ischial part of the acetabulum posteriorly, while the pubofemoral ligament attaches to the pubic portion inferiorly. Technically, ligaments do not have origins and insertions as muscle tendon groups do, but have attachment sites.
REFERENCES: Metzmaker JN, Pappas AM: Avulsion fractures of the pelvis. Am J Sports Med 1985;13:349-358.
Mader TJ: Avulsion of the rectus femoris tendon: An unusual type of pelvic fracture. Pediatr Emerg Care 1990;6:198-199.

- Figure 13b

The anterior bundle is the most important portion of the complex when treating valgus instability of the elbow. The ligament originates from the anteroinferior surface of the medial epicondyle. The anterior bundle inserts on the medial border of the coronoid at the sublime tubercle.
The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress, and the radial head is a secondary restraint. With anterior bundle sectioning, the resultant instability is most substantial between 60 and 70 degrees and is lowest at full extension and full flexion. True lateral radiographs reveal that the flexion-extension axis, or center of rotation, of the elbow lies in the center of the trochlea and capitellum. The origin of the anterior bundle of the UCL lies slightly posterior to the rotational center of the elbow. The anterior bundle is further divided into an anterior band and a posterior band. The eccentric origin of these anterior bundle components in relation to the rotational center through the trochlea creates a CAM effect during flexion and extension. The anterior band tightens during extension, and the posterior band tightens during flexion. This reciprocal tightening of the 2 functional components of the anterior bundle allows the ligament to remain taut throughout the full range of flexion.
Cadaver dissection studies have identified the origin and insertion of both the medial and lateral stabilizing elbow ligaments. The anterior bundle of the MCL is isometric throughout the flexion/extension arc of motion, making Response 3 incorrect. The posterior bundle of the MCL elongates with elbow flexion, so Responses 2 and 4 are incorrect. The posterior bundle of the MCL also demonstrates the most change in length from extension to flexion of all the elbow ligaments.
RECOMMENDED READINGS
24. [Hotchkiss RN, Weiland AJ. Valgus stability of the elbow. J Orthop Res. 1987;5(3):372-7. PubMed PMID: 3625360.](http://www.ncbi.nlm.nih.gov/pubmed/3625360)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/3625360)
25. [Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop Relat Res. 1985 Dec;(201):84-90. PubMed PMID: 4064425.](http://www.ncbi.nlm.nih.gov/pubmed/4064425)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/4064425)
26. [Schwab GH, Bennett JB, Woods GW, Tullos HS. Biomechanics of elbow instability: the role of the medial collateral ligament. Clin Orthop Relat Res. 1980 Jan-Feb;(146):42-52. PubMed PMID: 7371268. ](http://www.ncbi.nlm.nih.gov/pubmed/7371268)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/7371268)
CLINICAL SITUATION FOR QUESTIONS 79 THROUGH 81
Figure 79 is the radiograph of a 65-year-old active, right-hand-dominant woman with a 6-month history of right shoulder pain, motion loss, and progressive weakness after undergoing a hemiarthroplasty to address osteoarthritis 1 year ago. She denies recent trauma to her right shoulder and denies constitutional symptoms. Her surgical wound site is benign. She can actively forward flex to 90 degrees and abduct to 60 degrees. Passive forward flexion and abduction are 150 degrees and 90 degrees, respectively.

Patients with chronic ACL-deficient knees typically have lower than normal net quadriceps activity during the middle portion of the stance phase; the net moment about the knee reverses from one that demands quadriceps activity to one that demands increased hamstring activity. This type of gait is termed “quadriceps avoidance.” This avoidance is believed to be a functional adaptation to reduce anterior tibial translation, and it is most prevalent as the knee moves from 45° of flexion toward full extension, the arc of motion through which the ACL is most responsible for stability.
REFERENCES: Hurwitz DE, Andriacchi TP, Bush-Joseph CA, Bach BR Jr: Functional adaptations in patients with ACL-deficient knees. Exerc Sport Sci Rev 1997;25:1-20.
Andriacchi TP, Birac D: Functional testing in the anterior cruciate ligament-deficient knee. Clin Orthop 1993;288:40-47.
Solomonow M, Baratta R, Zhou BH, et al: The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med 1987;15:207-213.

■
Interbody fusion, when compared to PLF, is a predictor of more substantial blood loss. Multilevel posterior lumbar interbody fusion (PLIF) is an independent predictor of blood loss for posterior spine fusion. Some retrospective studies suggest that fusion rates are higher for transforaminal lumbar interbody fusion (TLIF) than PLF, but this finding has not been borne out in prospective studies. The main advantage of TLIF in the context of this question is restoration of neuroforaminal height, and many surgeons will consider TLIF or PLIF for that reason. The parasagittal MR image seen in Figure 3 shows neuroforaminal narrowing. The pre- and postsurgical radiographs show a difference in neuroforaminal height.

- Figure 13e

Extent of soft tissue injury has been shown in Level 2 evidence as having the highest impact on the decision to undergo limb salvage or amputation.
The referenced study by MacKenzie et al looked at 527 of the 601 patients initially enrolled in the Lower Extremity Assessment Project (LEAP) and looked at several variables which are thought to be predictors of amputation. Severe muscle injury had the highest impact on the decision to amputate the limb, likely related to the surgeon’s assessment that the salvaged limb would function poorly because of the risk of infection, nonunion, and poor function.
The absence of plantar sensation had the next most significant impact on surgical decision making. Factors that would influence proceeding with an amputation include an nonviable limb, irreparable vascular injury, warm ischemia time of more than 8 hours, or a severe crush injury with minimal remaining viable tissue. Amputation should also be considered when attempts at limb salvage leave the limb so severely damaged that function will be less satisfactory than that afforded by a prosthetic replacement, are a threat to the patient’s life, or would demand multiple surgical procedures and prolonged reconstruction time that is incompatible with the personal, sociologic, and economic consequences the patient is willing to undergo.

The genetiCdefect in achondroplasia involves fibroblast growth factor (FGF) receptor 3.
The other answers refer to:
| Condition | Protein/Defect | |---|---| | Osteogenesis imperfecta | Type I collagen | | Marfan syndrome | Fibrillin | | Spondyloepiphyseal dysplasia | Type II collagen | | Pseudoachondroplasia | Cartilage oligomeriCmatrix protein (COMP) | Correct Answer: Fibroblast growth factor (FGF) receptor 3

The images reveal a medium-sized tear of the rotator cuff. As more clinical studies are published comparing double-row with single-row rotator cuff repair, it has become clear that the retear rate is lower with a double-row construct for small and medium-sized tears. This may be attributable to the stronger time-zero repair construct that double-row repair provides. No study to date has demonstrated a significant difference in clinical outcomes (functional and pain scores at any time) or time to healing between the two techniques.

The popliteus muscle originates from the posterior aspect of the proximal tibia and serves as the primary barrier to tumor encroachment upon the tibial nerve and popliteal vessels. The medial and lateral heads of the gastrocnemius lie superficial to the neurovascular bundle. A portion of the soleus originates from the lateral proximal tibia, forming part of the soleal arch through which the neurovascular bundle passes; however, the majority of the soleus is superficial to the neurovascular structures.
RECOMMENDED READINGS
54. [Hudson TM, Springfield DS, Schiebler M. Popliteus muscle as a barrier to tumor spread: computed tomography and angiography. J Comput Assist Tomogr. 1984 Jun;8(3):498-501. PubMed PMID: 6586755.](http://www.ncbi.nlm.nih.gov/pubmed/6586755)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/6586755)
55. [Jadhav SP, More SR, Riascos RF, Lemos DF, Swischuk LE. Comprehensive review of the anatomy, function, and imaging of the popliteus and associated pathologic conditions. Radiographics. 2014 Mar-Apr;34(2):496-513. doi: 10.1148/rg.342125082. Review. PubMed PMID: 24617694. ](http://www.ncbi.nlm.nih.gov/pubmed/24617694)[View Abstract at](http://www.ncbi.nlm.nih.gov/pubmed/24617694)[ ](http://www.ncbi.nlm.nih.gov/pubmed/24617694)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24617694)
56. Cabanela M, Mendoza SA, Sanches-Sotelo J, translation eds. _Llusá M, Meri M, Ruano D. Surgical Atlas of the Musculoskeletal System_. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008.

The primary action of the posterior tibialis tendon is inversion of the foot; secondarily, it plantar flexes the ankle. The anterior tibialis tendon also inverts the foot and only partially antagonizes the posterior tibialis tendon. The primary action of the peroneus longus is plantar flexion of the first ray. It secondarily everts the posterior tibialis tendon. The action of the flexor digitorum longus tendon is synergistic with the posterior tibialis tendon. The primary action of the peroneus brevis tendon is eversion; therefore, it is the primary antagonist of the posterior tibialis tendon.
REFERENCES: Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993, pp 550-551.
Mann RA: Biomechanics of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 2-36.

Intravenous antibiotics are critical to prevent infection in open fractures. Delay in administration of intravenous antibiotics has been linked with increased risk of infection.
Open tibia fractures are associated with high rates of infection. Historically,
early debridement (within 6-8 hours) and early flap coverage (typically defined as less than 72 hours) were thought to minimize the risk of infection. Recent evidence has challenged these findings, with multiple studies demonstrating no significant link between the timing of debridement and rates of infection.
Multiple studies from the Lower Extremity Assessment Project (LEAP) found no significant difference in infection or complication with flap coverage more than 72 hours after injury.
Bhattacharyya et al retrospectively evaluated patients with type IIIB tibial fractures treated with extended use of negative pressure wound therapy. The authors found increased rates of infection beyond 7 days despite the use of negative pressure wound therapy.
Lack et al evaluated the timing of antibiotic administration on infection rates for type III tibial fractures. The authors found increased rates of infection with administration of antibiotics beyond 66 minutes. The authors discuss the possibility of pre-hospital intervention as many severely injured patients have delayed arrival at treatment centers.
Pollak et al prospectively analyzed rates of complication with flap coverage as part of the LEAP study. The authors found no increase in complications with flap coverage beyond 72 hours. The only significant risk for complication was the use of rotational flaps in comminuted or segmental (AO/OTA type C) tibial fractures.
Incorrect answers:
Answer 1: Lower rates of complication, including infection, were seen with free flaps in AO/OTA type C fractures in the study by Pollak et al.
Answer 2: Timing of flap coverage is controversial. Early studies demonstrated increased infection with delay beyond 72 hours, however recent studies using more rigorous statistical analysis do not support these findings.
Answer 3: No study has demonstrated lower infection rates with the use of plating versus nailing in open tibial fractures.
Answer 5: The timing of debridement with open fractures has been shown not to effect the rate of infection in multiple recent studies.

This is a giant-cell tumor of the tendon sheath. A solid lesion larger than 1.5 cm in the hand or foot warrants biopsy to rule out malignancy. The 3 most common benign tumors of the foot are ganglion cysts, giant-cell tumors of tendon sheath, and hemangiomas. Radiographs are nonspecific but may reveal extrinsic erosions of bone by a giant-cell tumor of the tendon sheath. MR findings of prominent low-signal intensity (seen with T2 weighting) and “blooming” artifact from the hemosiderin (seen with gradient-echo sequences) are nearly pathognomonic of this diagnosis, as
seen here. Pathology shows hemosiderin-laden macrophages and giant cells as seen in the histology. Uric acid reduction would be indicated for gout and wide local excision for a soft-tissue sarcoma. Observation awaiting mature mineralization would apply to heterotopic ossification.
RECOMMENDED READINGS
29. Murphey MD, Rhee JH, Lewis RB, Fanburg-Smith JC, Flemming DJ, Walker EA. Pigmented villonodular synovitis: radiologic-pathologic correlation. Radiographics. 2008 Sep-Oct;28(5):1493-
[518/. doi: 10.1148/rg.285085134. PubMed PMID: 18794322. ](http://www.ncbi.nlm.nih.gov/pubmed/18794322)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18794322)
30. [Ruggieri P, Angelini A, Jorge FD, Maraldi M, Giannini S. Review of foot tumors seen in a university tumor institute. J Foot Ankle Surg. 2014 May-Jun;53(3):282-5. doi: 10.1053/j.jfas.2014.01.015. Review. PubMed PMID: 24751209. ](http://www.ncbi.nlm.nih.gov/pubmed/24751209)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24751209)

The distal phalanx assumes a resting flexed posture. The patient is not able to actively extend the fingertip, but it can be passively extended.

55
Glenoid exposure, while better than with surface replacements, is not improved over traditional stemmed replacements. Metaphyseal comminution would make it unlikely that a stemless implant could be used in most four-part fractures. Stemless replacement does have the unique advantage of allowing placement of a prosthesis in the setting of a proximal humerus malunion without the need for an osteotomy, as the prosthesis is not constrained by the position of the stem. While early results are encouraging, there is no long-term data to suggest that survivorship is increased with stemless arthroplasty.

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1. Reference(s)
2. Bertoni F, Calderoni P, Bacchim P, et al: Benign fibrous histiocytoma of bone. J Bone Joint Surg 1986;68A:1225-1230. Unni KK: Dahlin's Bone Tumors: General Aspects and Data on 11,087 Cases, ed 4. Philadelphia, PA, JB Lippincott, 1996, pp 360-365.
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Imaging studies in the evaluation of plantar fasciitis should always include weight-bearing foot radiographs to reveal alignment and exclude calcaneal stress fracture, tumor, subtalar arthritis, and insertional posterior spurs. MRI is occasionally indicated in problematic cases. Ultrasound can be helpful to evaluate thickening and disease in the proximal plantar fascia. Ultrasound is quick and much more cost effective than MRI. Laboratory screenings to evaluate inflammatory arthritis are indicated only for patients with bilateral heel pain who may be more likely to have systemic disease.
In the nonsurgical treatment of plantar fasciitis, high-impact loading exercises may make the condition worse. Corticosteroid injections may provide short-term relief only and can occasionally cause plantar fascia rupture. They should be used with caution. PRP injections are expensive and currently not covered by insurance. Studies have not demonstrated long-term pain relief with PRP. Plantar fascia-specific stretching has been shown more effective than Achilles tendon stretching alone.
Surgical treatment is indicated for fewer than 5% of patients. It is not necessary to resect the heel spur because the spur is not attached to the plantar fascia and rarely contributes to a patient's pain. The open extensile approach is associated with a much longer recovery than the open or endoscopic approaches and is no longer justified. Multiple studies have demonstrated the efficacy of endoscopic and open plantar fasciotomy techniques.
RECOMMENDED READINGS
Bader L, Park K, Gu Y, O'Malley MJ. Functional outcome of endoscopic plantar fasciotomy. Foot Ankle Int. 2012 Jan;33(1):37-43. doi: 10.3113/FAI.2012.0037. PubMed PMID:
[22381234.](http://www.ncbi.nlm.nih.gov/pubmed/22381234)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22381234)
Lareau CR, Sawyer GA, Wang JH, DiGiovanni CW. Plantar and medial heel pain: diagnosis and management. J Am Acad Orthop Surg. 2014 Jun;22(6):372-80. doi: 10.5435/JAAOS-22-06-
[372/. PubMed PMID: 24860133.](http://www.ncbi.nlm.nih.gov/pubmed/24860133)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24860133)

Evaluation for tendon injury in a clenched-fist position is essential because tendons slide proximally in the open-hand position. Involvement of tendon or joint usually necessitates surgical debridement.

The Silfverskiold test indicates that the patient has an isolated contracture of the gastrocnemius; therefore, a gastrocnemius recession is indicated. Open Achilles tendon lengthening,gastrocnemius and soleus recession, and percutaneous Achilles tendon lengthening are all indicated for management of concomitant gastrocnemius and soleus contractures.

This patient has spiral distal tibia and proximal fibula fractures. Dedicated imaging of the ankle should be performed to exclude a posterior malleolus fracture. Imaging options include either dedicated ankle radiographs or CT scans.
Tibial shaft fractures arise from high- or low-energy injuries. Low-energy injuries are characterized by (1) torsional mechanism of injury, (2) spiral pattern, (3) fibula fracture at a different level. Surgical options for closed shaft fractures include IM nailing and plate fixation. Concomitant ankle fractures should be treated during the same surgery to improve outcome.
Boraiah et al. examined the association of posterior malleolus fractures with spiral distal tibial fractures. They found that 39% had posterior malleolus fractures. In simple fractures (92%), none of the posterior malleolar fracture lines were contiguous with the diaphyseal fracture lines. In comminuted fractures (8%), an occult fracture line extended into the posterior tibial lip.
Diagnosis was missed in 5% before CT scanning was initiated, and 0% after.
Stuermer et al. examined tibial fractures with associated ankle injury. Of spiral tibial fractures, 37% extended into the ankle, 5% involved the medial malleolus, 26% involved distal fibula, 8% had syndesmotic disruption, and 16% had posterior malleolar fracture. They recommend ankle radiographs for rotational trauma, spiral distal third fractures, Maisonneuve fractures, and fractures associated with an intact fibula.
Figures A and B are AP and lateral radiographs showing a spiral distal tibial fracture with a proximal fibula fracture. Illustration A is an axial CT scan showing the posterior malleolar fracture not seen on plain radiographs.
Illustration B shows a missed posterior malleolar fragment in a fracture treated with IM nailing that subsequently displaced.
Incorrect Answers:
Answers 1, 2, 3, 5: There is no association between spiral distal tibial fractures and injuries of the hip, knee or calcaneus.

In 1995, Fredrickson and colleagues classified stress fractures into four grades based upon bone scans:
Grade 1     Small ill-defined cortical area of mildly increased activity Grade 2     Well-defined cortical area of moderately increased cortical                     activity
Grade 3Â Â Â Â Â Wide, cortical-medullary area of increased activity
Grade 4Â Â Â Â Â Transcortical area of intensely increased activity
In a grade 4 stress fracture, the corresponding MRI will show: High periosteal signal on T2-weighted images
Low signal on T1-weighted images, often with a liner low signal line representing the fracture line
High signal on T2-weighted images, often with a liner low signal line representing the fracture line
C orrect Answer: High periosteal signal on T2; low marrow signal on T1; high marrow signal on T2

- Open capsular shift

24
The patient has sustained an injury to the musculocutaneous nerve, which is at risk during a coracoid transfer procedure. The terminal branch of this nerve is the lateral antebrachial cutaneous nerve of the forearm. The axillary nerve provides sensation to the lateral arm. The median nerve provides sensation more distally. The radial nerve is not likely to be injured with a coracoid transfer procedure; if it is, the injury would result in numbness near the wrist.in the posterior forearm.

- Ankle distraction arthroplasty_

The patient is experiencing impending failure of the replanted thumb. In a study by Moneim and Chacon, they found that vascular thrombosis in the postoperative period is the major factor in failure after replantation. When it occurs, it has to be aggressively dealt with by surgical exploration and revision of the vascular repair. The best results are obtained within 11 hours of the repair and nonsurgical management uniformly led to failure.

The pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament are all parts of the normal fascia that contribute to the formation of the spiral cord. C leland's ligament is not involved at all in the disease process.

OCD is an acquired lesion of the subchondral bone. Patients with OCD initially report nonspecific pain and variable amounts of swelling. Initial radiographs help identify the lesion and establish the status of the physes. An MRI scan is useful for assessing the potential for the lesion to heal with nonsurgical treatment. Nonsurgical treatment is appropriate for small, stable lesions in patients with open physes and focuses on activity restriction for 3 to 9 months. Surgical treatment is necessary for unstable or detached lesions. Stable lesions with intact articular cartilage can be treated with subchondral drilling to stimulate vascular ingrowth, with radiographic healing at an average of 4.4 months. Fixation is indicated for unstable or hinged lesions, and stabilization of the fragment can be achieved using a variety of implants through an arthroscopic or open approach. The fragment should be salvaged and the normal articular _surface restored whenever possible._

The structure shown is the posterolateral bundle of the anterior cruciate ligament (ACL). This bundle is optimally positioned in the knee to resist rotatory forces during terminal knee extension. "Resist anterior translation during knee flexion" best describes the anteromedial bundle. "Resist rotatory loads during knee flexion" is unlikely because the posterolateral bundle is tightest during knee extension. The posterior cruciate ligament, not the ACL, functions to resist posterior translation.

Epidural abscesses are potentially devastating. Nonsurgical care may be chosen for select patients. A baseline failure rate of 8.3% increases based on patient risk factors, which include a history of IV drug abuse, diabetes, age older than 65, CRP level higher than 115, WBC level higher than 12.5, and Staphylococcus aureus as the causative organism. Immunosuppression and abscess size are not significant risk factors for failure of nonsurgical care. Nonsurgical care may be regarded as "failed" if there is worsening of a patient's neurologic status. When nonsurgical care fails, delayed surgery is less successful at restoring motor function (vs early surgery).
RECOMMENDED READINGS
Kim SD, Melikian R, Ju KL, Zurakowski D, Wood KB, Bono CM, Harris MB. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2014 Aug 1;14(8):1673-9. doi: 10.1016/j.spinee.2013.10.011. Epub 2013 Oct 30. PubMed PMID:
[24373683/. ](http://www.ncbi.nlm.nih.gov/pubmed/24373683)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24373683)
[Patel AR, Alton TB, Bransford RJ, Lee MJ, Bellabarba CB, Chapman JR. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J. 2014 Feb 1;14(2):326-30. doi: 10.1016/j.spinee.2013.10.046. Epub 2013 Nov 12. PubMed PMID: 24231778. ](http://www.ncbi.nlm.nih.gov/pubmed/24231778)[View ](http://www.ncbi.nlm.nih.gov/pubmed/24231778)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24231778)
Duarte RM, Vaccaro AR. Spinal infection: state of the art and management algorithm. Eur Spine J. 2013 Dec;22(12):2787-99. doi: 10.1007/s00586-013-2850-1. Epub 2013 Jun 12.
[Review. PubMed PMID: 23756630. ](http://www.ncbi.nlm.nih.gov/pubmed/23756630)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23756630)

The ideal entry point is just medial to the lateral tibial spine (AP view), and anterior to the anterior articular margin (lateral view).
The ideal insertion point allows nail placement (1) without injury to the menisci or articular cartilage, and (2) allows the nail to travel down the center of the intramedullary canal of both fracture fragments, ending in the center of the ankle perpendicular to the joint. An excessively medial insertion point leads to valgus malalignment. Malposition in the sagittal plane may cause anterior knee pain from unrecognized intra-articular injury.
Mcconnell et al. reviewed the anatomic safe zone for tibial portal placement. The safe zone measures 12.6-22.9 mm wide. With proximal tibial fractures, a
superolateral portal minimizes stress during nail insertion and decreases angulation and rotation. The center point is slightly medial to the lateral tibial spine (on AP radiograph) and adjacent and anterior to the anterior articular margin (on lateral radiograph).
Song et al. evaluated the insertion point by examining the intramedullary canal with CT. The mean length from the LTS to the canal axis center was medial 1.1 mm (medial 1.5 mm in males, medial 0.9 mm in females).
Illustration A shows the safe zone on an AP radiograph. The black arrow represents the center of the safe zone. The white arrows indicate the medial-lateral boundaries of the safe zone. Illustration B is a lateral view of the proximal tibia. The black arrow shows the starting portal adjacent to the anterior articular margin.
Incorrect Answers:
Answers 1, 3, 4, 5: The ideal entry point is medial to the lateral tibial spine and anterior to the anterior articular margin.

While in the ABER position in the MRI machine, the MRI technician aligns the cut lines along the axis of the humerus and perpendicular through the glenoid, from superior to inferior. According to this, one might assume that the humerus would be seen in a sagittal plane and the glenoid in an axial plane. However, while the glenoid
does stay fixed in an axial plane, the humerus is externally rotated, resulting in a coronal view of the proximal humerus. All of the other options do not depict the anatomic relationship of the humerus and glenoid properly while in the ABER sequence.

Over the years, indications for total elbow arthroplasty (TEA) have evolved. With the introduction of better medications for rheumatoid arthritis and other inflammatory arthritides, end-stage arthritis of the elbow from this pathology has become less common. At the same time, there has been increased interest in TEA for treatment of acute distal humerus fractures, and ongoing use for fracture sequelae and osteoarthritis. Fevang and associates found in the Norwegian registry that fracture sequelae led to a 5.8 relative risk of failure
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compared with inflammatory arthritis. Data from the state of New York found that revision rates for osteoarthritis were 14.7%, whereas those for inflammatory arthritis were only 8.3%. All patients require a 5-lb lifetime lifting limit postoperatively to improve the longevity of the prosthesis.

- Reverse total shoulder arthroplasty (rTSA)_

This patient has an aneurysmal bone cyst of the vertebra. Selective arterial embolization is a minimally invasive treatment that often succeeds in arresting the lesions. Many times it is the only treatment needed. Selective arterial embolization can also be used as part of a strategy to be followed by curettage and reconstruction to decrease operative bleeding.
This lesion will continue to expand and might cause neurologic compromise or mechanical instability. Radiation therapy poses risks of later malignant degeneration. There are other ways of treating this lesion. Radical en bloc resection may unnecessarily injure neurologic structures.
While curettage is often necessary, there is no reason to introduce the risk of radiation therapy.

DISCUSSION: Endurance training causes selective hypertrophy of type I muscle fibers. It stimulates an increase in the enzymes of the Krebs cycle which increases the capacity for aerobic ATP resynthesis during exercise. There is a decrease in the rate of glycogen depletion. Depletion of glycogen has been linked to

fatigue during endurance exercise. Endurance training blunts the catecholamine response and may contribute to the reduction in heart rate observed for the same exercise intensity following training. The greater use of lipid reduces the contribution of carbohydrate to ATP resynthesis and preserves muscle glycogen.
REFERENCES: Jones AM, Carter H: The effect of endurance training on parameters of aerobic fitness. Sports Med 2000:29:373-386.
Spina RJ, Chi MM, Hopkins MG, et al: Mitochondrial enzymes increase in muscle in response to 7-10 days of cycle exercise. J Appl Physiol 1996;80:2250-2254.
Kiens B, Essen-Gustavsson B, Christensen NJ, et al: Skeletal muscle substrate utilization during submaximal exercise in man: Effect of endurance training. J Physiol 1993;469:459-478.

The extensor retinaculum is an important structure in maintaining and possibly augmenting the stability of the lateral ankle and subtalar joint. The inferior root of the extensor retinaculum inserts in the floor of the sinus tarsi, improving stability of the subtalar joint. This structure can be used to augment a repair of ankle instability.

Radiation therapy is used for soft-tissue sarcoma treatment to facilitate resection of tumors that are close to adjacent structures and to diminish risk for local recurrence. The disadvantages of radiation therapy for soft-tissue sarcoma include patient inconvenience, risk for secondary malignancy, and higher wound complication rates. The advantages of presurgical (neoadjuvant) radiation therapy include a smaller radiation field, formation of a “pseudocapsule” to facilitate a planned close-margin resection, tumor shrinkage, and lower local recurrence rates. The main disadvantage of presurgical radiation therapy is the much higher risk for wound healing complications (as demonstrated in numerous studies).
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7. [O'Sullivan B, Davis AM, Turcotte R, Bell R, Catton C, Chabot P, Wunder J, Kandel R, Goddard K, Sadura A, Pater J, Zee B. Preoperative versus postoperative radiotherapy in soft-tissue sarcoma of the limbs: a randomised trial. Lancet. 2002 Jun 29;359(9325):2235-41. ](http://www.ncbi.nlm.nih.gov/pubmed/12103287)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/12103287)
8. [Zagars GK, Ballo MT, Pisters PW, Pollock RE, Patel SR, Benjamin RS. Preoperative vs. postoperative radiation therapy for soft tissue sarcoma: a retrospective comparative evaluation of disease outcome. Int J Radiat Oncol Biol Phys. 2003 Jun 1;56(2):482-8. ](http://www.ncbi.nlm.nih.gov/pubmed/12738324)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/12738324)
9. [Peat BG, Bell RS, Davis A, O'Sullivan B, Mahoney J, Manktelow RT, Bowen V, Catton C, Fornasier VL, Langer F. Wound-healing complications after soft-tissue sarcoma surgery. Plast Reconstr Surg. 1994 Apr;93(5):980-7. PubMed PMID: 8134491. ](http://www.ncbi.nlm.nih.gov/pubmed/8134491)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/8134491)

- Soft-tissue interposition arthroplasty PREFERRED RESPONSE: 1- TEA