Orthopedic MCQs: Bone Tumors, Pathology & Lesions Review
14 Apr 2026
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Key Takeaway
This interactive board review contains 100 randomly selected orthopedic surgery questions with clinical images, immediate feedback, and detailed references.
Orthopedic MCQs: Bone Tumors, Pathology & Les...
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Question 1High Yield
A 24-year-old semiprofessional baseball player has noted increasing medial elbow pain for the past 2 months. This has been associated with a concomitant loss in velocity and control. He denies pain, numbness, or tingling in the hand or digits. Examination demonstrates medial elbow tenderness and swelling. Elbow range of motion is full. There is pain with milking maneuver and valgus stress test. Tinel’s sign is negative over the cubital tunnel, and there is no ulnar nerve subluxation. His MRI scan is shown in Figure
Explanation
The information and image provided describe a throwing athlete with a complete tear of his ulnar collateral ligament (UCL) of the elbow. Numerous techniques have been described for UCL reconstruction, and at this time, optimal graft choice and fixation methods have not been established. Most studies show no.
major differences in outcome between gracilis autograft palmaris autograft, and allograft. Similarly, no clear advantage has been established when comparing use of bone tunnels with interference screws, tunnels with a docking technique, modified docking techniques, and combination
19
approaches. Use of a muscle-splitting approach, rather than muscle detachment, appears to improve outcomes, with a larger percentage of patients reporting excellent results and a lower rate of postoperative ulnar neuropathy. With regard to the ulnar nerve itself, routine transposition is no longer indicated in patients such as this with no preoperative neurologic symptoms, as limited handling of the nerve is associated with improved patient-reported outcomes and lower rates of postoperative neuropathy
major differences in outcome between gracilis autograft palmaris autograft, and allograft. Similarly, no clear advantage has been established when comparing use of bone tunnels with interference screws, tunnels with a docking technique, modified docking techniques, and combination
19
approaches. Use of a muscle-splitting approach, rather than muscle detachment, appears to improve outcomes, with a larger percentage of patients reporting excellent results and a lower rate of postoperative ulnar neuropathy. With regard to the ulnar nerve itself, routine transposition is no longer indicated in patients such as this with no preoperative neurologic symptoms, as limited handling of the nerve is associated with improved patient-reported outcomes and lower rates of postoperative neuropathy
Question 2High Yield
-is the radiograph of a 52-year-old right-hand dominant man who fell while skiing. He was initially treated at a mountainside clinic where he was placed in a sling. He now reports moderate shoulder pain but has no other complaints. What is the most appropriate management?
Explanation
No detailed explanation provided for this question.
Question 3High Yield
Currently, what is the most common clinical study type in the orthopaedic literature?
Explanation
**
Although a recent push for prospective, randomized trials has been advocated by multiple orthopaedic journals, many studies published continue to be of Level 4 evidence (retrospective case series). Case series represented 64% of all studies reviewed by Freedman and associates in 2001 from the British and American volumes of Journal of Bone and Joint Surgery and from Clinical Orthopaedics and Related Research.
Obremskey and associates published that
58.1% of all studies from nine orthopaedic journals were Level 4 evidence. Further investigation of more current trends is likely warranted with the
current emphasis on publishing higher level-of-evidence studies in orthopaedic journals.
Although a recent push for prospective, randomized trials has been advocated by multiple orthopaedic journals, many studies published continue to be of Level 4 evidence (retrospective case series). Case series represented 64% of all studies reviewed by Freedman and associates in 2001 from the British and American volumes of Journal of Bone and Joint Surgery and from Clinical Orthopaedics and Related Research.
Obremskey and associates published that
58.1% of all studies from nine orthopaedic journals were Level 4 evidence. Further investigation of more current trends is likely warranted with the
current emphasis on publishing higher level-of-evidence studies in orthopaedic journals.
Question 4High Yield
Figure 1 is the radiograph of a 48-year-old man. He is of normal height and weight, medically healthy,and in good physical condition. What is the best treatment option?
Explanation
Immediate open reduction and internal fixation of this fracture is required to prevent necrosis of the overlying soft tissue. Because of the power and proximal pull of the triceps surae,nonsurgical management is not indicated with avulsion fractures of the calcaneus. It leaves a large void that will not fill in with bone, leaves the Achilles tendon weak, and has a high complication rate, especially skin breakdown. The Achilles tendon is securely attached to the fractured tuberosity. Bone-to-bone healing is more reliable than detaching the Achilles tendon from the tuberosity and reattaching it to the remainder of the calcaneus. Because of the size of the avulsed fragment, it will be difficult to correctly tension the tendon if the fractured piece is excised. Percutaneous Kirschner wire fixation is not strong enough to provide a stable fixation of the tuberosity, especially in view of the power of the Achilles tendon contracture.
Question 5High Yield
During the cocking and acceleration phases of the overhand throw (pitch), there are several static and dynamic restraints to provide medial elbow support and prevent valgus instability. The dynamic structures found to be most important during these phases of the overhand throw are the flexor digitorum
Explanation
DISCUSSION: Biomechanical analysis has demonstrated that local dynamic stability of the elbow is provided by the flexor digitorum superficialis and the flexor carpi ulnaris, especially during the cocking and acceleration phases of the overhand throw. This provides dynamic joint compression across the elbow joint and may be protective to the static restraints such as the ulnar collateral ligament. It also emphasizes the need to strengthen distant muscles in the forearm to assist with elbow biomechanics and potentially prevent injury.
REFERENCES: Davidson PA, Pink M, Perry J, et al: Functional anatomy of the flexor pronator muscle group in relation to the medial collateral ligament of the elbow. Am J Sports Med 1995;23:245-250. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 101-111.
Figure 63a Figure 63b
REFERENCES: Davidson PA, Pink M, Perry J, et al: Functional anatomy of the flexor pronator muscle group in relation to the medial collateral ligament of the elbow. Am J Sports Med 1995;23:245-250. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 101-111.
Figure 63a Figure 63b
Question 6High Yield
A 4-week-old girl with an unremarkable birth history is being evaluated for facial hypertelorism, depressed nasal bridge, generalized laxity and hypotonia, bilateral elbow flexion contractures with normal appearing flexion creases, bilateral shortened, telescoping thighs, bilateral recurvatum deformity of the knees, and flexible bilateral clubfoot deformity. Figures 1 through 3 are the radiographic survey of the pelvis and upper and lower extremities. What is the genetic etiology of this presentation?
Explanation
■
The key to distinguishing the etiology of this patient’s multiple congenital joint dislocations (bilateral elbows, hips, and knees) lies in the patient’s characteristic facial dysmorphism and described ligamentous laxity – all consistent with Larsen syndrome characterized by autosomal dominant inheritance and related to mutations in the FLNB gene. Larsen syndrome can include potentially lethal cervical kyphosis, which must be evaluated early to avoid myelopathy, respiratory failure, and early death. Infants with arthrogryposis can present with multiple teratologic dislocations as in this case; however, rather than this presentation of generalized laxity, arthrogrypotic patients have restricted joint motion, contracture, and absent flexion creases. Both Larsen syndrome and arthrogryposis are associated with clubfoot deformity and initial orthopaedic treatment typically focuses on Ponseti management. However, it could be potentially disastrous to proceed with extremity treatment prior to evaluating for cervical kyphosis and myelopathy in cases of Larsen syndrome. EhlersDanlos syndrome is characterized by generalized laxity and hypermobility, skin hyper extensibility, and potential late manifestations of joint instability, vascular complications, and kyphoscoliosis but is not associated with infantile joint dislocations. Ehlers-Danlos arises form a mutation in the COL3A1 gene. FGFR3 mutation is linked to achondroplasia.
■
The key to distinguishing the etiology of this patient’s multiple congenital joint dislocations (bilateral elbows, hips, and knees) lies in the patient’s characteristic facial dysmorphism and described ligamentous laxity – all consistent with Larsen syndrome characterized by autosomal dominant inheritance and related to mutations in the FLNB gene. Larsen syndrome can include potentially lethal cervical kyphosis, which must be evaluated early to avoid myelopathy, respiratory failure, and early death. Infants with arthrogryposis can present with multiple teratologic dislocations as in this case; however, rather than this presentation of generalized laxity, arthrogrypotic patients have restricted joint motion, contracture, and absent flexion creases. Both Larsen syndrome and arthrogryposis are associated with clubfoot deformity and initial orthopaedic treatment typically focuses on Ponseti management. However, it could be potentially disastrous to proceed with extremity treatment prior to evaluating for cervical kyphosis and myelopathy in cases of Larsen syndrome. EhlersDanlos syndrome is characterized by generalized laxity and hypermobility, skin hyper extensibility, and potential late manifestations of joint instability, vascular complications, and kyphoscoliosis but is not associated with infantile joint dislocations. Ehlers-Danlos arises form a mutation in the COL3A1 gene. FGFR3 mutation is linked to achondroplasia.
Question 7High Yield
In which of the following scenarios should a physician be relieved of their duties?
Explanation
**
Impairment of a healthcare professional is the inability or impending inability to practice according to accepted standards as a result of substance use, abuse, or dependency (addiction). A surgeon (resident, fellow or attending) who discovers chemical impairment, dependence, or incompetence in a colleague or supervisor has the responsibility to ensure that the problem is identified and treated. Mechanisms exist for the proper identification and treatment of the impaired physician. Misconduct can be reported to state and local agencies. One must be sure to act in good faith with reasonable evidence when reporting such an incident. If a patient is at risk for immediate harm or injury by an impaired physician, one should assert authority and relieve the physician of the patient care and then address the problem with the senior hospital staff as soon as possible. The referenced article by Baldisseri is a review on the ethics of dealing with impaired healthcare professionals, with a focus on physicians.
Impairment of a healthcare professional is the inability or impending inability to practice according to accepted standards as a result of substance use, abuse, or dependency (addiction). A surgeon (resident, fellow or attending) who discovers chemical impairment, dependence, or incompetence in a colleague or supervisor has the responsibility to ensure that the problem is identified and treated. Mechanisms exist for the proper identification and treatment of the impaired physician. Misconduct can be reported to state and local agencies. One must be sure to act in good faith with reasonable evidence when reporting such an incident. If a patient is at risk for immediate harm or injury by an impaired physician, one should assert authority and relieve the physician of the patient care and then address the problem with the senior hospital staff as soon as possible. The referenced article by Baldisseri is a review on the ethics of dealing with impaired healthcare professionals, with a focus on physicians.
Question 8High Yield
..A 25-year-old man is planning to have an elbow contracture release. His elbow range of motion is 40 degrees to 90 degrees of flexion. He has no heterotopic ossification. His ring and small fingers become numb as his elbow approaches his flexion endpoint. There is no evidence of instability of the ulna-humeral or radioulnar joints. To achieve the best possible outcome, the surgeon should
Explanation
- decompress the ulnar nerve.
Question 9High Yield
All of the following medications have been associated with an increased risk of osteoporosis EXCEPT:
Explanation
**
Numerous drugs are associated with an increased risk of osteoporosis in
adults, including oral corticosteroids, androgen-deprivation therapy, aromatase inhibitors, protease inhibitors, selective serotonin reuptake inhibitors,
prolactin-raising antiepileptic agents and many cytotoxic agents.
Additionally, a number of disease states are associated with osteoporosis, including endocrinopathies such as hyperparathyroidism, thyrotoxicosis and type I diabetes, hypogonadism, chronic glucocorticoid therapy, malnutrition, malabsorption states, chronic immobilization, rheumatoid arthritis, alcoholism, vitamin D deficiency, and multiple myeloma.
NSAIDs have not been shown to increase risk of osteoporosis.
Numerous drugs are associated with an increased risk of osteoporosis in
adults, including oral corticosteroids, androgen-deprivation therapy, aromatase inhibitors, protease inhibitors, selective serotonin reuptake inhibitors,
prolactin-raising antiepileptic agents and many cytotoxic agents.
Additionally, a number of disease states are associated with osteoporosis, including endocrinopathies such as hyperparathyroidism, thyrotoxicosis and type I diabetes, hypogonadism, chronic glucocorticoid therapy, malnutrition, malabsorption states, chronic immobilization, rheumatoid arthritis, alcoholism, vitamin D deficiency, and multiple myeloma.
NSAIDs have not been shown to increase risk of osteoporosis.
Question 10High Yield
Which of the following features is true of congenital scoliosis but not infantile idiopathic scoliosis:
Explanation
In congenital scoliosis, the vertebrae are abnormally formed from birth. The vertebrae are normal at birth in infantile idiopathic scoliosis.
Age of onset is before age 3 in both types of scoliosis.
The thoracic curve may be convex to the left slide or the right side in either curve type. In infantile idiopathic scoliosis, it is most commonly convex to the left.
The rib-vertebral angle difference (angle between the apical vertebral endplate and the rib on the convexity minus the rib on the concavity) greater than 20° predicts an increased risk of worsening in infantile idiopathic scoliosis but not in congenital scoliosis.
Bracing has not been shown to affect infantile idiopathic scoliosis.
Age of onset is before age 3 in both types of scoliosis.
The thoracic curve may be convex to the left slide or the right side in either curve type. In infantile idiopathic scoliosis, it is most commonly convex to the left.
The rib-vertebral angle difference (angle between the apical vertebral endplate and the rib on the convexity minus the rib on the concavity) greater than 20° predicts an increased risk of worsening in infantile idiopathic scoliosis but not in congenital scoliosis.
Bracing has not been shown to affect infantile idiopathic scoliosis.
Question 11High Yield
The disadvantages of a complete arthroscopiCrepair of a rotator cuff include all of the following except:
Explanation
ArthroscopiCrepair techniques generally require the use of suture anchors and limit some suture configuration options in the tendon. Complete arthroscopiCrepair is technically difficult, requires significantly greater and more complex instrumentation, and has a potentially longer operative time. However, it decreases postoperative pain
Question 12High Yield
A 37-year-old woman has had persistent right lateral ankle pain after sustaining a minor sprain 5 months ago. She has a sense of instability on
uneven ground. Physical therapy has not helped. She is tender along the peroneal tendons and in the sinus tarsi. She has a negative anterior drawer test result for the ankle and no tenderness over the anterior lateral malleolus. She also has bilateral pes planus that persists with heel rise.
uneven ground. Physical therapy has not helped. She is tender along the peroneal tendons and in the sinus tarsi. She has a negative anterior drawer test result for the ankle and no tenderness over the anterior lateral malleolus. She also has bilateral pes planus that persists with heel rise.
Explanation
- Casting
Question 13High Yield
In the majority of patients with chronic anterior cruciate ligament (ACL)-deficient knees, analysis of the gait pattern during level walking will most likely reveal which of the following changes?
Explanation
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.
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.
Question 14High Yield
Figures 1 and 2 are the radiographs of a 12-year-old boy who has been experiencing increased pain in his right, dominant elbow while pitching. He notes that his velocity is decreasing, and he can no longer throw as many pitches without discomfort. Examination reveals tenderness on palpation of his medial distal humerus, but no evidence is seen of instability to valgus stress at either 0° or 30° of elbow flexion. What is the most appropriate recommendation at this time?
Explanation
■
Radiographs and examination are consistent with medial epicondylar apophysitis, or "Little Leaguer elbow," which is thought to be secondary to repetitive traction stresses across the open physis while throwing. MRI generally does not change the treatment in these patients. Surgical fixation is indicated in patients with displaced avulsion fractures of the medial epicondyle, particularly in throwing athletes. In light of the lack of clinical instability, ulnar collateral ligament reconstruction is not indicated in this patient.
■
Radiographs and examination are consistent with medial epicondylar apophysitis, or "Little Leaguer elbow," which is thought to be secondary to repetitive traction stresses across the open physis while throwing. MRI generally does not change the treatment in these patients. Surgical fixation is indicated in patients with displaced avulsion fractures of the medial epicondyle, particularly in throwing athletes. In light of the lack of clinical instability, ulnar collateral ligament reconstruction is not indicated in this patient.
Question 15High Yield
-What is the most common anatomic location of the lateral femoral cutaneous nerve?
Explanation
Knee dislocations are known to have a high risk for vascular injury. Although the specific treatment of various combinations of ligamentous injuries is controversial, the need for emergent revascularization is not. In this particular patient, after vascular repair, the most important initial concern is protection of the vascular repair. A spanning external fixator, especially in this patient with gross instability, will allow for easier assessment of vascular status, evaluation of fasciotomy wounds,
and temporary stability of the knee. A cylinder cast can stabilize the knee but will not allow wound assessment or room for inevitable post-injury/postoperative swelling. Diagnostic knee arthroscopy is not necessary, and ligamentous repair/reconstruction should be delayed until the vascular repair is stable. PREFERRED RESPONSE: 1
and temporary stability of the knee. A cylinder cast can stabilize the knee but will not allow wound assessment or room for inevitable post-injury/postoperative swelling. Diagnostic knee arthroscopy is not necessary, and ligamentous repair/reconstruction should be delayed until the vascular repair is stable. PREFERRED RESPONSE: 1
Question 16High Yield
A 21-year-old collegiate pitcher has had pain in his dominant shoulder for the past 3 months despite management consisting of rest, rehabilitation, and an analysis of throwing mechanics. An arthroscopic photograph from the posterior portal is shown in Figure 10. The biceps anchor to the bone was not detached to probing. Treatment of the lesion to the left of the cannula should consist of arthroscopic
Explanation
The lesion is a variation of a type I superior labrum anterior and posterior lesion; therefore, appropriate treatment is simple debridement. Biceps tenodesis or release is not indicated because the biceps tendon and anchor are intact. There is no indication for labral repair or capsulorraphy.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 261-270.
Snyder SJ, Banas MP, Karzel RP: An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg 1995;4:243-248.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 261-270.
Snyder SJ, Banas MP, Karzel RP: An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg 1995;4:243-248.
Question 17High Yield
Figures 18a and 18b are the radiographs of an obese 75-year-old man with a rigid acquired flatfoot deformity. What is the best treatment option?
Explanation
For stage III adult-acquired flatfoot deformity characterized by dysfunction of the posterior tibial tendon, rigid valgus deformity of the hindfoot, and arthritic changes of the hindfoot joints,arthrodesis is the favored procedure. In an overweight patient with degenerative changes affecting the subtalar and Chopart joints, triple arthrodesis is the best treatment option. Subtalar arthrodesis only addresses the talocalcaneal joint and continues to render the patient symptomatic in the talonavicular and calcaneocuboid joints. Advanced stage III disease precludes reconstructive procedures involving calcaneal osteotomy and tendon transfer.
Question 18High Yield
A 32-year-old taxi driver sustains a displaced supination external rotation ankle injury after slipping off of a curb. He subsequently undergoes surgical fixation, and a post-operative radiograph is shown in Figure A. At the eight-week postoperative visit, you are asked to fill out a return to work form. How long from today’s visit will his braking time be expected to return to normal?
Explanation
Patients recover the ability to safely operate the brakes of an automobile 9 weeks following operative repair of an ankle fracture. Because this patient is currently 8 weeks out from surgery, his braking time will be expected to return to normal one week from now.
Egol et al studied the time braking ability returns to normal in patients with operatively treated ankle fractures. Patients were studied at 6, 9, and 12 weeks postoperatively and compared to healthy controls. It was determined that total braking time returned to normal by 9 weeks.
Egol et al studied the time braking ability returns to normal in patients with operatively treated ankle fractures. Patients were studied at 6, 9, and 12 weeks postoperatively and compared to healthy controls. It was determined that total braking time returned to normal by 9 weeks.
Question 19High Yield
A baseball player has had diffuse scapular soreness for the past 8 weeks. He reports that it began insidiously over several days and gradually has become worse. He denies any history of trauma. Examination reveals drooping of the shoulder, with lateral winging of the scapula at rest. He is otherwise neurologically intact. What is the best course
of action?
of action?
Explanation
Lateral scapular winging is characteristic of trapezius palsy, whereas medial scapular winging is characteristic of long thoracic nerve palsy. During sports activity, injury to the spinal accessory nerve is rare but may occur with blunt or stretching trauma. Patients often report an asymmetric neckline, drooping shoulder, winging of the scapula, and weakness of forward elevation. Evaluation should include a complete electrodiagnostic examination.
REFERENCES: Wiater JM, Bigliani LU: Spinal accessory nerve injury. Clin Orthop 1999;368:5-16.
Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop 1999;368:17-27.
Mariani PP, Santoriello P, Maresca G: Spontaneous accessory nerve palsy. J Shoulder Elbow Surg 1998;7:545-546.
Porter P, Fernandez GN: Stretch-induced spinal accessory nerve palsy: A case report. J Shoulder Elbow Surg 2001;10:92-94.
Cohn BT, Brahms MA, Cohn M: Injury to the eleventh cranial nerve in a high school wrestler. Orthop Rev 1986;15:59-64.
REFERENCES: Wiater JM, Bigliani LU: Spinal accessory nerve injury. Clin Orthop 1999;368:5-16.
Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop 1999;368:17-27.
Mariani PP, Santoriello P, Maresca G: Spontaneous accessory nerve palsy. J Shoulder Elbow Surg 1998;7:545-546.
Porter P, Fernandez GN: Stretch-induced spinal accessory nerve palsy: A case report. J Shoulder Elbow Surg 2001;10:92-94.
Cohn BT, Brahms MA, Cohn M: Injury to the eleventh cranial nerve in a high school wrestler. Orthop Rev 1986;15:59-64.
Question 20High Yield
Figures 1 through 5 are the radiographs and MRI scans of an 80-year-old woman who had a total hip arthroplasty (THA) 10 years ago and recently experienced an episode of dislocation that was reduced. She currently has no pain, but has a limp and moderate apprehension. Her erythrocyte sedimentation rate is 32 and C-reactive protein is 34. Her cobalt level is 32.8 ug/L (normal <1ug/L) and chromium level 14 ug/L (normal < 5ug/L). The hip aspiration is negative. What is the most appropriate treatment? 35
Explanation
36
The patient has a metal-on-metal articulation with pseudotumor, causing instability and destruction of the abductors. Although inflammatory markers are elevated, this may occur with adverse local soft-tissue reaction, and aspiration may be necessary to rule out infection. Conversion to a polyethylene articulation is necessary to prevent ongoing damage. The MRI scan reveals compromise of abductors by the pseudotumor, but sparing of the gluteus maximus.This facilitates abductor reconstruction to address the limp and improve stability.
The patient has a metal-on-metal articulation with pseudotumor, causing instability and destruction of the abductors. Although inflammatory markers are elevated, this may occur with adverse local soft-tissue reaction, and aspiration may be necessary to rule out infection. Conversion to a polyethylene articulation is necessary to prevent ongoing damage. The MRI scan reveals compromise of abductors by the pseudotumor, but sparing of the gluteus maximus.This facilitates abductor reconstruction to address the limp and improve stability.
Question 21High Yield
Which nerve is most commonly injured after total knee arthroplasty?
Explanation
The tibial or peroneal nerves usually are not injured during total knee arthroplasty. Incidence of peroneal nerve damage is highest in knees with a valgus deformity and an associated flexion contracture attributable to nerve stretch. This nerve injury occurs in as many as 9% of patients undergoing knee arthroplasty. Tibial nerve injury is a rare occurrence and usually an iatrogenic transection injury. The infrapatellar branch of the saphenous nerve and its nerve plexus is commonly injured after the medial parapatellar approach, and altered sensation attributable to injury is reported in up to 70% of cases. Injury typically manifests as numbness inferior to the patella. The sartorial branch of the saphenous nerve provides sensation distal to the knee and is uncommonly injured with a medial parapatellar approach. These concepts are illustrated in video 57, “Selective Exposures in Orthopaedic Surgery: The Knee, 2nd Edition.”
RECOMMENDED READINGS
1. Clarke HD, Bush-Joseph CA, Wolf BR. Selective Exposures in Orthopaedic Surgery: The Knee, 2nd Edition [DVD]. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2012.
2. [Hunter LY, Louis DS, Ricciardi JR, O'Connor GA. The saphenous nerve: its course and importance in medial arthrotomy. Am J Sports Med. 1979 Jul-Aug;7(4):227-30. PubMed PMID: 474860.](http://www.ncbi.nlm.nih.gov/pubmed/474860)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/474860)
3. [Mistry D, O'Meeghan C. Fate of the infrapatellar branch of the saphenous nerve post total knee arthroplasty. ANZ J Surg. 2005 Sep;75(9):822-4. PubMed PMID: 16174002.](http://www.ncbi.nlm.nih.gov/pubmed/16174002)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16174002)
4. [Schinsky MF, Macaulay W, Parks ML, Kiernan H, Nercessian OA. Nerve injury after primary total knee arthroplasty. J Arthroplasty. 2001 Dec;16(8):1048-54. PubMed PMID: 11740762.](http://www.ncbi.nlm.nih.gov/pubmed/11740762)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11740762)
RECOMMENDED READINGS
1. Clarke HD, Bush-Joseph CA, Wolf BR. Selective Exposures in Orthopaedic Surgery: The Knee, 2nd Edition [DVD]. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2012.
2. [Hunter LY, Louis DS, Ricciardi JR, O'Connor GA. The saphenous nerve: its course and importance in medial arthrotomy. Am J Sports Med. 1979 Jul-Aug;7(4):227-30. PubMed PMID: 474860.](http://www.ncbi.nlm.nih.gov/pubmed/474860)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/474860)
3. [Mistry D, O'Meeghan C. Fate of the infrapatellar branch of the saphenous nerve post total knee arthroplasty. ANZ J Surg. 2005 Sep;75(9):822-4. PubMed PMID: 16174002.](http://www.ncbi.nlm.nih.gov/pubmed/16174002)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16174002)
4. [Schinsky MF, Macaulay W, Parks ML, Kiernan H, Nercessian OA. Nerve injury after primary total knee arthroplasty. J Arthroplasty. 2001 Dec;16(8):1048-54. PubMed PMID: 11740762.](http://www.ncbi.nlm.nih.gov/pubmed/11740762)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11740762)
Question 22High Yield
Figures 14a and 14b show the initial radiographs of an 18-year-old man who fell while snowboarding. Figures 14c and 14d show the radiographs obtained following closed reduction. Examination reveals that the elbow is stable with range of motion. Management should now consist of
Explanation
The initial radiographs reveal a simple elbow dislocation without associated fractures. After successful closed reduction, the range of stability should be assessed. If the elbow is stable, nonsurgical management should consist of a short period of immobilization followed by range-of-motion exercises. Immobilization for more than 3 weeks results in significant elbow stiffness. Surgical repair is indicated for dislocations that are irreducible, have associated fractures, or where stability cannot be maintained with closed treatment.
REFERENCES: Cohen MS, Hastings H II: Acute elbow dislocations: Evaluation and management. J Am Acad Orthop Surg 1998;6:15-23.
O’Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 409-420.
REFERENCES: Cohen MS, Hastings H II: Acute elbow dislocations: Evaluation and management. J Am Acad Orthop Surg 1998;6:15-23.
O’Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 409-420.
Question 23High Yield
Figures 60a and 60b show the radiographs of the ankle and distal leg of an 1-
2. year-old girl after she twisted her ankle while playing soccer. She has no
3. history of ankle or leg pain. Examination reveals localized swelling and
4. tenderness over the lateral ankle, and the tibia is not tender. The bone lesion
5. identified in the tibia most likely is
6. 1- osteoblastoma.
7. 2- osteoid osteoma.
8. 3- ossifying fibroma.
9. 4- fibrous dysplasia.
10. 5- nonossifying fibroma.
2. year-old girl after she twisted her ankle while playing soccer. She has no
3. history of ankle or leg pain. Examination reveals localized swelling and
4. tenderness over the lateral ankle, and the tibia is not tender. The bone lesion
5. identified in the tibia most likely is
6. 1- osteoblastoma.
7. 2- osteoid osteoma.
8. 3- ossifying fibroma.
9. 4- fibrous dysplasia.
10. 5- nonossifying fibroma.
Explanation
1.
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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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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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Question 24High Yield
Which inflammatory marker is most closely tied to a systemic inflammatory response following orthopaedic injury and treatment?
Explanation
No detailed explanation provided for this question.
Question 25High Yield
Indications for operative treatment in an acute elbow dislocation include:
Explanation
Recurrent dislocations with extension past 50° represent a significant injury to the elbow and require a stabilization period. Instability to valgus stress represents injury to the anterior band of the medial collateral ligament of the elbow and will heal with protected motion. The majority of radial head fractures (Mason type I and II) that are less than 30º of the radial head and less than 30º angulation heal with good functional results. Most dislocations will have osteochondral lesions. Ulnar nerve parathesias can be associated with dislocations but is not an indication for operative fixation.
Question 26High Yield
Regarding the management of web space abscess, which of the following statements is not true:
Explanation
Transverse incisions can lead to contractures that limit finger abduction. Leaving wounds open allow for continued drainage. If preferred, closed suction drains can be used after closure of the wound. All devitalized tissue must be debrided and all signs of infection removed and irrigated copiously. Early motion is encouraged to prevent stiffness.
Question 27High Yield
In which of the following osteonecrotiCconditions does the marrow cavity become packed with abnormal cells:
Explanation
There are two conditions that cause osteonecrosis secondary to the marrow cavity becoming packed with abnormal cells â
Gaucher disease and sickle cell disease. There is probable occlusion of the intraosseous arteries with both of these conditions.
With Gaucher disease, the marrow cavity is filled with Gaucher cells (macrophages filled with cerebroside). In sickle cell disease, the marrow cavity is filled with sickled red blood cells.
Gaucher disease and sickle cell disease. There is probable occlusion of the intraosseous arteries with both of these conditions.
With Gaucher disease, the marrow cavity is filled with Gaucher cells (macrophages filled with cerebroside). In sickle cell disease, the marrow cavity is filled with sickled red blood cells.
Question 28High Yield
A 57-year-old man who plays recreational sports reports pain in his dominant shoulder. An MR arthrogram is shown in Figure 57. During arthroscopy of the shoulder, what pathology is most likely to be found?
Explanation
DISCUSSION: The MR arthrogram shows medial subluxation of the biceps tendon out of the bicipital groove and a subscapularis tendon tear. Biceps tendon subluxation is almost always associated with subscapularis tears. Whereas other diagnoses can be associated, none of them is directly related to this finding or seen on the MR arthrogram.
REFERENCES: Lafosse L, Jost B, Reiland Y, et al: Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am 2007;89:1184-1193.
Tonino PM, Gerber C, Itoi E, et al: Complex shoulder disorders: Evaluation and treatment. J Am Acad Orthop Surg 2009:17:125-136.
REFERENCES: Lafosse L, Jost B, Reiland Y, et al: Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am 2007;89:1184-1193.
Tonino PM, Gerber C, Itoi E, et al: Complex shoulder disorders: Evaluation and treatment. J Am Acad Orthop Surg 2009:17:125-136.
Question 29High Yield
Figure 1 is the MR image of a 14-year-old football player who injured his right knee during a game. He describes feeling a "pop" and then needing help walking off the field. His knee is visibly swollen. Knee range of motion is between 0° and 70°. What is the most appropriate treatment option?
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---
Explanation
The MR image shows bone bruises (“kissing contusions”) consistent with an ACL tear. During the ACL subluxation event, the posterolateral tibial plateau subluxes anteriorly, making contact with the mid portion of the lateral femoral condyle and resulting in this characteristic bone bruise pattern on MRI. Randomized clinical trials comparing early accelerated versus nonaccelerated rehabilitation programs have demonstrated no significant differences in long-term results with regard to function, reinjury, and successful return to play. These studies did not address timing of return to play with an early accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity, number of graft failures, or KOOS scores.
Question 30High Yield
A 17-year-old high school soccer player sustains an anterior cruciate ligament (ACL) tear at the beginning of the season. An MRI scan confirms a complete ACL tear with no meniscal injuries. The patient plans an early return to play and would like to avoid surgery. Therefore, the patient and family should be advised that nonsurgical management consisting of rehabilitative exercises and the use of a functional knee brace will most likely result in
Explanation
While there are athletes who can function at a full level with an ACL tear, they are in the minority. As yet, there is no reliable way to predict the patients who will be able to compensate for the loss of the ACL. Studies have confirmed the risk of recurrent instability and meniscal injury in athletes with an ACL-deficient knee who participate in cutting sports. One study showed that only 12 of 43 patients who attempted rehabilitation and bracing were able to return successfully for the season. Another study showed that 17 of 31 athletes who were able to return to their sport sustained 23 meniscal tears because of recurrent instability.
REFERENCES: Shelton WR, Barrett GR, Dukes A: Early season anterior cruciate ligament tears: A treatment dilemma. Am J Sports Med 1997;25:656-658.
Snyder-Mackler L, Fitzgerald GK, Bartolozzi AR III, Ciccotti MG: The relationship between passive joint laxity and functional outcome after anterior cruciate ligament injury. Am J Sports Med 1997;25:191-195.
REFERENCES: Shelton WR, Barrett GR, Dukes A: Early season anterior cruciate ligament tears: A treatment dilemma. Am J Sports Med 1997;25:656-658.
Snyder-Mackler L, Fitzgerald GK, Bartolozzi AR III, Ciccotti MG: The relationship between passive joint laxity and functional outcome after anterior cruciate ligament injury. Am J Sports Med 1997;25:191-195.
Question 31High Yield
Which of the following is considered a contraindication to functional bracing for the treatment of humeral shaft fractures?
Explanation
Most closed humeral shaft fractures and fractures caused by a low-velocity hand gun can be managed nonsurgically with closed reduction and application of a coaptation splint followed by a functional brace. Contraindications to use of the functional brace include:
1) massive soft-tissue or bone loss; 2) an unreliable or noncompliant patient; and 3) an inability to maintain acceptable fracture alignment of up to 20 degrees of anterior or posterior angulation, 30 degrees of varus or valgus angulation, and greater than 3 cm of shortening.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Pollock FH, Drake D, Bovill EG, Day L, Trafton PG: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.
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.
1) massive soft-tissue or bone loss; 2) an unreliable or noncompliant patient; and 3) an inability to maintain acceptable fracture alignment of up to 20 degrees of anterior or posterior angulation, 30 degrees of varus or valgus angulation, and greater than 3 cm of shortening.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Pollock FH, Drake D, Bovill EG, Day L, Trafton PG: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.
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.
Question 32High Yield
Which of the following is not usually associated with radial deficiency:
Explanation
Patients with thrombocytopenia absent radii, Fanconi anemia, Holt-Oram syndrome, and cardiac anomolies all are associated with radial deficiency. Larsen syndrome is associated with multiple, larger joint dislocation.
Question 33High Yield
A genetiCmutation accounts for the manifestations of achondroplasia. Which of the following proteins has a genetiCmutation that has been linked to achondroplasia:
Explanation
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 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
Question 34High Yield
A 52-year-old woman has right hip pain and obvious swelling 3 years after undergoing a resurfacing arthroplasty. Her implant consists of a 42-mm femoral component and 48-mm socket. Her components are well positioned, and her metal ion levels are slightly elevated (less than 4 ppm) with a normal erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level. What is the most likely cause of her discomfort?
Explanation
This patient likely has a soft-tissue reaction (pseudotumor) related to metal-on- metal articulation. Although the components are well positioned, patient gender and small head size are both known risk factors for failure of hip resurfacing arthroplasties. Metal ion levels are elevated but are not always markedly increased in the setting of a problematic metal-on-metal articulation. The patient should have a metal artifact reduction sequence MR imaging study to confirm the presence of a pseudotumor. Chronic infection is very unlikely in the setting of normal ESR and CRP findings. Impingement and lumbar disk disease would not explain the swelling around the hip.
Question 35High Yield
A 13-year-old girl has hip pain and the inability to bear weight. On anteroposterior and lateral hip radiographs the femoral head is displaced inferiorly and posteriorly by 50% of its diameter. Recommended treatment includes:
Explanation
In situ fixation has results superior to any of the other methods.
Besides being extremely cumbersome, spica cast treatment carries significant risk of redisplacement and chondrolysis. There is no indication for traction in this situation.
The amount of displacement can be accepted as long as it is stabilized.
Metaphyseal osteotomy carries a risk of avascular necrosis. It should only be undertaken in grade III slips.
Besides being extremely cumbersome, spica cast treatment carries significant risk of redisplacement and chondrolysis. There is no indication for traction in this situation.
The amount of displacement can be accepted as long as it is stabilized.
Metaphyseal osteotomy carries a risk of avascular necrosis. It should only be undertaken in grade III slips.
Question 36High Yield
Figures 2a and 2b are the clinical photographs taken at the time of cubital tunnel surgery. The ulnar nerve is indicated by the red arrow. What is the name of the structure at the tip of the blue arrow?
Explanation
The clinical photographs reveal an anconeus epitrochlearis. This is an atavistic or anomalous muscle that originates on the medial olecranon (ulna) and inserts on the medial epicondyle. It is widely present in animals that move their elbows in the coronal plane. The anconeus epitrochlearis muscle may be contributing a factor to the development of cubital tunnel syndrome. When present, this muscle can compress the ulnar nerve and should be released.
RECOMMENDED READINGS
3. [Masear VR, Meyer RD, Pichora DR. Surgical anatomy of the medial antebrachial cutaneous nerve. J Hand Surg Am. 1989 Mar;14(2 Pt 1):267-71. PubMed PMID: 2703673. ](http://www.ncbi.nlm.nih.gov/pubmed/2703673)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/2703673)
4. [Masear VR, Hill JJ Jr, Cohen SM. Ulnar compression neuropathy secondary to the anconeus epitrochlearis muscle. J Hand Surg Am. 1988 Sep;13(5):720-4. PubMed PMID: 3241044. ](http://www.ncbi.nlm.nih.gov/pubmed/3241044)[View](http://www.ncbi.nlm.nih.gov/pubmed/3241044)[ ](http://www.ncbi.nlm.nih.gov/pubmed/3241044)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/3241044)
RECOMMENDED READINGS
3. [Masear VR, Meyer RD, Pichora DR. Surgical anatomy of the medial antebrachial cutaneous nerve. J Hand Surg Am. 1989 Mar;14(2 Pt 1):267-71. PubMed PMID: 2703673. ](http://www.ncbi.nlm.nih.gov/pubmed/2703673)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/2703673)
4. [Masear VR, Hill JJ Jr, Cohen SM. Ulnar compression neuropathy secondary to the anconeus epitrochlearis muscle. J Hand Surg Am. 1988 Sep;13(5):720-4. PubMed PMID: 3241044. ](http://www.ncbi.nlm.nih.gov/pubmed/3241044)[View](http://www.ncbi.nlm.nih.gov/pubmed/3241044)[ ](http://www.ncbi.nlm.nih.gov/pubmed/3241044)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/3241044)
Question 37High Yield
The lateral arm flap is based on what arterial supply?
Explanation
The lateral arm flap is based on the posterior radial collateral artery, a branch of the profunda brachial artery.
REFERENCES: Katsaros J, Tan E, Zoltie N: The use of the lateral arm flap in upper limb surgery. J Hand Surg 1991;16:598-604.
Katsaros J, Schusterman M, Beppu M, et al: The lateral upper arm flap: Anatomy and clinical applications. Ann Plast Surg 1984;12:489-499.
REFERENCES: Katsaros J, Tan E, Zoltie N: The use of the lateral arm flap in upper limb surgery. J Hand Surg 1991;16:598-604.
Katsaros J, Schusterman M, Beppu M, et al: The lateral upper arm flap: Anatomy and clinical applications. Ann Plast Surg 1984;12:489-499.
Question 38High Yield
A 42-year-old woman reports neck stiffness, upper extremity pain, clumsiness, weakness, and instability of gait. Examination reveals 4+ of 5 strength in the upper extremities and 3+ biceps, brachioradialis, and patellar reflexes with a positive Hoffman sign bilaterally. MRI and CT scans are shown in Figures 1 and
Explanation
■
The sagittal T2-weighted MRI scan shows moderate-severe multilevel cervical stenosis. The cord compression is noted to be not only at the disk levels but also at the midvertebral body levels, and the posterior longitudinal ligament appears to be thickened. The CT scan confirms that the posterior longitudinal ligament is indeed thickened and ossified, compatible with a diagnosis of ossification of the posterior longitudinal ligament. This diagnosis is most common in individuals of Japanese descent and has a genetic linkage. The anterior osteophytes are smaller than those seen in diffuse idiopathic skeletal hyperostosis and are not syndesmotic. Patients with ankylosing spondylitis typically have non-marginal syndesmophytes. Patients with rheumatoid arthritis may have evidence of instability at C1C2 on flexion-extension radiographs and subaxial subluxations.
The sagittal T2-weighted MRI scan shows moderate-severe multilevel cervical stenosis. The cord compression is noted to be not only at the disk levels but also at the midvertebral body levels, and the posterior longitudinal ligament appears to be thickened. The CT scan confirms that the posterior longitudinal ligament is indeed thickened and ossified, compatible with a diagnosis of ossification of the posterior longitudinal ligament. This diagnosis is most common in individuals of Japanese descent and has a genetic linkage. The anterior osteophytes are smaller than those seen in diffuse idiopathic skeletal hyperostosis and are not syndesmotic. Patients with ankylosing spondylitis typically have non-marginal syndesmophytes. Patients with rheumatoid arthritis may have evidence of instability at C1C2 on flexion-extension radiographs and subaxial subluxations.
Question 39High Yield
Anterior approach
Explanation
The nerve most commonly injured in the posterior approach to the hip is the sciatic nerve. Overall injury prevalence is 1% to 2%. This nerve is more commonly injured in cases of hip dysplasia with excessive leg lengthening. The superior gluteal nerve is at highest risk with the direct lateral approach to the hip. This nerve courses in the gluteus medius muscle and is
at risk when splitting the muscle 5 cm proximal to the greater trochanter. The lateral femoral 73
cutaneous nerve is commonly damaged with anterior total hip replacement surgery. Neuropraxia has been reported in 81% of patients. The inferior gluteal nerve travels from the greater sciatic notch and enters the gluteus maximus muscle. It is at risk when the posterior approach to the hip is used.
RECOMMENDED READINGS
1. Hoppenfeld S, deBoer P. Surgical Exposures in Orthopedics. 3rd ed. Philadelphia.
PA: Lippincott Williams & Wilkins; 2003:365-453.
2. [DeHart MM, Riley LH Jr. Nerve injuries in total hip arthroplasty. J Am Acad Orthop Surg. 1999 Mar-Apr;7(2):101-11. Review. PubMed PMID: 10217818. ](http://www.ncbi.nlm.nih.gov/pubmed/10217818)[View Abstract](http://www.ncbi.nlm.nih.gov/pubmed/10217818)[ at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10217818)
3. Goulding K, Beaulé PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Clin Orthop Relat Res. 2010 Sep;468(9):2397-404. doi: 10.1007/s11999-010-1406-5. PubMed PMID:
[20532717.](http://www.ncbi.nlm.nih.gov/pubmed/20532717)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20532717)
Figures 87a and 87b are sagittal and coronal MR images of the affected elbow of a 36-year-old man who has a history of painful mechanical symptoms in his dominant arm when extending his elbow in full supination. What is the most likely cause of his painful snapping?
A
B
1. Lacertus fibrosis contracture
2. Intra-articular loose bodies 74
3. Olecranon fossa impingement
4. Radiocapitellar plica
PREFERRED RESPONSE: 4- Radiocapitellar plica
DISCUSSION
The MRI studies show a radiocapitellar plica. This anomalous structure has been associated with symptomatic snapping. Lacertus fibrosis contracture will not cause painful snapping. An intra-articular pathology such as loose bodies is not present on these imaging studies. Olecranon fossa impingement causes posterior pain in extension and is not shown in the images.
RECOMMENDED READINGS
1. [Antuna SA, O'Driscoll SW. Snapping plicae associated with radiocapitellar chondromalacia. Arthroscopy. 2001 May;17(5):491-5. PubMed 11337715. ](http://www.ncbi.nlm.nih.gov/pubmed/11337715)[View Abstract](http://www.ncbi.nlm.nih.gov/pubmed/11337715)[ ](http://www.ncbi.nlm.nih.gov/pubmed/11337715)[at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11337715)
2. [Ruch DS, Papadonikolakis A, Campolattaro RM. The posterolateral plica: a cause of refractory lateral elbow pain. J Shoulder Elbow Surg. 2006 May-Jun;15(3):367-70. PubMed PMID: 16679240. ](http://www.ncbi.nlm.nih.gov/pubmed/16679240)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16679240)
at risk when splitting the muscle 5 cm proximal to the greater trochanter. The lateral femoral 73
cutaneous nerve is commonly damaged with anterior total hip replacement surgery. Neuropraxia has been reported in 81% of patients. The inferior gluteal nerve travels from the greater sciatic notch and enters the gluteus maximus muscle. It is at risk when the posterior approach to the hip is used.
RECOMMENDED READINGS
1. Hoppenfeld S, deBoer P. Surgical Exposures in Orthopedics. 3rd ed. Philadelphia.
PA: Lippincott Williams & Wilkins; 2003:365-453.
2. [DeHart MM, Riley LH Jr. Nerve injuries in total hip arthroplasty. J Am Acad Orthop Surg. 1999 Mar-Apr;7(2):101-11. Review. PubMed PMID: 10217818. ](http://www.ncbi.nlm.nih.gov/pubmed/10217818)[View Abstract](http://www.ncbi.nlm.nih.gov/pubmed/10217818)[ at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10217818)
3. Goulding K, Beaulé PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Clin Orthop Relat Res. 2010 Sep;468(9):2397-404. doi: 10.1007/s11999-010-1406-5. PubMed PMID:
[20532717.](http://www.ncbi.nlm.nih.gov/pubmed/20532717)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20532717)
Figures 87a and 87b are sagittal and coronal MR images of the affected elbow of a 36-year-old man who has a history of painful mechanical symptoms in his dominant arm when extending his elbow in full supination. What is the most likely cause of his painful snapping?
A
B
1. Lacertus fibrosis contracture
2. Intra-articular loose bodies 74
3. Olecranon fossa impingement
4. Radiocapitellar plica
PREFERRED RESPONSE: 4- Radiocapitellar plica
DISCUSSION
The MRI studies show a radiocapitellar plica. This anomalous structure has been associated with symptomatic snapping. Lacertus fibrosis contracture will not cause painful snapping. An intra-articular pathology such as loose bodies is not present on these imaging studies. Olecranon fossa impingement causes posterior pain in extension and is not shown in the images.
RECOMMENDED READINGS
1. [Antuna SA, O'Driscoll SW. Snapping plicae associated with radiocapitellar chondromalacia. Arthroscopy. 2001 May;17(5):491-5. PubMed 11337715. ](http://www.ncbi.nlm.nih.gov/pubmed/11337715)[View Abstract](http://www.ncbi.nlm.nih.gov/pubmed/11337715)[ ](http://www.ncbi.nlm.nih.gov/pubmed/11337715)[at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11337715)
2. [Ruch DS, Papadonikolakis A, Campolattaro RM. The posterolateral plica: a cause of refractory lateral elbow pain. J Shoulder Elbow Surg. 2006 May-Jun;15(3):367-70. PubMed PMID: 16679240. ](http://www.ncbi.nlm.nih.gov/pubmed/16679240)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16679240)
Question 40High Yield
After oophorectomy or menopause, bone loss per year is estimated to be:
Explanation
The normal estimated age-related bone loss per year is 0.5%. After oophorectomy or during the first 6 to 8 years after menopause, bone loss can be as high as 2.0% to 3.0% per year
Question 41High Yield
Figures 1 through 4 are the radiographs, sagittal-cut CT scan, and coronal T1 MR image of a 16-year-old boy who has wrist stiffness and pain after sustaining an injury 2 years ago. There is no bleeding from the proximal pole during surgery. Which procedure will most likely result in restoration of alignment and healing?
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Explanation
The imaging studies show an established scaphoid waist nonunion with a humpback deformity (significant flexion through the nonunion site) and carpal collapse. In addition, the proximal pole appears sclerotic on the plain radiographs and appears poorly perfused on the MR image. Correction of alignment of this scaphoid nonunion would require a volar approach with a structural bone graft. Additionally, the graft would need to provide a vascular supply to the bone. Both the 1,2 ICSRA (the Zaidenberg graft) and the 4+5 ECA grafts are vascularized grafts from the dorsal distal radius. Neither of these grafts would correct the humpback deformity, and the 4+5 ECA graft pedicle is not long enough to reach the scaphoid. An iliac crest bone graft could be used to correct the deformity, but would not provide an adequate blood supply. A free-vascularized medial femoral condyle graft provides both adequate bone graft to correct the _deformity and revascularization of the scaphoid._
Question 42High Yield
A patient sustains a grade III medial collateral ligament injury. One year later, when compared to collagen in an uninjured ligament, an increase is likely in the
Explanation
**
Studies on animal models have shown that there is a change in collagen fiber type and distribution early in the healing process. There is a higher portion of type III fibers than in
normal ligament initially, but this ratio returns to normal about 1 year after the injury occurs. Healing ligaments show an increased number of collagen fibers, but the number of mature collagen cross-links is
45% of predicted value after 1 year. There is also a decrease in the mass and diameter of the collagen fibers.
Studies on animal models have shown that there is a change in collagen fiber type and distribution early in the healing process. There is a higher portion of type III fibers than in
normal ligament initially, but this ratio returns to normal about 1 year after the injury occurs. Healing ligaments show an increased number of collagen fibers, but the number of mature collagen cross-links is
45% of predicted value after 1 year. There is also a decrease in the mass and diameter of the collagen fibers.
Question 43High Yield
A 51-year-old man presents with persistent right shoulder pain several weeks after falling off a roof. On examination, he has pain with palpation over the greater tuberosity, active forward shoulder flexion of 60°, and passive forward shoulder flexion of 160°. He has 2/5 forward flexion and external rotation strength. Initial plain radiographs are unremarkable. A coronal MRI scan of his shoulder is shown in Figure
Explanation
13
Several investigations continue to elucidate the difference between dual row and single row repairs. Modern dual row repairs involve fixating the rotator cuff tendon along both the medial and lateral aspect of the greater tuberosity as well as linking both points of fixation together. This allows closer restoration of native footprint coverage in comparison with single row repairs. However, doubling the number of implants results in increased healthcare costs without a clear clinical or biomechanical benefit. Several studies report statistically similar outcomes, retear rates, and biomechanical properties between single and dual row repair when the number of suture limbs across the repair site is the same.
Several investigations continue to elucidate the difference between dual row and single row repairs. Modern dual row repairs involve fixating the rotator cuff tendon along both the medial and lateral aspect of the greater tuberosity as well as linking both points of fixation together. This allows closer restoration of native footprint coverage in comparison with single row repairs. However, doubling the number of implants results in increased healthcare costs without a clear clinical or biomechanical benefit. Several studies report statistically similar outcomes, retear rates, and biomechanical properties between single and dual row repair when the number of suture limbs across the repair site is the same.
Question 44High Yield
What is the single most important nutritional factor affecting athletic performance?
Explanation
Maintenance of adequate hydration is the single most important factor affecting athletic performance. While carbohydrate loading may be beneficial for some endurance athletes, the consumption of carbohydrates during exercise does not appear to be beneficial for athletes engaged in events that last less than 1 hour. In general, athletes consuming a balanced diet do not need electrolyte supplementation.
REFERENCES: Maughan RJ, Noakes TD: Fluid replacement and exercise stress: A brief review of studies on fluid replacement and some guidelines for the athlete. Sports Med 1991;12:16-31.
Barr SI, Costill DL, Fink WJ: Fluid replacement during prolonged exercise: Effects of water, saline, or no fluid. Med Sci Sports Exerc 1991;23:811-817.
REFERENCES: Maughan RJ, Noakes TD: Fluid replacement and exercise stress: A brief review of studies on fluid replacement and some guidelines for the athlete. Sports Med 1991;12:16-31.
Barr SI, Costill DL, Fink WJ: Fluid replacement during prolonged exercise: Effects of water, saline, or no fluid. Med Sci Sports Exerc 1991;23:811-817.
Question 45High Yield
Which of the following statements best describes the anatomy of the sartorial branch of the saphenous nerve during medial meniscal repair?
Explanation
DISCUSSION: Dunaway and associates reported that the nerve was extrafascial in only 43% of their cadaveric specimens. Therefore, in medial meniscal repair, the nerve may be present during deep dissection. The sartorial branch of the saphenous nerve is posterior to the sartorius; dissection should remain anterior to the sartorius. The branch becomes extrafascial between the gracilis and the sartorius. The nerve is anterior to the semitendinosus with the knee in extension. The infrapatellar branch of the saphenous nerve exits the adductor canal and travels to the anteromedial aspect of the knee.
REFERENCES: Dunaway DJ, Steensen RN, Wiand W, et al: The sartorial branch of the saphenous nerve: Its anatomy at the joint line of the knee. Arthroscopy 2005;21:547-551.
Rodeo SA: Arthroscopic meniscal repair with use of the outside-in technique. Instr Course Lect 2000;49:195-206.
DISCUSSION: Dunaway and associates reported that the nerve was extrafascial in only 43% of their cadaveric specimens. Therefore, in medial meniscal repair, the nerve may be present during deep dissection. The sartorial branch of the saphenous nerve is posterior to the sartorius; dissection should remain anterior to the sartorius. The branch becomes extrafascial between the gracilis and the sartorius. The nerve is anterior to the semitendinosus with the knee in extension. The infrapatellar branch of the saphenous nerve exits the adductor canal and travels to the anteromedial aspect of the knee.
REFERENCES: Dunaway DJ, Steensen RN, Wiand W, et al: The sartorial branch of the saphenous nerve: Its anatomy at the joint line of the knee. Arthroscopy 2005;21:547-551.
Rodeo SA: Arthroscopic meniscal repair with use of the outside-in technique. Instr Course Lect 2000;49:195-206.
Question 46High Yield
What is the most likely cause of her symptoms?
Explanation
- Rotator cuff tear_
Question 47High Yield
Which of the following collagens forms part of the matrix immediately surrounding the chondrocytes and may help attach the chondrocyte to the matrix macromolecular framework:
Explanation
Type II, IX, and XI collagen forms a fibrillar network that gives cartilage its form and tensile stiffness and strength. Type VI collagen forms part of the matrix immediately surrounding chondrocytes and may help attach the cells attach to the matrix macromolecular framework.
Question 48High Yield
A 14-year-old male cross-country runner is being evaluated for exercise-induced leg pain. The pain is localized along the distal two-thirds of the posteromedial tibia. Radiographs are normal. What is likely to be the greatest risk factor for this condition?
Explanation
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Medial tibial stress syndrome (MTSS) is an exercise-induced pain localized to the distal two-thirds of the posteromedial tibia. Reported risk factors include female sex, greater body weight or body mass index, increased navicular drop, prior use of orthotics, previous running injury, reduced running experience, and greater hip external rotation. Reduced plantar flexor muscle endurance has been associated with MTSS in adults.
Medial tibial stress syndrome (MTSS) is an exercise-induced pain localized to the distal two-thirds of the posteromedial tibia. Reported risk factors include female sex, greater body weight or body mass index, increased navicular drop, prior use of orthotics, previous running injury, reduced running experience, and greater hip external rotation. Reduced plantar flexor muscle endurance has been associated with MTSS in adults.
Question 49High Yield
A 28-year-old Hispanic male assembly line worker sustains an injury while lifting a 40-lb bag onto a palette. He experiences immediate low back pain, and within 5 days, he develops severe left leg pain. His MRI scans are shown in Figures 1 and
Explanation
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Workers’ compensation is a system that provides healthcare and wage-replacement benefits for workers injured in the occupational setting. Back pain is the most common workers compensation claim in the United States, accounting for up to 25% of all claims and one-third of total compensation costs. Numerous studies have reported that workers’ compensation is an independent negative risk factor for unsatisfactory outcomes after surgical procedures.
Keeney and associates published a prospective study looking at which factors were predictive for proceeding to surgery in the workers’ compensation population. Their findings showed that young age (<35 years-old), female gender, and Hispanic ethnicity were negative predictive factors for proceeding with surgical treatment. Which medical professional the work compensation patient sought made a difference; nearly 43% of injured workers whose first visit was to a surgeon eventually underwent a surgical procedure.
Workers’ compensation is a system that provides healthcare and wage-replacement benefits for workers injured in the occupational setting. Back pain is the most common workers compensation claim in the United States, accounting for up to 25% of all claims and one-third of total compensation costs. Numerous studies have reported that workers’ compensation is an independent negative risk factor for unsatisfactory outcomes after surgical procedures.
Keeney and associates published a prospective study looking at which factors were predictive for proceeding to surgery in the workers’ compensation population. Their findings showed that young age (<35 years-old), female gender, and Hispanic ethnicity were negative predictive factors for proceeding with surgical treatment. Which medical professional the work compensation patient sought made a difference; nearly 43% of injured workers whose first visit was to a surgeon eventually underwent a surgical procedure.
Question 50High Yield
The anterior approach to the hip (iliofemoral or Smith-Peterson) puts which of the following anatomic structures at greatest risk?
Explanation
DISCUSSION: The anterior approach to the hip involves a dissection between the sartorius and the tensor fascia lata (TFL) superficially, followed by a deep dissection between the rectus femoris and gluteus medius. The lateral femoral cutaneous nerve generally enters the top of the thigh overlying the sartorius, and then usually crosses the interval between the sartorius muscle and the tensor fascia lata more distally. As the fascia between the sartorius and the TFL is incised, the nerve is at risk. The ascending branch of the lateral femoral circumflex artery is also at risk during this approach. The femoral nerve should not be in the plane of dissection as it lies medial to the sartorius.
REFERENCE: Hoppenfeld S, DeBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippinocott, 1984, pp 301-315.
REFERENCE: Hoppenfeld S, DeBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippinocott, 1984, pp 301-315.
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Consultant Orthopedic & Spine Surgeon