Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...

Anterior debridement, strut graft, and posterior fusion with instrumentation provide the patient with the best chance of a positive result. This procedure minimizes graft dislodgement and posterior overgrowth.
A two-drug therapy alone for at least 6 months leaves the patient at a significant risk of progressive kyphosis and neurologic deficit.
A two-drug therapy for at least 6 months along with a body cast also leaves the patient with significant risk of progressive kyphosis and neurologic deficit.
The lack of anterior support from a two-drug therapy and posterior spinal fusion to prevent deformity leaves the patient with significant risk of kyphosis.
Even with an anterior spinal debridement and a rib strut graft, there is a risk of graft dislodgment over this large defect and of posterior growth into kyphosis.

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)

- Percutaneous lag screw fixation
This patient’s MR images are indicative of a nondisplaced navicular stress fracture, which is best treated with percutaneous lag screw fixation. She has persistent symptoms despite appropriate nonsurgical treatment. Although all of the above choices may allow successful healing of her navicular, surgery has been shown to result in a shorter recovery and a more predictable outcome, which is especially important to serious athletes. Use of bone morphogenic protein has not been established as a treatment for this injury.
RECOMMENDED READINGS
1. [Lee S, Anderson RB. Stress fractures of the tarsal navicular. Foot Ankle Clin. 2004 Mar;9(1):85-104. Review. PubMed PMID: 15062216. ](http://www.ncbi.nlm.nih.gov/pubmed/15062216)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15062216)
2. Anderson RB, Cohen BE. Stress fractures of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:1590-1597.

Figure C and Illustration A (below) demonstrate the radiographic "double-arc" finding.
McKee et al described a unique "shear fracture of the distal articular surface of the humerus" which involved coronal fractures of the capitellum and a portion of the trochlea. He described the characteristic radiographic finding as the "double-arc sign" which represents the subchondral bone of the displaced capitellum and lateral trochlea ridge.
Incorrect Answers:
Figure A shows a radial head fracture. Figure B shows an elbow dislocation.
Figure D shows a pediatric lateral condyle fracture.
Figure E shows a pediatric medial epicondyle apophyseal avulsion fracture.

- isointense signal to the rotator cuff. PREFERRED RESPONSE: 1- calcium carbonate apatite.
PREFERRED RESPONSE: 1- physical therapy and nonsteroidal anti-inflammatory medications.

- Observe the nerve injury with further workup/intervention only if there is no sign of nerve recovery by 3 months after surgery

Because the MRI scan shows a complete rupture of the distal biceps tendon, the preferred treatment is anatomic repair of the tendon to the radial tuberosity either with the use of suture anchors or transosseous sutures through a two-incision technique. Several studies have documented superior results with anatomic repair of the distal biceps tendon when compared with results of nonsurgical management or repair of the tendon by attachment to the brachialis muscle. Patients undergoing anatomic repair of the distal biceps tendon through a two-incision technique typically regain a functional range of motion and nearly normal strength.
REFERENCES: D’Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. Am J Sports Med 1993;21:114-119.
Boyd JB, Anderson LD: A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Am 1961;43:1041-1043.
Morrey BF, Askew LJ, An KN, Dobyns JH: Rupture of the distal tendon of the biceps brachii: A biomechanical study. J Bone Joint Surg Am 1985;67:418-421.
Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD: Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique: Report of four cases. Clin Orthop 1990;253:133-136.

The radiographs and CT scan images show a depressed lateral tibial plateau fracture, which is correctly classified as a Schatzker III tibial plateau fracture. This fracture typically occurs as the result of the femoral condyle directly impacting the articular surface in older patients with osteopenia.
The referenced article by Bennett et al reviews the associated soft tissue injury with tibial plateau fractures. They found a 56% frequency of associated soft tissue injuries overall, with MCL injured in 20%, the LCL in 3% , the menisci in 20%, the peroneal nerve in 3%, and the anterior cruciate ligaments in 10%.
Schatzker type IV and type II fracture patterns were associated with the highest frequency of soft tissue injuries.

Radiography is the best initial study. Vacuum phenomenon may be found within the disk space. Other possible sources for back pain such as osteoporotic collapse, osteolytic collapse, and deformity also can be evaluated. The other tests may be beneficial and are more appropriate as later imaging options.
RECOMMENDED READINGS
Yu WD, Williams SL. Spinal imaging: Radiographs, computed tomography, and magnetic resonance imaging. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine
3/. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:57-67.
Bess RS, Brodke DS. Degenerative disease of the lumbar spine. In: Fischgrund JS, ed. Orthopaedic Knowledge Update 9. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:551-563.

DISCUSSION: Pediatric flexor tendon injuries have several remarkable distinctions from those in adults. Delayed presentation is more common in children, at times requiring staged flexor tendon reconstruction. Three to four weeks of postoperative immobilization following acute repair is recommended in children as opposed to early motion protocols used in adults. Temporary paralytic agents (botulinum toxin type A) have also been shown to facilitate the rehabilitation phase of flexor tendon care in very young children.
REFERENCE: Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2008, p 675.

The posterior and superior acromioclavicular ligaments provide the most restraint to posterior translation of the acromioclavicular joint and must be preserved during a Mumford procedure. Anterior and superior acromioclavicular joint ligaments are the opposite of the
nd prevent anterior translation of the clavicle. Injuries to the conoid and trapezoid ligaments are more pronounced with grade III or higher acromioclavicular separations, with superior migration of the clavicle relative to the acromion.
Correct answer : B

With arthrodesis of the proximal interphalangeal joint (PIP), the long flexor tendon that remains intact flexes the toe at the metatarsophalangeal (MP) joint and also at the distal interphalangeal (DIP) joint, thus the development of a mallet toe deformity.

Lacerated radial nerves are associated with open humeral fractures. All open humeral fractures with radial nerve palsy should be managed with radial nerve exploration and skeletal stabilization. Closed humeral fractures with associated radial nerve palsy usually have an intact nerve with neurapraxia. Most of these patients recover without surgical treatment. If the patient has multiple injuries, skeletal stabilization may be indicated to improve mobilization. For an isolated closed humeral fracture with a radial nerve palsy, the treatment of choice is splinting for 1 to 2 weeks, followed by a humeral fracture brace.
REFERENCES: Ring D, Chin K, Jupiter JB: Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am 2004;29:144-147.
Foster RJ, Swiontkowski MF, Bach AW, et al: Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am 1993;18:121-124.

Dupuytrenâs disease is characteristically unpredictable in its clinical progression. It may spontaneously resolve or quickly progress to advanced disease.

The patient sustained a high-angle femoral neck fracture. The follow-up clinical findings and radiograph show that she now has a nonunion with failed internal fixation. The joint appears preserved. In a healthy, young patient, arthroplasty of the femoral head, although possible, is not ideal. Excellent healing and function can be obtained in 70% to 80% of patients with femoral neck nonunion with a valgus intertrochanteric osteotomy.
REFERENCES: Marti RK, Schuller HM, Raaymakers EL: Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br 1989;71:782-787.
Ballmer FT, Ballmer PM, Baumgaertel F, et al: Pauwels osteotomy for nonunions of the femoral neck. Orthop Clin North Am 1990;21:759-767.

This scenario is a classic example of the development of Charcot foot. A red, swollen, deformed foot without ulceration suggests neuroarthropathy. Normal inflammatory marker findings, no history of fever or chills, and radiographs demonstrating bone loss support the diagnosis. Limb elevation with dramatic reduction in erythema is also characteristic of this disease process and does not occur with infection. Total-contact casting is the cornerstone of treatment for acute Charcot disease. Hemoglobin A1C is an indicator of glucose averaged over a 3-month period, providing the most reliable indication of a patient's ongoing glucose control. The pathophysiology of bone destruction is believed to be hypervascularity of bone. Infection and Charcot disease may develop simultaneously, but the combination is rare.
RECOMMENDED READINGS
[Kaynak G, Birsel O, Güven MF, Ogüt T. An overview of the Charcot foot pathophysiology. Diabet Foot Ankle. 2013 Aug 2;4. doi: 10.3402/dfa.v4i0.21117.Print 2013. PubMed PMID: 23919113.](http://www.ncbi.nlm.nih.gov/pubmed/23919113)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23919113)
[Pinzur MS, Lio T, Posner M. Treatment of Eichenholtz stage I Charcot foot arthropathy with a weightbearing total contact cast. Foot Ankle Int. 2006 May;27(5):324-9. PubMed PMID: 16701052. ](http://www.ncbi.nlm.nih.gov/pubmed/16701052)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16701052)

Dupuytren contracture involves proliferative fibrodysplasia of the subcutaneous palmar connective tissue. The flexor tendons are not involved. Pretendinous bands of the palmer aponeurosis form nodules and cords causing metacarpophalangeal joint contracture. The interphalangeal joint can be affected but only rarely is the distal interphalangeal joint involved. There is no inflammatory response but a proliferation of myofibroblasts with an increase in Type 3 collagen. The disease is most often seen in men between the ages of 40 and 60 years old and is associated with epilespy, alcoholism and diabetes. C arpal tunnel syndrome is often seen in young women and can be exacerbated by pregnancy.

The beginning and end of the range may change, but the total amount of motion remains about the same.
The amount of the range cannot be significantly increased. The endpoint can change, but not the amount of the range. The joint does not usually become stiffer.
There may be an indication for surgery to put the joints in a functional position.

The clinical presentation and images are most consistent with left hip osteonecrosis as a result of coagulation and vascular occlusion caused by sickle cell anemia.
Sickle cell disease is a genetic disorder of hemoglobin synthesis characterized by 2 abnormal hemoglobin S alleles. Under low oxygen conditions the affected blood cells become "sickle shaped" and unable to pass through vessels. This results in vascular occlusion that may have a variety of clinical consequences depending on the body part affected.
Hernigou et al. review the natural history of symptomatic osteonecrosis in adults with sickle cell disease. Once symptomatic , osteonecrosis of the hip in sickle cell disease has a high likelihood of progressing and leading to femoral head collapse. Deterioration can be rapid and in most patients operative intervention is necessary to prevent further collapse or alleviate intractable pain.
Mont et al. performed a literature review on the natural history of untreated asymptomatic osteonecrosis of the femoral head. Their findings supported that asymptomatic osteonecrosis had a high prevalence of progression to symptomatic femoral head collapse. Small, medially located lesions had a low rate of progression, while medium to large sized osteonecrotic lesions did progress in a substantial number of patients. They recommended
consideration of joint-preserving surgical treatment in asymptomatic patients with a medium-sized or large, laterally located lesion.
Figure A shows an AP pelvis with left hip osteonecrosis. Figure B shows a T2 coronal MRI with left hip osteonecrosis. Illustration A shows an example of a hemoglobin molecule which has become "sickle shaped," and as a result is unable to pass through vessels efficiently.
Incorrect Answers:

: Progressive slippage of the physis though the hypertrophic zone describes
slipped capital femoral epiphysis.
Answer 3: These radiographs are most consistent with osteonecrosis of the femoral head. There is an increased incidence of Salmonella osteomyelitis in patient with Sickle Cell disease, but Staphylococcus aureus is still the most common organism.
Answer 4: Accumulation of glycosaminoglycan breakdown products describes lysosomal disorders.
Answer 5: COL5A1 or COL5A2 mutation describes the mutation of Ehlers Danlos syndrome.

What mechanism allows Staphylococcus epidermidis to adhere to surfaces and resist phagocytosis?

1) Creation of active efflux pumps

2) Methylation of 23s rRNA

3) Biofilm production

4) Alteration of cell wall permeability

5) Beta-lactamase production

Staphylococcus epidermidis is a gram-positive bacteria that utilizes a glycocalyx/biofilm to adhere to orthopedic implants and other surfaces and resist phagocytosis.
The biofilm creates a well-protected environment where bacteria can proliferate and thrive essentially undetected by the host immune system. This leads to chronic infections of orthopedic implants that can go undetected for years.
Arciola et al note that S. epidermidis can colonize surfaces in a self-generated viscous biofilm composed of polysaccharides and that the ica genes found in
56% of S. epidermidis isolates were associated with their ability to produce biofilm.
Olson et al discuss the importance of polysaccharide intercellular adhesin (PIA), a
substance produced by 50-60% of S. epidermidis strains, in the adherence of S. epidermidis to biomaterials through biofilm creation. PIA plays a critical role in initial adherence of S. epidermidis to biomaterials, biofilm
maturation and aggregation.
Illustration A shows microscopy of Staphylococcus epidermidis, which is a gram- positive, coagulase-negative cocci. Illustration B is an overview of the different classes of organisms in microbiology.
Incorrect Answers:
Answer 1,2,4,5: Efflux pump production, hydrolysis of B-lactam drugs with beta- lactamase, alteration in cell wall permeability, and ribosomal alteration are mechanisms that Staphylococcus uses to resists antibiotics.

Compared to cold-forged cobalt chrome, titanium alloys have which property?

1) Increased fatigue strength

2) Increased yield strength

3) Increased endurance limit

4) Decreased ductility

5) Decreased tensile strength

Titanium implants have decreased tensile (ultimate) strength when compared to cobalt chrome.
Ultimate strength, or tensile strength, is the maximum stress a material can withstand before undergoing breakage or failure. The ranking of ultimate strength, from highest to lowest is: 1) cobalt chrome, 2)titanium, 3)stainless steel, and 4) cortical bone.
Young's modulus of elasticity is defined as the measure of stiffness of a material in the elastic zone. A higher Young's modulus indicates a stiffer material. While titanium is highly biocompatible with a low modulus of elasticity (Young's modulus), it has poor wear characteristics making it non- suitable for femoral heads in total hip arthroplasty.
Long et al. present a review on titanium implants with a focus on bio- mechanical properties. Their study supports previous data which showed high rates of ultra-high molecular weight polyethylene wear due to accelerated breakdown when in contact with a titanium surface.
Incorrect Answers:
Answer 1: Fatigue strength, or the maximum cyclic load (10 million cycles) that a standard sized metal can absorb before fracture, is lower in titanium compared to cobalt chrome.
Answer 2: Yield strength, or the maximal stress a material can take before permanent deformation, is decreased in titanium compared to cobalt chrome. Answer 3: Endurance limit is another way of saying fatigue strength, which is discussed in incorrect answer 1. Answer 4: Ductility, or the measure of how much strain a material can take before rupturing, is higher for titanium than cobalt chrome

Peak bone mass attainment in both men and women is most dependent on which sex-steroid?

1) Testosterone

2) Progesterone

3) Growth Hormone

4) Estrogen

5) Cortisol

Estrogen has been shown to be important for both men and women in attaining peak bone mass.
Risk factors for osteoporosis are: increasing age, female sex, early menopause, fair-skinned, family history of hip fracture, low body weight, smoking, glucocorticoid use, excessive alcohol, low protein intake, and anticonvulsant or antidepressant use.

Which of the following contributes most to the ability of hyaline cartilage to attract water?

1) Aggrecan

2) Biglycan

3) Decorin

4) Fibromodulin

5) Osteocalcin

Aggrecan molecules bind to hyaluronic acid molecules via link proteins to form a macromolecule complex, known as a proteoglycan aggregate, which attracts water.
Proteoglycans are composed of subunits known as glycosaminoglycans. Glycosaminoglycans include two subtypes: chondroitin sulfate and keratin sulfate. These glycosaminoglycans link to a protein core by sugar bonds to form an aggrecan molecule. Link proteins then stabilize many of these aggrecan molecules to hyaluronic acid to form the proteoglycan aggregate. Cartilage also contains ancillary proteoglycans that are much smaller than the aggregating proteoglycans. These small proteoglycans include decorin, biglycan, and fibromodulin. They bind to other molecules (eg, type II collagen) and assist in matrix stabilization.
Ulrich-Vinther et al. authored a Level 5 review on cartilage structure. The negative charge present within the hyaline cartilage extracellular matrix attracts cations and results in an increase in tissue osmolality. This then attracts water, which decreases the osmolality. Thus, articular cartilage has a high tissue pressure, but the presence of type II collagen matrix prevents it from swelling.
Nap et al. present a basic science review article on aggrecans. They discus that the main function of aggrecan in cartilage is to resist compressive forces.
They note that the negative charge of the aggrecan molecule disaccharides create the high osmotic swelling pressure of cartilage.
Illustration A depicts the molecular organization of an aggregated proteoglycan molecule. Incorrect Answers:
Answer 2,3,4: These are small proteoglycans that bind to other molecules (eg, type II collagen) and assist in matrix stabilization.
Answer 5: Osteocalcin is the most prevalent noncollagenous protein in bone.

What effect do bisphosphonate medications have on spinal fusion surgery when taken in the postoperative period?

1) Any effect can be counteracted by taking calcium supplements

2) No effect

3) Increased risk of wound infection

4) Smaller fusion mass

5) Decreased fusion rate

Bisphosphonates (e.g. alendronate) are used to treat osteoporosis. The mechanism of action is inhibiting the formation of the ruffled border of osteoclasts, resulting in decreasing bone turnover.
Huang et al performed a rat study comparing alendronate to placebo and found that fusion rates were lower in those treated with alendronate. However,
the fusion masses were larger in the alendronate treated rats despite lower fusion rates (why #4 is incorrect).
Lehman et al in another placebo controlled rate study found that the fusion rates for placebo (76%) were greater than the alendronate group (45%). Alendronate works on osteoclasts and does not affect calcium directly. Taking calcium should have no effect on alendronate (why #1 is incorrect). At this time there are no formal recommendations of when to stop bisphosphonate medication prior to spinal fusion surgery.

A therapeutic study presents a systematic review of 15 high- quality randomized controlled trials with homogeneous results. What level of evidence is this considered?

1) I

2) II

3) III

4) IV

5) V

A systematic review of high-quality clinical trials is considered a Level I study.
A systematic review is a powerful tool used to identify, evaluate and appraise all high- quality research related to a specific question. Systematic reviews, in contrast to most narrative review articles, adhere to strict scientific design by following eight steps; 1) defining a question and developing inclusion criteria,
2) searching for studies, 3) selecting studies and collecting data, 4) assessing risk of bias, 5) data analysis and meta-analyses, 6) addressing biases, 7) presenting results, and 8) interpreting results and drawing conclusions. When the results from the systematic review are homogeneous (less variability between studies than would be expected by chance), the data from a systematic review can be combined into a meta- analysis.
Wright et al. discuss the levels of evidence in orthopaedic journals as presented by the AAOS Evidence-Based Practice Committee. Based on levels of evidence, the AAOS provides grades of recommendation (A, B, C, I). Grade A recommendations are supported by Level 1 studies with consistent findings, whereas Grade I do not have enough evidence to support a recommendation.
Illustration A shows an "evidence pyramid." MA = meta-analysis, SR = systematic review, RCT = randomized controlled trial.
Incorrect Answers:
Answer 2: An example of a Level II study is prospective comparative study. Answer 3: An example of a Level III study is a case control trial.
Answer 4: An example of a Level IV study is a case series.
Answer 5: An example of a Level V study is one based on expert opinion.

Progressive overloading of muscles in adults during exercise leads to which of the following?

1) Increased muscle fiber length

2) Decreased musculotendinous junction length

3) Slowed peak contraction velocity

4) Muscle fiber hypertrophy

5) Decreased sarcomere length

Strength training is achieved by incremental progressive loading of muscles, in effort to increase muscle fiber contraction coordination and eventually hypertrophy of the muscle fibers themselves.
Kraemer et al. provide an American College of Sports Medicine position statement on appropriate training regimens. They recommend that loads
corresponding to 8-12 repetition maximum (RM) be used in novice training. For intermediate to advanced training, it is recommended that individuals use a wider loading range, from 1-12 RM in a periodized fashion. For local muscular endurance training, it is recommended that light to moderate loads (40-60% of 1 RM) be performed for high repetitions (> 15) using short rest periods (
Which of the following would lead to accelerated maturation in the zone of hypertrophy at the physis?

1) An activating mutation in TGF-ß

2) A deactivating mutation in the parathyroid hormone-related peptide (PTHrP) receptor

3) A deactivating mutation in prostaglandin E2

4) An activating mutation in the SMAD-3 protein

5) An activating mutation in the Indian Hedgehog (Ihh) protein

A deactivating mutation in the parathyroid hormone-related peptide (PTHrP) receptor would lead to accelerated maturation in the zone of hypertrophy.
PTHrP has been shown to play an important role in the regulation of cell proliferation at the physis. It is postulated that physeal chondrocytes regulate the local production of PTHrP by secreting a protein called Indian Hedgehog (Ihh). Ihh stimulates the chondrocytes to produce PTHrP, which slows the maturation of proliferative
chondrocytes.
Ballock et al. discuss the biology of the growth plate. With regards to cell proliferation, they describe how the proliferation of chondrocytes in the growth plate is under the control of a feedback loop involving PTHrP, Indian
Hedgehog, and TGF-ß.
Illustration A shows the Ihh/PTHrP negative-feedback loop. Incorrect Answers:
Answer 1: TGF-ß is a potent inhibitor of maturation, including cell hypertrophy, Type-X collagen expression, and alkaline phosphatase activity. An activating mutation would lead to decelerated maturation at the physis.
Answer 3: Prostaglandin E2 has not been shown to affect cell proliferation and maturation at the physis.
Answer 4: SMAD-3 increases the activity of TGF-ß. This would lead to decelerated maturation at the physis.
Answer 5: As described above, Ihh controls the release of PTHrP from chondrocytes. Activating Ihh would lead to more production of PTHrP, which would delay maturation at the physis.

All of the following statements regarding sclerostin are true EXCEPT?

1) It is a product of the SOST gene

2) Overexpression results in decreased bone mass

3) It is thought to be associated with sclerosteosis and Van Buchem disease

4) It activates the Wnt pathway

5) It is derived from osteocytes

Sclerostin inhibits the Wnt pathway, making answer choice 4 the correct answer.
Sclerostin is an osteocyte-derived negative regulator of Wnt signaling in osteoblasts. Amongst other things, the Wnt pathway and the Wnt proteins are important regulators of bone mass. They are thought to work by stimulating the production of osteoblasts. By inhibiting the Wnt pathway, sclerostin leads to decreased bone mass.
Dijke et al. discuss the role of the SOST gene in the conditions sclerosteosis and Van Buchem disease. They describe the SOST as a gene that encodes sclerostin, which is a negative regulator of Wnt signaling in osteoblasts. The
authors argue that the high bone mass seen in sclerosteosis and Van Buchem disease may be caused by increased Wnt signaling.
Day et al. review the Wnt and hedgehog signaling pathways. The Wnt and hedgehog pathways, they describe, control the differentiation of progenitor cells into osteoblasts or chondrocytes. They found that up-regulation of Wnt signaling leads to suppression of chondrocyte formation and enhanced ossification, which may be important in fracture healing.
Illustration A shows the pathway by which Wnt promotes osteoblast formation. In addition to increasing osteoblast formation, the pathway upregulates OPG, which blocks osteoclastogenesis. Illustration B shows how sclerostin inhibits
the Wnt pathway, resulting in a net decrease in bone mass. Illustration C shows an example of Van Buchem disease, an autosomal recessive disorder characterized by hyperostosis of the skull, mandible, clavicles, ribs, and diaphyseal cortices of the long bone.
Incorrect Answers:
Answers 1, 2, 3, 5: These statements are all correct regarding sclerostin.

Which of the following is more likely to occur following a total knee arthroplasty without patellar resurfacing versus a total knee arthroplasty with patellar resurfacing in patients with rheumatoid arthritis?

1) Patellar dislocation

2) Anterior knee pain

3) Extensor tendon rupture

4) Decreased quadriceps strength

5) Patellar clunk syndrome

Patients with rheumatoid arthritis who undergo a total knee arthroplasty without patellar resurfacing are more likely to have anterior knee pain when compared to the same patient population with resurfaced patellas.
Resurfacing the patella during total knee arthroplasty is a topic of controversy. Those against resurfacing note minimal issues with patellar tilt and
overstuffing the patellofemoral joint. Supporters of resurfacing state that the patellofemoral joint will eventually become arthritic if not resurfaced, and that the rate of anterior knee pain is much higher. Multiple studies, however, have shown superior results in patients with rheumatoid arthritis that have had their patella resurfaced.
Burnett et al. review the indications for patellar resurfacing during total knee arthroplasty. They consider not resurfacing the patella in patients less than 60 with non-inflammatory arthritis and a maintained patellofemoral joint space.
Holt et al. also review the role of patellar resurfacing. They mention that patellar resurfacing should be routinely done in patients with rheumatoid arthritis, preoperative patellofemoral pain, height greater than 160cm, weight greater than 60kg, or advanced patellar changes either pre- or intra- operatively.
Illustration A shows plain anteroposterior (a) and lateral (b) radiographs of the knee in a patient with rheumatoid arthritis. Degenerative changes are present in all 3 joint compartments. There is collapse of the lateral compartment with resultant valgus deformity. Erosion of the anterior aspect of the distal femoral metaphysis due to pannus is also seen.
Incorrect Answers:
Answer 1: Patellar dislocation has not been found to be higher in patellas that are not resurfaced.
Answer 3: Extensor tendon rupture is more common in patients that have had their patella resurfaced.
Answer 4: Multiple studies have not shown a difference in quadriceps strength with or without resurfacing.
Answer 5: Patellar clunk syndrome is more common in patients who have had their patella resurfaced.

Which of the following pharmacologic treatments for osteoporosis has been associated with the potential risk for osteosarcoma development?

1) Ergocalciferol

2) Non-nitrogen containing bisphosphonate

3) Monoclonal Ig2 against RANKL

4) Nitrogen containing bisphosphonates

5) Recombinant parathyroid hormone (1-34)

Recombinant parathyroid hormone (1-34) (Forteo) has been demonstrated to cause osteosarcoma in animal models but has not been to shown to cause the same effect in humans.
1-34 amino terminal residues of parathyroid hormone(1-84) administered in daily subcutaneous injections leads to bone formation. Continuous infusion leads to bone resorption.
Subbiah et al. published a case report on a patient that developed osteosarcoma following external beam radiation and recombinant teriparatide use. They discuss that though there have been nearly a 1/2 million patients treated safely with recombinant terirparatide and it is important to recognize patients that are contraindicated for treatment with recombinant teriparatide.
The FDA's Black Box warning states the following: "In male and female rats, teriparatide caused an increase in the incidence of osteosarcoma (a malignant bone tumor) that was dependent on dose and treatment duration. The effect was observed in rats at systemic exposures to teriparatide ranging from 3 to
60 times the exposure in humans given a 20-mcg dose. Because of the uncertain relevance of the rat osteosarcoma finding to humans, teriparatide should be prescribed only to patients for whom the potential benefits are considered to outweigh the
potential risk. Teriparatide should not be prescribed for patients who are at increased baseline risk for osteosarcoma (including those with Paget's disease of bone or unexplained elevations of alkaline phosphatase, open epiphyses, or prior external beam or implant radiation therapy involving the skeleton)"
Incorrect Answers:
Answer 1: Ergocalciferol does not cause an increase in sarcoma
Answer 2 & 4: Bisphosphonates can cause esophagitis, dysphagia, gastric ulcers, osteonecrosis of the jaw (ONJ), and atypical subtrochanteric fractures. Answer 3: Denosumab (Prolia) can cause arthralgia, nasopharyngitis, and back pain.

While conducting a retrospective review of patients undergoing two different techniques for open reduction and internal fixation of ankle fractures, the investigator would like to assess whether there is any significant difference between the mean patient age in the two groups. The two groups are normally distributed. Which of the following tests would be most appropriate?

1) Student t-test

2) Analysis of Variance (ANOVA)

3) Fisher exact test

4) Kruskal-Wallis test

5) Chi-square test

A Student-test would be the most appropriate test for analyzing means of parametric (continuous) variables that are normally distributed between two groups.
Data can be characterized as non-parametric (categorical, ordinal) or parametric (continuous). Parametric data, such as age, are observations for which difference between the numbers have meaning on a numerical scale. Non-parametric data are observations which can be expressed as a
dichotomous (yes or no) outcome such as gender.
Kocher and Zurakowski present a Level 5 review of epidemiology and biostatistics. The authors state that univariate or bivariate analysis, such as the student t-test, is used to assess the relationship of a single independent and a single dependent variable.
Incorrect Answers:
Answer 2: Analysis of variance is used to evaluate means of parametric data between three or more groups when the data is normally distributed
Answer 3: Fisher exact test is used to compare proportions for non-parametric data when the expected frequency is small (less than five per group)
Answer 4: Kruskal-Wallis test is used to evaluate medians of three or more groups when the data are not normally distributed.
Answer 5: Chi-square test is used to compare proportions for categorical or ordinal data (non-parametric)

Which of the following arteries provides the blood supply to the outer third of a long bone diaphysis?

1) Nutrient artery

2) Periosteal arterioles

3) Medullary artery

4) Emissary artery

5) Perichondral artery of LaCroix

Periosteal arterioles (low pressure system) supply the outer third of the adult diaphyseal cortex.
Blood supply to long bone comes from three sources: 1) nutrient artery
system, 2) metaphyseal-epiphyseal system, and 3) periosteal system. Nutrient arteries (high pressure system) enter the long bone diaphyseal cortex and
then enter the medullary canal where it branches into ascending and descending arteries and supplies the inner 2/3 of the diaphysis via Haversian systems.
Bong et al. present a review article regarding intramedullary nail effects on bone healing. They report that intramedullary nails can have negative effects on endosteal and cortical blood flow but this is offset by an increase in extraosseous circulation. During early fracture healing blood flow is centripetal
(outside to inside) because high pressure nutrient artery system is often disrupted. Illustration A depicts the blood supply for the adult diaphsysis. Incorrect
Answers:
Answer 1: High pressure system that branches from major systemic arteries and supplies the inner 2/3 of mature bone.
Answer 3: The nutrient artery enters through the medullary canal and divides into ascending and descending arteries.
Answer 4: Cortical capillaries drain to the emissary venous system. There is no described emissary artery for long bones.
Answer 5: Perichondrial artery is the major source of nutrition of the growth plate

DNA methylation, histone modification, nucleosome location, or noncoding RNA are hypothesized to contribute to the process whereby inheritable genetic alterations occur that do not involve DNA mutation. Which of the following terms best defines this process?

1) Transgenes

2) Epigenetics

3) Gene enhancers

4) Gene promoters

5) Transformation

Epigenetic changes are defined as inheritable genetic alterations that do not involve DNA mutation.
The cells in a multicellular organism have almost identical DNA sequences, yet maintain different terminal phenotypes. This nongenetic cellular memory, which records developmental and environmental cues is the basis for epigenetics. DNA methylation, histone modification, nucleosome location, or noncoding RNA are hypothesized to contribute to the process.
Maher et al discuss epigenetic influences in the realm of orthopaedics. They report new data stating that increases in matrix metalloproteinase (MMP) expression in osteoarthritis is associated with altered methylation of key promoter sequences. They also report elevated levels of an enzyme involved in epigenetic gene silencing in osteoarthritis- affected chondrocytes, SIRT1, increased the expression of matrix genes and suppressed that of MMPs.
Incorrect Answers:
Answer 1: Transgenes are genes that are artificially introduced into a single- celled embryo and are present in all cells of that organism.
Answer 3: Gene enhancers are a region of a gene that positively regulates rates of transcription.
Answer 4: Gene promoters are a regulatory segment of DNA that controls start of transcription adjacent to the transcription initiation site of a gene.
Answer 5: Transformation refers to inserting a plasmid into a bacterium with added recombinant DNA.

A 72-year-old woman presents with severe hip pain after stepping off of a curb. She denies any trauma or prior history of hip pain. Her past medical history is reviewed including a list of her current medications. Which of the following of her medications would place her at increased risk for a non-traumatic hip fracture?

1) Phenytoin

2) Cephalexin

3) Simvastatin

4) Glipizide

5) Allopurinol

Phenytoin is an anticonvulsant which has been found to increase the risk of osteoporosis and, subsequently, nontraumatic fractures.
Possible mechanisms explaining the association between anticonvulsants and bone loss include hepatic induction of cytochrome P450 enzymes (increases vitamin D catabolism), direct osteoblast inhibition, impaired calcium absorption, elevated homocysteine, inhibition of response to PTH, hyperparathyroidism, reduced reproductive sex hormones, and reduced vitamin K level.
Lee et al. found that anticonvulsant use (phenobarbital, carbamazepine, phenytoin, and valproate) increases the risk of osteoporosis, and also increases the risk of fracture by 1.2 to 2.4 times.
Jette et al. found an increased fracture risk for carbamazepine, clonazepam, gabapentin, phenobarbital, and phenytoin. Odds ratios ranged from 1.24 (clonazepam) to 1.91 (phenytoin).
Incorrect Answers:
Answers 2-5: These medications do not place a patient at a significant risk for non- traumatic hip fracture.

What part of the articular cartilage has the highest concentration of proteoglycans and the lowest concentration of water?

1) Superficial

2) Transitional

3) Deep

4) Tidemark

5) Calcified cartilage

This question requires that you know the 4 zones of articular cartilage: the superficial zone, the transitional zone, the deep zone (also called middle or radial zone) and the zone of calcified cartilage. The deep zone has chondrocytes with a more spheroidal shape which align themselves perpendicular to the joint surface. This zone has the largest diameter collagen fibrils, the highest concentration of proteoglycans, and the lowest
concentration of water. The collagen fibers of this zone pass into the tidemark, a thin basophilic line seen of H&E stains that corresponds to the boundary between calcified and uncalcified cartilage. Lastly the calcified cartilage zone is a thin zone of calcified cartilage that separates the radial zone (uncalcified cartilage) and the subchondral bone. The cells in this region have a smaller
volume than the cells of the radial zone, and these cells have extremely low level of metabolic activity.

The cross-sectional area of a muscle is the factor most responsible for which of the following?

1) Amount of maximal tension

2) Speed of contraction

3) Duration of contraction

4) Type of contraction

5) Fatigability

Force generation, or the amount of maximal tension that can be generated by a given skeletal muscle is most dependent on the cross-sectional area of the muscle.
The cross-sectional area is the main determining factor in force generated by the muscle and is controlled by the number of myofibrils that contract. Weight lifting can lead to muscle hypertrophy, increased cross-sectional area, and increased force (ability to lift heavier weights). Fiber types have less to do with the force of contraction and more to do with the duration and speed of contraction.
Baroni et al. investigated the chronology of neural and morphological adaptations to knee extensor eccentric training. After 12 training weeks, significant increases in strength and anatomical cross-sectional area (19%) were seen.
Illustration A shows how muscle hypertrophy from strength training increases cross- sectional area.
Incorrect Responses:
The other functional attributes of a muscle, such as speed and duration of contraction and fatigability are more predicated on muscle fiber type than on the area.

An orthopaedic resident wants to answer a focused research question of whether mobile bearing knee arthroplasty has superior functional outcomes compared to fixed bearing knee arthroplasty. The resident mathematically combines the results from multiple retrospective cohort studies following QUORUM (Quality of Reporting of Meta-analyses) guidelines. What is the highest level of evidence that this meta-analysis can achieve?

1) Level I

2) Level II

3) Level III

4) Level IV

5) Level V

The level of evidence assigned to a meta-analysis is based on the lowest level of evidence of the included studies. In this case, the studies included in the meta-analysis were retrospective cohort (Level III) studies.
A meta-analysis is a systematic review that combines the results of multiple studies to answer a focused clinical question.
Clarke discusses the QUORUM guidelines which are intended to address standards for
improving the quality of reporting of meta-analyses of clinical randomized controlled trials. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and MOOSE (Meta-analysis Of Observational Studies in Epidemiology) guidelines are similar standards. A
similar set of guidelines called CONSORT (Consolidated Standards of Reporting Trials) guidelines are available for randomized trials.
Incorrect Answers:
1: Level I studies include high-quality randomized controlled trials
2: Level II studies include lower-quality RCTs and prospective cohort studies.
4: Level IV studies include case-series or poor-quality cohort and case-control studies. 5: Level V studes are expert opinion articles.

An adolescent patient is treated with a 6mm solid intramedullary nail. Compared to a 12mm solid nail of the same material, the 6mm nail has:

1) 1/2 the torsional rigidity

2) 1/4 the torsional rigidity

3) 1/16 the torsional rigidity

4) 1/8 the torsional rigidity

5) the same torsional rigidity

Nail radius affects nail bending and torsional rigidity. For a solid circular nail, the torsional rigidity is proportional to the fourth power of the radius. Thus a nail with 1/2 the diameter (6mm compared to 12mm) and therefore 1/2 the radius (3mm compared to 6mm) would have(1/2)^4 = 1/16 the torsional rigidity (answer 3). Bong et al. performed a great review of the biomechanics and biology of intramedullary nailing of the lower extremity.

The ability of a study to detect the difference between two interventions if one in fact exists describes which of the following?

1) Positive predictive value

2) Hawthorne effect

3) Effect size

4) Power

5) P value

The study power is defined as the ability of a study to detect the difference between two interventions if one in fact exists.
The power of a statistical test is correlated to the magnitude of the treatment effect, the designated type I (alpha) and type II (beta) error rates, and the sample size n. The power is equal to (1-beta) whereby beta is the false negative rate.
Kocher et al. present a Level 5 review of epidemiology and biostatistics. The review discusses study design, hypothesis testing, diagnostic performance, measures of effect, outcomes assessment, evidence-based medicine, and biostatistics. They discuss that in the orthopaedic literature power is typically set at 80%, (leaving a 20% chance that the study will display no significant association when there is an actual association.) Illustration A shows the interaction of study variables on the power of a study. Incorrect Answers:
Answer 1: Positive predictive value is the probability that a patient with a positive test actually has the disease. This value is dependent on the prevalence of disease
Answer 2: Hawthorne effect is a behavior that is changed when participants have knowledge that their behavior is being monitored.
Answer 3: Effect size is the difference in outcome between the treatment group and the control group divided by the standard deviation.
Answer 5: P value is defined as the probability, under the assumption of no difference (null hypothesis), of obtaining a result equal to or more extreme than what was actually observed if the experiment were repeated over and over

Which of the following best describes the appearance of chondrocytes and orientation of collagen fibrils in the superficial zone of articular cartilage?

1) Round chondrocytes oriented parallel with the tidemark and collagen fibrils oriented perpendicular to the tidemark

2) Round chondrocytes oriented parallel with the tidemark and collagen fibrils oriented parallel to the tidemark

3) Flattened chondrocytes oriented parallel with the tidemark and collagen fibrils oriented perpendicular to the tidemark

4) Flattened chondrocytes oriented perpendicular with the tidemark and collagen fibrils oriented perpendicular to the tidemark

5) Flattened chondrocytes oriented parallel with the tidemark and collagen fibrils oriented parallel to the tidemark

Flattened chondrocytes oriented parallel with the tidemark and collagen fibrils oriented parallel to the tidemark best describes the orientation of collagen fibrils in the superficial zone of articular cartilage.
The primary orientation of the collagen fibers in the superficial zone is parallel with the joint surface, in order to resist compressive and sheer forces. This zone is the thinnest one, and it sometimes is referred to as the gliding zone. The surface layer, known as the lamina splendens, is cell-free and composed mainly of randomly oriented, flat bundles of fine collagen fibrils. Deep to the lamina splendens are more densely packed collagen fibers interspersed with elongated, oval chondrocytes oriented parallel to the articular surface.
Sophia Fox et al. in a review article state that the superficial zone comprises 10-20% of articular cartilage and is composed of mostly type II and IX collagen.
Illustration A displays that articular cartilage has four distinct zones: (1) a superficial (tangential) zone, (2) a middle (transitional) zone, (3) a deep (radial) zone, and (4) the calcified zone. Illustration B demonstrates the collagen orientation and chondrocyte appearance in the different articular cartilage layers.
Incorrect Answers:
Answer 1-4: None of these accurately describe the appearance of
chondrocytes and orientation of collagen fibrils in the superficial zone of articular cartilage.

A 52-year-old male underwent a right total knee arthroplasty 3 days ago and reports new onset dyspnea. His vitals signs include a temperature of 98.8, pulse of 133, blood pressure of 130/77, respiratory rate of 28, and oxygen saturation of 91% on room air. A chest radiograph shows atelectasis. Which of the following findings is most likely also present?

1) Hyperchloremic metabolic acidosis

2) Jugular venous distention with tracheal deviation

3) EKG demonstrating S-wave in lead I Q-wave in lead III T-wave inversion in lead III

4) Pleural effusion with pleural/serum protein >0.5 and pleural/serum LDH > 0.6

5) Increased carbon monoxide diffusing capacity (DLCO)

The patient's clinical presentation is consistent with a pulmonary embolism and an EKG demonstrating S-wave in lead I Q-wave in lead III T-wave inversion in lead III is most likely associated with this diagnosis.
The most commonly seen signs in the EKG associated with PE are sinus tachycardia, right axis deviation and right bundle branch block. Sinus tachycardia is however only found in 8–69% of people with PE. The S1Q3T3 pattern discussed here is from acute right heart strain and is termed the "McGinn-White sign" after the initial describers but is only found in about 10-
20% of people with a PE. Patients undergoing total knee arthroplasty (TKA) without DVT prophylaxis have symptomatic PE at a rate of approximately 8%. Patients undergoing TKA have a higher risk for the presence of DVT but are at a lower risk for symptomatic PE than patients undergoing total hip arthroplasty.
Stein et al. present a study that found that dyspnea or tachypnea occurred in
92% of patients diagnosed with a pulmonary embolism. They also report that dyspnea or tachypnea was less commonly encountered in elderly patients with no previous cardiopulmonary disease.
Illustration A is a table that describes some of the characteristic findings of pulmonary embolism on a chest radiograph.
Incorrect answers:
Answer 1: Non-saddle pulmonary emboli are most often associated with respiratory alkalosis due to tachypnea.
Answer 2: Jugular venous distention with tracheal deviation is seen with tension pneumothorax.
Answer 4: Pleural effusion with pleural/serum protein >0.5 and pleural/serum LDH > 0.6 is consistent with an exudate such as pneumonia
Answer 5: Increased carbon monoxide diffusing capacity (DLCO) is not seen with pulmonary emboli.

The estimated range of values which likely includes the unknown parameter under investigation is defined as which of the following?

1) Standard deviation

2) Mode

3) Variance

4) Confidence interval

5) Incidence

When an unknown value is sought, the confidence interval gives the statistician a set of parameters within which the “true” value is located. The confidence interval is used to indicate the reliability of an estimate. The standard deviation is a quantity calculated to indicate the extent of deviation for a group as a whole. The mode is the value which
occurs most frequently in a given set of data. The variance is a quantity equal to the square of the standard deviation. The incidence is the frequency of an occurrence (or disease).

**Which of the following is true regarding the cell seen in Figure A?**
1) Originates from hematopoietic cells from a macrophage lineage

2) Derived from undifferentiated mesenchymal cells

3) They are former osteoblasts trapped in the matrix they produced

4) They become cartilage under intermediate strain and low oxygen tension

5) They form bone by producing non-mineralized matrix

The image shown in Figure A shows an osteoclast remodeling cortical bone through a cutting cone mechanism. Osteoclasts orginate from hematopoietic cells from a macrophage cell lineage.
Osteoclasts can be distinguished from other bone cells by their multinucleated giant cells and ruffled border on the cell periphery which increases the surface area for bone resorption. Their main function is to reabsorb bone after being stimulated by RANK-L and IL-1. A balance between osteoclast and osteoblast activity is necessary for a stable calcium level in the blood.
Caterson et al. review mesenchymal stem cells and their ability to regenerate musculoskeletal tissue. They state that potential applications include replacement of bone graft for segmental defects, nonunions, spinal fusions, and articular resurfacing.
Illustration A shows the differences between osteoblasts, osteoclasts and osteocytes. Video V describes the role and function of osteoblasts and osteocytes.
Incorrect Answers:
Answer 2: This is true of osteoblasts. Answer 3: This is true of osteocytes.
Answer 4: This is true of osteoprogenitor cells. Answer 5: This is true of osteoblasts.

What is the equation for determining specificity of a clinical test?

1) True negatives divided by the sum of the true negatives and false positives

2) True negatives divided by the sum of the true negatives and false negatives

3) True positives divided by the sum of the true negatives and false positives

4) True positives divided by the sum of the true positives and false negatives

5) True positives divided by the sum of the true positives and false positives

Specificity is the probability that a test result will be negative in patients without disease (answer 1). The sensitivity is the probability that a test result will be positive in patients with disease (answer 4). The positive predictive value is the number of patients with a positive test result who are correctly diagnosed and the negative predictive value is the opposite of this (answers 5 and 2, respectively). The referenced review article by Kocher describes many of the statistical tools useful for practicing orthopaedic surgeons.

Which of the following graft materials has the least potential to elicit an immune response?

1) Fresh irradiated corticocancellous bulk allograft

2) Fresh frozen fibular strut allograft

3) Fresh frozen Achilles tendon allograft

4) Fresh Achilles tendon allograft

5) Freeze dried cancellous bone chips

Of the options listed, freeze dried cancellous allograft has the least potential to elicit an immune response. Remember, all allograft tissue has more of an immune response generating capability than autograft tissue, which has the least of any of these materials.
All allograft materials carry immunogenic properties, which decrease as the material is processed via the various sterilizing, freezing, or drying process(es). As the processing increases, the mechanical characteristics of the graft tends to decrease.
Ahlmann et al. compared the complications associated with harvesting iliac crest bone graft from the anterior crest and posterior crest. They found the rates of both minor complications (p = 0.006) and all complications (p =
0.004) were significantly higher after the anterior harvest procedures than they were after the posterior procedures. They recommend that iliac crest bone graft be harvested posteriorly whenever possible.
Incorrect Answers:
Answer 1: Most bone and soft tissue allografts undergo irradiation to remove bacteria or other infectious agents, but this does not prevent an immune
response in itself.
Answer 2: Fresh frozen allografts have more immunogenic potential than freeze dried, but less than fresh materials. Fresh allograft is not typically utilized, as the processing of allograft (bone or soft tissue) provides the safety of minimizing infectious disease transmission.
Answer 3: Fresh frozen allografts have more immunogenic potential than freeze dried, but
less than fresh materials. Thus fresh Achilles tendon allograft has the highest immunogenicity.
Answer 4: Fresh Achilles tendon allograft will elicit the greatest immunogenic response.

**Which of the following statements is correct regarding Vitamin D?**

1) 1,25-dihydrocholecalciferol is the best laboratory study to determine a Vitamin D deficiency

2) 25-hydroxycholecalciferol is the active form of Vitamin D

3) 24,25-dihydroxycholecalciferol is an inactive form of Vitamin D

4) 1,25-dihydrocholecalciferol is converted to 25-hydroxycholecalciferol in the kidney

5) The half-life of 1,25-dihydrocholecalciferol is longer than 25- hydroxycholecalciferol

24,25-dihydroxycholecalciferol in an inactive form of Vitamin D. High levels of
1,25-dihydroxyvitamin D stimulate the enzymatic production of 24,25- dihydroxyvitamin D, the inactive form of vitamin D, thereby self-regulating the action of 1,25-dihydroxyvitamin D.
Vitamin D is paramount to proper calcium homeostasis and has important clinical implications in the orthopaedic patient. Vitamin D3 is synthesized in the skin and is converted to 25-hydroxycholecalciferol in the liver. 25- hydroxycholecalciferol is then converted in the kidney into 1,25- dihydroxycholecalciferol, the active form of vitamin D. The best test to determine Vitamin D deficiency is the measurement of 25- hydroxycholecalciferol, as it has a longer half-life and circulating levels are
1,000x more than 1,25-dihydrocholecalciferol.
Patton et al. review the importance of Vitamin D in the orthopaedic patient. They discuss the implications of Vitamin D deficiency, and urge orthopaedic surgeons to be proficient in both the diagnosis and treatment of the condition.
Bogunovic et al. measured the levels of 25-hydroxycholecalciferol in 723 patients who were to undergo orthopaedic surgery. 40% of these patients were noted to be deficient in Vitamin D, with the highest rates in patients scheduled to undergo trauma and sports surgery.
Illustration A reviews Vitamin D metabolism. 24,25-dihydroxycholecalciferol is referred to as pre-Vitamin D.
Incorrect Answers:
Answer 1: 25-hydroxycholecalciferol is the best laboratory study to determine
Vitamin D deficiency due to its long half-life and high circulating levels. Answer 2: 1,25- dihydroxycholecalciferol is the active form of Vitamin D. Answer 4: 25- hydroxycholecalciferol is then converted in the kidney into 1,25- dihydroxycholecalciferol. Answer 5: The half-life of 25-hydroxycholecalciferol is 2-3 weeks, while the
half-life of 1,25-dihydrocholecalciferol is only 4-6 hours.

You are the team physician for a collegiate football team and receive weekly injury reports from the athletic trainer. All players with sickle-cell trait are listed at the bottom to remind all on-field**
**personnel that they may need which of the following?

1) Oxygen supplementation and oral or IV hydration

2) Additonal layers of warm clothes

3) Increased pain medication

4) Avoidance of non-steroidal anti-inflammatory medicines

5) Days of rest due to increased joint pain

Players with a blood test indicating the presence of sickle-cell trait (SCT) are at risk for exertional sickling collapse which responds initially to rest, hydration and oxygen.
SCT is not a disease but a condition, resulting from inheritance of one gene for sickle hemoglobin (S) and one gene for normal hemoglobin (A).
The vital concern is exertional sickling collapse, which can be fatal, occurs in a variety of sports, and is a leading cause of death in college football.
According to the review by Eichner, sickling collapse is an “intensity”- associated syndrome that differs from the other common causes of collapse. The best approach in college football may be tailored precautions to prevent sickling collapse and enable athletes with SCT to thrive. Other clinical concerns in SCT are compartment syndromes and lumbar myonecrosis, splenic infarction, gross hematuria, hyposthenuria, and venous thromboembolism.
Kark et al. reviewed all cases of sudden death occurring among 2 million enlisted recruits during basic training in the U.S. Armed Forces from 1977 to
1981/. They concluded that "recruits in basic training with the sickle-cell trait have a substantially increased, age-dependent risk of exercise-related sudden death unexplained by any known preexisting cause".
Incorrect Responses:
2/. no research to support need for warmer clothes and cases occur year round. 3&5/. these are typical of sickle cell disease, not SCT.
4/. important in patients with renal impairment, which is not typically seen in SCT.

A physician is interested in using platelet-rich plasma (PRP) for treatment of osteochondral lesions of the talus. He is reviewing a prospective cohort study that compares 40 patients treated with PRP and cast immobilization for 6 weeks vs. 36 patients treated conservatively with cast immobilization for 6 weeks. All patients were treated at the same time and institution. The study was not randomized although treatment and control groups were matched
**appropriately to reduce selection bias. Follow-up in each group was**
> 80% over 1 year. The paper reported significant improvement with use of PRP based on three standard foot and ankle outcome scores (AOFAS, SF-36, FOAS). What is the level of evidence for this study?

1) Level I

2) Level II

3) Level III

4) Level IV

5) Level V

This is prospective cohort study with Level-II evidence.
Level of evidence provides guidance to the study quality. It is used to assess therapeutic studies (as with this question), prognostic studies, diagnostic studies and economic or decision models. When determining the level of evidence, readers must critically appraise the study question, treatment, intervention and outcomes of the study design. Level-II therapeutic studies consist of well-designed prospective cohort studies, poor-quality randomized controlled trials (follow-up less than 80%) and systematic review of Level-II studies or non-homogenous Level-I studies.
Wright et al. provided an excellent summary of clinical research study level of evidence. This has been provided as Illustration A.
Illustration A shows a chart of level of evidence. There is a column for each type of study which corresponds to a row that outlines the level of evidence based on study
design.
Incorrect Answers:
Answer 1: Level-I evidence include randomized controlled studies with follow- up>80% and systematic review of Level-I RTC studies (homogenous studies) Answer 3: Level-III evidence include case control studies, retrospective cohort studies and systematic review of Level-III studies
Answer 4: Level-IV evidence include case series with no control group (or compare to a historical control group)
Answer 5: Level V evidence include expert opinion

Low serum phosphate and normal calcium levels are found in what common etiology of hereditary rickets?

1) X-linked hypophosphatemic

2) Vitamin D-dependent, type I

3) Vitamin D-dependent, type II

4) Autosomal dominant hypophosphatemic

5) Jansen's metaphyseal chondrodysplasia

Low serum phosphate and normal calcium levels are found in X-linked hypophosphatemic rickets.
X-linked hypophosphatemic rickets is the most common form of hereditary rickets. It is an X-linked dominant disorder which has been linked to the PHEX gene. Laboratory findings
of this disorder include low serum phosphate, normal serum calcium and 25 hydroxycholecalciferol levels, and inappropriately low 1,25-dihydroxyvitamin D3.
Carpenter et al. showed hypophosphatemic rickets was initially referred to as “vitamin D resistant rickets” due to its lack of response to therapeutic vitamin D. Current treatment with activated vitamin D metabolites (calcitriol or
alfacalcidol) and phosphate salts have been shown to help with this condition.
Illustration A shows an insufficiency fracture of the proximal tibia in an adult patient with X-linked hypophosphatemic rickets. A stress fracture on the medial tibia may be a presenting feature of untreated disease.
Incorrect Answers:
Answer 2: Vitamin D-dependent rickets, type I, is a rare autosomal recessive disorder. Answer 3: Vitamin D-dependent rickets, type II, is a rare autosomal recessive disorder, most often caused by mutations in the vitamin D receptor gene. Answer 4: Autosomal dominant hypophosphatemic results from a rare mutation in the fibroblast growth factor 23 (FGF23) gene.
Answer 5: Jansen's metaphyseal chondrodysplasia is a skeletal dysplasia that results from ligand-independent activation of the type 1 parathyroid hormone
receptor (PTHR1).

A healthy patient undergoes routine pre-operative laboratory testing and is found to have a leukocyte count of 1.5 × 10(9) cells/L. When the historical records are examined, this is found to be the patients base-line level over a period of years. Which of the following statements is most likely to be true:

1) The patient is at a significantly higher risk of surgical infection

2) The patient is more likely to be of African than of European descent

3) The patient is more likely to be of European than of Middle Eastern descent

4) The patient is more likely to be a non-athlete than an athlete

5) The patient is more likely to be female than male

The clinical presentation is consistent with Benign Ethnic Neutropenia, a condition in which a patient has chronic, benign, inborn and lifelong absolute neutrophl count below population mean. This condition is found in the U.S. to be most common in African- Americans, some groups of Middle Eastern patients, males, children under 5 years old, and athletes compared to non- athletes.
A standardized level at present for abnormally low absolute neutrophil count (ANC) is below 1.5 x 10(9) cells/L, however this may not have clinical or scientific relevance as a cutoff point, particularly in the affected Ethnic groups. Fewer than 1% of all populations have absolute neutrophil count
A 14-year-old patient has sustained a complete ACL tear of his right knee. Which of the following options has shown to be the most limiting factor for access to pediatric orthopaedic management in the United States?

1) Sex of the patient

2) Type of health insurance

3) Child greater than 10 years of age

4) Acute knee injuries requiring operative treatment

5) Timing of the referral

The type of health insurance in the pediatric population has shown to be a significant factor for access to specialized healthcare in the United States.
Access to pediatric orthopaedic management has been well investigated. Numerous Level 4 studies have shown that orthopaedic offices in urban and rural areas prefer treating patients with private insurance over patients with Medicaid.
Iobst et al. telephoned 100 urban and rural orthopaedic outpatient offices to schedule an appointment for a 10-year-old patient with a forearm fracture. They showed that 8/100 offices would schedule an appointment within 1 week to the child with Medicaid insurance, as compared to 36/100 that gave an appointment to a child with private insurance.
Pierce et al. contacted 42 orthopaedic practices to schedule an appointment for a 14- year-old patient with an ACL injury. They showed that 38/42 offices scheduled an appointment for the child within 2 weeks with private insurance. This compared to 6/42 that scheduled an appointment for a similar child with Medicaid.
Incorrect Answers:
Answers 1,3,4,5: The limiting determinant to healthcare in the pediatric population has shown to be the type of health insurance. Sex, age of child, operative vs nonoperative injuries and timing of referral have not been shown to affect access to healthcare.

The perioperative use of which medication has been shown to increase the risk of post-operative infection following orthopaedic procedures in patients with rheumatoid arthritis (RA)?

1) Naproxen

2) Leflunomide

3) Sulfasalazine

4) Etanercept

5) Aspirin

Of the medications listed, only etanercept has been shown to increase the risk of post- operative infection following orthopaedic procedures in patients with RA.
Etanercept is a TNF-alpha antagonist with a short half-life that is administered once or twice weekly in patients with RA. Since TNF-alpha plays a central role in the pathogenesis of RA and is instrumental in causing joint destruction, the inhibition of this molecule has shown excellent results in controlling disease. The most powered study on TNF-alpha inhibitor use in the perioperative period following an orthopaedic procedures demonstrated a significant increase in
post-operative infection.
Howe et al. review the medical management of patients with RA who underwent orthopaedic procedures. They state that while there is conflicting information regarding TNF-alpha antagonists, they recommend holding them prior to major orthopaedic interventions.
Giles et al. review 91 patients with rheumatoid arthritis who underwent an orthopaedic procedure. They found TNF-alpha inhibitor therapy to be significantly associated with the development of a serious postoperative infection (p=.041)
Perhala et al. review 61 patients with RA who were treated with methotrexate during the perioperative period surrounding a total joint arthroplasty. They
failed to find a significant increase in complications in this patient group, stating the perioperative use of methotrexate does not affect wound healing or increase the likelihood of periprosthetic infection.
Illustration A shows the site of action of TNA-alpha inhibitors in the RA pathway.
Incorrect Answers:
Answer 1: Naproxen should be discontinued 3 days prior to surgery because of its ability to increase bleeding time and the subsequent potential for increased blood loss.
Answer 2: Leflunomide is an inhibitor of pyrimidine synthesis. It has not been shown to increase the risk of post-operative infection.
Answer 3: Sulfasalazine's mechanism of action is largely unknown, but it has not been shown to increase the risk of post-operative infection.
Answer 5: Aspirin has not been shown to increase infection if continued in the perioperative period.

Communication breakdown is the leading cause of which of the following?

1) Delayed diagnoses

2) Medication errors

3) Surgical site infections

4) 1 and 2

5) All of the above

Communication failures are the leading cause of wrong side surgeries, medication errors and diagnostic delays.
Poor communication sets up environments in which medical errors can take place. Per the Joint Commission, medical errors may be the among the top 10 causes of death in the United States. Establishing open lines of communication is critical to reduce the risk of error and enhance patient safety.
Gandhi et al. designed a framework to study missed or delayed diagnoses and their causes. The most significant factors contributing to errors were poor handoffs, failures in judgment, failures in memory and failures in knowledge.
O’Daniel et al. review the importance of professional communication and collaborative team efforts. They note that patient safety is at risk when poor communication is in place. The leading cause for medication errors, treatment delays and wrong-site surgeries is communication failure.
Illustration A shows the leading causes of death in the United States. This includes “preventable errors” as a cause.
Incorrect Answers:
Answers 1, 2: Communication failures can lead to delays in diagnosis and
treatment, medication errors and wrong side surgery
Answers 3, 5: Communication failure is not a direct contributor to surgical site infection

**Which of the following is true regarding osteoprotegerin (OPG)?**

1) It is secreted by osteoclasts

2) It increases bone resorption

3) Binds to prostoglandin E2 before stimulating osteoclasts

4) Osteoprotegerin knock-out mice develop osteopetrosis

5) Binds to and sequesters RANKL

Osteoprotegerin is a decoy receptor for RANKL. Binding to RANKL causes decreased production of osteoclasts by inhibiting the differentiation of osteoclast precursors.
Bone resporption/remodeling is a complex process regulated by a large variety of molecules. Molecules that have shown to inhibit osteoclasts include OPG, calcitonin, estrogen, TGF-B, and IL-10. Corticosteroids have been shown to decrease production of OPG, thereby enhancing osteoclast formation and longevity. Prolia, or denosumab, is a newly approved drug used to treat osteoporosis and has a mechanism of action similar to osteoprotegerin
(inhibits binding of RANKL to RANK).
Boyle et al. review osteoclast differentiation and activation. The authors state that targeted disruption of OPG causes increased osteoclastogenesis and/or activation resulting in osteopenia.
Illustration A shows how OPG binds to RANKL inhibiting the stimulation of osteoclasts.
Incorrect Answers:
Answer 1: OPG is secreted by osteoblasts.
Answer 2: OPG decreases bone resorption by inactivating RANKL. Answer 3: OPG does not bind to prostoglandin E2, nor does it stimulate osteoclasts.
Answer 4: RANKL knock-out mice creates an osteopetrosis-like condition.

A 55-year-old woman has T-score -2.0 at the femoral neck. According to the World Health Organization Fracture Risk Assessment Tool (FRAX), she has a ten- year probability of sustaining a hip fracture of 1.5% and a ten-year probability of sustaining a major osteoporotic fracture of 8.9%. Which of the following statements is true regarding her antiresorptive therapy management?

1) Antiresorptive therapy should be started based on her T-score

2) Antiresorptive therapy should be started based on her risk of hip fracture alone

3) Antiresorptive therapy should be started based on her risk of major osteoporotic fracture alone

4) Antiresorptive therapy should not be started

5) Antiresorptive therapy should be started based on her risks of both hip fracture and major osteoporotic fracture

This patient has osteopenia. Assessment by FRAX shows that ten-year risk of hip fracture is less than 3% and her ten-year risk of major osteoporosis- related fracture is less than 20%. Therefore, antiresorptive therapy is not indicated at this time.
According to the 2008 National Osteoporosis Foundation guidelines, pharmacologic treatment for osteoporosis should be considered if patients are
postmenopausal women or men greater than 50 years old AND meet one of the following criteria: (1) they have a prior hip or vertebral fracture, (2) they have a T score -2.5 or less at the femoral neck or spine, (3) they have a T score between -1.0 and -2.5 at the femoral neck or spine AND a 10-year risk of hip fracture greater than 3% or 10-year risk of major osteoporosis-related fracture greater than 20%.
FRAX (World Health Organization Fracture Risk Assessment Tool) calculates
10-year risk of fracture based on the following variables: age, sex, race, height, weight, BMI, history of fragility fracture, parental history of hip fracture, use of oral glucocorticoids, secondary osteoporosis and alcohol use to calculate 10-year risk of fracture.
Unnanuntana et al. reviewed the assessment of fracture risk. Besides FRAX score and T-score, they discussed biochemical markers of bone formation and resorption, which are useful for monitoring the efficacy of antiresorptive / anabolic therapy, and may help identify patients at high risk for fracture.
Ekman et al. reviewed the role of the orthopaedic surgeon in minimizing mortality and morbidity associated with fragility fractures. The surgeon should consider prescribing appropriate medications, physical therapy, assessing fall risk and preventing falls and changing lifestyle factors (exercise, smoking and alcohol).
Illustration A shows the FRAX online tool ([_http://www.shef.ac.uk/FRAX/tool.aspx?country_ _=__=9)._ Illustration B shows the](http://www.shef.ac.uk/FRAX/tool.aspx?country=9/)) clinical risk factors considered in FRAX calculation.
Incorrect Answers:
Answer 1: T-score of -2.0 is not an indication for initiating treatment. Answers 2, 3, 5: Her FRAX score does not show a risk of hip or osteoporosis- related fracture high enough to be an indication for initiating treatment.

A 32-year-old runner sustains a trimalleolar left ankle fracture. She undergoes open reduction and internal fixation and is kept non- weightbearing after surgery. At 2 months, what changes will occur in the articular cartilage of both her knees as a result of her current weightbearing regimen?

1) Cartilage thickening in the left (ipsilateral) knee and no change in cartilage thickness in the right (contralateral) knee

2) Cartilage thinning in both knees

3) Cartilage thinning in the left (ipsilateral) knee and no change in cartilage thickness in the right (contralateral) knee

4) Cartilage thinning in the left (ipsilateral) knee and increased cartilage thickness in the right (contralateral) knee

5) Increased cartilage thickness in both knees

After a period of off-loading, the off-loaded limb will experience cartilage thinning. The contralateral limb will not demonstrate any cartilage changes.
Physiologic loading of cartilage increases proteoglycan synthesis and cell proliferation and is chondroprotective. Joint immobilization leads to cartilage thinning, tissue softening, and reduced proteoglycan content, leading to cartilage erosion. Joint overuse leads to cartilage damage (in vitro only).
Hinterwimmer et al. examined cartilage atrophy after partial load bearing
using quantitative MRI. They found cartilage thinning in all knee compartments (greatest thinning, medial tibia; least thinning, patella). There was no change in cartilage morphology in the contralateral knee.
Sun reviewed the relationship between mechanical loading and cartilage degeneration. In OA, cartilage breakdown occurs at the articular surface, and is then fueled by synovial proteases and cytokines. In RA, synovial cells and macrophages are the source of degradative enzymes and incite cartilage destruction.
Milward-Sadler et al. examined mRNA levels following mechanical stimulation in normal and osteoarthritic chondrocytes. Normal chondrocytes showed increased aggrecan mRNA and decreased matrix metalloproteinase 3 (MMP-3) mRNA after stimulation. This
chondroprotective response was absent in osteoarthritic chondrocytes.
Illustration A shows pro- and anti-inflammatory mechanisms of mechanical loading on chondrocytes. Underloading and overloading induce cartilage damage through pathways involving the upregulation of MMPs and ADAMTSs (ADAMTS, a disintegrin and metalloproteinase with thrombospondin motifs, or aggrecanase). Physiological loading blocks these increases.
Incorrect Answers:
Answer 1: Cartilage THINNING (not thickening) will occur on the offloaded limb (left). Answers 2 and 5: There will be a difference in cartilage thickness between knees as a result of different weightbearing status on both lower extremities. Answer 4: Noticeable cartilage hypertrophy does not occur on the uninjured limb.

A morbidly obese 40-year-old man is scheduled to undergo hemilaminectomy for resection of an painful osteoid osteoma of the T6 lamina. He is positioned prone on a Jackson table and localization is performed with intraoperative fluoroscopy prior to the start of the case. At close to the end of the case, intraoperative frozen section reveals only normal bone fragment from the resected lamina. A probe is placed and a cross-table lateral radiograph reveals that the T7 lamina was resected instead of T6. At this point, the surgeon should**
**do all of the following EXCEPT

1) Complete the surgery

2) Abort the case and obtain further imaging

3) Apologize to the patient and family

4) Formally document the error in the operative report

5) Inform the patient and family immediately after the operation
should include a disclosure of known facts and an explanation as to the likely cause, as well as ongoing treatment, follow up care, and prognosis.
The AAOS Information Statement about Wrong Site Surgery identifies 3 treatment steps following discovery of an error during surgery under general anesthesia: Return the patient to his preoperative condition, perform the correct procedure at the correct site, and advise the patient and family of what occurred and the likely consequences, if any, of the wrong- site surgery.
The AAOS Information Statement on Communicating Adverse Events states that the surgeon has an ethical and professional obligation to disclose the error to the patient and/or family. Disclosure should include what happened, why it happened, health implications, and what measures are being instituted to prevent recurrences.
Incorrect Answers:
Answer 1: Completion of the surgery at the correct site is necessary unless proceeding with the surgery at the correct site would increase the risk associated with extended operating time, or if correct-site surgery would result in an additional unacceptable disability.
Answers 3: Many patients have expressed that an apology is important. In the apology, the physician should express support for the patient and family, show compassion and concern, and acknowledge their emotional response and needs. This will help to set clear goals for the future patient-physician interaction.
Answer 4: Full disclosure is recommended and there should be no attempt at concealment or obfuscation. This is especially true for the operative report. Answer 5: A composed dialogue between the surgeon and both patient and family after the event is preferred to a hurried call from the operating room which is prone to misunderstanding and leaves no room for questions and answers.

All of the following are Standards of Professionalism relating to interactions with industry for practicing orthopaedic surgeons EXCEPT:

1) Decline gifts from industry with a market value over $100 (unless they are medical textbooks or patient educational materials)

2) Disclose to the patient any financial arrangements with industry that relates to the patient's treatment

3) Accept no direct financial inducements from industry for utilizing a particular implant

4) Disclose any relationship with industry to colleagues who may be influenced by your work

5) Decline to participate in industry sponsored non-CME courses or
conferences

The AAOS has adopted the Standards of Professionalism (SOP). These SOP’s establish mandatory, minimum levels of acceptable conduct for fellows and members of the AAOS to engage in relationships with industry. There are 17 standards with relation to industry. Answer choice 5 is not a SOP as surgeons are allowed to participate in or consult in meetings that are conducive to the effective exchange of information. The SOP also stipulate that tuition, travel, and modest hospitality (including meals and receptions) are allowed to attend an industry-sponsored non-CME course.

A prospective randomized trial is conducted to test the efficacy of Vitamin C versus placebo in treating patients who develop chronic regional pain syndrome (CRPS) after distal radius fractures. At first follow-up, the rates of CRPS are 1% and 9% in the study and placebo group, respectively. Which statistical test is most appropriate to determine significance?

1) Single factor analysis of variance

2) Chi-square test

3) Student t-test

4) Mann-Whitney rank sum test

5) Wilcoxon rank sum test

In the study provided, we need to determine whether distributions of categorical variables differ from one another. The appropriate study is the chi- square test.
Data can be classified as numerical (continuous) or categorical (proportional). Responses to such questions as "What is your major?" or Do you own a car?" are categorical because they yield data such as "biology" or "no." In contrast, responses to such questions as "How tall are you?" or "What is your G.P.A.?" are numerical. When comparing two independent means from numeric data, a t-test is performed. However, if categorical data is being compared, the chi- square test will determine if the proportions are really different.
Kocher et al. review basic clinical epidemiology and biostatistics relevant to orthopaedic surgery. Amongst other things, they describe that data can be summarized in terms of measures of central tendency, such as mean, median, and mode, and in terms of measures of dispersion, such as range, standard deviation, and percentiles.
Illustration A shows an algorithm for determining which test to use for varying data. Incorrect Answers:
Answer 1: Analysis of variance (ANOVA) is used to compare means of three or more independent groups in which the data are normally distributed.
Answer 3: Student t-test is used for comparing means of continuous data that is normally
distributed.
Answer 4: The Mann-Whitney and Wilcoxon rank sum tests are used for comparing means of non-continuous data.
Answer 5: The Mann-Whitney and Wilcoxon rank sum tests are used for comparing means of non-continuous data.

A 35-year-old patient is involved in a motor vehicle accident and sustains multiple fractures including a closed comminuted proximal meta-diaphyseal tibia fracture. The surgeon is considering bridge plating the fracture using a minimally invasive approach. Which of the following is true regarding bridge plating?

1) A locked plate construct (locked screws) or hybrid construct (locked and non- locked screws) is necessary.

2) Periosteal stripping is performed through two incisions proximal and distal to the fracture.

3) Bridge plating is performed following direct reduction of the fracture.

4) AO Type A diaphyseal fractures are best treated with this technique.

5) Bridge plating with a long working length creates a flexible, axially stable construct.

In bridged plating, only the most proximal and distal screw holes are filled. This creates a flexible, axially stable construct.
Bridge plating is applicable to all long-bone fractures with complex fragmentation and where intramedullary nailing or conventional plate fixation is not suitable. The construct preserves the blood supply to the fracture fragments as the fracture site is undisturbed during the operative procedure. It provides RELATIVE stability, allowing for some motion at the fracture site, leading to callus formation and secondary bone healing. The construct is FLEXIBLE because of increased distance between the 2 screws closest to the fracture (long working length), allowing for stress distribution and permitting more motion at the fracture site. The construct is also AXIALLY STABLE because the plate acts as an extramedullary splint and resists axial compression.
Livani et al. advocate using an anterior or antero-lateral approach for minimally invasive plating of the humerus. They recommend that distal access is obtained first, allowing identification of the lateral antebrachial cutaneous nerve. For distal fractures, they recommend extending the plate down to the lateral column.
Apivatthakakul et al. defined minimally-invasive plate osteosynthesis (MIPO) danger zones from the lateral epicondyle. They found the musculocutaneous nerve averaged 18- 43% of the humeral length, the danger zone for the radial nerve averaged 36-59% of the humeral length, and the most dangerous screws that penetrated or touched the radial nerve lay 47-53% of the humeral length.
Illustration A shows a distal tibia fracture. Illustration B shows radiographs 5 months after bridge plating of this fracture. There is callus formation, characteristic of indirect bone healing.
Answer 1: Locked plates are not necessary for bridge plating. Conventional plate/screws may be used.
Answer 2: Bridge plating through a minimally invasive approach avoids periosteal stripping and the plate lies in a submuscular location. It is especially important where comminution is present and preservation of tenuous
periosteal blood supply is critical.
Answer 3: Bridge plating is usually applied following some form of indirect reduction. Indirect reduction involves manipulating fragments into the correct position without opening the fracture site, thus minimizing damage to the blood supply. The main principle of indirect reduction is distraction.
Answer 4: AO Type A simple diaphyseal fractures are best treated with intramedullary nailing (relative stability) or anatomic reduction and compression plate fixation (absolute stability).

Which of the following components of bone is most responsible for compressive strength?

1) Type I collagen

2) Osteocalcin

3) Proteoglycans

4) Osteonectin

5) Osteopontin

Proteoglycans, in addition to calcium hydroxyapatite [Ca10(PO4)6(OH)2], are most responsible for providing compressive strength.
Bone is composed of both organic and inorganic components. Inorganic components include calcium hydroxyapatite and osteocalcium phosphate. Organic components include collagen, proteoglycans, matrix proteins, cytokines and growth factors. While Type I collagen is responsible for providing the tensile strength of bone, proteoglycans and calcium hydroxyapatite [Ca10(PO4)6(OH)2] are most responsible for providing compressive strength. Proteoglycans contain a core protein with various
numbers of covalently attached side chains of glycosaminoglycans. In addition to providing compressive strength, they are also responsible for binding growth factors and inhibiting mineralization.
Knothe et al. review the osteocyte. They discuss that osteocytes are the most abundant
cells in bone, are actively involved in maintaining the bony matrix, and may act as mechanosensors.
Illustration A shows a proteoglycan aggregate, which can form when individual molecules link onto a chain of hyaluronic acid.
Incorrect Answers:
Answer 1: Type I collagen is responsible for the tensile strength of bone. Answer 2: Osteocalcin is the most abundant non-collagenous protein in the matrix and promotes the mineralization and formation of bone.
Answer 4: Osteonectin is believed to have a role in regulating calcium or organizing mineral in matrix.
Answer 5: Osteopontin is a cell-binding protein.

A prospective, randomized controlled trial of 150 patients undergoing total hip arthroplasty is performed to test whether repair of the capsule during a posterior approach reduces post-operative dislocations in the first three months. The study found no difference in dislocation rate if the capsule was repaired versus not repaired (p =**
**.34). Subsequently, a multicenter follow-up study of 2000 patients showed that repairing the capsule led to a decreased dislocation rate**
**in the first three months (p = .03). Assuming the second study reflects reality, which of the following errors occurred in the first study?

1) Observer bias

2) Type-II error

3) Alpha error

4) Type-I error

5) Confounding error

In this situation, the null hypothesis was accepted when it should have been rejected.
This is a type-II error.
A study can have two types of errors. Type-I errors, or alpha errors, occur when the null hypothesis is rejected when it should have been accepted. The alpha level refers to the probability of a type-I error. By convention, the alpha level of significance is set at 0.05, which means that we accept the finding of a significant association if there is less than a one in twenty chance that the observed association was due to chance alone. Type-II errors, or beta errors, occur when the null hypothesis is accepted when it should be rejected. This
often occurs when studies are underpowered. In the example above, the null hypothesis is that repair of the capsule does not reduce dislocations within the first three months. Since the first study did not show a statistically significant difference, the null hypothesis was accepted. Since a more powered study showed that repair of the capsule does reduce dislocations, the null hypothesis should have been rejected in the initial study (if it was adequately powered).
Fosgate et al. review the importance of sample size calculations when performing research. They state that sample size ensures statistical significance if the subsequent data collection is perfectly consistent with the assumptions made for the sample size calculation (assuming power was set as
50% or greater).
Illustration A shows the difference between type-I and type-II errors. Video V is a lecture discussing statistical definition review of PPV, NPV, sensitivity and specificity.
Incorrect Answers:
Answer 1: Observer bias is when the observer (usually the investigator) influences the results of an experiment as a result of their own bias. Answer 3: Alpha errors are the same as type I error (see below).
Answer 4: A type-I error would reject the null hypothesis when it is true. Answer 5: A confounder is a variable that has associations with both the dependent and independent variables, potentially distorting their relationship. Confounders are not technically considered "errors," but instead are variables
that properly constructed studies attempt to avoid.

**Which of the following is a potential cause of fretting corrosion?**

1) The micromotion at the femoral head-neck junction in a modular total hip replacement

2) A stainless-steel cerclage wire is in contact with a titanium-alloy femoral stem

3) Friction between polyethylene liner and femoral head leading to osteolysis

4) The formation of pits within a stainless-steel plate and the subsequent release of metal ions

5) The formation of an adherent oxide coating on titanium implants

Micromotion at the femoral head-neck junction can lead to fretting corrosion, one of the most common causes of failure of a modular implant.
Modular components give surgeons excellent intraoperative flexibility, but are susceptible to various types of corrosion. While titanium and cobalt-chrome contain a protective surface oxide layer, continued micromotion at the modular junction may disrupt the protective layer leading to fretting corrosion, defined as micromotion at contact sites under load. This may eventually lead to a painful synovitis that necessitates a revision procedure.
Srinivasan et al. review modularity in total hip arthroplasty. Amongst other things, they discuss the modularity of the femoral head/neck junction, describing the morse taper interlocking system that provides both axial and rotational stability.
Illustration A shows an example of corrosion at the head/neck junction of a total hip arthroplasty.
Incorrect Answers:
Answer 2: This is an example of galvanic corrosion, as two dissimilar metals are in contact with each other.
Answer 3: This is an example of adhesive wear.
Answer 4: This is an example of pitting corrosion, or crevice corrosion. Answer 5: This process is called self-passivization, enabling titanium to become corrosion resistant.

Which of the following situations is most likely to decrease sentinel event errors?

1) Physician and nurse training is lengthened by 20%

2) Resident hours are decreased to 55 hours per week

3) An environment is created where all members of the healthcare team feel empowered to express their concerns and beliefs

4) Holding individuals responsible for errors in clinical judgement

5) Physicians and nurses are assigned to a smaller number of patients

Creating an environment where all members of the healthcare team feel empowered to express their beliefs increases communication, the key element in decreasing sentinel events.
Research has shown that 70% of sentinel event errors are caused by improper communication. Specific ways to improve communication include effective clinical handover between shifts and breaking down the "hierarchy" so that all members of the team can discuss their expectations and concerns. Barriers to effective communication include distractions, cultural differences, power distance relationships, time pressures, and lack of organization.
Leonard et al. describe specific clinical experiences in the application of surgical briefings, properties of high reliability perinatal care, the value of critical event training and simulation, and benefits of a standardised communication process in the care of patients transferred from hospitals to skilled nursing facilities. They recommend embedding standardized tools and behaviors to bridge differences in communications styles between clinicians.
Incorrect Answers:
Answer 1: Increasing training time is unlikely to decrease sentinel event errors if effective communication is not established.
Answer 2: Some studies have shown increased error rates with decreased resident physician work hours.
Answer 4: Holding individuals responsible for errors in clinical judgement has not specifically been cited as a way to decrease errors within a healthcare setting.
Answer 5: While this may decrease sentinel event errors, this has not been to be as effective as improvements in communication.

Which of the following side effects is most strongly associated with the use of NSAIDs?

1) Hepatic dysfunction

2) Renal impairment

3) Prolonged QTc

4) Seizures

5) Hematuria

All NSAIDs have the potential to cause serious renal impairment.
NSAIDs work by inhibiting the cyclooxygenase pathway (COX), which is comprised of the COX-1 and COX-2 pathways. The COX-1 pathway is involved in prostaglandin E2– mediated gastric mucosal protection and thromboxane effects on coagulation, while the COX-2 pathway is mainly involved with the modulation of pain and fever without effect on platelet function. While selective COX-2 inhibitors have a decreased side effect profile, all NSAIDS
have the potential to cause renal impairment and their use should be limited in patients with underlying renal disease.
Horlocker et al. review multimodal pain management in the perioperative setting of a total joint arthroplasty. Specifically, they note that NSAIDs should be used cautiously in patients with underlying renal dysfunction who are to undergo a procedure with major blood loss.
Griffin et al. reviewed 1,799 patients hospitalized for acute renal failure. They found that NSAIDs increased the risk of renal failure by 58% and that NSAID use resulted in 25 excess hospital admissions per 10,000 years of use.
Illustration A shows the COX pathways and their inhibition by NSAIDs. Incorrect Answers:
Answers 1, 3, 4, 5: NSAIDs have not been shown to be strongly associated with these side effects.

It is recommended that invasive dental work be completed prior to the initiation of which of the following medications?

1) Glucosamine

2) Cholecalciferol

3) Levothyroxine

4) Teriparatide

5) Bisphosphonates

Bisphosphonate therapy combined with invasive dental work increases the risk for development osteonecrosis of the jaw.
Bisphosphonates are a class of drugs that prevent bone mass loss by inhibiting osteoclast resorption. They are used in the treatment of vertebral compression fractures, non- vertebral fragility fractures, osteogenesis imperfecta, multiple myeloma, and avascular necrosis. Because bisphosphonates have been associated with osteonecrosis of the jaw, it is suggested that all invasive
dental work be completed prior to initiation of treatment.
Pazianas et al. (2011) review the safety profile of bisphosphonates. Specifically, they cite gastrointestinal discomfort, atypical femur fractures, osteonecrosis of the jaw, ocular inflammation, and musculoskeletal pain as common side effects. They state there is limited evidence surrounding
bisphosphonate's association with esophageal cancer and atrial fibrillation.
Pazianas et al. (2007) reviewed 11 publications that reported 26 cases of osteonecrosis of the jaw following initiation of bisphosphonate treatment. Age
>60 years, female sex, and previous invasive dental treatment were the most common characteristics of those who developed ONJ.
Illustration A shows the various bisphosphonates and their mechanisms of action. Illustration B shows an example of osteonecrosis of the jaw, a side effect that has been linked to bisphonphonate treatment.
Incorrect Answers:
Answer 1: Glucosamine is a dietary supplement used in the management of osteoarthritis. It is not contraindicated prior to dental work.
Answer 2: Cholecalciferol is Vitamin D3. Toxicity and side effects are rare with Vitamin D therapy.
Answer 3: Levothyroxine is used in the treatment of hypothyroidism. It is not contraindicated prior to dental work.
Answer 4: Teriparatide (Forteo) has been used in the treatment of osteonecrosis of the jaw caused by bisphosphonates.

Figures A and B show radiographs of a 24-year-old female with a soccer injury. A physical examination reveals an isolated, closed injury with no clinical features of neurovascular injury or compartment syndrome. She has been consented to be treated with intramedullary nail fixation. A pre-operative note by the anaesthesiology team makes reference to the patients fair skin and natural red-hair color. How will this information affect the post-operative management of this patient?
1) Longer duration of anticoagulation due to increased risk of DVT

2) Avoiding anticoagulation medications due to increased risk of bleeding

3) Require higher dosages of post-operative analgesia

4) Longer period of non-weight bearing on surgical limb

5) Avoiding opioids due to higher risk of unrecognized allergies

Female patients with natural red-hair may require higher dosages of post- operative analgesia compared to other hair types.
Melanocortin-1-receptor (MC1R) is one of the key proteins involved in hair color and skin tone. Mutations of the MC1R alleles can render this protein non- functional, which results in a phenotype of red-hair and fair skin. Mutations of the MC1R have shown to modulate the pain response and opioid efficacy in these patients. Women are more commonly affected and often require more anaesthetic and higher dosages of opioid to achieve comparable MAC level and pain-relief, respectively, as women with other hair types.
Liem et al. showed that a greater concentration of induction and maintenance agents (sevoflurane and desflurane, respectively) were required to sustain comparable MAC levels in red-haired patients as dark haired patients.
Fillingim et al. reviewed the affect of gender, sex and pain. They concluded there is a biopsychosocial element of pain that is perceived differently by men and women. In terms of postoperative and procedural pain, the outcome might be more severe in women than men.
Delaney et al. looked at the involvement of the melanocortin-1 receptor in acute pain in mice. They found that while the MC1R is better known as a gene involved in mammalian hair colour, it was shown to be involved in the pain pathway of inflammatory but not neuropathic origin. Mutations of MC1R showed increased tolerance to noxious pain stimulus in mice.
Figures A and B are AP and lateral radiographs of a left tibia. There is a low energy, distal third shaft fracture with no cortical apposition on the AP view.
Incorrect Answers:
Answer 1,2: Mutations in the Melanocortin-1-receptor (MC1R) has not shown to affect the coagulation pathway, with no increased risk of bleeding or clotting.
Answer 4: Mutations in the Melanocortin-1-receptor (MC1R) does not affect fracture fixation or weight-bearing status post-operatively
Answer 5: There is not a higher risk of opioid allergy in these patients.

Which of the following medications used for thromboprophylaxis following orthoapedic surgery is a direct inhibitor of factor Xa?

1) Dextran

2) Rivaroxaban (Xarelto)

3) Coumadin

4) Fondaparinux (Arixtra)

5) Aspirin

Rivaroxaban (Xarelto), an oral anticoagulant, is a direct inhibitor of factor Xa.
Rivaroxaban (Xarelto) is a member of a new class of oral, direct (antithrombin- independent) factor Xa inhibitors, which restrict thrombin generation both in vitro and in vivo. Inhibition of Factor Xa interrupts the intrinsic and extrinsic pathway of the blood coagulation cascade, inhibiting both thrombin formation and development of thrombi.
Eriksson et al. compare rivaroxaban to enoxaparin for the prevention of symptomatic venous embolism following total hip arthroplasty. Major venous thromboembolism occurred in 4 of 1686 patients (0.2%) in the rivaroxaban group and in 33 of 1678 patients (2.0%) in the enoxaparin group. Additionally, major bleeding events were similar between the two groups.
Illustration A shows the mechanisms of action of various agents used for thromboprophylaxis.
Incorrect Answers:
Answer 1: The antithrombotic effect of dextran is mediated through its binding of erythrocytes, platelets, and vascular endothelium, increasing their electronegativity and thus reducing erythrocyte aggregation and platelet adhesiveness. Dextrans also reduce factor VIII-Ag Von Willebrand factor, thereby decreasing platelet function.
Answer 3: Coumadin inhibits vitamin K 2,3-epoxide reductase, thereby limiting the production of vitamin K-dependent clotting factors (II, VII, IX, X) as well
as Protein C and Protein S.
Answer 4: Fondaparinux is an indirect inhibitor of factor Xa, not direct.
Answer 5: Aspirin inhibits the production of prostaglandins and thromboxanes.

The origin of bovine derived grafts is particularly important to which of the following religious groups?

1) Christianity

2) Islam

3) Hinduism

4) Buddhism

5) Judaism

The origin of bovine-derived surgical implants should be discussed in further detail with patients ascribing to Hinduism.
Patients come from a variety of religious backgrounds. Depending on a patient’s religion, the origin of surgical implants may have implications for their use. In Hinduism, bovine animals are considered sacred. Use of cow by- products is considered purifying in nature. Subsequently, the origin of bovine derived implants should be discussed with patients ascribing to Hinduism.
Easterbrook et al. evaluated the utility of porcine and bovine surgical implants amongst those of Jewish, Muslim and Hindu faiths. Hindu religious leaders, who were surveyed, did not approve of the use of bovine surgical implants.
Enoch et al. evaluated the acceptability of biological products amongst various religious groups. The Hindu religious leaders were found to not have an objection to the use of biological implants derived from cows.
Illustration A shows a clinical photo of a fetal bovine derived dermal substitute. Incorrect Answers:
Answers 1, 2, 4, 5: While the origin of implants should be discussed with all patients prior to use, bovine derived implants may have specific implications with Hindu patients. Use of porcine-implants should be discussed with patients who are of Jewish and Muslim faiths.

Immunological testing of anti-cyclic citrullinated peptide antibodies (anti- CCP) is most commonly used for the diagnosis and prognosis of which immunological condition?

1) Ankylosis spondylitis

2) Rheumatoid arthritis

3) Psoriatic arthritis

4) Systemic lupus erythematosus

5) Reiter's syndrome

Anti-cyclic citrullinated peptide antibodies (anti-CCP) are commonly used as a marker for the diagnosis and prognosis of rheumatoid arthritis (RA).
Immunological studies are commonly performed to investigate cases of suspected rheumatoid arthritis. Rheumatoid factor has historically been used as a primary marker for RA. However, in more recent years, the use of anti- CCP antibodies has shown to be as sensitive as, and more specific than, rheumatoid factor (RF) in early and fully established disease. In general, anti-
CCP assays equate to a sensitivity of 50-75% and a specificity of 90-95%. High levels of anti-CCP have been shown to be indicative of a more erosive disease process and may be detected before the onset of arthritis.
Gardner and Kadel reviewed the laboratory studies most commonly used in rhuematologic diseases. Standard ordering for clinically suspected RA include Rf, anti- CCP, ESR/CRP as well as other markers of autoimmune diseases such as antinuclear antibodies, anticardiolipin antibodies and lupus anticoagulant, HLA-B27, and uric acid levels.
Illustration A shows the sensitivity and specificity of anti-CCP vs. RF in a variety of autoimmune diseases.
Incorrect Answers:
Answers 1,3-5: Anti-CCP is not routinely used to diagnose and monitor these conditions.

Vitamin C has been shown to decrease the likelihood of which of the following complications following surgery on the foot and ankle in non-diabetic patients?

1) Nonunion

2) Complex Regional Pain Syndrome, type II

3) Malunion

4) Complex Regional Pain Syndrome, type I

5) Wound infection

Vitamin C has been shown to decrease the likelihood of developing complex regional pain syndrome (CRPS), type 1, when given post-operatively to patients undergoing foot and ankle and wrist surgery.
CRPS is a frequent post-operative complication, with rates varying from 10-
37%. Type I CRPS does not have an identifiable nerve lesion, while type II has an identifiable nerve lesion. Multiple studies have shown that vitamin C decreases rates of CRPS following distal radius fractures, and more recently, the same has been shown following foot and ankle surgery. While the exact mechanism of CRPS is unknown, vitamin C has been shown to reduce lipid peroxidation, scavenge hydroxyl radicals, protect the capillary endothelium, and inhibit vascular permeability. All of these characteristics of vitamin C may play a role in modulating the pain pathway.
Zollinger et al. perform a double-blind, prospective, multicenter trial where
416 patients with 427 wrist fractures were randomly allocated to treatment with placebo or treatment with 200, 500, or 1500 mg of vitamin C daily for fifty days. The prevalence of complex regional pain syndrome was 2.4% in the vitamin C group and 10.1% in the placebo group.
Besse et al. compare two groups of patients undergoing surgery on the foot and ankle to determine the effect of vitamin C on the development of CRPS, type I. CRPS type I occurred in 18 cases (9.6%) in the group not given vitamin C, and 4 cases (1.7%) in the group given vitamin C.
Illustration A shows an example of a limb affected by CRPS. Note the increased swelling, a common physical exam finding in patients afflicted with the disease.
Incorrect Answers:
Answers 1, 2, 3, 5: Vitamin C has not been shown to decrease the incidence of these conditions.

A 25-year-old Spanish speaking male presents to the emergency department 6 hours after sustaining the injury seen in Figure A. He is grossly intoxicated and screaming in pain. Physical examination reveals a closed injury with overlying muscular compartments that are extremely firm to palpation. After sedating the patient, measurements of the intracompartmental pressures were all found to be**
**> 75mmHg. His wife is Spanish speaking and expected to arrive to the hospital in 2-3 hours with a relative to help with translation. No medical translator is**
**available. You attempt to outline the risk and benefits of surgery to the patient, but the he repeatedly interrupts you and yells out ,"No surgery!". An English-Spanish speaking friend is with the patient and says that he has known the patient for over 2 years and will help with any decision making. What would be the next most appropriate step in the management of this patient?
1) Delay surgery to monitor the patient for impending compartment syndrome

2) Proceed with surgery with urgent fasciotomy after documenting the necessity of treatment without consent

3) Delay the surgery until the wife arrives and able to give informed consent with the aid of a translator

4) Proceed with surgery for urgent fasciotomy after obtaining informed consent from the patients friend

5) Respect the patients autonomy and reassess the patient in the morning when he demonstrates capacity to accurately comprehend the proposed treatment

This patient is presenting with compartment syndrome of the right tibia. In a situation of required surgery for limb threatening injury without available legal consent the surgeon should confirm and document the necessity of care with a fellow colleague.
Physicians are responsible for whether a patient is able to reasonably understand their medical condition and the nature of any proposed medical procedure, including the risks, benefits, and available alternatives. If the patient lacks this capacity, disclosure imposed by the doctrine of informed
consent are excused because irreparable harm that may result from the physician’s hesitation to provide treatment. Detailed documentation is also important. In addition, the attending physician should contact the Risk Management Dept at the hospital for support prior to surgical intervention or have a medical translator involved to ensure information is being translated properly.
Katz et al. reviewed the medical decision making process of Hispanic people. They showed that Hispanic people are more likely to permit their physician to take the predominant role in making health decisions compared to Non- Hispanic people.
Figure A shows a comminuted tibia and fibula fracture. Incorrect Answers
Answer 1: This patient has confirmed compartmental syndrome. Surgical delay would be negligent.
Answer 3: Delay until his wife arrives would be necessary in non-life or-limb threatening conditions. In this case however, surgical delay could result in significant harm to the patient and therefore, the doctrine of informed consent can be excused.
Answer 4: Consent can only be given by a friend that has pre-existing notice of the patients views in the setting of emergencies and only when the dedicated decision maker is not available. The patients friend does not have enduring power of attorney and has not been appointed as a formal substitute decision-maker.
Answer 5: The patient does not demonstrate capacity to make an informed decision about his health. Therefore the views of his autonomy cannot be formulated.

A Spanish speaking child sustained the injury seen in Figure A after a fall at school. He was casted in the emergency department without the assistance of an interpreter and advised to return to see an orthopaedic surgeon in 1 week. However, the family returns to the emergency department with the child 3 months later, still in the cast. What is the most likely reason the child did not attend the recommended orthopaedic follow-up visit.?
1) The child is a victim of neglect

2) The child had no symptoms of pain

3) He was allowed to return to school wearing the cast

4) Concerns of cost

5) Follow-up instructions were not effectively communicated

The most likely reason the child did not attend the recommended orthopaedic follow-up visit was a language barrier preventing effective communication of the intended follow-up instructions.
Communication skills and cultural competence is a key element in good orthopaedic care. Poor communication can often lead to devastating outcomes. In this example, poor communication resulted in this patient being lost to
follow-up. Language barriers must be accommodated and alternative methods of communication must be utilized.
Levinson et al. examined how patients present their medical issues in clinical encounters and how physicians respond to these clues in routine primary care and surgical settings. They showed that good communication relies mostly on the physicians ability to identify patient clues within the clinical encounter.
Poor communication between the physician tended to delay clinical visits, poor follow-up and unsatisfactory outcomes.
Figure A is an AP radiograph of the elbow in a skeletally immature patient. Figure B is a lateral radiograph of the elbow with a posterior fat pad sign, suggestive of an occult fracture.
Incorrect Answers:
Answer 1,2,3,4: The most likely reason for loss to follow-up in this scenario is miscommunication regarding follow-up.

A 25-year-old female presents to the emergency room within increasing left shoulder pain after walking into a door 5 months ago. She previously sustained a femoral fracture 2 years ago after tripping on a rug. Relevant skeletal survey radiographs and tissue biopsy results are shown in Figures A through D. Laboratory investigations show normal glomerular filtration rate and creatinine clearance. Dual energy x-ray absorptiometry (DEXA) scan shows T-score of -1.4 and**
**-1.2 at the hip and lumbar spine, respectively. Which of the following laboratory values in Figure E most likely reflects this patient's condition?
1) A

2) B

3) C

4) D

5) E

This patient has primary hyperparathyroidism. Laboratory investigations are likely to show elevated serum intact parathyroid hormone (PTH), alkaline phosphatase (ALP) and ionized serum calcium, and low serum phosphate.
Primary hyperparathyroidism is most commonly caused by a single adenoma (80-90%). Besides the signs and symptoms of hypercalcemia, patients present
with calcification of menisci and articular cartilage, erosions in hand bones, "salt and pepper skull", and brown tumors (osteoclastomas), which appear as lytic regions expanding the cortex and causing pathological fractures, so named because of hemosiderin deposition.
Singhal et al. reviewed primary hyperparathyroidism. They advocate routine serum calcium levels for patients with pathologic fractures. If this is elevated, total and ionized calcium and intact PTH levels should be obtained. They feel that surgery for orthopaedic stabilization and parathyroidectomy should be performed simultaneously for better outcome.
Mankin et al. reviewed metabolic bone disease. They suggest that patients with mild disease with normal calcium levels do not require treatment. For patients with high calcium levels, treatment should include maintenance of fluid balance, localization and removal of the adenoma, bony stabilization, and medications (calcitonin, estrogen, bisphosphonates, and calcimimetics such as cinacalcet).
Figure A is an AP radiograph showing a lytic expansile lesion with pathological fracture in metadiaphyseal region of left humerus with similar lesion in the
fifth posterior rib. Figure B is an AP radiograph showing a lytic expansile lesion in the third metacarpal of the right hand and the fifth metacarpal of the left hand. Figure C is a low power micrograph of a brown tumor demonstrating a central zone of bone resorption, and filling with fibroblastic tissue, with a peripheral rim of osteoid production. Figure D is a high power micrograph of a brown tumor. In areas of bone resorption, there are numerous osteoclast-like giant cells amidst a fibrous stroma. This is unlike a true giant cell tumor, which lacks a fibrogenic stroma.
Incorrect Answers:
Answer 2: Elevated PTH and ALP, and low serum calcium and high serum phosphate are characteristic of secondary hyperparathyroidism. This occurs in chronic renal disease, where there is overproduction of PTH because of hyperphosphatemia, hypocalcemia,
and impaired 1,25-dihydroxyvitamin D production by the diseased kidneys. This patient has normal renal function. Answer 3: Elevated PTH, ALP, serum calcium and phosphate occur in tertiary hyperparathyroidism. This again occurs in chronic renal disease after prolonged chronic secondary hyperparathyroidism or after renal transplantation, where the parathyroid glands become autonomous and PTH levels do not normalize. This patient has normal renal function.
Answer 4: Normal PTH, low ALP and high serum calcium and phosphate occur in hypophosphatasia. The defect lies in tissue-nonspecific isoenzyme of alkaline phosphatase (TNSALP) and urine phosphoethanolamine levels are
elevated.
Answer 5: Low PTH, normal ALP, low serum calcium and high serum phosphate levels suggest hypoparathyroidism.

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DISCUSSION: The child has a type I hip fracture without associated dislocation. This is an acute hip fracture through the proximal femoral physis, and can occur with or without associated dislocation. He had no prodrome of hip or thigh pain and no femoral neck changes to indicate that this is an unstable slipped capital femoral epiphysis. Osteonecrosis in these transepiphyseal hip fractures is the most common and most devastating complication. The rate of osteonecrosis is most dependent on the initial displacement of the fracture. These fractures should be treated emergently, and decompression of the hip joint is recommended by many authors.
REFERENCES: Moon ES, Mehlman CT: Risk factors for avascular necrosis after femoral neck fractures in children: 25 Cincinnati cases and meta analysis of 360 cases. J Orthop Trauma 2006;20:323-329. Canale ST: Fractures of the hip in children and adolescents. Orthop Clin North Am 1990;21:341-352.

**2010 Pediatric Orthopaedic Examination Answer Book • 29**

5/. pelvic external fixation followed by sacroiliac screws
This patient sustained an open-book pelvic fracture with a pubic symphysis diastasis of less than 2.5cm. From the Young and Burgess classification, he has anteroposterior compression (AP) type 1 injury. Treatment of this is protected weight-bearing and symptomatic treatment. Stress examination can be utilized in order to ensure that the injury is, in fact, a APC-1 injury, and not a more severe posterior injury that would require operative intervention.

Subscapularis tears can be associated with disruption of the transverse ligament supporting the biceps. The remaining aspects of the rotator cuff, superior labrum, and capsule can be intact with this injury.
REFERENCES: Petersson CJ: Spontaneous medial dislocation of the tendon of the long biceps brachii. Clin Orthop 1986;211:224-227.
Gerber C, Sebesta A: Impingement of the deep surface of the subscapularis tendon and the reflection pulley on the anterosuperior glenoid rim: A preliminary report. J Shoulder Elbow Surg 2000;9:483-490.

Management of the non-infected plantar neuropathic ulcer is nonoperative, with the exception of refractory recurrent ulceration. In this case, surgery may be indicated. The most reliable means of healing the ulcer is with the use of a total contact cast that
permits immediate ambulation and protection for the rest of the foot. Shoe modifications are required following healing of the ulcer but are insufficient as part of the initial treatment program.

Cubitus varus is a common complication of displaced supracondylar humeral fractures that are treated with closed reduction and cast immobilization. Treatment with closed reduction and percutaneous pinning decreases the incidence of this complication. Cubitus varus also can occur in minimally displaced fractures when unrecognized collapse of the medial column of the distal humerus is not corrected with manipulation. This can be detected on physical examination of the carrying angle or on radiographs measuring Baumann’s angle, both in comparison to the opposite side. Cubitus varus may result in unacceptable cosmesis and may predispose the patient to fractures of the lateral condyle. The lateral radiograph demonstrates the crescent sign from overlap of the distal humerus with the olecranon seen in patients with cubitus varus. Patients with growth arrest to the medial trochlear physis would have atrophy of the trochlea on radiographs.
REFERENCES: Flynn JM, Sarwark JF, Waters PM, et al: The surgical management of pediatric fractures of the upper extremity. Instr Course Lect 2003;52:635-45.
Papandrea R, Waters PM: Posttraumatic reconstruction of the elbow in the pediatric patient. Clin Orthop 2000;370:115-126.
Lins RE, Simovitch RW, Waters PM: Pediatric elbow trauma. Orthop Clin North Am 1999;30:119-132.

- diabetes.

The findings are typical for an osteochondroma. It is found as an outgrowth of bone and cartilage from those bones that arise from enchondral ossification. It may be flat, verrucous, or with a long stalk and cauliflower-like cap. Osteochondromas can become symptomatic secondary to irritation of the adjacent musculature. They cease to proliferate when epiphyseal growth ceases.
REFERENCE: Schmade GA, Conrad EV III, Raskind WH: The natural history of hereditary multiple exostoses. J Bone Joint Surg Am 1994;76:986-992.

Figures 1 and 2 show a scaphoid nonunion with substantial bone resorption at the nonunion site. Cast immobilization and bracing with bone stimulator use would not be successful treatments at this point because the fracture is 6 months old and there is considerable bone resorption at the fracture site. Scaphoid excision with intercarpal fusion is an option to use only after bone-grafting procedures have failed or arthritis is present. Bone-grafting procedures using both vascularized and nonvascularized graft sources are associated with a high success rate that decreases with avascular necrosis of the proximal pole. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis.

This is a classic example of a flexor tendon sheath rupture with gradual loss of active and passive extension and an unremarkable radiograph. Originally described by Bollen in 67 British rock climbers, closed ruptures of the digital flexor pulley system often appear in a delayed fashion with PIP joint flexion contractures. The mechanism of injury is a rapidly applied extension force in the acutely flexed digit, resulting in a closed rupture of the retinacular sheath, rather than a flexor profundus avulsion. In the setting of a significant PIP flexion contracture, a rupture of multiple pulleys including A2, A3, and A4 most commonly is found. In such a scenario, significant flexor tendon bowstringing results, precluding successful nonsurgical management. The proper treatment includes release of the sheath scar and pulley reconstruction. Temporary PIP joint pinning also may be required.
This patient already has participated in a prolonged course of hand therapy with worsening and a fixed PIP contracture, so continued therapy is not recommended. Response 2 is incorrect because the flexor tendons are functioning well with reasonable active DIP motion. Similarly, Response 3 is incorrect because there are no findings consistent with flexor tendon adhesions.
RECOMMENDED READINGS
62. Bollen SR. Soft tissue injury in extreme rock climbers. Br J Sports Med. 1988 Dec;22(4):145-7. PubMed PMID: 3228682.
63. Bowers WH, Kuzma GR, Bynum DK. Closed traumatic rupture of finger flexor pulleys. J Hand Surg Am. 1994 Sep;19(5):782-7. PubMed PMID: 7806800.

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatment _of a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair._

Pasteurella multocida is the most common organism found in animal bites.

In the intertrochanteric hip fracture displayed, a sliding hip screw (SHS) or cephalomedullary nail (CMN) would be indicated; the SHS is the cheaper implant.
In a standard obliquity intertrochanteric fracture without lateral wall comminution, an SHS is a cost-effective option. In reverse obliquity fractures or those with lateral wall comminution (unstable), there is an increased failure rate with this implant and an CMN should be considered. There is some controversy in terms of short and intermediate nail indications, which are attractive because they do not require reaming. SHS implants are contraindicated in subtrochanteric fractures. Although some hospitals receive discounts on implants, in general, intramedullary nail options are more expensive than SHS.
Swart et al. examined the cost-effectiveness of different fixation options for intertrochanteric hip fractures. They compared SHS and CMN implants using an expected-value decision-analysis model, taking into account fracture patterns, failure rates, and revision costs. In their study, the average cost of a SHS was
$2,000 compared to $3,200 for a standard CMN. They concluded that the SHS was likely more cost-effective for stable and questionably stable fractures compared to CMN fixation; CMN was more cost-effective for reverse obliquity patterns.
Kaplan et al. provided a review article on the surgical management of intertrochanteric fractures. Factors to determine treatment should include the patient's medical co-morbidities, pre-existing arthritis, bone quality, and fracture morphology. Their study did not find an appreciable difference in patient outcomes using either CMN or SHS for stable intertrochanteric fractures; surgeon experience and implant costs should, therefore, drive the decision making process for implant selection.
Figures A and B are AP and lateral right hip radiographs, respectively, demonstrating a standard obliquity intertrochanteric hip fracture. Illustration A is an AP post-operative radiograph showing a hip fracture treated with a SHS.
Incorrect Answers:
Answers 1 and 2: Both of these options are appropriate for this fracture but more costly than a SHS.
Answer 4: Arthroplasty is not indicated for this patient with an intertrochanteric fracture and preserved joint space.
Answer 5: Cannulated screws are not indicated for an intertrochanteric fracture.

DISCUSSION: The 2007 AAOS guidelines for thrombophlebitis prophylaxis for patients undergoing total hip and knee arthroplasty includes preoperative risk assesment for deep venous thrombosis, pulmonary embolism, and

bleeding. Regional anesthesia when appropriate is suggested. Inferior vena cava filters may be appropriate in selected patients. When warfarin is used as a chemoprophylactic agent, the goal INR is less than or equal to 2 to minimize the risk of bleeding. This is in contrast to the 2004 ACCP guidelines for warfarin with a goal INR of 2-3.
-

REFERENCE: American Academy of Orthopaedic Surgeons Guideline on the Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty. [www.aaos.org/Research/](http://www.aaos.org/Research/) guidelines/PEguide.asp

Figure 46

Prevalence of flexor tendon rupture after distal radius fracture is between 2% and 12%. The FPL tendon is the most common flexor tendon rupture associated with volar plating. It is usually seen with plates that are distal to the watershed line (W) and with plates extending volar to the critical line (C) (Figure below). The watershed line (W) is the location of the origin of the volar carpal ligaments and the bone prominence

---

at which flexor tendons are most closely opposed to the distal radius (Figure 4). In this scenario, the lateral radiograph shows that the plate is not distal to the watershed line (W) and is between the critical line (C) and the line parallel to the volar cortex of the radius (R). This is the optimal position for the plate. Placement of a volar locking plate distal to the watershed line of the distal radius and excessive plate prominence has been associated with FPL tendon rupture. This patient is only 2 weeks past surgery and there is some FPL function. FPL weakness after volar distal radius plating is common and has been seen in as many as 50% of patients. This usually recovers spontaneously by 2 months, and no treatment is needed. A nerve conduction study would be indicated if an anterior interosseous nerve compression were considered, but it is too early for this test. A CT scan could be obtained to judge the alignment of the fracture fragment and position of the screws, but it is not indicated in this case. Exploration could be performed if an FPL rupture were considered, but, because it is only 2 weeks after surgery, there is some FPL function, the plate is proximal to the watershed line, and immediate exploration is not indicated. If this does not improve after 2 to 3 months, further investigation with ultrasound or MRI would be indicated.

If a single flexor digitorum profundus (FDP) tendon is debrided more than 1 cm prior to repair, the tendon is advanced too far distally, essentially shortening the musculotendon unit. The finger will likely develop a flexion posture. Because of the common muscle belly and interconnections of the profundi, the long and small fingers adjacent to the injured finger will be affected because of loss of some of their normal proximal excursion. The result is an inability of the adjacent fingers to completely flex. This condition, known as quadrigia, is named after the Roman chariot driver who held control of the reins of 4 horses, forcing them to move as 1. Quadrigia occurs when the FDP tendon is advanced too far distally, when a tendon graft is too short, or when the profundus is sutured over the end of an amputated digit.
Intrinsic muscles of the hand flex the metacarpophalangeal (MP) joints and extend the PIP joint. Intrinsic tightness causes decreased PIP flexion when the MP joint is in extension. The lumbrical muscle modulates tension on the flexor profundus tendon. When a tendon graft to repair the profundus tendon is too long, a lumbrical plus deformity occurs. This is a paradoxical PIP extension as the finger is flexed. Disruption of the tendon repair causes limited flexion of the injured finger.
RECOMMENDED READINGS
14. Malerich MM, Baird RA, McMaster W, Erickson JM. Permissible limits of flexor digitorum profundus tendon advancement--an anatomic study. J Hand Surg Am. 1987 Jan; 12(1):30-3. PubMed PMID: 3805640. View Abstract at PubMed
15. Schreuders TA. The quadriga phenomenon: a review and clinical relevance. J Hand Surg Eur Vol. 2012 Jul;37(6):513-22. doi: 10.1177/1753193411430810. Epub 2011 Dec 14. Review.
PubMed PMID: 22170246. View Abstract at PubMed

All of the tissues noted above are stronger than native ACL. Although it is often thought that the bone-patellar tendon-bone graft is the strongest when selecting a graft source for ACL reconstruction, biomechanical studies show that the quadruple semitendinosus and gracilis tendons are the strongest of the tissues listed.
REFERENCES: Woo SL, Hollis JM, Adams DJ, et al: Tensile properties of the human femur-anterior cruciate ligament-tibia complex: The effects of specimen age and orientation. Am J Sports Med 1991;19:217-225.
Staubli HU, Schatzmann L, Brunner P, et al: Quadriceps tendon and patellar ligament cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 1996;4:100-110.
Wilson TW, Zafuta MP, Zobitz M: A biomechanical analysis of matched bone-patellar tendon-bone and doubled looped semitendinosus and gracilis tendon grafts. Am J Sports Med 1999;27:202-207.

DISCUSSION:
Although less common in comparison with lateral elbow tendinopathy, medial elbow tendinopathy remains a significant cause of elbow disability. Fortunately, most patients can anticipate resolution of symptoms with nonsurgical management. For patients with recalcitrant symptoms, surgical intervention should be discussed as a treatment alternative. The literature reports successful results with surgical intervention via debridement
of pathologic tissue, release of the flexor carpi radialis - pronator teres origin, and/or repair of the flexor carpi radialis - pronator teres origin. Several authors have raised concern of the impact of concomitant ulnar neuropathy on results following surgical treatment for medial epicondylitis. Kurvers and Verhaar and Gabel and Morrey, among others, have reported a statistically significant association between concomitant ulnar neuropathy and worse outcomes following surgery. Most patients can anticipate a return to prior activity levels after surgery without any consistently reported loss of flexor/pronator strength. Prior corticosteroid injections
have not been found to impact results.

- 50%_

Lateral subtalar dislocations, which are less common than medial subtalar dislocations, are high-energy injuries that are frequently associated with small osteochondral fractures. It is generally recommended that large fragments be internally fixed, and small fragments entrapped within the joint be excised. Although arthrosis frequently occurs after this injury and is the most common long-term complication, primary subtalar arthrodesis is not indicated. A talar neck fracture is not evident on the radiographs, and lateral subtalar dislocation usually does not lead to instability.
REFERENCE: Saltzman C, Marsh JL: Hindfoot dislocations: When are they not benign? J Am Acad Orthop Surg 1997;5:192-198.
3/. Figure 2 shows the lateral radiograph of an 8-year-old boy who sustained an acute injury to the elbow after falling down the stairs. Management should consist of
1- closed reduction, followed by a long arm cast in 120 degrees of flexion.
2- closed reduction, followed by percutaneous cross pin fixation.
3- open reduction and internal fixation using an oblique screw combined with an absorbable suture as a tension band.
4- a large intramedullary screw.
5- a long arm cast in full extension.
PREFERRED RESPONSE: 3
DISCUSSION: The patient has a flexion-type olecranon fracture, and the integrity of the extensor mechanism is disrupted. With this degree of displacement, closed reduction and extension casting would not be adequate. The strongest construct is an oblique screw across the fracture site, with a tension band. Healing is rapid in this age group; therefore one of the heavy absorbable sutures can be used as the tension band. Two parallel pins with the stainless steel tension band wire (AO technique) can be used but requires wire dissection for removal. Once the fracture is healed, the single screw can be removed easily with only a small incision. The presence of the screw, across the apophysis, has not been shown to produce any significant growth disturbance. Use of a large intramedullary screw would not be advisable because of the small size of the proximal fragment.
REFERENCES: Murphy DF, Greene WB, Gilbert JA, Dameron TB Jr: Displaced olecranon fractures in adults: Biomechanical analysis of fixation methods. Clin Orthop 1987;224:210-214.
Chambers HG, Wilkins KE: Part IV: Fractures of the proximal radius and ulna, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 629-630.
4/. A 28-year-old man sustains the closed injury shown in Figures 3a through 3c after falling 8 feet while rock climbing. Management should consist of
1- open reduction and internal fixation via an anteromedial arthrotomy.
2- talectomy.
3- primary tibiotalocalcaneal arthrodesis.
4- open reduction and internal fixation via a medial malleolar osteotomy and limited anterior lateral arthrotomy.
5- closed reduction and a non-weight-bearing cast.
PREFERRED RESPONSE: 4
DISCUSSION: The radiographs show a comminuted talar body fracture. The goal of treatment is to minimize the risks of posttraumatic arthrosis of the ankle and subtalar joint and to maintain vascularity. Open reduction and internal fixation with an attempt at anatomic reduction will lead to improved outcomes. Attempting to repair this fracture via an arthrotomy only is extremely difficult, and the addition of a medial malleolar osteotomy is warranted. A limited anterior lateral arthrotomy with minimal soft-tissue stripping may assist with fixation of anterior-lateral and lateral fragments and allow better assessment of reduction of the major fracture line. Nonsurgical care would lead to inadequate reduction and increased risk of both ankle and hindfoot arthrosis. Talectomy and primary ankle and hindfoot arthrodesis should not be performed as primary surgical reconstructive options in this closed injury pattern.
REFERENCES: Sanders R: Fractures and fracture-dislocations of the talus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp
1465-1518.
Grob D, Simpson LA, Weber BG, Bray T: Operative treatment of displaced talus fractures. Clin Orthop 1985;199:88-96.
5/. Which of the following types of displaced posterior pelvic disruptions must undergo anatomic reduction and internal fixation to ensure the best clinical outcome?
1- Sacral fracture through the foramen
2- Sacral fracture through the ala
3- Sacroiliac joint dislocation
4- Reverse fracture-dislocation of the sacroiliac joint through the ilium
5- Iliac wing fracture
PREFERRED RESPONSE: 3
DISCUSSION: Although all of the above displaced injuries require reduction, the sacroiliac joint dislocation is a ligamentous injury. Without fixation, healing is unlikely and the result will be a painful dislocation. Both Holdsworth and Tile showed that the sacroiliac joint must be reduced anatomically and stabilized. The injuries through bone will unite fairly rapidly and, if reduced and stabilized with traction or external fixation, will generally result in an acceptable outcome unless modified by other associated problems such as neurologic injury.
REFERENCES: Tile M: Fractures of the Pelvis and the Acetabulum. Baltimore, MD, Williams and Wilkins, 1995.
Holdsworth F W: Dislocation and fracture dislocation of the pelvis. J Bone Joint Surg Br 1948;30:461-465.
Henderson RC: The long-term results of nonoperatively treated major pelvic disruptions. J Orthop Trauma 1989;3:41-47.
6/. A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals that the knee is held in 45 degrees of flexion, and any attempt to actively or passively extend the knee produces pain and muscle spasms. A lateral radiograph is shown in Figure 4. What is the most likely diagnosis?
1- Patellar sleeve fracture
2- Avulsion of the tibial tubercle
3- Avulsion of the anterior tibial spine
4- Osteochondral fracture of the femoral condyle
5- Osteochondral fracture of the patella
PREFERRED RESPONSE: 1
DISCUSSION: This is a typical patellar sleeve fracture. The patellar tendon avulses a portion of the distal bony patella, along with the retinaculum and articular cartilage from the inferior pole of the patella. It is common in children between ages 8 and 10 years. Anatomic reduction and repair of the extensor mechanism are mandatory to reestablish full knee extension.
REFERENCES: Houghton GR, Ackroyd CE: Sleeve fractures of the patella in children: A report of three cases. J Bone Joint Surg Br 1979;61:165-168.
Wu CD, Huang SC, Liu TK: Sleeve fracture of the patella in children: A report of five cases. Am J Sports Med 1991;19:525-528.
7/. A 12-year-old girl sustains an acute injury to the right elbow in a fall. An AP radiograph is shown in Figure 5. Nonsurgical management will most likely result in
1- a painful nonunion.
2- asymptomatic nonunion.
3- chronic elbow instability.
4- tardy ulnar nerve palsy.
5- cubitus varus.
PREFERRED RESPONSE: 2
DISCUSSION: The patient has a significantly displaced medial epicondyle fracture. The only absolute indication for surgical treatment is irreducible incarceration in the joint. Nonsurgical management usually results in a painless nonunion with good elbow function and little elbow instability. Prolonged immobilization should be avoided to prevent stiffness. Tardy ulnar nerve palsy and cubitus varus are not complications of medial epicondyle fractures.
REFERENCES: Chamber HG, Wilkins KE: Part IV: Apophyseal injuries of the distal humerus, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 801-812.
Farsetti P, Potenza V, Caterini R, Ippolito E: Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am 2001;83:1299-1305.
8/. Which of the following factors is considered most important when assessing an ankle fracture for surgical treatment?
1- Level of the fibular fracture
2- Displacement of the fibular fracture
3- Size of the posterior malleolus
4- Position of the talus in the mortise
5- Rupture of the deltoid ligament
PREFERRED RESPONSE: 4
DISCUSSION: Although all of these factors may influence the decision to perform surgery, the most important is the position of the talus in the mortise. The goal of treatment of ankle fractures is to maintain the talus centered in the mortise. If it is in this position, the other factors do not enter into the decision to intervene surgically.
REFERENCES: Stover MD, Kellam JF: Articular fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 105-119.
Hahn DM, Colton CL: Malleolar fractures, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 559-581.
Tile M: Fractures of the ankle, in Schatzker J, Tile M (eds): Rationale of Operative Fracture Care, ed 2. Berlin, Springer-Verlag, 1998, pp 523-561.
9/. A 35-year-old woman who underwent open reduction and internal fixation of a calcaneal fracture 14 months ago reports pain that has failed to respond to nonsurgical management. Examination reveals limited painful subtalar motion but no hindfoot deformity. A lateral radiograph is shown in Figure 6. Surgical reconstruction is best accomplished with
1- calcaneal osteotomy.
2- subtalar joint arthrodesis.
3- triple arthrodesis.
4- pantalar arthrodesis.
5- distraction bone block arthrodesis.
PREFERRED RESPONSE: 2
DISCUSSION: The patient has posttraumatic subtalar joint arthrosis that developed following a calcaneal fracture. Because there is no hindfoot deformity, in situ subtalar joint arthrodesis is the treatment of choice. Calcaneal osteotomy or distraction bone block arthrodesis is beneficial in patients with severe talar dorsiflexion or malunion of the calcaneal body. Triple arthrodesis is not warranted without changes at the transverse tarsal joint, and typically even with injury into the calcaneocuboid joint, this joint is often asymptomatic. Pantalar arthrodesis is not indicated as the pathology is occurring at the subtalar joint and not in the ankle joint.
REFERENCES: Sanders R: Fractures and fracture-dislocations of the calcaneus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999,
pp 1422-1464.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.
Chandler JT, Bonar SK, Anderson RB, Davis WH: Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures. Foot Ankle Int 1999;20:18-24.
10/. Which of following side effects is most commonly seen in a pediatric patient undergoing ketamine anesthesia?
1- Respiratory depression
2- Increased salivary secretion
3- Hypertension
4- Emergence phenomena
5- Cerebral vasoconstriction
PREFERRED RESPONSE: 2
DISCUSSION: The most common deleterious side effect of ketamine is increased salivation and tracheobronchial secretions. For this reason, an antisialagogue agent should be given. While lack of sufficient respiratory depression is one of the major advantages of using ketamine, apnea can occur if the drug is given too rapidly intravenously. Emergence phenomena is common in adults but relatively rare in children.
REFERENCES: Furman JR: Sedation and analgesia in the child with a fracture, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 62-63.
White PF, Way WL, Trevor AJ: Ketamine: Its pharmacology and therapeutic uses. Anesthesiology 1982;56:119-136.
McCarty EC, Mencio GA, Walker LA, Green NE: Ketamine sedation for the reduction of children’s fractures in the emergency department. J Bone Joint Surg Am 2000;82:912-918.
11/. Figures 7a and 7b show the radiographs of a 51-year-old woman who injured her left leg after falling off a stepladder. Surgical reconstruction is performed with a compression screw and side plate; the postoperative radiograph is shown in Figure 7c. Following gradual progression of weight bearing, she reports that she slipped again and placed full weight on the extremity. She now notes a new onset of increased pain in her left thigh and hip region. Follow-up radiographs are shown in Figures 7d and 7e. Reconstruction should consist of
1- conversion to a longer side plate with the same compression screw and tube angle.
2- in situ bone grafting.
3- hardware removal and reconstruction with an intramedullary device that provides fixation into the femoral head and neck.
4- hardware removal and retrograde femoral nailing.
5- revision reconstruction with cerclage wiring.
PREFERRED RESPONSE: 3
DISCUSSION: The initial fracture was an unstable reverse oblique intertrochanteric fracture with subtrochanteric extension. Initial fixation with a high-angled screw and side plate construct may not provide stability as well as a 95 degree fixed-angle device or a intramedullary hip screw device. The follow-up radiographs show loss of fixation and further propagation of the fracture distally. Reconstruction would best be accomplished with hardware removal and conversion to a long intramedullary nail with femoral head fixation or a 95 degree angled plate and screw device. Conversion to a longer plate does not improve the biomechanical situation at the primary fracture site. In situ bone grafting would not provide any additional stability and would not correct the deformity. The proximal femoral fracture is not amenable to retrograde nailing. Cerclage wiring will not sufficiently enhance stability and is not indicated.
REFERENCES: Bridle SH, Patel AD, Bircher M, Calvert PT: Fixation of intertrochanteric fractures of the femur: A randomized prospective comparison of a gamma nail and dynamic hip screw. J Bone Joint Surg Br 1991;73:330-334.
DeLee JC: Fractures and dislocations of the hip, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 1659-1825.
Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.
12/. An intoxicated 68-year-old man fell at home. Examination reveals abrasions on his forehead, 2/5 weakness of his hand intrinsics and finger flexors, and 4/5 strength of the deltoid, biceps, and triceps bilaterally. Lower extremity motor function is 5/5. Sensory examination to pain and temperature is diminished in his hands but intact in his lower extremities. Deep tendon reflexes are depressed in all four extremities, but perianal sensation and rectal tone are intact. Foley catheterization yields 700 mL of urine. Radiographs of the cervical spine reveal multilevel spondylosis without fracture or subluxation. An MRI scan reveals high-intensity signal change within the cord substance at C5. What is the most likely diagnosis?
1- Brown-Sequard syndrome
2- Central cord syndrome
3- Anterior cord syndrome
4- Posterior cord syndrome
5- Bilateral brachial plexus palsy
PREFERRED RESPONSE: 2
DISCUSSION: Central cord syndrome is characterized by greater neurologic involvement of the upper extremities than the lower extremities. This is typically seen in older patients with cervical spondylosis without associated bony injury or joint subluxation. The prognosis for recovery is fair. Patients with Brown-Sequard syndrome have an ipsilateral motor deficit and contralateral loss of pain and temperature. Prognosis for recovery depends on the mechanism of injury, which is often of a penetrating nature. Anterior cord syndrome results from anterior compression such as occurs with a burst or teardrop fracture of the vertebral body; patients have bilateral motor loss, pain, and temperature loss with preservation of proprioception and vibratory sensation (posterior column function). The prognosis for recovery is generally poor. Posterior cord syndrome is rare and is associated with loss of posterior column function (proprioception and vibration).
REFERENCES: Northrup BE: Evaluation and early treatment of acute injuries to the spine and spinal cord, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 541-549.
Schneider RC, Thompson JM, Rebin J: The syndrome of acute central cervical spinal cord injury. J Neurol Neurosurg Psychiatry 1958;21:216-227.
13/. A 23-year-old woman sustains an injury to her right hand after falling off her snowboard. Examination reveals that she has difficulty moving her fingers. A radiograph and a clinical photograph are shown in Figures 8a and Figure 8b. Management should consist of
1- closed reduction and buddy taping.
2- in situ pinning.
3- open reduction and internal fixation.
4- casting for 6 weeks.
5- dynamic extension splinting.
PREFERRED RESPONSE: 3
DISCUSSION: The radiograph reveals oblique fractures of the third and fourth metacarpals. The rotational component of the fracture displacement is well visualized on the clinical photograph, which shows scissoring of the middle finger over the ring finger. The fracture obliquity results in rotational deformity that cannot be adequately maintained and held by closed treatment. The treatment of choice is open reduction and internal fixation.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999, pp 711-771.
Freeland AE, Benoist LA, Melancon KP: Parallel miniature screw fixation of spiral and long oblique hand phalangeal fractures. Orthopedics 1994;17:199-200.
Freeland AE, Geissler WB: Plate fixation of metacarpal shaft fractures, in Blair WF (ed): Techniques in Hand Surgery. Baltimore, MD, Williams and Wilkins, 1996, pp 255-264.
14/. A 32-year-old man sustained an L1 burst fracture with 90% canal compromise, intact posterior elements, and kyphosis of 25% at the L1 level. He has an incomplete neurologic injury. Definitive management should consist of
1- bed rest for 8 weeks, followed by mobilization in a total contact thoracolumbosacral orthosis.
2- immediate laminectomy only.
3- anterior decompression, vertebral body reconstruction, and stabilization.
4- in situ posterior fusion.
5- short segment posterior fixation and fusion.
PREFERRED RESPONSE: 3
DISCUSSION: With an incomplete injury, the best chance for recovery occurs when the canal is cleared and the neural structures are decompressed. Anterior decompression, vertebral body reconstruction, and anterior stabilization have been shown to be highly effective in the treatment of burst-type injuries. Laminectomy alone is contraindicated because it increases the instability. Short segment posterior fixation has a high rate of failure in this type of injury at this level.
REFERENCES: Kaneda K, Abumi K: Burst fractures with neurologic deficits of the thoracolumbar spine. J Bone Joint Surg Am 1997;79:69-83.
McGuire R Jr: The role of anterior surgery in the treatment of thoracolumbar fractures. Orthopedics 1997;20:959-962.
15/. The management of a complex multifragmentary diaphyseal fracture of either the tibia or femur has changed during the last decade. Which of the following principles of treatment is now considered less important?
1- Anatomic alignment
2- Indirect reduction
3- Anatomic reduction of the fragments
4- Relatively stable fixation
5- Functional aftercare
PREFERRED RESPONSE: 3
DISCUSSION: Although the original concept of internal fixation was one of anatomic reduction and stable fixation, over the past 10 to 15 years there has been a change based on the advent of intramedullary nailing and bridge plating. It is now appreciated that in a multifragmentary diaphyseal fracture, particularly of the lower extremity, the achievement of axis alignment (mechanical and anatomic axis) is all that is required. Healing will occur by callus. Relatively stable fixation is achieved through intramedullary nailing or bridge plating, providing adequate pain relief for functional aftercare.
REFERENCES: Perren SM, Claes L: Biology and mechanics of fracture management, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000,
pp 7-32.
deBoer P: Diaphyseal fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 93-104.
Mast J, Jakob R, Ganz R: Planning and Reduction Techniques in Fracture Surgery. Berlin, Springer-Verlag, 1989.
16/. A 68-year-old woman who sustained a closed distal tibia fracture 2 years ago was initially treated with an external fixator across the ankle for 12 weeks, followed by intramedullary nailing of the fibula and lag screw fixation of the tibia. She continued to report persistent pain so she was treated with a brace and a bone stimulator. She now reports pain in her ankle. Examination reveals ankle range of motion of 8 degrees of dorsiflexion to 25 degrees of plantar flexion. She is neurovascularly intact. Current radiographs are shown in Figures 9a through 9c. What is the next most appropriate step in management?
1- A cast and weight bearing as tolerated
2- A brace and an ultrasound bone stimulator
3- Intramedullary nailing
4- Open reduction and plate fixation with bone grafting
5- Fibular osteotomy
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a nonunion of the distal fifth of the tibia. The nonunion appears to be oligotrophic, somewhere between atrophic and hypertrophic. Management requires stabilization and stimulation of the local biology, which can be accomplished with open reduction and internal fixation with bone grafting. Bracing or casting does not provide enough stability. Ultrasound bone stimulation has been shown to speed fresh fracture repair but is not indicated in nonunions. The distal segment is too short for intramedullary nailing. A fibular osteotomy alone would increase instability and, even with prolonged casting, would be unlikely to lead to successful repair.
REFERENCES: Carpenter CA, Jupiter JB: Blade plate reconstruction of metaphyseal nonunion of the tibia. Clin Orthop 1996;332:23-28.
Lonner JH, Siliski JM, Jupiter JB, Lhowe DW: Posttraumatic nonunion of the proximal tibial metaphysis. Am J Orthop 1999;28:523-528.
Stevenson S: Enhancement of fracture healing with autogenous and allogeneic bone grafts. Clin Orthop 1998;355:S239-S246.
Wiss DA, Johnson DL, Miao M: Compression plating for non-union after failed external fixation of open tibial fractures. J Bone Joint Surg Am 1992;74:1279-1285.
17/. A patient has a displaced midshaft transverse fracture of the humerus and is neurologically intact. Following closed reduction and application of a coaptation splint, the patient cannot dorsiflex the wrist or the fingers at the metacarpophalangeal joints of the hand. What is the next most appropriate step in management?
1- Observation with a high expectation for recovery
2- Observation for 1 week, followed by exploration if recovery is not evident
3- Immediate exploration of the radial nerve and fracture fixation
4- Immediate exploration of the radial nerve without fracture fixation
5- Removal of the coaptation splint and repeat reduction
PREFERRED RESPONSE: 1
DISCUSSION: The answer to this question is controversial. All of the standard textbooks state that development of a radial nerve palsy during initial fracture management may represent a laceration or injury of the nerve by bone fragments at the time of manipulation; therefore, surgery should be considered. However, it appears that there is no scientific basis for this decision. A review of the available literature shows that the results were the same for patients who were observed as for those who underwent radial nerve exploration. The indications for surgical exploration include palsies associated with open fractures, irreducible closed fractures, and vascular injuries. The only other relative indication for surgical exploration is following manipulation of a Holstein-Lewis fracture (a distal third fracture of the humerus with a lateral spike). In this type of fracture, exploration may be necessary if a closed reduction leads to radial nerve palsy because the spike may lacerate or compress the nerve. Observation for return of nerve function may be appropriate for 3 months or longer prior to considering late exploration.
REFERENCES: Bostman O, Bakalim G, Vainionpaa S, Wilppula E, Patiala H, Rokkanen P: Radial palsy in shaft fracture of the humerus. Acta Orthop Scand 1986;57:316-319.
Shaz JJ, Bhatti NA: Radial nerve paralysis associated with the fractures of the humerus: A review of 62 cases. Clin Orthop 1983;172:171-176.
Holstein A, Lewis GB: Fractures of the humerus with radial nerve paralysis. J Bone Joint Surg Am 1963;458:1382-1388.
18/. A 24-year-old woman has a spleen laceration and hypotension. Radiographs reveal a pulmonary contusion and a displaced mid-diaphyseal fracture of the femur. The trauma surgeon clears her for stabilization of the femoral fracture. What technique will offer the least potential for initial complications?
1- External fixation
2- Plate fixation
3- Unreamed unlocked intramedullary nailing
4- Reamed statically locked intramedullary nailing
5- Reamed unlocked nailing
PREFERRED RESPONSE: 1
DISCUSSION: A concern in the multiply injured patient who has a pulmonary contusion is the potential for further pulmonary compromise because of embolization of marrow, blood clot, or fat during manipulation of the medullary canal. Recent evidence has shown that the presence of a lung injury is the most important determining factor in future deterioration. However, despite the lung injury and its potential consequences, this patient’s femur fracture needs stabilization. Because damage control in the multiply injured patient requires a technique that can be performed rapidly and consistently, the treatment of choice is application of an external fixator. By placing two pins above and below the fracture and with longitudinal traction, the fracture is quickly realigned and stabilized. This allows the patient to be resuscitated and treated at a later date when definitive management of the fracture can be carried out. There is little difference between plate fixation and intramedullary nailing.
REFERENCES: Bosse MJ, MacKenzie EJ, Riemer BL, et al: Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated with either intramedullary nailing with reaming or with a plate: A comparative study. J Bone Joint Surg Am 1997;79:799-809.
Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN: External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: Damage control orthopedics. J Trauma 2000;48:613-623.
Pape HC, Auf’m’Kolk M, Puffrath T, et al: Primary intramedullary femur fixation in multiple trauma patients with associated lung contusion: A cause of posttraumatic ARDS? J Trauma 1993;34:540-548.
19/. Figure 10 shows the radiograph of a 9-year-old girl who injured her left lower leg after being thrown from a horse. Examination reveals no other injuries. Which of the following forms of management will provide the lowest rate of complications and the earliest return to function?
1- Distal femoral pin and 90-90 traction for 3 weeks, followed by a spica cast
2- Closed reduction and stabilization with an external fixator
3- Closed reduction and stabilization with an interlocking nail
4- Closed reduction and stabilization with multiple flexible intramedullary nails
5- Open reduction and stabilization with a plate and screws
PREFERRED RESPONSE: 4
DISCUSSION: Because the patient has a transverse midshaft fracture with no evidence of comminution, the treatment of choice is closed reduction and stabilization with flexible intramedullary nails. Transverse fractures treated with an external fixator heal with poor callus and have a high refracture rate. In addition, the pin tracks produce undesirable and excessive scarring. Femoral pin traction is safe and effective but results in considerable muscle wasting and a slow return to function. Interlocking nails run the risk of greater trochanteric growth disturbance and/or osteonecrosis of the femoral head in this age group. Plate fixation, while effective, requires considerable tissue dissection with large scar formation. It also requires a rather extensive dissection for later plate removal.
REFERENCES: Ligier JN, Metaizeau JP, Prevot J, Lascombes P: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-77.
Heinrich SD, Drvaric D, Darr K, MacEwen GD: Stabilization of pediatric diaphyseal femoral fractures with flexible intramedullary nails (a technique paper). J Orthop Trauma 1992;6:452-459.
20/. A 25-year-old woman has had continuous pain after falling on her outstretched wrist 12 weeks ago. A current radiograph is shown in Figure 11. Management should consist of
1- open reduction and internal fixation with bone grafting.
2- closed reduction and percutaneous pin fixation.
3- aspiration and steroid injection.
4- closed manipulation and a long arm cast.
5- in situ open bone grafting.
PREFERRED RESPONSE: 1
DISCUSSION: The patient has a scaphoid fracture with cystic resorption of the distal aspect of the midthird of the scaphoid. This fracture is unlikely to heal without intervention. Percutaneous pinning, closed manipulation, and bone grafting will not restore alignment. Treatment requires restoration of scaphoid length, bone grafting, and internal fixation to obtain healing with normal alignment.
REFERENCES: Cooney WP, Linscheid RL, Dobyns JH, Wood MB: Scaphoid nonunion: Role of anterior interpositional bone grafts. J Hand Surg Am 1988;13:635-650.
Fernandez DL: A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg Am 1984;9:733-737.
Stark HH, Rickard TA, Zemel NP, Ashworth CR: Treatment of ununited fractures of the scaphoid by illiac bone grafts and Kirschner-wire fixation. J Bone Joint Surg Am
1988;70:982-991.
Feldman MD, Manske PR, Welch RL, Szerzinski JM: Evaluation of Herbert screw fixation for the treatment of displaced scaphoid nonunions. Orthopedics 1997;20:325-328.
21/. A 7-year-old boy sustains an acute injury to the distal radial metaphysis, along with a completely displaced Salter-Harris type I fracture of the ulnar physis, as shown by the arrows in Figure 12. After satisfactory reduction of both injuries, what is the major concern?
1- Loss of reduction of the ulnar physis
2- Loss of reduction of the radial metaphysis
3- Physeal arrest of the distal radius
4- Physeal arrest of the distal ulna
5- Osteonecrosis of the ulnar epiphysis
PREFERRED RESPONSE: 4
DISCUSSION: While injury of the distal radial metaphysis is a rather common occurrence, the incidence of physeal arrest is only about 4% to 5% of patients. While injury of the distal physis of the ulna is rare, the incidence of physeal arrest is greater than 50% in fractures of this structure. These patients need to be followed closely both clinically and radiographically to look for the signs of distal ulnar/physeal arrest such as loss of the prominence of the ulna and ulnar deviation of the hand. Radiographically, progressive shortening of the ulna is observed.
REFERENCES: Nelson OA, Buchanan JR, Harrison CS: Distal ulnar growth arrest. J Hand Surg Am 1984;9:164-170.
Ogden JA: Skeletal Injury in the Child. New York, NY, Springer-Verlag, 2000, pp 632-635.
22/. A 28-year-old man sustained a fracture-dislocation of T8 in a motor vehicle accident 1 week ago. The injury resulted in complete paraplegia. Management should consist of
1- mobilization in a kinetic therapy bed for 8 weeks.
2- initiation of a steroid protocol.
3- immediate laminectomy of T7, T8, and T9.
4- application of a total contact orthosis.
5- open reduction and posterior segmental stabilization and grafting.
PREFERRED RESPONSE: 5
DISCUSSION: With a complete injury in the thoracic spinal cord, the likelihood of neurologic recovery is small. If possible, treatment should be planned to allow rapid mobilization and rehabilitation without the use of braces and their associated skin problems. The use of long segment fixation provides for rapid mobilization without having to use braces postoperatively. The use of steroid protocol is controversial and should be considered only if it can be started within 8 hours of the injury. Laminectomy is contraindicated because it will increase instability.
REFERENCE: Tasdemiroglu E, Tibbs PA: Long-term follow-up results of thoracolumbar fractures after posterior instrumentation. Spine 1995;20:1704-1708.
23/. A 30-year-old woman sustained a nondisplaced unilateral facet fracture of C5 in a motor vehicle accident. She is neurologically intact and has no other injuries. Management should consist of
1- skeletal tong traction for 6 weeks.
2- halo application.
3- immobilization in a rigid collar for 6 weeks.
4- open reduction posteriorly with interspinous wiring and bone grafting.
5- open reduction anteriorly with diskectomy, interbody grafting, and plating.
PREFERRED RESPONSE: 3
DISCUSSION: The patient has a stable bony fracture that will heal with immobilization in a rigid collar. Flexion-extension radiographs may be obtained at 6 weeks to verify that there is no instability; mobilization may then be begun.
REFERENCE: Clarke CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 457-464.
24/. A 26-year-old man is brought to the emergency department unresponsive and intubated after being found lying on the side of the road. He has a Glasgow Coma Scale score of 6. A chest tube has been inserted on the right side of the chest for a pneumothorax. An abdominal CT scan reveals a small liver laceration and minimal intraperitoneal hematoma. A pneumatic antishock garment (PASG) is on but not inflated. He has bilateral tibia fractures. A pelvic CT scan shows an anterior minimally displaced left sacral ala fracture and left superior and inferior rami fractures. He has received 2 L of saline solution and 4 units of blood but remains hemodynamically unstable. What is the next most appropriate step in management?
1- Inflation of the abdominal portion of the PASG
2- Application of a pelvic clamp
3- Application of a pelvic external fixator
4- Rapid infusion of 4 more units of blood
5- Angiography and embolization
PREFERRED RESPONSE: 5
DISCUSSION: There is no identifiable thoracic, abdominal, or long bone source of ongoing bleeding. The patient has a lateral compression Burgess-Young type I pelvic ring injury. This injury does not increase the pelvic volume because it is not unstable in external rotation. Application of a PASG, a pelvic clamp, or an external fixator may be helpful if the patient has a pelvic injury that is unstable in external rotation or translation but would be of little use in this injury pattern. Persistent hemodynamic instability after administration of 4 units of blood is the decision point where most authors would recommend angiography and embolization. If the pelvis is unstable in external rotation or translation, inflation of the PASG trousers or application of an external fixator is recommended before angiography. Attributing the hemodynamic instability to the head injury before ruling out the pelvis as a source is not indicated.
REFERENCES: Burgess AR, Eastridge BJ, Young JW, et al: Pelvic ring disruptions: Effective classification system and treatment protocols. J Trauma 1990;30:848-856.
Evers BM, Cryer HM, Miller FB: Pelvic fracture hemorrhage: Priorities in management. Arch Surg 1989;124:422-424.
Flint L, Babikian G, Anders M, Rodriguez J, Steinberg S: Definitive control of mortality from severe pelvic fracture. Ann Surg 1990;211:703-707.
25/. A patient has a displaced complex intra-articular distal humeral fracture. What factor is considered most important when deciding on what surgical approach to use?
1- Visualization of the articular surface
2- Avoidance of an olecranon osteotomy
3- A muscle-sparing approach
4- The likelihood a total elbow arthroplasty will be performed
5- The likelihood that reconstruction of the anterior elbow joint will be performed
PREFERRED RESPONSE: 1
DISCUSSION: When managing a complex intra-articular fracture, it is imperative that there is adequate visualization of the joint; this usually means an extensile approach. At the elbow, this is usually through a transolecranon osteotomy. The recent addition of a muscle-sparing approach as described by Bryan and Morrey has gained popularity, but it is difficult to maintain soft-tissue viability and it may put the ulnar nerve at risk. A triceps-splitting approach, which can be used for simple single articular splits into the joint where extra-articular reduction is available, is possible and good results have been reported. To date, there is minimal data on these alternative approaches for comminuted intra-articular distal humeral fractures.
REFERENCES: McKee MD, Mehne DK, Jupiter JP: Fractures of the distal humerus: Part II, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1483-1522
McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR: Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82:1701-1707.
Patterson SD, Bain GI, Mehta JA: Surgical approaches to the elbow. Clin Orthop
2000;370:19-33.
Bryan RS, Morrey BF: Extensive posterior exposure of the elbow: A triceps-sparing approach. Clin Orthop 1982;166:188-192.
26/. The use of nasotracheal intubation for airway management is contraindicated in the acute multiply injured patient when the patient has
1- suspected cervical spine trauma.
2- head injuries and spontaneous respirations.
3- respiratory arrest.
4- a need for prolonged ventilatory support.
5- a hemopneumothorax.
PREFERRED RESPONSE: 3
DISCUSSION: The use of nasotracheal intubation is less desirable in patients with respiratory arrest because placement of the tube is most reliable when the patient is breathing. Nasotracheal intubation is advantageous in patients with suspected cervical spine trauma because it does not require hyperextension of the neck. A nasotracheal tube may be more comfortable than an orally placed tube because it is fixed at several points and moves less freely within the larynx, subglottic area, and trachea. The presence of a hemothorax or pneumothorax does not affect the choice of airway control but does require placement of a chest tube.
REFERENCES: Colice GL: Prolonged intubation versus tracheostomy in the adult. J Intern Care Med 1987;2:85.
Shackford S: Spine injury in the polytrauma patient: General surgical and orthopaedic considerations, in Levine AM, Eismont FJ, Garfin S, Zigler JE (eds): Spine Trauma. Philadelphia, PA, WB Saunders, 1998, pp 9-15.
27/. A 65-year man has right hip pain after a fall. Radiographs reveal a reverse oblique intertrochanteric femoral fracture. Treatment consists of reduction and internal fixation. Which of the following implants is most commonly associated with nonunion and hardware failure?
1- Sliding hip screw
2- Dynamic condylar screw
3- 95 blade plate
4- Cephalomedullary nail
5- Intramedullary hip screw
PREFERRED RESPONSE: 1
DISCUSSION: Reverse oblique intertrochanteric femoral fractures account for 5% of all intertrochanteric or subtrochanteric fractures. They are uncommon but not rare and will be encountered in practice. The sliding hip screw is associated with the most problems because of its design. When reverse oblique fractures are fixed with a sliding hip screw, the action of the construct causes medial displacement of the distal fragment rather than compression of the proximal and distal fragments. All of the other implants prevent medial displacement of the distal segment. It should not be assumed that simply using one of the other implants is reason for success. There is a significant failure rate for each of these implants with reverse oblique fractures. The implant must be ideally placed and the fracture must be reduced.
REFERENCES: Haidukewych GJ, Israel TA, Berry DB: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.
Baumgaertner MR, Chrostowski JH, Levy RN: Intertrochanteric hip fracture, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1833-1881.
28/. Figure 13a shows the radiograph of a 9-year-old girl who sustained complete transverse fractures of the radial and ulnar shafts while in-line skating. A manipulative closed reduction is performed, and the result is seen in Figure 13b. What is the next most appropriate step in management?
1- Wedge the cast to correct angulation.
2- Accept the present alignment and continue follow-up.
3- Perform open reduction and internal fixation of both the radius and ulna with plates and screws.
4- Perform open reduction and internal fixation of both the radius and ulna with intramedullary rods.
5- Remanipulate both the radius and ulna and stabilize with an external fixator.
PREFERRED RESPONSE: 2
DISCUSSION: Bayonet apposition of the radius and ulnar shafts is quite acceptable, as long as the angulation is less than 10 degrees. The rotation must be acceptable as well. This patient went on to full healing, with full supination and pronation of the forearm and no cosmetic deformity.
REFERENCES: Price CT, Scott DS, Kurzner ME, Flynn JC: Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-712.
Vittas D, Larsen E, Torp-Pedersen S: Angular remodeling of midshaft forearm fractures in children. Clin Orthop 1991;265:261-264.
29/. In Figure 14, the primary fracture line in a calcaneal fracture is best depicted by which of the following schematics?
1- A
2- B
3- C
4- D
5- E
PREFERRED RESPONSE: 1
DISCUSSION: The schematic labeled A best depicts the primary fracture line in a calcaneal fracture. The primary fracture line in an axial-loading fracture of the calcaneus occurs from superior-lateral to inferior-medial. This fracture line separates the calcaneus into sustentacular and tuberosity fragments and typically enters the subtalar joint through the posterior facet. Although additional fracture lines typically occur, the primary fracture line is almost always present. If surgical reduction is planned, reducing the primary fracture is always a key step.
REFERENCES: Macey LR, Benirschke SK, Sangeorzan BJ, Hansen ST: Acute calcaneal fractures: Treatment option and results. J Am Acad Orthop Surg 1994;2:36-43.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.
30/. A 45-year-old man who sustains a medial subtalar dislocation while playing basketball undergoes immediate closed reduction. No fractures or osteochondral defects are noted on postreduction radiographs. The next most appropriate step in management should consist of
1- a long leg cast for 6 weeks.
2- an ankle support and return to activities.
3- a short leg cast for 4 weeks.
4- open repair of ligaments and active range of motion.
5- open repair of ligaments and casting for 6 weeks.
PREFERRED RESPONSE: 3
DISCUSSION: Most subtalar dislocations can be easily reduced by closed methods. If no fractures or defects are seen on the postreduction radiographs, then the success rate with cast immobilization is good. Medial dislocations have a better prognosis than lateral dislocations. Late instability is rare; therefore, the duration of immobilization should not be excessive. Most subtalar dislocations result in some stiffening of the hindfoot, and painful degenerative arthrosis is the most common serious complication.
REFERENCE: Saltzman C, Marsh JL: Hindfoot dislocations: When are they not benign? J Am Acad Orthop Surg 1997;5:192-198.
31/. A 21-year-old woman sustained a minimally displaced traumatic spondylolisthesis of C2 (Hangman’s fracture) after striking the windshield with her forehead during a motor vehicle accident. Management should consist of
1- skeletal tong traction for 6 weeks.
2- anterior C2-3 diskectomy, grafting, and plate fixation.
3- halo application for 8 weeks.
4- a rigid collar for 4 to 6 weeks, followed by mobilization.
5- posterior stabilization with C2 pedicle screws.
PREFERRED RESPONSE: 4
DISCUSSION: According to the classification of Levine and Edwards, a type I Hangman’s fracture is minimally displaced without angulation and represents a stable injury. Good clinical success has been achieved with nonsurgical management consisting of use of a rigid collar until the patient reports pain relief, followed by quick mobilization.
REFERENCE: Levine AM, Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985;67:217-226.
32/. A 25-year-old patient who sustained multiple bilateral rib fractures, a pulmonary contusion, a left nondisplaced transtectal acetabular fracture, and a closed humerus fracture in a motor vehicle accident 2 weeks ago is transferred from another hospital. The humerus fracture has been surgically treated. There are no signs of infection, and the trauma surgeon wants to mobilize the patient as soon as possible. Radiographs are shown in Figures 15a and 15b. Management of the humerus fracture should consist of
1- open reduction and plate fixation.
2- a humeral fracture brace.
3- a locking intramedullary nail.
4- insertion of at least two additional pins.
5- removal of the pins and a long arm hanging cast.
PREFERRED RESPONSE: 1
DISCUSSION: The radiographs show a distal third humerus fracture that is angulated, rotated, and not rigidly fixed. Rigid fixation is needed because mobilization is highly desirable to improve pulmonary function. The acetabular fracture is through the weight-bearing dome but is nondisplaced. Nonsurgical management of the acetabular fracture requires at least 6 weeks of touchdown weight bearing to minimize the forces across the hip joint. Open reduction and plate fixation would achieve anatomic reduction and immediate mobilization. A single posterolateral 4.5-mm plate or two 3.5-mm plates at 90 degrees are possible alternatives. Immediate weight bearing on a plated humerus fracture with the use of crutches or a walker has been shown to be safe and would allow touchdown weight bearing, protecting the hip. None of the other options would achieve this goal for this distal fracture.
REFERENCE: Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD: Effect of immediate weightbearing on plated fractures of the humeral shaft. J Trauma 2000;49:278-280.
33/. Figure 16 shows the radiograph of a 23-year-old man who has severe right shoulder pain after his motorcyle hit a bridge guardrail. He is neurologically intact. Nonsurgical management will most likely result in
1- nonunion of the clavicle or glenoid.
2- thoracic outlet syndrome.
3- less than 50% range of motion compared with the contralateral shoulder.
4- less than 50% strength compared with the contralateral shoulder.
5- high patient satisfaction and good shoulder function.
PREFERRED RESPONSE: 5
DISCUSSION: Internal fixation of the clavicle, glenoid, or both has been recommended for fractures of the clavicle and glenoid neck (floating shoulders). Recently, the inherent instability of these dual fractures has been questioned in a biomechanical model without further disruption of the coracoclavicular or acromioclavicular ligamentous structures. Nonsurgical management of the majority of combined scapular/glenoid fractures in patients with less than 10 mm of displacement has resulted in excellent shoulder function and will most likely achieve an excellent result in this patient.
REFERENCES: Egol KA, Connor PM, Karunakar MA, Sims SH, Bosse MJ, Kellam JF: The floating shoulder: Clinical and functional results. J Bone Joint Surg Am 2001;83:1188-1194.
Williams GR Jr, Naranja J, Klimkiewicz J, et al: The floating shoulder: A biomechanical basis for classification and management. J Bone Joint Surg Am 2001;83:1182-1187.
Edwards SG, Whittle AP, Wood GW: Nonoperative treatment of ipsilateral fractures of the scapular and clavicle. J Bone Joint Surg Am 2000;82:774-779.
34/. An 18-year old man has a simple oblique fracture of the humeral shaft that requires surgical stabilization to maintain reduction and facilitate mobilization. Which of the following methods will provide the best outcome?
1- Unreamed intramedullary nail
2- Reamed statically locked intramedullary nail
3- External fixation
4- Plate fixation and interfragmentary compression
5- Bridge plate stabilization
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a simple fracture pattern that can be reduced anatomically and stabilized with absolute stability by interfragmental compression and protection plating. This will guarantee a 95% to 98% union rate with no radial nerve palsy. Intramedullary nailing does not equal these results in a simple fracture pattern in the humerus. Bridge plating is indicated for multifragmented fracture patterns when anatomic reduction and absolute stability cannot be achieved. External fixation is reserved for severe open fractures.
REFERENCES: Chapman JR, Henley MP, Agel J, Benca PJ: Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-166.
Farragos AF, Schemitsch EH, McKee MD: Complications of intramedullary nailing for fractures of the humeral shaft: A review. J Orthop Trauma 1999;13:258-267.
Modabber M, Jupiter JB: Operative management of diaphyseal fractures of the humerus: Plate versus nail. Clin Orthop 1998;347:93-104.
35/. A 28-year-old painter has had increasing pain in his hand and forearm after sustaining a paint injection wound to the tip of his left index finger 24 hours ago. Management should consist of
1- hospital admission and IV antibiotics.
2- emergent surgical debridement.
3- oral antibiotics, splinting, and elevation.
4- nonsteroidal anti-inflammatory drugs and splinting.
5- oral antibiotics and a tetanus shot.
PREFERRED RESPONSE: 2
DISCUSSION: The clinical presentation soon after injury may be surprisingly innocuous, but all high-pressure injection injuries of various materials are best treated by emergent surgical debridement of all foreign material from the flexor tendon sheath as well as the subcutaneous tissues. Subsequent hospital admission, IV antibiotics, and possible repeat debridements usually are necessary. The use of antibiotics alone is inadequate treatment of this severe injury.
REFERENCES: Pinto MR, Turkula-Pinto LE, Cooney WP, Wood MB, Dobyns JH: High-pressure injection injuries of the hand: Review of 25 patients managed by open wound technique. J Hand Surg Am 1993;18:125-130.
Urbaniak JR, Evans JP, Bright DS: Microvascular management of ring avulsion injuries. J Hand Surg Am 1981;6:25-30.
Tsai TM, Manstein C, DuBou R, Wolff T, Kutz JE, Kleinert HE: Primary microsurgical repair of ring avulsion amputation injuries. J Hand Surg Am 1984;9:68-72.
Kay S, Werntz J, Wolff T: Ring avulsion injuries: Classification and prognosis. J Hand Surg Am 1989;14:204-213.
Schnall SB, Mirzayan R: High-pressure injection injuries to the hand, in Kozin SH (ed): Hand Clinics: Upper Extremity Trauma. Philadelphia, PA, 1999, pp 245-248.
36/. A 21-year-old basketball player inverts his foot during practice. Examination reveals obvious deformity of the hindfoot with a prominence of the talar head dorsolaterally and medial displacement of the forefoot. A radiograph is shown in Figure 17. What is the most likely obstacle to closed reduction?
1- Posterior tibial tendon
2- Impaction fracture of the head of the talus
3- Posterior tibial neurovascular bundle
4- Achilles tendon
5- Calcaneus fracture
PREFERRED RESPONSE: 2
DISCUSSION: The patient has a medial subtalar dislocation. These injuries should be reduced as soon as possible to minimize risk to the skin. Most often, this can be done easily, and further radiographic evaluation then can be performed as necessary. On rare occasions, closed reduction is not possible because of fractures of the articular surface of the talus, navicular, interposed extensor digitorum brevis, or transverse fibers of the cruciate crural ligament. The posterior tibial tendon is the most common obstruction to closed reduction in lateral subtalar dislocations, which are less common than medial dislocations. The majority of both injuries can be managed by closed reduction and immobilization.
REFERENCES: Mulroy RD: The tibialis posterior tendon as an obstacle to reduction of a lateral anterior subtalar dislocation. J Bone Joint Surg Am 1953;37:859-863.
Heckman JD: Fractures and dislocations of the foot, in Rockwood CA, Green DP, Bucholz RW (eds): Fractures in Adults. Philadelphia, PA, JB Lippincott, 1991, pp 2093-2100.
Saltzman C, Marsh JL: Hindfoot dislocations: When are they not benign? J Am Acad Orthop Surg 1997;5:192-198.
37/. A 27-year-old woman sustained a bilateral C5-6 facet subluxation in a motor vehicle accident. Neurologic evaluation reveals normal motor, sensory, and reflex functions. She is awake, alert, and cooperative. Initial management should consist of
1- halo application.
2- skeletal traction and attempted closed reduction.
3- a soft cervical collar.
4- immediate transfer to the operating room for closed reduction.
5- immediate transfer to the operating room for open reduction and
stabilization posteriorly.
PREFERRED RESPONSE: 2
DISCUSSION: As long as the patient is alert and cooperative, an attempt can be made to reduce the dislocation. This should not be attempted in a patient who is obtunded, comatose, or uncooperative. If any neurologic changes are noted during the reduction maneuver, the attempt should be stopped, appropriate radiographic studies obtained, and open reduction and stabilization planned in the operating room.
REFERENCE: Eismont FJ, Arena MJ, Green BA: Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets: Case reports. J Bone Joint Surg Am 1991;73:1555-1560.
38/. A 22-year-old patient sustained a jamming injury to the right little finger. The lateral radiograph shown in Figure 18 reveals comminution of the base of the middle phalanx, with palmar and dorsal metaphyseal cortical involvement. The articular surface also is disrupted. Management should consist of
1- indirect fracture reduction via traction and early mobilization.
2- volar plate arthroplasty.
3- open reduction and internal fixation.
4- closed reduction and percutaneous pin fixation.
5- cast immobilization.
PREFERRED RESPONSE: 1
DISCUSSION: This fracture, known as a pilon fracture, represents comminution of the base of the middle phalanx with both palmar and dorsal cortical disruption. The treatment method that allows the best function and fewest complications is indirect reduction achieved through specific dynamic splinting or the use of specifically designed proximal interphalangeal joint external fixators. Early mobilization can be achieved by either of these techniques. Volar plate arthroplasty is indicated for a simple fracture-dislocation of the proximal interphalangeal joint with comminution of the volar fracture fragment and dorsal dislocation of the remaining articular surface. Open reduction and internal fixation or percutaneous pinning adds surgical risks and scarring and typically will not provide added stability. Cast immobilization will not achieve the goal of early range of motion.
REFERENCES: Stern PJ, Roman RJ, Kiefhaber TR, McDonough JJ: Pilon fractures of the proximal interphalangeal joint. J Hand Surg Am 1991;16:844-850.
Krakauer JD, Stern PJ: Hinged device for fractures involving the proximal interphalangeal joint. Clin Orthop 1996;327:29-37.
39/. Figure 19 shows the radiograph of a 12-year-old boy who sustained an injury to his hand when another child fell on him. Management should consist of
1- early motion and muscle strengthening.
2- immobilization in a thumb spica cast with the thumb abducted.
3- open reduction and internal fixation through a volar approach.
4- open reduction and internal fixation through a dorsal approach.
5- closed reduction and percutaneous pin fixation.
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a Salter-Harris type III fracture of the proximal phalanx of the thumb. It is usually caused by an abduction injury where the ulnar collateral ligament avulses a fragment away from the proximal epiphysis and is the most common childhood gamekeeper’s injury. If there is greater than 1 mm of separation or a significant articular step-off, an open reduction, performed through an extensor aponeurosis-splitting approach, is required to reestablish joint congruity and stability. Percutaneous or closed methods of reduction are usually ineffective. The dorsal approach avoids the volar neurovascular structures. Since the ulnar collateral ligament is still attached, this area does not need to be visualized. The major goal is to reestablish joint congruity and bony stability. This can be easily performed via the dorsal approach.
REFERENCES: Carey TP: Fracture and dislocations of the phalanges, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994, pp 435-436.
Ogden JA: Skeletal Injury in the Child. New York, NY, Springer-Verlag, 2000, p 668.
40/. Figures 20a through 20c show the radiographs of a 69-year-old woman who has severe pain in her dominant right arm after falling on the ice. History includes arthritis, hypertension, and heart disease. She is neurovascularly intact. Management should consist of
1- a long arm cast.
2- immediate functional bracing.
3- closed reduction and percutaneous pin fixation.
4- percutaneous olecranon pin traction.
5- total elbow arthroplasty.
PREFERRED RESPONSE: 5
DISCUSSION: The radiographs reveal a severely comminuted distal humerus fracture. A long arm cast, functional bracing, and closed reduction and percutaneous pin fixation all have a poor outcome and could result in a nonunion that will be very difficult to treat. Open reduction and internal fixation is indicated in most supracondylar humerus fractures, but total elbow arthroplasty is a good alternative in elderly patients who have multiple medical problems and when the fracture pattern may preclude stable enough internal fixation to allow postoperative motion.
REFERENCES: Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am 1997;79:826-832.
Morrey BF: Fractures of the distal humerus: Role of elbow replacement. Orthop Clin North Am 2001;31:145-155.
41/. An 18-year-old man has acute respiratory distress after sustaining injuries in a motorcycle accident. He has a blood pressure of 80/60 mm Hg and a pulse rate of 110/min. Examination reveals chest tympany to percussion, distended neck veins, and deviation of the trachea away from his right hemithorax where the breath sounds are diminished. Heart sounds are regular and normal on auscultation. Initial management should consist of
1- administration of 2 L of saline solution.
2- subxiphoid pericardial aspiration.
3- rapid infusion of 500 mL of colloid solution.
4- insertion of a large-bore needle in the right third or fourth intercostal space.
5- intubation followed by mechanical ventilation.
PREFERRED RESPONSE: 4
DISCUSSION: Tension pneumothorax occurs when air trapped in the pleural space between the lung and chest wall achieves sufficient pressure to compress the lungs and shift the mediastinum. Urgent needle decompression of the pleural space air followed by definitive chest tube placement is the treatment of choice.
REFERENCE: Mattox KL, Feliciano DV, Moore EE (eds): Management of Shock, ed 4. New York, NY, McGraw Hill, 2000, p 215.
42/. A 27-year-old man has neck pain after being involved in a motor vehicle accident. A lateral cervical radiograph is shown in Figure 21. What would be the most common neurologic finding?
1- Cruciate paralysis
2- Quadraplegia
3- Normal function
4- Absent bulbocavernosus reflex
5- Greater occipital nerve dysesthesia
PREFERRED RESPONSE: 3
DISCUSSION: The radiographic findings are consistent with a type II Hangman’s fracture or traumatic spondylolisthesis of C2. This occurs with more than 3 mm of displacement according to the classification of Levine and Edwards. Even though the radiograph reveals significant displacement, the overall space available for the neural elements is increased, therefore minimizing the risk of neural compromise. Neurologic injury is most frequently encountered in type III injuries that are associated with bilateral facet dislocations of C2 on C3 but is infrequent in type I (less than 3 mm displacement) and type II traumatic spondylolisthesis. When neurologic deficits are associated with type II injuries, it is usually the result of an associated head injury. Cruciate paralysis occurs as a result of the crossover of the motor and sensory tracts at different levels of the cord at the C1-C2 junction. This results in normal sensation but complete loss of motor function.
REFERENCES: Levine AM: Traumatic spondylolisthesis of the axis (Hangman’s fracture), in Levine AM, Eismont FJ, Garfin S, Zigler JE (eds): Spine Trauma. Philadelphia, PA, WB Saunders, 1998, pp 287-288.
Francis WR, Fielding JW, Hawkins RJ, Pepin J, Hensinger R: Traumatic spondylolisthesis of the axis. J Bone Joint Surg Br 1981;63:313-318.
43/. After stabilizing a bimalleolar ankle fracture with a plate and lag screws for the fibula and two interfragmental compression screws for the medial malleolus, a syndesmosis screw is indicated in which of the following situations?
1- In all suprasyndesmotic fibular fractures
2- In all transsyndesmotic fibular fractures
3- When there is increased medial clear space with external rotation stress
4- If the deltoid ligament is ruptured
5- If the posterior malleolus is fractured
PREFERRED RESPONSE: 3
DISCUSSION: It is imperative to recognize the need for a position screw (syndesmosis screw) to hold the syndesmosis in proper alignment when surgically stabilizing an ankle fracture. Although many different fracture patterns are suspicious for a disrupted syndesmosis, the only sure way to assess the syndesmosis is to stress it with abduction and external rotation of the talus and attempt to displace the fibula from the incisura fibularis. Under fluoroscopy, the talus will move laterally and displace the fibula, show a valgus talar tilt, or show an increase in the medial clear space. If any or all of these signs occur, a syndesmosis screw is inserted after making sure that the fibula is reduced into the incisura fibularis. This screw may traverse three or four cortices but must not act as a lag screw. It usually is inserted with the ankle in maximal dorsiflexion, although this is probably not necessary because it is almost impossible to overcompress the syndesmosis. The diameter of the screw does not make any difference. It may or may not be removed but not before 3 months.
REFERENCES: Tornetta P III, Spoo JE, Reynolds FA, Lee C: Overtightening of the ankle syndesmosis: Is it really possible? J Bone Joint Surg Am 2001;83:489-492.
Stover MD, Kellam JF: Articular fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 105-119.
Hahn DM, Colton CL: Malleolar fractures, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 559-581.
Tile M: Fractures of the ankle, in Schatzker J, Tile M (eds): Rationale of Operative Fracture Care, ed 2. Berlin, Springer-Verlag, 1998, pp 523-561.
44/. A 32-year-old man sustains multiple injuries in a motorcycle accident including ipsilateral open right femur and comminuted tibia fractures. He has acute abdominal distention and tenderness to palpation. The pelvis is stable to examination. He has a blood pressure of 70/40 mm Hg despite appropriate fluid resuscitation and a pulse rate of 120/min; the pulse is thready. Which of the following procedures is considered the highest priority in the management of this patient?
1- Emergent CT of the abdomen and pelvis
2- Insertion of a Swan-Ganz catheter to monitor the cardiac index
3- Administration of albumin solution
4- Emergent laparotomy in the operating room
5- Application of a pneumatic antishock garment
PREFERRED RESPONSE: 4
DISCUSSION: The patient is in hemorrhagic shock, and timely hemostasis in the operating room should be the highest priority. Further imaging and insertion of central lines carry the risk of further delays in arresting the source of the patient’s bleeding. Albumin (colloid) solutions have questionable indications, are expensive, and have been associated with increased mortality. Crystalloid solutions such as normal saline or lactated Ringer’s solution are the initial resuscitative fluid of choice until blood becomes available. Pneumatic antishock garments have been associated with higher mortality rates, particularly in patients with cardiac and thoracic vascular injuries.
REFERENCES: Krettek C, Simon RG, Tscherne H: Management priorities in patients with polytrauma. Langenbecks Arch Surg 1998;383:220-227.
Weigelt JA: Resuscitation and initial management. Crit Care Clin 1993;9:657-671.
45/. A 35-year-old man sustained an injury to his lower extremity after falling 10 feet from a ladder; initial management was nonsurgical. He now reports chronic hindfoot and anterior ankle pain. Radiographs are shown in Figures 22a and 22b. Surgical reconstruction of this painful process should consist of
1- talectomy and tibiocalcaneal arthrodesis.
2- in situ subtalar joint arthrodesis.
3- distraction bone block subtalar joint arthrodesis.
4- lateral wall exostectomy of the calcaneus.
5- tibiotalar joint arthrodesis.
PREFERRED RESPONSE: 3
DISCUSSION: The radiographs reveal a hindfoot deformity that developed following a severe, comminuted, intra-articular fracture of the calcaneus. There is deformity of the calcaneal body and collapse of the talus into the calcaneus, leading to dorsiflexion of the talus and anterior ankle joint impingement. Distraction bone block subtalar joint arthrodesis will assist with correction of the calcaneal height and will allow for an improved talar declination angle. With this procedure, care must be taken to avoid placing the hindfoot into further varus. A similar reconstruction option not listed would be a calcaneal osteotomy and arthrodesis as described by Romash. Talectomy and tibiocalcaneal arthrodesis are not warranted because the primary structure of the talus and ankle joint is well preserved. In situ subtalar joint arthrodesis will not correct the deformity, and symptoms about the ankle and hindfoot would most likely persist. Lateral wall calcaneal exostectomy may decrease pain from subfibular impingement but will not deal directly with subtalar joint arthrosis and deformity.
REFERENCES: Carr JB, Hansen ST , Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-86.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.
Romash MM: Reconstructive osteotomy of the calcaneus with subtalar arthrodesis for malunited calcaneal fractures. Clin Orthop 1993;290:157-167.
46/. An 8-year-old boy falls and injures his thumb. A radiograph is shown in Figure 23. Initial management should consist of
1- closed reduction.
2- closed reduction and percutaneous pinning.
3- open reduction through a volar approach.
4- open reduction through a dorsal approach.
5- splinting for comfort.
PREFERRED RESPONSE: 1
DISCUSSION: The radiograph shows a complete simple dislocation of the metacarpophalangeal joint. The clue to this injury is the perpendicular alignment of the proximal phalanx to the metacarpal on the lateral radiograph. This must be differentiated from the complete complex dislocation pattern that is irreducible because of the interposed volar plate. In lateral radiographs of these injuries, the long axes of the proximal phalanx and the metacarpal are parallel. Simple dislocations are amenable to closed reduction and casting. Some authors have recommended ulnar collateral ligament repair if instability is detected on examination after reduction.
REFERENCES: O’Brien ET: Part IV: Dislocations of hand and carpus, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 429-431.
Bohart PC, Gelberman RH, Vardell RF, Solomon PB: Complex dislocations of the MCP joint. J Bone Joint Surg Am 1974;56:1459-1463.
47/. A 28-year-old anesthesia resident has aching pain in his dominant right forearm after injuring it while playing basketball 1 week ago. He reports that he is unable to perform regional anesthesia that requires manipulation of a needle. Examination reveals that he is unable to flex the interphalangeal joint of the thumb, and flexion of the distal interphalangeal joint of the index finger is weak. Management should consist of
1- stretching of the forearm in pronation, wrist flexion, and splinting.
2- primary tendon repair of the flexor pollicis longus and flexor digitorum profundus to the index finger, followed by immobilization.
3- electrodiagnostic examination, followed by decompression of the anterior interosseous nerve within the next 2 to 3 weeks.
4- splinting followed by observation; surgical decompression of the median nerve may be required if no improvement in seen in 3 months.
5- splinting followed by observation; surgical decompression of the anterior interosseous nerve may be required if no improvement is seen in 6 months.
PREFERRED RESPONSE: 5
DISCUSSION: The patient has anterior interosseous nerve palsy. Initial management should consist of splinting followed by observation; surgical decompression may be required if there is no improvement in the functional deficit in 6 months. Anterior interosseous nerve palsy is classically described as an inability to flex the interphalangeal joint of the thumb because of flexor pollicis longus paralysis and a weakness or inability to flex the distal interphalangeal joint of the index finger because of weakness and/or paralysis of the flexor digitorum profundus to the index finger. There has been some controversy in the literature as to whether this represents a true peripheral compression neuropathy or neuritis. Recent recommendations have been to extend the period of observation from 3 to 6 months before surgical decompression, as most cases will resolve within 6 months.
REFERENCES: Miller-Breslow A, Terrono A, Millender LH: Nonoperative treatment of anterior interosseous nerve paralysis. J Hand Surg Am 1990;15:493-496.
Stern PJ, Fassler PR: Anterior interosseous nerve compression syndrome, in Gelberman RH (ed): Operative Nerve Repair and Reconstruction. Philadelphia, PA, 1991, vol 2, pp 983-1002.
48/. A 5-year-old girl sustains an isolated injury to the right shoulder area after falling off the monkey bars. Examination reveals intact neurovascular function in the extremity distally, but she is quite uncomfortable. An AP radiograph of the proximal humerus is shown in Figure 24. Her parents state that she is a very talented gymnast. Considering her age and potential athletic career, management should consist of
1- a shoulder spica cast with the upper extremity in the salute position.
2- a sling and swathe for 3 weeks, followed by gradual motion and strengthening.
3- closed reduction and antegrade intramedullary pinning.
4- closed reduction and retrograde intramedullary nailing.
5- open reduction and internal fixation with small plates and screws.
PREFERRED RESPONSE: 2
DISCUSSION: In this age group, bayonet apposition can produce very good results. Healing occurs rapidly, and remodeling usually is complete in less than 1 year. All of the other methods have significant risks of complications and are unnecessary for this fracture.
REFERENCES: Martin RF: Fractures of the proximal humerus and humeral shaft, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994,
pp 144-148.
Sanders JO, Rockwood CA Jr, Curtis RJ: Fractures and dislocation of the humeral shaft and shoulder, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 937-939.
49/. The cortical injury to the posterolateral distal fibula shown in Figure 25 indicates involvement of which of the following structures?
1- Deltoid ligament
2- Anterior talofibular ligament
3- Calcaneal fibular ligament
4- Superior peroneal retinaculum
5- Syndesmosis
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a rim avulsion fracture that is the result of a forceful twisting injury as the superior peroneal retinaculum is avulsed from its fibular attachment along with a small rim of bone. Injuries to the anterior talofibular ligament or calcaneal fibular ligament would show cortical avulsions more anteriorly or distally at the fibular tip. Deltoid ligament injuries would reveal medial radiographic changes. In a true injury to the syndesmosis, if osseous structures do show avulsion, it would be more directly posterior or anterior on the distal fibula or would occur on the tibial surface.
REFERENCES: Murr S: Dislocation of the peroneal tendons with marginal fracture of the lateral malleolus. J Bone Joint Surg Br 1961;43:563-565.
Clanton TO: Athletic injuries to the soft tissues 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 1090-1209.
50/. A 52-year-old woman underwent open reduction and internal fixation for radial and ulnar shaft fractures 2 months ago. In a second fall she refractured her forearm and required revision surgery with bone grafting. One month after the second operation she notes erythema, swelling, and drainage from the volar radial incision. In addition to antibiotic treatment, management should consist of
1- observation and splinting.
2- local wound drainage under local anesthesia.
3- incision and drainage, deep wound cultures, removal of the plates and screws, and cast application.
4- incision and drainage, deep wound cultures, and removal of the fixation only if it is loose.
5- incision and drainage, deep wound cultures, and bone grafting.
PREFERRED RESPONSE: 4
DISCUSSION: Deep infections after plating of closed fractures of the forearm are unusual. However, the risk increases with repeat surgeries. Debridement of all infected, nonviable tissue is the initial step in management. The fixation may be retained if it is stable, but if the plate and screws are loose, they should be removed and revision performed after removal of nonviable bone. Either external fixation or repeat plating may be performed. Late infections after fracture union may be treated with plate and screw removal, debridement, and IV antibiotics.
REFERENCES: Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 53-63.
Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr: Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am 1986;68:1008-1017.
Chapman MW, Gordon JE, Zissimos AG: Compression-plate fixation of acute fractures of the diaphysis of the radius and ulna. J Bone Joint Surg Am 1989;71:159-169.
51/. A left-handed 23-year-old man who fell 5 feet from a ladder onto his left elbow sustained the closed injury shown in Figure 26. Management should consist of
1- percutaneous pin fixation.
2- a percutaneous 6.5-mm screw.
3- long arm casting in flexion.
4- open reduction and internal fixation with a tension band plate.
5- closed reduction and long arm casting in extension.
PREFERRED RESPONSE: 4
DISCUSSION: The radiographs reveal a displaced olecranon fracture. To maximize joint congruity of this intra-articular injury, open reduction and internal fixation is the treatment of choice. A tension band plate will assist with maintenance of the reduction and may aid in early range of motion because injuries to the elbow are prone to stiffness. The oblique fracture line is particularly well suited to plate fixation. Percutaneous pin fixation is unlikely to achieve anatomic joint reduction that can be obtained with open means. External immobilization will not accomplish joint reduction and will most likely lead to a nonunion.
REFERENCES: Hotchkiss RN: Fractures and dislocations of the elbow, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 929-1024.
Murphy DF, Greene WB, Gilbert JA, Dameron TB Jr: Displaced olecranon fractures in adults: Biomechanical analysis of fixation methods. Clin Orthop 1987;224:210-214.
Hume MC, Wiss DA: Olecranon fractures: A clinical and radiographic comparison of tension band wiring and plate fixation. Clin Orthop 1992;285:229-235.
52/. Which of the following is a long-term complication of ankle arthrodesis for posttraumatic arthritis?
1- Progressive limb-length discrepancy
2- Contralateral ankle arthritis
3- Ipsilateral hindfoot and midfoot arthritis
4- Ipsilateral knee arthritis
5- Talar osteonecrosis
PREFERRED RESPONSE: 3
DISCUSSION: Ankle arthrodesis for posttraumatic ankle arthrosis provides reliable pain relief. However, the long-term sequela of joint arthrodesis is the development of arthrosis in the surrounding joints. Over time, following ankle arthrodesis, the ipsilateral hindfoot and midfoot joints show signs of joint space wear, and this may be symptomatic. With a stable ankle arthrodesis, progressive limb-length discrepancy or talar osteonecrosis is not expected. Ankle arthrodesis has not been definitively linked to ipsilateral knee arthritis or contralateral ankle arthritis.
REFERENCES: Coester LM, Saltzman CL, Leupold J, Pontarelli W: Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 2001;83:219-228.
Mazur JM, Schwartz E, Simon SR: Ankle arthrodesis: Long-term follow-up with gait analysis. J Bone Joint Surg Am 1979;61:964-975.
53/. A 19-year-old female long-distance runner has an incomplete tension-side femoral neck stress fracture. Management should consist of
1- limited weight bearing for 6 weeks, followed by a progressive return to activity.
2- no weight bearing for 6 weeks, followed by no running for 6 months.
3- no weight bearing for 2 weeks, followed by internal fixation if symptoms persist.
4- internal fixation at the time of diagnosis.
5- cessation of running for 6 weeks.
PREFERRED RESPONSE: 4
DISCUSSION: Unlike compression-side stress fractures, tension-side stress fractures on the superior side of the femoral neck are at a very high risk of displacement, even if the patient is not bearing weight. It is highly recommended to treat these fractures like acute fractures and to proceed with internal fixation emergently. Once the fracture has displaced, the prognosis is poor in terms of returning to sports, even when reduced and internally fixed. Nonsurgical management, such as limited weight bearing and low-impact activities, works very well for other lower extremity stress fractures. A training program evaluation (shoes, tracks, schedule) is always indicated for all patients with stress fractures.
REFERENCE: Boden BP, Osbahr DC: High-risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.
54/. A 7-year-old girl who sustained a type III posteromedial extension supracondylar fracture underwent a closed reduction at the time of injury. Figure 27a shows the position of the fracture fragments prior to percutaneous medial and lateral pin fixation. Following surgery, healing was uneventful and the patient regained a full painless range of motion. Fifteen months after the injury, she now reports loss of elbow motion and moderate pain with activity. A current AP radiograph is shown in Figure 27b. What is the most likely cause of her symptoms?
1- Latent osteomyelitis from the percutaneous pins
2- Muscle weakness because of a lack of postinjury rehabilitation
3- Tardy ulnar nerve paralysis from injury by the medial pin
4- Osteonecrosis of the trochlea, producing joint incongruity
5- A new acute process
PREFERRED RESPONSE: 4
DISCUSSION: The patient sustained a very distal supracondylar fracture of the humerus. Fractures in this area can disrupt the blood vessels supplying the lateral ossification center of the trochlea. With disturbance of the blood supply in this area, local osteonecrosis occurs and disrupts the support for the overlying articular surface, producing joint incongruity and localized degenerative arthritis.
REFERENCES: Haraldsson S: The interosseous vasculature of the distal end of the humerus with special reference to the capitellum. Acta Orthop Scand 1957;27:81-93.
Morrissy RT, Wilkins KE: Deformities following distal humeral fracture in childhood. J Bone Joint Surg Am 1984;66:557-562.
55/. A 55-year-old man sustained an isolated closed fracture of the humerus. Initial neurologic examination reveals no active wrist or finger extension. Radiographs are shown in Figures 28a and 28b. Management should consist of
1- closed treatment and observation for return of nerve function.
2- closed treatment and immediate tendon transfer.
3- open nerve exploration without internal fixation of the fracture.
4- open nerve exploration with plating of the fracture.
5- open nerve exploration with intramedullary rodding of the fracture.
PREFERRED RESPONSE: 1
DISCUSSION: The patient has an isolated closed injury involving the humeral diaphysis. The lack of wrist and finger extension indicates injury to the radial nerve. Based on these findings, ongoing observation of the nerve is warranted with delayed exploration after 3 to 4 months if there are no signs of progressive return of nerve function. Treatment of the fracture should include external immobilization and fracture bracing. An indication for nerve exploration and surgical stabilization would be an open fracture.
REFERENCES: Zuckerman JD, Kovil KJ: Fractures of the shaft of the humerus, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 1025-1053.
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.
56/. Examination of a 41-year-old man who was thrown from a motorcycle reveals that both legs appear externally rotated and there is bruising in the perineal area. He has a blood pressure of 80/40 mm Hg, a pulse rate of 140/min, a respiratory rate of 25/min, and he appears confused. Following administration of 4 L of saline solution and 2 units of packed red blood cells, he has a blood pressure of 80/40 mm Hg, a pulse rate of 160/min, and a respiratory rate of 25/min. The abdominal assessment for intraperitoneal blood is negative. An AP radiograph shows an anteroposterior compression injury with 7 cm of symphysis diastasis but no posterior displacement in the sacroiliac joints. What is the next most appropriate step in management?
1- Stabilization of the pelvis through noninvasive methods
2- Additional crystalloid solution replacement
3- External fixation in the operating room
4- Angiographic embolization
5- Continuing observation of vital signs
PREFERRED RESPONSE: 1
DISCUSSION: Because the patient has sustained a major high-energy injury to the pelvic ring, it can be assumed that there is serious bleeding or hemodynamic instability related to a pelvic vascular injury. The goal of intervention at this time is to assist in the resuscitative effort and to stop the bleeding. All attempts at providing fluid and blood are important, but without cessation of the bleeding continued loss occurs and significant problems can ensue such as coagulopathy and multiple organ failure. Noninvasive methods of stabilizating the pelvic ring should be used to stop the bleeding. These methods include wrapping a sheet around the pelvis or using commercially available belts, vacuum beanbags, or pneumatic shock garments. This will provide time to prepare for arteriography and/or external fixation. The next step is debatable but in view of negative findings for intra-abdominal blood, arteriography performed with the pelvis reduced using noninvasive methods would be ideal.
REFERENCES: Bassam D, Cephas GA, Ferguson KA, Beard LN, Young JS: A protocol for the initial management for unstable pelvic fractures. Am Surg 1998;64:862-867.
Levine AM (ed): Orthopaedic Knowledge Update: Trauma. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 217-226.
Mucha P Jr, Welch TJ: Hemorrhage in major pelvic fractures. Surg Clin North Am 1988;68:757-773.
57/. A 32-year-old man sustained a closed injury after falling 25 feet from a roof. His ankle and foot are severely swollen. Radiographs and CT scans are shown in Figures 29a through 29d. Initial management should consist of
1- closed reduction and application of a long leg cast.
2- open reduction and internal fixation with plate and screw fixation.
3- percutaneous plate fixation.
4- spanning external fixation with delayed limited open reduction and internal fixation.
5- primary ankle arthrodesis.
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a severe high-energy injury from axial loading to the left ankle and distal tibia. This is a closed injury, but the soft tissues are injured and severely swollen. Initial treatment should focus on skeletal stabilization, and incisions directly over the fracture area should be avoided until soft-tissue stabilization has occurred. Immediate spanning external fixation with plans for a delayed reconstruction as needed for the joint surface is the treatment of choice. Closed reduction and application of a constrictive long leg cast may lead to increased risk of tissue necrosis. Immediate open procedures to internally fix the fracture add the risks of soft-tissue necrosis and are to be avoided. Percutaneous plating may be one of the delayed fixation options but should not be used immediately. Primary ankle arthrodesis is not indicated.
REFERENCES: Thordarson DB: Complications after treatment of tibial pilon fractures: Prevention and management strategies. J Am Acad Orthop Surg 2000;8:253-265.
Marsh JL, Bonar S, Nepola JV, DeCoster TA, Hurwitz SR: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-1509.
Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A randomized, prospective study. J Bone Joint Surg Am 1996;78:1646-1657.
58/. Which of the following parameters is considered most important when assessing an acetabular fracture for surgical indications?
1- Age of the patient
2- Failure to maintain reduction of the head under the dome without traction
3- Presence of a femoral head impaction lesion
4- Direction of the femoral head displacement
5- Fragmentation of the fracture
PREFERRED RESPONSE: 2
DISCUSSION: The most important aspect in the decision for surgery in an acetabular fracture is the ability of the femoral head to remain concentrically reduced under the dome in AP and Judet oblique views of the pelvis. If this parameter is present, then the need for surgery is determined by other aspects such as fragmentation, age, incongruity, and displacement. If the head remains stable under the dome without traction, there is sufficient acetabular dome to provide stability, and nonsurgical treatment may be appropriate.
REFERENCES: Tile M: Assessment and management of acetabular fractures, in Tile M (ed): Pelvic and Acetabular Fractures, ed 2. Baltimore, MD, Williams and Wilkins, 1995, pp 305-354.
Letournel E: Acetabular fractures: Classification and management. Clin Orthop 1980;151:81-106.
Letournel E, Judet R: Fractures of the Acetabular, ed 2. Berlin, Springer-Verlag, 1993, pp 29-49.
59/. A 57-year-old man has had right ankle pain for the past 10 months following an injury that went untreated. Radiographs are shown in Figures 30a through 30c. Management should consist of
1- ankle arthrodesis.
2- modified Brostrom ligament reconstruction.
3- restoration of fibular length, alignment, and rotation.
4- cast immobilization.
5- tibial shortening osteotomy.
PREFERRED RESPONSE: 3
DISCUSSION: The radiographs reveal a malunited distal fibular fracture with shortening. Because there appears to be an adequate cartilage space within the ankle joint, the role of reconstruction would be to prevent arthrosis and the need for ankle arthrodesis, as well as to decrease symptoms. The treatment of choice is restoration of fibular length, alignment, and rotation with osteotomy plating, and bone grafting as needed. There is no indication for ligament reconstruction of a mechanically stable ankle, and tibial shortening osteotomy will not assist in correcting the deformity. Cast immobilization may assist with improvement of symptoms but will not correct the overall process. Determination of fibular length is best done by comparing the talocrural angle of the injured side with the uninjured side. The goal is to perfectly reduce the talus in the ankle mortise.
REFERENCES: Marti RK, Raaymakers EL, Nolte PA: Malunited ankle fractures: The late results of reconstruction. J Bone Joint Surg Br 1990;72:709-713.
Geissler W, Tsao A, Hughes J: Fractures and injuries of the ankle, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 2201-2206.
Yablon IG, Leach RE: Reconstruction of malunited fractures of the lateral malleolus. J Bone Joint Surg Am 1989;71:521-527.
60/. A 32-year-old man sustains a forceful inversion injury while playing soccer. Examination reveals tenderness in the lateral hindfoot and midfoot region with associated ecchymosis and swelling. Radiographs show proximal migration of the os peroneum. Active eversion is still present. These findings indicate disruption of the
1- extensor digitorum brevis.
2- plantar fascia.
3- peroneus brevis.
4- peroneus longus.
5- syndesmosis.
PREFERRED RESPONSE: 4
DISCUSSION: The os peroneum is an accessory ossicle located within the peroneus longus tendon. It is typically located at the level of the cuboid groove in the lateral hindfoot and midfoot region. Proximal migration of the os peroneum indicates disruption of the peroneus longus tendon and is an important clue to diagnosis. This unusual condition can cause chronic lateral ankle pain, and surgical repair may be indicated. Active eversion indicates that the peroneus brevis is clinically intact. Disruption of the extensor digitorum brevis, plantar fascia, or syndesmosis would have no effect on the position of the os peroneum.
REFERENCES: Thompson FM, Patterson AH: Rupture of the peroneus longus tendon: Report of three cases. J Bone Joint Surg Am 1989;71:293-295.
Clanton TO: Athletic injuries to the soft tissues 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 1090-1209.
61/. A 24-year-old man sustained a grade IIIb open tibial fracture and an ipsilateral grade IIIa femoral fracture in a motorcycle accident. He is unresponsive, intubated, and has a Glasgow Coma Scale score of 8. He is resuscitated and taken to the operating room for definitive orthopaedic care. Which of the following intraoperative problems will most likely adversely affect his long-term outcome?
1- Blood loss during debridement
2- Prolonged tourniquet time
3- Failure to stabilize both fractures with intramedullary nails
4- Episodic hypotension
5- Loss of dorsalis pedis pulse
PREFERRED RESPONSE: 4
DISCUSSION: Traumatic brain injury is considered to be either primary or secondary. Primary injury is direct or impact damage to the brain, and secondary injury can have intracranial or systemic causes. While treatment has little impact on primary brain injury, secondary brain injury can be avoided. There are also many causes of intracranial secondary brain injury, including intracranial hypertension or cerebral edema. There are many causes of systemic secondary brain injury, but none has a greater impact on outcome than hypotension or hypoxia. In fact, the occurrence of hypotension postinjury causes a 10- to 15-fold increase in mortality. In a series by Pietropaoli and associates, the mortality rate for head-injured patients that were normotensive during surgery was 25%, but if they were hypotensive the mortality rate was 82%. In the same series, the number of patients with a Glasgow Coma Scale score of either 4 or 5 dropped from 58% in those patients that were normotensive during surgery to 6% in those patients that became hypotensive during surgery. Efforts to avoid hypotension postinjury and especially during surgery should be of primary importance.
REFERENCES: Chesnut RM, Marshall LF, Klauber MR, et al: The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216-222.
Pietropaoli JA, Rogers FB, Shackford SR, Wald SL, Schmoker JD, Zhuang J: The deleterious effects of intraoperative hypotension on outcome in patients with severe head injury. J Trauma 1992;33:403-407.
Schmeling GJ, Schwab JP: Polytrauma care: The effect of head injuries and timing of skeletal fixation. Clin Orthop 1995;318:106-116.
Townsend RN, Lheureau T, Protech J, Reimer B, Simon D: Timing fracture repair in patients with severe brain injury (Glascow Coma Scale score
J: Fracture of the forearm, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 323-337.
Jupiter JB, Leibovic SJ, Ribbans W, Wilk RM: The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.
72/. A 15-year-old baseball pitcher who reports increasing pain in his right shoulder over the past 3 weeks states that the pain increases the more he pitches. Radiographs of both shoulders are shown in Figures 35a and 35b. What is the next most appropriate step in management?
1
Increased pitching activity in conjunction with aggressive physical therapy

2
Biopsy of the lesion in the proximal humerus

3
Complete rest with no activity

4
Immobilization in a shoulder spica cast in the salute position

5
Cessation of pitching and a vigorous program of muscle strengthening

The patient has a rotational stress fracture of the proximal humeral physis (Little Leaguer’s shoulder). The symptoms of increasing pain with activity and relief with rest are typical of a stress injury. Treatment should consist of cessation of throwing activity but rehabilitation of the shoulder girdle muscles. The pitching technique should be evaluated as well.
REFERENCES: Barnett LS: Little League shoulder syndrome: Proximal humeral epiphyseolysis in the adolescent baseball pitchers: A case report. J Bone Joint Surg Am 1985;67:495-496.
Cahill BR, Tullos HS, Fain RH: Little league shoulder: Lesions of the proximal humeral epiphyseal plate. J Sports Med 1974;2:150-152.
73/. A 36-year-old man sustains a traumatic spondylolisthesis of L5 on S1. Surgical stabilization requires pedicular fixation into the sacrum. If the screw is placed in a medial to lateral direction and penetrates the sacral ala, what nerve root is at risk?
1- L2
2- L3
3- L4
4- L5
5- S1
PREFERRED RESPONSE: 4
DISCUSSION: The L5 nerve root lies directly over the superior and anterior alae. If the screw is directed approximately 20 degrees laterally and bicortical purchase is achieved, there is the risk of injuring the L5 nerve root. If the screw is directed medially into the body of S1, there is little risk of injury. The same root is at risk during placement of an iliosacral screw.
REFERENCES: Ebraheim NA, et al: Lumbosacral nerve and dorsal screw placement. Orthopedics 2000;23:245-247.
Ebraheim NA, Mermer M, Xu R, Yeasting RA: Radiological evaluation of S1 dorsal screw placement. J Spinal Disord 1996;9:527-535.
Routt ML Jr, Nork SE, Mills WJ: Percutaneous fixation of pelvic ring disruptions. Clin Orthop 2000;375:15-29.
74/. A 25-year-old woman who fell on her outstretched hand reports chronic pain over the hypothenar eminence region and some dorsal ulnar wrist pain. She also notes difficulty playing golf and tennis. Plain radiographs of the hand and wrist are unremarkable. A CT scan is shown in Figure 36. What is the next most appropriate step in management?
1- Ultrasound therapy
2- MRI for further soft-tissue evaluation
3- Open reduction and internal fixation of the hook of the hamate
4- Excision of the hook of the hamate
5- Electrodiagnostic evaluation
PREFERRED RESPONSE: 4
DISCUSSION: The CT scan reveals a hook of the hamate nonunion with irregular resorption at the fracture site, which is at the base of the hamate. Symptomatic relief of the pain and discomfort has been well documented after excision of the hook of the hamate. Ultrasound therapy will not provide long-term symptomatic relief or induce nonunion healing. MRI for further soft-tissue evaluation is inappropriate because this is a bony problem; the bony architecture of the wrist is best visualized by CT. Open reduction and internal fixation of the hook of the hamate does not provide the symptomatic relief that is found with excision of the hook of the hamate. In addition, the technical difficulties and relative risk of persistent nonunion after open reduction and internal fixation are not merited when hamate excision can be effected easily and causes no long-term untoward effects. Electrodiagnostic evaluation is inappropriate because there is no history of the persistent numbness and tingling that is found in peripheral compression neuropathies.
REFERENCES: Stark HH, Chao EK, Zemel NP, Rickard TA, Ashworth CR: Fracture of the hook of the hamate. J Bone Joint Surg Am 1989;71:1206-1207.
Failla JM: Hook of hamate vascularity: Vulnerability to osteonecrosis and nonunion. J Hand Surg Am 1993;18:1075-1079.
Carter PR, Easton RG, Littler JW: Ununited fracture of the hook of the hamate. J Bone Joint Surg Am 1977;59:583-588.
Egawa M, Asai T: Fracture of the hook of the hamate: Report of six cases and the suitability of computerized tomography. J Hand Surg Am 1983;8:393-398.
75/. An active 72-year-old woman sustained a mid-diaphyseal right humerus fracture 16 months ago. History reveals that she was first treated with a brace for 7 months. Additional treatment consisted of intramedullary nailing 9 months ago. Recently the rod was removed, and the patient now reports pain and gross motion at the fracture site. Current radiographs are shown in Figures 37a and 37b. What is the next most appropriate step in management?
1- Electrical stimulation with an implanted coil
2- Ultrasound stimulation for 30 minutes per day
3- Locked intramedullary nailing with bone graft
4- Ilizarov external fixation with intermittent distraction and compression
5- Plate and screw fixation with bone graft
PREFERRED RESPONSE: 5
DISCUSSION: The patient has a well-established nonunion in a very porotic bone. Electrical stimulation has been found effective in treating tibial nonunions, but there is very little data on humeral nonunions, especially chronic well-established ones. Ultrasound stimulation is effective in accelerating fracture healing, but there is little data concerning the treatment of nonunions. Intramedullary nailing with bone graft is an option, but it maybe difficult to obtain a rigid construct in a very porotic bone. An Ilizarov-type external fixator would be an alternative, but there is little clinical data for the humerus and it may be poorly tolerated. A plate and screw construct with bone graft combines rigidity with the biologic advantage of the bone graft. A recent series reported on the use of a plate combined with onlay allograft for recalitrant nonunions. Cement augmentation for screw fixation either in the canal or added to the screw holes may be helpful in select cases.
REFERENCES: Hornicek FJ, Zych GA, Hutson JJ, Malinin TI: Salvage of humeral nonunions with onlay bone plate allograft augmentation. Clin Orthop 2001;386:203-209.
Jupiter JB: The treatment of complex non-unions of the humeral shaft with a combination of surgical techniques. J Bone Joint Surg Am 1990;72:701-707.
76/. A 47-year-old man ruptured his left patellar tendon and twisted his right ankle in a fall. Initial radiographs of the ankle are unremarkable. One week following repair of the left patellar tendon, he reports increased pain with weight bearing in his right ankle. A follow-up radiograph is shown in Figure 38. Management of the ankle injury should consist of
1- functional rehabilitation with range of motion and strengthening.
2- reduction and screw fixation of the syndesmosis.
3- closed reduction and a long leg cast.
4- repair of the talofibular ligaments.
5- fibular osteotomy and plate fixation.
PREFERRED RESPONSE: 2
DISCUSSION: The radiograph reveals disruption of the syndesmosis with lateral displacement of the talus and widening of the medial ankle clear space. No fibular fracture is noted, although radiographs of the entire tibia and fibula are necessary to rule out a more proximal fibula fracture. There is clear instability of the syndesmosis, and surgical stabilization is needed, either by direct repair of the ligaments or more commonly with surgical stabilization of the fibula to the tibia with screws. Functional rehabilitation and early range of motion are indicated with anterior-lateral ankle sprains but not with true instability of the syndesmosis. In anterior syndesmotic injuries in which there are no signs of instability on plain radiographs or with stressing, cast immobilization and protected weight bearing until tenderness subsides is warranted. Long leg cast immobilization is unlikely to be adequate in maintaining reduction of the syndesmosis. Repair of the talofibular ligaments or fibular osteotomy does not address the pathology at the syndesmosis. Chronic syndesmotic disruption is likely to lead to chronic ankle pain and early arthrosis.
REFERENCES: Wuest TK: Injuries to the distal lower extremity syndesmosis. J Am Acad Orthop Surg 1997;5:172-181.
Edwards GS Jr, DeLee JC: Ankle diastasis without fracture. Foot Ankle 1984;4:305-312.
77/. A 45-year-old man reports severe discomfort following a twisting injury to his right ankle and foot. Plain radiographs are negative; however, the CT scans shown in Figures 39a and 39b reveal a fracture. Management should consist of
1- open reduction and internal fixation.
2- percutaneous pin fixation.
3- excision of the fracture fragment.
4- primary calcaneocuboid joint arthrodesis.
5- a walking cast or removable cast boot.
PREFERRED RESPONSE: 5
DISCUSSION: The CT scans show a fracture of the anterior process of the calcaneus that involves less than 25% of the joint surface with minimal to no displacement. The preferred treatment is external immobilization in either a walking cast or, more typically, a removable cast boot. For larger fractures that involve more than 25% of the articular surface with joint incongruity, open reduction and internal fixation may be indicated. Primary calcaneocuboid joint arthrodesis is not warranted because symptoms are rare in most patients. Delayed excision of the fragment is a late reconstructive option if painful nonunion develops. Percutaneous pin fixation is not indicated beceause there tends to be inherent stability in this fracture.
REFERENCES: Heckman JD: Fractures and dislocations in the foot, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 2267-2405.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.
78/. Which of the following complications occurs more commonly after antegrade femoral nail insertion when compared with retrograde insertion?
1- Increased blood loss
2- Decreased range of motion of the knee
3- Infection
4- Hip pain
5- Muscle weakness
PREFERRED RESPONSE: 4
DISCUSSION: There is no difference between the rates of union, malunion, range of motion of the hip or knee, muscle weakness, or infection for the two types of femoral nail insertion. The only difference is the location of the morbidity, which is around the insertion point of the rod. The antegrade technique has more morbidity about the hip, and the retrograde insertion technique has more morbidity about the knee.
REFERENCES: Morgan E, Ostrum RF, DiCicco J, McElroy J, Poka A: Effects of retrograde femoral intramedullary nailing on the patellofemoral articulation. J Orthop Trauma 1999;13:13-16.
Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R: Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma 2001;15:161-169.
Ostrum RF, Agarwal A, Lakatos R, Poka A: Prospective comparison of retrograde and antegrade femoral intramedullary nailing. J Orthop Trauma 2000;14:496-501.
Tornetta P III, Tiburzi D: Antegrade or retrograde reamed femoral nailing: A prospective, randomized trial. J Bone Joint Surg Br 2000;82:652-654.
79/. A 24-year-old man has right forearm pain after sliding head first into home plate. Examination reveals that the arm is swollen, but there are no neurovascular deficits or skin lacerations. Radiographs reveal a both-bone forearm fracture. The ulna has an oblique fracture with a 30% butterfly fragment, and the radius is comminuted over 75% of its circumference. In addition to reduction and plate fixation of both bones, management should consist of
1- bone grafting the radius only.
2- bone grafting both the radius and ulna.
3- bone graft substitute for both the radius and ulna.
4- no additional grafting.
5- no additional grafting but postoperative electrical stimulation.
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a both-bone fracture with a comminuted radial shaft. Open reduction and internal fixation of both bones is the treatment of choice. In the past, Chapman and associates recommended bone grafting radial shaft fractures with more than 30% comminution of the circumference. This has remained the recommendation in most textbooks. More recent studies, where modern biologic plating techniques were used, found that the addition of bone graft to comminuted fractures was not necessary because the union rate did not differ from that of nongrafted comminuted fractures.
REFERENCES: Anderson LD, Sisk TD, Tooms RE, Park WI III: Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am 1975;57:287-297.
Chapman MW, Gordon JE, Zissimos AG: Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg Am 1989;71:159-169.
Wright RR, Schmeling GJ, Schwab JP: The necessity of acute bone grafting in diaphyseal forearm fractures: A retrospective review. J Orthop Trauma 1997;11:288-294.
Wei SY, Born CT, Abene A, Ong A, Hayda R, Delong WG Jr: Diaphyseal forearm fractures treated with and without bone graft. J Trauma 1999;46:1045-1048.
80/. A 32-year-old woman has an isolated left posterior wall acetabular fracture in which about 25% of the wall surface is involved. Which of the following criteria would indicate the need for surgical reduction and fixation?
1- Fracture comminution
2- Displacement of 1 mm at the fracture site
3- Involvement of the ischial facet
4- Femoral head subluxation during fluoroscopic examination
5- Presence of a bilateral pneumothorax
PREFERRED RESPONSE: 4
DISCUSSION: Fractures with a posterior wall fragment that makes up less than one third of the surface generally are stable. Conversely, fractures with a fragment making up more than 50% of the surface are unstable. Patients with an intermediate fracture fragment should undergo a fluoroscopic examination under sedation or anesthesia to determine if the fragment is truly stable. If so, the patient can be treated nonoperatively and safely mobilized.
REFERENCES: Tornetta P III: Non-operative management of acetabular fractures: The use of dynamic stress views. J Bone Joint Surg Br 1999;81:67-70.
Keith JE Jr, Brashear HR Jr, Guilford WB: Stability of posterior fracture-dislocations of the hip: Quantitative assessment using computed tomography. J Bone Joint Surg Am 1988;70:711-714.
81/. A 25-year-old man reports wrist pain following a motorcycle accident. Examination reveals minimal swelling, slightly limited active range of motion, and point tenderness in the snuff box region. AP and oblique radiographs are shown in Figures 40a and 40b. Management should consist of
1- closed reduction and a short arm cast for 10 weeks.
2- closed reduction and a long arm cast for 10 weeks.
3- open reduction and internal fixation.
4- limited intercarpal fusion.
5- proximal row carpectomy.
PREFERRED RESPONSE: 3
DISCUSSION: The radiographs reveal a scaphoid fracture with displacement and comminution and an unstable fracture pattern. Treatment should consist of open reduction and internal fixation. In displaced scaphoid fractures and fractures with unstable fracture patterns, closed reduction is ineffective and is likely to lead to nonunion. Limited intercarpal fusion and proximal row carpectomy are used to correct a variety of traumatic and posttraumatic problems of the wrist.
REFERENCES: Amadio PC, Taleisnik J: Fractures of the carpal bone, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 809-823.
Rettig ME, Kozin SH, Cooney WP: Open reduction and internal fixation of acute displaced scaphoid waist fractures. J Hand Surg Am 2001;26:271-276.
Cooney WP, Dobyns JH, Linscheid RL: Fractures of the scaphoid: A rational approach to management. Clin Orthop 1980;149:90-97.
Szabo RM, Manske D: Displaced fractures of the scaphoid. Clin Orthop 1988;230:30-38.
82/. A 42-year-old woman reports that she has low back pain and had a transient loss of consciousness after falling off a horse. She denies having neck pain but notes that she was involved in a motor vehicle accident 2 years ago and had neck pain at that time. Examination reveals full range of motion of the neck and no localized tenderness. The neurologic examination is normal. A lateral radiograph of the cervical spine is obtained. Figures 41a and 41b show CT and MRI scans. What is the most likely diagnosis?
1- Cervical sprain
2- Atlas fracture
3- Acute displaced odontoid fracture
4- Odontoid nonunion
5- Hangman’s fracture
PREFERRED RESPONSE: 4
DISCUSSION: The examination findings do not correlate with an acute injury (full range of cervical motion and the absence of pain). Radiographically, the fracture appears old based on the smooth contour of the fracture fragments and the absence of soft-tissue swelling. Flexion-extension radiographs can be obtained to determine potential instability; if present, stabilization and fusion should be considered.
REFERENCES: Schatzker J, Rorabeck CH, Waddell JP: Non-union of the odontoid process: An experimental investigation. Clin Orthop 1975;108:127-137.
Clark CR, White AA III: Fractures of the dens: A multicenter study. J Bone Joint Surg Am 1985;67:1340-1348.
83/. What neurologic structure is most at risk when performing intramedullary screw fixation of a fifth metatarsal base fracture?
1- Saphenous nerve
2- First branch of the lateral plantar nerve
3- Superficial peroneal nerve
4- Sural nerve
5- Deep peroneal nerve
PREFERRED RESPONSE: 4
DISCUSSION: The sural nerve and its terminal branches course through the lateral hindfoot and midfoot area and are directly at risk in surgeries involving the peroneal tendon complex and the fifth metatarsal. The first branch of the lateral plantar nerve originates in the tarsal tunnel region and courses across the plantar heel area to innervate the abductor digiti minimi; it is not at direct risk with fifth metatarsal surgery. The saphenous, superficial peroneal, and deep peroneal nerves are not at risk anatomically with a lateral midfoot incision.
REFERENCES: Donley BG, McCollum MJ, Murphy GA, Richardson EG: Risk of sural nerve injury with intramedullary screw fixation of fifth metatarsal fractures: A cadaver study. Foot Ankle Int 1999;20:182-184.
Lawrence SJ, Botte MJ: The sural nerve in the foot and ankle: An anatomic study with clinical and surgical implications. Foot Ankle Int 1994;15:490-494.
84/. A 25-year-old man sustained an L1 compression fracture in a fall from his roof. He is neurologically intact and has no other injuries. Radiographs reveal a 25% loss of height anteriorly and 5 degrees of kyphosis at the fracture site. A CT scan reveals no compromise of the posterior column. Management should consist of
1- bed rest only for 6 weeks.
2- mobilization in a kinetic therapy bed for 6 weeks, followed by a hyperextension brace.
3- a total contact thoracolumbosacral orthosis and rapid mobilization.
4- anterior decompression, vertebral reconstruction, and stabilization.
5- posterior reduction, stabilization, and grafting.
PREFERRED RESPONSE: 3
DISCUSSION: The patient has a stable fracture that can be initially treated with bed rest, followed by bracing and quick mobilization. The outcome is good and surgery is not required. These fractures can be treated nonsurgically if there is less than 50% compression, 15 degrees of angulation, and intact posterior structures.
REFERENCES: Cantor JB, Lebwohl NH, Garvey T, Eismont FJ: Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine 1993;18:971-976.
Rechtine GR II, Cahill D, Chrin AM: Treatment of thoracolumbar trauma: Comparison of complications of operative versus nonoperative treatment. J Spinal Disord 1999;12:406-409.
85/. A 35-year-old man sustained a 10% compression fracture of the C5 vertebra in a diving accident. Radiographs show good alignment, and examination reveals no neurologic compromise. An MRI scan reveals no significant soft-tissue disruption posteriorly. Management should consist of
1- observation.
2- a rigid collar for 6 weeks.
3- halo vest application.
4- open reduction and posterior stabilization.
5- open reduction, diskectomy, grafting, and anterior plate stabilization.
PREFERRED RESPONSE: 2
DISCUSSION: The patient has a stable flexion-compression injury of the cervical spine. The fracture occurs as a result of compression failure of the vertebral body. If the force continues, a tension failure of the posterior structures occurs, leading to potential dislocation. Immobilization in a rigid cervical orthosis will allow this fracture to heal.
REFERENCES: Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 457-464.
Allen GL, Ferguson RL, Lehmann TR, O’Brien RP: A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine 1982;7:1-27.
86/. Figures 42a and 42b shows the radiographs of a 20-year-old man who sustained a hyperextension injury to his little finger. Multiple attempts at closed reduction have been unsuccessful. Management should now consist of
1- external traction.
2- open reduction and internal stabilization.
3- repeat closed reduction under general anesthesia.
4- open reduction.
5- percutaneous pin fixation in the current position.
PREFERRED RESPONSE: 4
DISCUSSION: The radiographs show a complex dislocation of the little finger metacarpophalangeal joint. This is characterized by obvious dislocation on the AP and lateral views and a type of bayonet apposition best visualized on the lateral view. Irreducibility of this injury is caused by displacement of the volar plate that has been traumatically avulsed from its origin on the metacarpal, with subsequent displacement into the metacarpophalangeal joint. This abnormal position of the volar plate causes irreducibility that can be corrected only by open reduction. This can be effected either by dorsal or palmar approaches.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 711-771.
Becton JL, Christian JD Jr, Goodwin HN, Jackson JG III: A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg Am 1975;57:698-700.
Green DP, Terry GC: Complex dislocation of the metacarpophalangeal joint: Correlative pathological anatomy. J Bone Joint Surg Am 1973;55:1480-1486.
87/. A 34-year-old man sustains an extra-articular fracture of the proximal phalanx of his right index finger in a fall. Examination reveals that the fracture is closed and oblique in orientation. Closed reduction and splinting fail to maintain the reduction. Management should now consist of
1- repeat closed reduction and buddy taping.
2- closed reduction and percutaneous pin fixation, followed by casting.
3- open reduction and plate fixation, followed by casting.
4- open reduction and screw fixation, followed by splinting and early motion.
5- open reduction and intramedullary fixation with absorbable implants.
PREFERRED RESPONSE: 2
DISCUSSION: The patient has an unstable oblique fracture of the proximal phalanx that is easily reducible but unstable; therefore, the treatment of choice is closed reduction and percutaneous pin fixation, followed by casting. Closed reduction and percutaneous pin fixation offers a better functional result than open reduction and plate fixation. Repeat closed reduction and buddy taping is inadequate because of the inherently unstable fracture pattern. Buddy taping will allow the dislocation to recur. The other options represent more aggressive surgical techniques than are necessary to treat this fracture.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 711-771.
Green DP, Anderson JR: Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am 1973;55:1651-1653.
88/. Figures 43a and 43b show the AP and lateral radiographs of the radius and ulna of a 9-year-old patient. The fracture is manipulated and placed in a long arm cast with the elbow flexed to 90 degrees and the forearm to neutral rotation. Figures 43c and 43d show the alignment of the fracture after the manipulation. What is the next most appropriate step in management?
1- Stabilize the present reduction internally with intramedullary pins.
2- Accept the present reduction and obtain follow-up radiographs in 1 week.
3- Remanipulate the fracture and place the forearm in pronation.
4- Remanipulate the fracture and place the forearm in supination.
5- Stabilize the present reduction with plates and screws.
PREFERRED RESPONSE: 4
DISCUSSION: By placing the forearm at neutral rotation, as shown in Figures 43c and 43d, the distal fragment has become malrotated by 90 degrees. This is evident by the fact that the bicipital tuberosity is rotated 90 degrees to the radial styloid. Normally, it should be directly opposite (180 degrees) to the radial styloid. The correct alignment was present in the original radiographs shown in Figures 43a and 43b. Another clue to the malrotation in the postreduction radiographs is the difference in the diameters of the opposing radial shafts. To correct this rotational malalignment, the distal fragment needs to be remanipulated into supination so that it is correctly aligned with the supinated proximal radius.
REFERENCES: Evans EM: Fractures of the radius and ulna. J Bone Joint Surg Br 1951;33:548-561.
Milch H: Roentgenographic differentiation between torsion and rotational fractures of the forearm. Bull Hosp Jt Dis 1949;10:216-225.
89/. Which of the following findings is an indication for adjunctive use of high-dose steroids?
1- C6 level injury secondary to a unilateral facet fracture-dislocation with weakness of wrist extension
2- C6 burst fracture with no neurologic deficit
3- L3 burst fracture with cauda equina syndrome
4- Incomplete spinal cord injury in a patient 24 hours after injury
5- Complete C6 level deficit in patient with spinal shock and a fracture-dislocation at C5 on C6 5 hours after injury
PREFERRED RESPONSE: 5
DISCUSSION: According to NASCIS III, the high-dose steroid protocol involves infusion of 30 mg/kg methylprednisolone followed by 5.4 mg/kg/h for 24 hours if the patient has sustained a spinal cord injury within the last 3 hours. The drip is continued for 48 hours if administration is started between 3 and 8 hours of the onset of neurologic deficit. No benefit has been conclusively demonstrated with steroids administered beginning 8 hours or longer after injury. Steroid use is not indicated for nerve root deficits, brachial plexus deficits, or gunshot wounds.
REFERENCES: Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 319-328.
Bracken MB, Shepard MJ, Holford TR, et al: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury: Results of the Third National Acute Spinal Cord Injury randomized controlled trial. National Acute Spinal Cord Injury Study. JAMA 1997;277:1597-1604.
90/. A 22-year-old man sustained a stable pelvic fracture, bilateral femur fractures, and a left closed humeral shaft fracture in a motor vehicle accident. Examination 24 hours after injury reveals that the patient is confused and has shortness of breath. A clinical photograph of his conjunctiva is shown in Figure 44. He has a temperature of 101 degrees F (38.3 degrees C) and a pulse rate of 120/min. Laboratory studies show a hemoglobin level of 8 g/dL, a platelet count of 50,000/mm3, and a PaO2 of 57 mm Hg on 2L of oxygen. What is the most likely diagnosis?
1- Pulmonary embolism
2- Fat embolism syndrome
3- Sepsis
4- Pneumonia
5- Pneumothorax
PREFERRED RESPONSE: 2
DISCUSSION: The major criteria for the diagnosis of fat embolism syndrome include hypoxemia (PaO2 of less than 60 mm Hg), central nervous system depression, and a petechial rash that is most often located in the axillae, conjunctivae, and palate. The rash is often transient. Tachycardia, pyrexia, anemia, thrombocytopenia, and the presence of fat in the urine are all considered minor criteria. To establish the diagnosis of fat embolism syndrome, one major and four minor signs should be present. Pulmonary embolism, which is the major differential diagnosis, usually is not associated with conjunctival petechia or thrombocytopenia.
REFERENCE: Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 308-316.
91/. Figure 45 shows the current radiograph of an 11-year-old girl who sustained a simple nondisplaced fracture of the distal radius 4 weeks ago. Management at the time of injury consisted of application of a short arm cast but no manipulation. What is the major concern at this time?
1- Stiffness of the wrist joint
2- Physeal growth arrest
3- Physeal overgrowth
4- Osteonecrosis of the metaphysis
5- Posttraumatic arthritis
PREFERRED RESPONSE: 2
DISCUSSION: The fracture pattern represents a Peterson type I physeal injury, which is a comminuted metaphyseal fracture in which the fracture lines extend up to the physis. Because there is no displacement of the physis and the fracture lines do not cross the physis, there may be a tendency to dismiss this injury as a simple metaphyseal fracture with no significant sequelae. A small percentage of patients (3% in Peterson’s series) experience growth arrest. In this patient, a disabling ulnar plus deformity, defined as increased ulnar length in relationship to the distal radius, developed.
REFERENCES: Peterson HA: Physeal fractures: Part 2. Two previously unclassified types. J Pediatr Orthop 1994;14:431-438.
Peterson HA: Physeal and apophyseal injuries, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 108-109.
92/. Which of the following is considered the best measure of the adequacy of resuscitation in the first 6 hours after injury?
1- Blood pressure
2- Urine output
3- Central venous pressure
4- Heart rate
5- Base deficit
PREFERRED RESPONSE: 5
DISCUSSION: The end point of resuscitation is adequate tissue perfusion and oxygenation. Blood lactate is the end point of anaerobic metabolism. The level of blood lactate reflects global hypoperfusion and is directly proportional to oxygen debt. Two separate prospective studies have verified a significant difference in mortality when blood lactate was used as a measure of resuscitation when compared to traditional parameters (mean arterial pressure, urine output, central venous pressure, and heart rate). Base deficit is a direct measure of metabolic acidosis and an indirect measure of blood lactate levels. It correlates well with organ dysfunction, mortality, and adequacy of resuscitation. It is easy to measure, can be obtained rapidly, and is an excellent assessment of the adequacy of resuscitation.
REFERENCES: Porter JM, Ivatury RR: In search of the optimal end points of resuscitation in trauma patients: A review. J Trauma 1998;44:908-914.
Elliot DC: An evaluation of the end points of resuscitation. J Am Coll Surg 1998;187:536-547.
93/. A 26-year-old man sustains a displaced bimalleolar fracture by sliding into second base while playing baseball. Following initial closed reduction and splinting of the fracture, moderate swelling is noted. What is the safest time to perform surgery?
1- Immediately
2- When skin wrinkles are present and abrasions are epithelialized
3- Five days after injury
4- Following analysis of laser Doppler skin measurements
5- Following measurement of transcutaneous oxygen tension
PREFERRED RESPONSE: 2
DISCUSSION: Following any closed fracture, the most important determinant for the timing of surgery is the condition of the soft tissues and especially the skin. The best determinant of appropriate soft-tissue condition is the presence of wrinkling of the skin (wrinkle sign) at the site of the incision. A wrinkle sign is present when all the interstitial edema has left the skin; this may take up to 14 to 21 days of elevation. Any abrasion must be epithelialized so that there are no bacteria left at the site. To date, no other method of soft-tissue viability measurement has been shown to be of any clinical benefit.
REFERENCES: Stover MD, Kellam JF: Articular fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 105-119.
Hahn DM, Colton CL, Malleolar fractures, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 559-581.
Tile M: Fractures of the ankle, in Schatzker J, Tile M (eds): Rationale of Operative Fracture Care, ed 2. Berlin, Springer-Verlag, 1998, pp 523-561.
94/. A 28-year-old woman sustained an injury to her dominant right arm after falling off her porch. Examination reveals a deformity at the elbow. She is neurovascularly intact. Figures 46a and 46b show the radiographs obtained before closed reduction, and postreduction radiographs are shown in Figure 46c and 46d. What is the most likely early complication?
1- Radial nerve injury
2- Intra-articular loose body causing a block to motion
3- Lack of active elbow flexion
4- Recurrent dislocation
5- Forearm compartment syndrome
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a complex fracture-dislocation of the elbow. The radial head is fractured, and there is a displaced coronoid fracture. These associated fractures indicate that the elbow is at high risk for recurrent instability after initial treatment. To prevent this complication, surgical treatment will most likely be required and will consist of some or all of the following: radial head open reduction and internal fixation or replacement, coronoid open reduction and internal fixation, medial and lateral ligament repairs, and even articulated external fixation. This patient was treated with open reduction and internal fixation of the radial head, and the elbow redislocated postoperatively.
REFERENCES: Ring D, Jupiter JB: Reconstruction of posttraumatic elbow instability. Clin Orthop 2000;370:44-56.
O’Driscoll SW: Classification and evaluation of recurrent instability of the elbow. Clin Orthop 2000;370:34-43.
O’Driscoll SW, Morrey BF, Korinek S, An KN: Elbow subluxation and dislocation. Clin Orthop 1992;280:186-197.
95/. What is the most likely long-term sequela of the injury shown in Figures 47a and 47b?
1- Peroneal tendon instability
2- Ankle joint instability
3- Subtalar joint arthrosis
4- Ankle joint arthritis
5- Entrapment of the flexor hallucis longus tendon
PREFERRED RESPONSE: 3
DISCUSSION: The imaging studies show a comminuted lateral talar process fracture. This injury is often missed on plain radiographs; therefore, CT provides the best method of diagnostic evaluation. The most likely long-term sequela of this injury is subtalar joint arthrosis. Although this injury involves the fibular gutter region, progression to true ankle arthritis is unlikely. There does not appear to be any association with this injury and chronic mechanical instability of the ankle or disruption of the superior peroneal retinaculum and subsequent peroneal tendon instability. Entrapment of the flexor hallucis longus tendon may occur with fractures of the sustentaculum tali but not with injuries of the lateral talar process. Surgical management includes open reduction and internal fixation versus excision; the goal is preservation of the large articular surface fragments. In this patient, there is significant comminution and early fragment excision may be the best option for acute treatment.
REFERENCES: Tucker DJ, Feder JM, Boylan JP: Fractures of the lateral process of the talus: Two case reports and a comprehensive literature review. Foot Ankle Int 1998;19:641-646.
Sanders R: Fractures and fracture-dislocations of the talus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1465-1518.
96/. A 16-year-old high school football player has diffuse pain with attempted digital flexion after injuring the ring finger of the dominant hand 1 week ago. Examination reveals that he is unable to flex the distal interphalangeal joint. Management should consist of
1- surgical exploration and tendon reinsertion of the flexor digitorum profundis.
2- surgical exploration and tendon reinsertion of the flexor digitorum superficialis.
3- steroids and physical therapy.
4- surgical release of the anterior interosseous nerve.
5- surgical release of the median nerve.
PREFERRED RESPONSE: 1
DISCUSSION: The patient has an avulsion of the flexor digitorum profundus. Treatment should include surgical exploration and tendon reinsertion. This is not an avulsion of the flexor digitorum superficialis because the patient’s deficiency is the inability to flex the distal interphalangeal joint, not the proximal interphalangeal joint. Surgical release of the anterior interosseous nerve is not indicated because the flexor digitorum profundus of the ring finger is innervated by the ulnar nerve. A median nerve contusion causes wrist pain and/or numbness and tingling in the median nerve distribution.
REFERENCES: Strickland JW: Flexor tendons: Acute injuries, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 1851-1897.
Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin 1985;1:77-83.
97/. A 25-year-old construction worker lands on his outstretched hand in a fall. The position of his wrist at the time of impact causes a force that leads to hyperextension, ulnar deviation, and intercarpal supination. Radiographs are shown in Figures 48a and 48b. What type of injury pattern is shown?
1- Scaphoid fracture
2- Radiocarpal dislocation
3- Midcarpal dislocation
4- Transscaphoid dorsal perilunate dislocation
5- Volar lunate dislocation
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a transscaphoid dorsal perilunate dislocation. The radiographs clearly define a dorsal dislocation of the capitolunate joint, and the scaphoid fracture component is easily visible on the AP view. A scaphoid fracture alone is an unlikely diagnosis because of the midcarpal dislocation component. The radiocarpal joint is not dislocated because the lunate is sitting in the lunate fossa of the radius. Isolated radiocarpal dislocations are not associated with a midcarpal disruption. While a midcarpal dislocation is a component of a dorsal perilunate dislocation, this diagnosis does not address the scaphoid fracture. A volar lunate dislocation is not seen because the lunate is reduced in the lunate fossa of the distal radius. Volar lunate dislocations are in the spectrum of injury of perilunate dislocations and fracture-dislocations; however, the radiographs show a transscaphoid dorsal perilunate dislocation.
REFERENCES: Mayfield JK, Johnson RP, Kilcoyne RK: Carpal dislocations: Pathomechanics and progressive perilunar instability. J Hand Surg Am 1980;5:226-241.
Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J: Perilunate dislocations and fracture-dislocations: A multicenter study. J Hand Surg Am 1993;18:768-779.
98/. A 25-year-old construction worker lands on his outstretched hand in a fall. The position of his wrist at the time of impact causes a force that leads to hyperextension, ulnar deviation, and intercarpal supination. Radiographs are shown in Figures 48a and 48b. Management should consist of
1- closed reduction and a long arm cast.
2- closed reduction, percutaneous pin fixation, and a long arm cast.
3- closed reduction and an external fixator.
4- open reduction and internal fixation and soft-tissue repair.
5- proximal row carpectomy.
PREFERRED RESPONSE: 4
DISCUSSION: Open reduction and internal fixation is the treatment of choice for accurate reduction of the disrupted intercarpal ligaments. In addition, the displaced scaphoid fracture will require open reduction and internal fixation and possible bone grafting. Closed reduction and long arm casting will not allow accurate reduction of the dislocated intracarpal intervals, and it is unlikely to allow accurate reduction of the scaphoid. The maneuver required to effect closed reduction of a displaced scaphoid fracture will most likely cause the scaphoid lunate interval to displace. Closed reduction with percutaneous pin fixation or with an external fixator is unable to effect anatomic reduction of the injury. Proximal row carpectomy is used as a salvage procedure for a variety of degenerative and posttraumatic problems of the wrist.
REFERENCES: Kozin SH: Perilunate injuries: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:114-120.
Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J: Perilunate dislocations and fracture-dislocations: A multicenter study. J Hand Surg Am 1993;18:768-779.
Sotereanos DG, Mitsionis GJ, Ginnakopoulos PN, Tomaino MM, Herndon JH: Perilunate dislocation and fracture dislocation: A critical analysis of the volar-dorsal approach. J Hand Surg Am 1997;22:49-56.
99/. A 17-year-old boy who fell on a pitchfork in a barn 1 day ago now has a painful, swollen forearm. Examination reveals erythema, exquisite tenderness, and crepitus to palpation of the forearm. He has a pulse rate of 110/min and a blood pressure of 80/60 mm Hg. Radiographs show subcutaneous air and no fractures. Gram stain of wound drainage reveals a gram-positive bacillus. The next most appropriate step in management should consist of
1- surgical debridement with wound closure and IV antibiotics.
2- surgical debridement with wound closure over suction drains and IV antibiotics.
3- surgical debridement with open wound management and IV antibiotics.
4- IV antibiotics alone.
5- hyperbaric oxygen therapy.
PREFERRED RESPONSE: 3
DISCUSSION: The successful treatment of necrotizing soft-tissue infections such as clostridial myonecrosis depends on prompt recognition and aggressive surgical debridement of all involved muscle, fascia, and soft tissue, resecting to a clearly normal healthy, viable margin. The effective antibiotic regimen for clostridial infection is high-dose penicillin; however, necrotizing infections are frequently polymicrobial so initially broad-spectrum antibiotics are indicated. Hyperbaric oxygen therapy may be used as an adjunct to surgical treatment but is insufficient as a primary therapy. Prolonged application of tourniquets and wound closure should be avoided.
REFERENCES: Pellegrini VD, Evarts CM: Complications, in Rockwood CA Jr, Green DP (eds): Fractures in Adults, ed 3. Philadelphia, PA, JB Lippincott, 1991, pp 365-370.
Gerding DN, Peterson LR: Infections caused by anaerobic bacteria, in Shulman ST, Phair JP, Peterson LR, Warren JR (eds): Infectious Diseases, ed 5. Philadelphia, PA, WB Saunders, 1997, pp 416-417.
Stephens DC: Myositis and fascitis, in Root RK (ed): Clinical Infectious Diseases, ed 1. Oxford, England, Oxford Press University, 1999, pp 769-770.
100. In the management of an open tibia fracture, what factor is considered most important in preventing deep infection?
1- Size of the skin lesion
2- Degree and the completeness of the debridement
3- Amount of contamination
4- Method of fixation
5- Cultures of the wound
PREFERRED RESPONSE: 2
DISCUSSION: The most important aspect of management of any open fracture, and in particular the tibia, is the degree and the completeness of the debridement of the soft tissue and most importantly, the muscle. The ultimate function is determined by the amount of muscle left, as well as the ability to heal. The amount of necrotic muscle left in the wound also determines the predisposition to infection. The method of fixation, the size of the wound, and the amount of contamination are controlled by the surgeon or the injury and have little to do with the long-term outcome. Initial wound cultures have little predictive value.
REFERENCES: Clifford P: Open fractures, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 617-638.
Lee J: Efficacy of cultures in the management of open fractures. Clin Orthop 1997;339:71-75.

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Distal radial physeal fractures are common injuries. Reduction should be done gently and not repeated multiple times. Fractures presenting late like this one are difficult to manipulate atraumatically, but have good remodeling potential. Therefore, a cast should be applied to limit any further displacement, but no manipulation or operation is recommended.

The radiographs reveal a displaced proximal humerus fracture in a skeletally immature patient. There is tremendous remodeling potential, and similar outcomes are seen in both operative and nonoperative treatment. Worse outcomes are seen with older patients, as the remodeling potential decreases. In a study of 32 pediatric proximal humeral fractures, subgroup analysis of the nonoperative cases showed that, for every 1-year increase in age at initial injury, the odds of a less than desirable outcome increased by a factor of 3.81.

Transfer of fascicles from (1) ulnar nerve to the nerve to the biceps and (2) median nerve to the motor nerve of the brachialis would be appropriate in the
treatment of an acute (<3-6 months) upper brachial plexus palsy.
Upper trunk injury (C5, C6) often results from the avulsion of both the C5 and C6 nerve roots. Injuries of this nature usually result from a downward force on the shoulder with lateral bending of the cervical spine in the opposite direction. This results in what is commonly called an Erb-Duchenne palsy. Patients often present with a flail shoulder and loss of elbow flexion. Other common treatments for C5 and C6 root avulsion include neurotization of the musculocutaneous (MSC) nerve by the spinal accessory (SA) or intercostal nerve, and neurotization of the supra-scapular nerve by the SA.
Liverneaux et al. looked at short term results of (1) ulnar nerve fascicle transfer to the nerve to the biceps and (2) fascicle of the median nerve to the motor branch to the brachialis in 15 patients with acute C5 - C6 nerve root avulsion injuries. Grade 4 elbow flexion was restored in each of the 10 patients. There was no secondary deficit in grip strength or sensation.They concluded that this double nerve transfer technique will likely reduce the need for secondary procedures to augment elbow flexion.
Teboul et al. reviewed thirty-two patients with an upper nerve-root brachial plexus injury that underwent ulnar nerve fascicle transfer to the nerve of biceps to restore elbow flexion. After the nerve transfer, twenty-four patients achieved grade 3 elbow flexion strength or better. They note that this procedure will spare the C5 nerve root and other nerves for grafting or transfer elsewhere.
Illustration A shows harvesting of an ulnar nerve fascicle for transfer. Illustration B shows transfer of the fascicle of the ulnar nerve to the motor nerve of the biceps.
Incorrect Answers:
Answer 1: C8 - T1 nerve root avulsion would result in ulnar nerve dysfunction. Transfer of the non-functional ulnar nerve to the motor nerve of the biceps would be a redundant procedure.
Answer 3: Nerve transfers in upper brachial plexus palsy more than 20-24 moths post-injury is a relative contraindication due to the eventual loss of neuromuscular end plates at 20 to 24 months after denervation. Free functioning muscle transfers are more commonly indicated in late presenting injuries.
Answer 4: Medial and posterior cord injury from gunshot wound likely leave the musculocutaneous nerve intact (lateral cord). Therefore, this transfer technique would not be indicated.
Answer 5: C6 ASIA A spinal cord injury would likely result in motor and
sensory quadriplegia. Nerve transfers using the ulnar nerve (C8-T1) would also be redundant as this nerve would be non-functional in this patient.

The patient is hemodynamically stable, has no other injuries, and is medically cleared for the operating room. Therefore, there is no need for damage control fixation.
Ostrum et al conducted a review of 20 patients treated by percutaneous stabilization for ipsilateral fractures of the femur and tibial shafts. All patients were treated with a retrograde femoral intramedullary nail and a small diameter tibial intramedullary nail through a 4-cm medial parapatellar tendon incision. Six of the tibial shaft fractures required revision surgery, and no patients reported signs or symptoms of knee pain. Ostrum concluded that although this is an excellent treatment option for patients with ipsilateral femoral and tibial shaft fractures, the tibial fracture complication rates remain high.
Franklin et al reviewed 38 cases of open ankle fractures that had been treated with immediate splinting, antibiotics, debridement, and internal fixation. They found that all of the fractures united, but three patients required subsequent ankle fusion because of cartilage damage noted at the initial operation. Of the thirty-five ankles with complete follow-up, the functional result was excellent in twenty-six and fair or poor in nine.

Home exercises and re-examination in follow-up is the most appropriate treatment in view of lack of any worrisome features. If this child had severe pain or significant night pain, then further imaging studies would be warranted.
The magnetic resonance imaging is not indicated in this situation. The bone scan has a low likelihood of being positive.
Bracing is not indicated for the curve or the pain.
C omputer tomography is unlikely to demonstrate any pathology.

If there is a contraindication to performing surgery, nonoperative methods of treatment for an acute C harcot neuroarthropathy may be acceptable. This patientâs midfoot is dislocated and is likely to result in a worsening deformity over time, with ulceration and infection possible. Open reduction with internal fixation has not proven sufficient in patients presenting with the symptoms indicated in the scenario. Arthrodesis is most likely to yield a satisfactory outcome.

Due to radial inclination, a true lateral view of the wrist will not show whether screws from a volar plate are intra-articular; a 23° elevated lateral view is needed to adequately assess this.
The amount of elevation will depend on the degree to which the surgeon restores radial inclination; for example, if the surgeon only restores 15° of radial inclination, then the surgeon would only have to elevate the wrist 15° from a true lateral in order to have the radiographic beam point down the joint line. Failure to diagnose intra-articular screws intraoperatively can lead to degenerative changes.
Tweet et al. performed a survey of orthopedic surgeons regarding their preferred method of visualizing screw placement during wrist fixation. The majority of surgeons reported that they obtain multiple views, including AP/PA wrist views, a 23° lateral inclination view, and a true lateral view. They also performed a cadaveric study looking at different x-ray views and screw penetration. They reported that live rotational fluoroscopy provided the highest sensitivity (93%) and specificity (96%) for the detection of intra-articular screw penetration.
Patel et al. evaluated the ability of surgeons at different levels to critically assess distal radius fixation and screw placement. They found that supplementation with a 23° lateral view increased accuracy and confidence in all position, specialty, and experience groups. Confidence scores were significantly higher following the evaluation of three views versus two views. Residents exhibited the greatest improvements in accuracy and confidence. For first-phase (standard view) assessments, accuracy scores were significantly better for attendings with less than 10 years of post-fellowship experience than those with more.
Illustration A is a non-elevated lateral of the wrist, while illustration B is a 23° elevated lateral radiograph. Illustration C is an example of a skyline view, which assesses for screws penetrating the dorsal cortex.
Incorrect Answers:
Answer 1: The dorsal skyline view shows dorsal screw length and is useful to
check for long distal screws.
Answers 2 and 3: The AP and PA wrist views do not show intra-articular screw penetration due to the volar tilt and concavity of the joint.
Answer 5: A 45° oblique lateral view does not visualize the joint as this angle does not match the radial inclination.

DISCUSSION: Approximately 5% of female recruits incur a stress fracture during the 13 weeks of Marine Corps basic training. Approximately 40% of these were femoral or pelvic stress fractures that were more severe than in civilian athletes or male military recruits. Only women who reported no menses during the previous year had a greater likelihood of femoral or pelvic stress fractures than did women who reported 10 to
12 menses. The referenced study did not find a statistically significant increase in risk of stress fracture in those recruits who had lesser menstrual irregularities in the year prior to recruit training, but there was a trend toward increased risk of stress fracture.
REFERENCES: Shaffer RA, Rauh MJ, Brodine SK, et al: Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med 2006;34:108-115.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2004, pp 273-283.

DISCUSSION: Nakamura and associates have reported good results in patients with resection for hemivertebra-related congenital scoliosis who have a progression of their deformity. Because of the progression, observation is not appropriate for this patient’s deformity. Bracing has not been shown to alter the progression of congenital scoliosis. The “growing rod” technique is also not effective in preventing progression related to hemivertebra. Distraction instrumentation carries an increased risk of neurologic complications in children with congenital spine deformities. Progression after posterior arthrodesis alone can occur through the so-ca**l** ed “crankshaft phenomenon.”
REFERENCES: Nakamura H, Matsuda H, Konishi S, et al: Single-stage excision of hemivertebrae via the posterior approach alone for congenital spine deformity: Follow-up period longer than ten years.
Spine 2002;27:110-115.
Ruf M, Harms J: Posterior hemivertebra resection with transpedicular instrumentation: Early correction in children aged 1 to 6 years. Spine 2003;15:2132-2138.

78 • American Academy of Orthopaedic Surgeons

Figure 95a Figure 95b Figure 95c Figure 95d

The radiograph shows a subtalar (talocalcaneal) dislocation with a talonavicular dislocation as well. If subtalar dislocations also involve dislocation of the articulations at both the talonavicular and ankle (tibiotalar) joint, a talar extrusion is seen. Subtalar dislocations are associated with high energy, open (25%), and irreducible (33%) fractures. Medial dislocations account for 65%, and reduction is blocked by the extensor digitorum brevis (EDB). Lateral dislocations that are irreducible are blocked by the posterior tibialis, FHL, and FDL tendons. These dislocations often require emergent open reductions, tendon relocation, and stabilization.
Bibbo et al reported clinical and radiographic outcome on 25 patients and the majority of these patients had radiographic degenerative changes at 5 years follow up.
The review reference by Bohay and Manoli covers subtalar joint dislocations and notes the importance of anatomic reduction to achieve optimal outcomes.

The patient has a complete tear of the ulnar collateral ligament as defined by MCP joint laxity of greater than 30° (or 15° greater laxity compared with the opposite side). Primary repair is the treatment of choice because displacement of the ligament superficial to the adductor aponeurosis (Stener lesion) must be corrected. Any volar plate injury can be addressed during repair of the ulnar collateral ligament.
REFERENCE: Heyman P: Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint. J Am Acad Orthop Surg 1997;5:224-229.