Ortho Board Review: Trauma, Hip, Nerve MCQs Part 75

About This Board Review Set

This is Part 75 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

This set has been strictly audited and contains 100 100% verified, high-yield multiple-choice questions (MCQs) modelled on the exact format of the Orthopaedic In-Training Examination (OITE) and the American Academy of Orthopaedic Surgeons (AAOS) board examinations.

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Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 75

This module focuses heavily on: Foot, Fracture, Hip, Nerve, Trauma.

Sample Questions from This Set

Sample Question 1: Figures 52a and 52b show the radiographs of a left proximal femoral lesion noted serendipitously following minor trauma to the left hip. The patient has no thigh pain and is fully active without limitation. What is the most likely diagnosis...

Sample Question 2: Which of the following bones is most frequently involved in stress fractures in athletes? Review Topic...

Sample Question 3: 4A4B4CA 30-year-old man was involved in a high-speed motorcycle collision and sustained the injury shown in Figure 4a. Hypotension ensued shortly after arrival in the emergency department. Figure 4b is the initial contrast pelvic CT image w...

Sample Question 4: Which of the following best describes the course of the ulnar nerve in the midforearm?...

Sample Question 5: A 17-year-old football player is unable to flex the distal interphalangeal (DIP) joint of his ring finger. He states that he injured the finger 6 weeks ago while attempting to tackle another player who pulled free from his grip, but he did ...

Why Active MCQ Practice Works

Evidence consistently demonstrates that active recall through spaced MCQ practice yields substantially greater long-term retention than passive reading alone (Roediger & Karpicke, 2006). All questions in this specific module have been algorithmically verified for clinical integrity and complete explanations.

Comprehensive 100-Question Exam

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Question 1

Figures 52a and 52b show the radiographs of a left proximal femoral lesion noted serendipitously following minor trauma to the left hip. The patient has no thigh pain and is fully active without limitation. What is the most likely diagnosis of this bony lesion?

Explanation

DISCUSSION: The radiographs reveal a geographic lesion of the proximal femur with the classic “ground glass” appearance noted in fibrous dysplasia. This intramedullary lesion is modestly expansile, demonstrates some minimal cortical thinning, and has no aggressive features. Chondroblastoma, giant cell tumor, and osteoblastoma are more lytic in appearance, and the location is not typical for giant cell tumor or chondroblastoma. While enchondroma may be considered, the uniform ground glass appearance, lack of punctuate mineralization, and distinct margination of the lesion make that diagnosis less likely.
REFERENCE: Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 2

Which of the following bones is most frequently involved in stress fractures in athletes? Review Topic

Explanation

The tibia is the most frequent stress fracture location in most series in both athletes and modern military training. The anterior midshaft region of the tibia may be at higher risk secondary to tensile forces and a relative paucity of blood supply.

Question 3

4A 4B 4C A 30-year-old man was involved in a high-speed motorcycle collision and sustained the injury shown in Figure 4a. Hypotension ensued shortly after arrival in the emergency department. Figure 4b is the initial contrast pelvic CT image with an unrecognized blush consistent with arterial bleeding. During surgical repair, the patient was noted to have active bleeding and an angiogram was obtained (Figure 4c). Which structure is the likely cause of his bleeding?

Explanation

DISCUSSION
Pelvic bleeding occurs predominantly from disruption of the posterior venous plexus and bleeding from the fractured bone. Occasionally arterial bleeding is seen, with injury to the superior gluteal artery most common. Anterior pelvic bleeding occurs from injury to the obturator artery (commonly from a pubic bone fracture laceration) and less frequently from the pudendal artery near the symphysis. The location of the bleeding on CT and angiography images does not correspond to the superior gluteal, external iliac, or femoral arteries.
RECOMMENDED READINGS
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009 Apr;40(4):343-53. Epub 2009 Mar 17. Review.PubMed PMID: 19278678. View Abstract at PubMed
Loffroy R, Yeguiayan JM, Guiu B, Cercueil JP, Krausé D. Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization. CJEM. 2008 Jul;10(4):392-5. PubMed PMID: 18652733. View Abstract at PubMed
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures.Injury. 2009 Oct;40(10):1023-30. Epub 2009 Apr 16. Review. PubMed PMID:19371871. View Abstract at PubMed
RESPONSES FOR QUESTIONS 5 THROUGH 8

5B
- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation
Please choose from the responses to identify the most likely complication in each scenario.

Question 4

Which of the following best describes the course of the ulnar nerve in the midforearm?

Explanation

DISCUSSION: In the midforearm, the ulnar nerve travels deep to the flexor carpi ulnaris muscle and ulnar to the ulnar artery as it lies on the flexor digitorum profundus muscle. In this region, the ulnar nerve and artery lie side-by-side, whereas more proximal in the forearm, the ulnar artery originates from the brachial artery in the antecubital fossa, and the ulnar nerve lies within the cubital tunnel.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 118-131.
Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System: Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy, 1991, vol 8,

pp 46-47.

Question 5

A 17-year-old football player is unable to flex the distal interphalangeal (DIP) joint of his ring finger. He states that he injured the finger 6 weeks ago while attempting to tackle another player who pulled free from his grip, but he did not inform his coach at the time of the injury. Current radiographs show an observable fleck of bone volar to the base of the proximal phalanx. Treatment should consist of

Explanation

DISCUSSION: Flexor digitorum profundus ruptures are classified into three types. In type I, the tendon retracts into the palm. In type II, the tendon retracts to the level of the proximal phalanx, the vinculum remains intact, and the blood supply is preserved to the tendon. A small fleck of bony fragment observed at the A2 pulley is pathognomonic for a type II rupture. Successful primary repair of the type II rupture has been reported as late as 2 months after the injury. Type III injuries have large fragments of the distal phalanx attached and are caught distally by the A1 pulley. Type III ruptures can be repaired up to several months after the injury.
REFERENCES: Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin

1985;1:77-83.
Kiefhaber TR: Closed tendon injuries in the hand. Oper Tech Sports Med 1996;4:227-241.

Question 6

A 68-year-old woman undergoes a complicated four-level anterior cervical diskectomy and fusion at C3-7 with iliac crest bone graft and instrumentation for multilevel cervical stenosis. Surgical time was approximately 6 hours and estimated blood loss was 800 mL. Neuromonitoring was stable throughout the procedure. The patient’s history is significant for smoking. The most immediate appropriate postoperative management for this patient should include Review Topic

Explanation

Airway complications after anterior cervical surgery can be a catastrophic event necessitating emergent intubation for airway protection. Multilevel surgeries requiring long intubation and prolonged soft-tissue retraction as well as preexisting comorbidities may predispose a patient to postoperative airway complications. Sagi and associates reported that surgical times greater than 5 hours, blood loss greater than 300 mL, and multilevel surgery at or above C3-4 are risk factors for airway complications. In surgical procedures with the aforementioned factors, serious consideration should be given to elective intubation for 1 to 3 days to avoid urgent reintubation.

Question 7

A previously healthy 14-year-old boy now reports fatigue, and has a bilateral Trendelenburg gait, right hip pain, and bilateral knee and foot pain. Biopsy of a right sacral mass reveals intermediate grade osteosarcoma. There are no metastases. Laboratory studies reveal a serum calcium level of 7.7 mg/dL (normal 8.5 to 10.5), a phosphate level of 2.0 mg/dL (normal 2.7 to 4.5), a 1,25-dihydroxyvitamin D level of less than 10 pg/mL (normal 18 to 62), a parathyroid hormone level of 19 pg/mL (normal 10 to 60), and an alkaline phosphatase level of 428 U/L (normal 15 to 351). What is the most likely cause of the patient’s symptoms?

Explanation

DISCUSSION: The laboratory findings are typical for rickets. Oncogenic rickets is a paraneoplastic syndrome that results from a substance secreted by the tumor that interferes with renal tubule reabsorption of phosphate. This substance previously had been called phosphatonin but recently has been identified as fibroblast growth factor 23. Nutritional rickets is rare in developed countries. Delayed onset familial hypophosphatemic rickets is possible, but the likelihood of having two rare diseases is unlikely. Osteosarcoma does not sequester calcium. Alkaline phosphatase levels can be elevated in osteosarcoma but does not cause muscle weakness. Tumor cachexia would occur only with advanced metastatic disease. A unilateral sacral mass would not cause a bilateral L5 neuropathy or the abnormal laboratory findings.
REFERENCES: Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 29-2001. A 14-year-old with abnormal bones and a sacral mass. N Engl J Med 2001;345:903-908.
Jonsson KB, Zahradnik R, Larsson T, White KE, Sugimoto T, Imanishi Y, et al: Fibroblast growth factor 23 in oncogenic osteomalacia and X-linked hypophosphatemia. N Engl J Med 2003;348:1656-1663.

Question 8

A researcher experimenting with limb patterning removes some tissue from 1 part of the limb bud (which we shall call Site A) and transplants it along the anteroposterior (AP) axis to create a mirror-hand duplication. Which of the following is true?

Explanation

The ZPA is located on the posterior (ulnar) margin of the limb bud. It expresses Shh protein. When tissue from ZPA is added to the anterior (radial) margin of the limb bud, ulnar dimelia, or mirror hand duplication, occurs.
The ZPA controls AP (radioulnar) growth. The signaling molecule is Shh, which is dose dependent. Higher Shh doses lead to posterior (ulnar) digits ulnar sided polydactyly. The extent of duplication is dose dependent (higher dose = more replication). Reduced Shh leads to loss of digits. Posterior elements (little finger/ulna) are formed EARLY prior to anterior elements which are formed LATE (radius/thumb). Disruption of AP patterning will result in loss of later forming elements (radius/thumb).
Al-Qattan et al. reviewed embryology of the upper limb. They summarized that embryology of the upper limb can be viewed in 2 distinct ways: the steps of limb development and the way that the limb is patterned along its 3 spatial axes. Cell signaling plays a major role in regulating growth and patterning of the vertebrate limbs. Signaling cell dysfunction results in congenital differences according to the affected signaling axis.
Illustration A shows an experiment to create ulnar dimelia by adding ZPA tissue to the anterior limb bud. The video shows development of the limb.
Incorrect Answers:

Question 9

A 3-year-old child sustains a T2/T3 fracture-dislocation with complete paraplegia secondary to a car accident in which the child was an unrestrained passenger. What is the likelihood that this child will develop subsequent spinal deformity in the future? Review Topic

Explanation

More than than 90% of preadolescent children who sustain a significant spinal cord injury subsequently develop scoliosis. Conversely, progressive paralytic spinal deformity is uncommon in the postadolescent patient. Bracing has not been shown to be effective in the prevention of scoliosis in the preadolescent patient with spinal cord injury.

Question 10

Figures below show the clinical photograph and radiograph obtained from a 62-year-old man who has deformity and pain 1 year after primary total hip arthroplasty. What is the reason for the observed deformity?

Explanation

DISCUSSION:
Figure 1 reveals an external rotation deformity of the right lower extremity. This deformity can have numerous causes, including extra-articular deformity. Figure 2 reveals a loose, subsided femoral component. Femoral stems typically subside into retroversion due to proximal femoral biomechanics, which cause a compensatory external rotation deformity. The combined findings from both images suggest an external rotation deformity most likely related to subsidence into retroversion.

Question 11

Revision of failed hip resurfacing arthroplasty should involve

Explanation

DISCUSSION
Hip resurfacing offers several potential advantages over conventional total hip arthroplasty, particularly for patients younger than 75 years of age. This intervention can be
relatively bone conserving and is appropriate in settings involving proximal femoral deformity, precluding the use of a traditional femoral component. The use of hip resurfacing in osteonecrosis has been controversial, however. Although there are several reports of successful use of these implants to address osteonecrosis, concerns remain about extensive femoral head involvement (exceeding 40%) and ability to support the femoral head cap. Consequently, hip resurfacing is not recommended for patients with large femoral head lesions.
Evaluation of painful hip resurfacings requires a systematic approach. Radiographs can help surgeons assess implant position, loosening, or fractures. Serological studies including ESR, CRP, and serum cobalt and chromium levels can give clues as to whether infection, metallosis, or both are the underlying cause(s) of failure. Hip aspiration in the setting of metal-on-metal bearings necessitates a manual cell count and differential to avoid falsely elevated automated cell counts.
Revision of failed hip resurfacings should involve revisions of both the femoral and acetabular components. Although successful retention of the acetabular shell has been described, concerns remain regarding cup circumference mismatch, which can lead to suboptimal clearance between the new bearing surfaces.

Question 12

Figure 1 is the clinical photograph of a 65-year-old right-hand dominant man who has finger contracture and stiffness. He experiences minimal pain but has severe functional limitations and elects for treatment with injectable collagenase Clostridium histolyticum . What types of collagen will be affected by this injection?

Explanation

EXPLANATION:
Type II collagen is the predominant type found in articular cartilage. Type IV collagen is the predominant type found in the basement membranes of neurovascular structures. Collagenase Clostridium histolyticum injection targets type I and type III collagen.

Question 13

What structure is most at risk with anterior penetration of C1 lateral mass screws?

Explanation

DISCUSSION: Posterior screw fixation of the upper cervical spine has gained a great deal of popularity due to its stable fixation, obviating the use of halo vest immobilization, and its high fusion rates. The use of screws in this location, however, has introduced a whole new set of potential complications. Vertebral artery injury is one of the most feared complications associated with screws in the C1/C2 region. This structure, however, is lateral and posterior at the C2 level and then penetrates the foramen transversarium of C1 to lie cephalad to the arch of C1 before entering the foramen magnum. It is the internal carotid artery that lies immediately anterior to the arch of C1 that is particularly at risk by anterior penetration of C1 lateral mass or C1-C2 transarticular screws as demonstrated by Currier and associates. The internal carotid artery lies posterior to the pharynx. The external carotid artery and the glossopharyngeal nerve are not at risk with this method of fixation.
REFERENCES: Currier BL, Todd LT, Maus TP, et al: Anatomic relationship of the internal carotid artery to the C1 vertebra: A case report of cervical reconstruction for chordoma and pilot study to assess the risk of screw fixation of the atlas. Spine 2003;28:E461-E467.
Grant JC: Grant’s Atlas of Anatomy, ed 6. Baltimore, MD, Williams & Wilkins, 1972.
Harms J, Melcher RP: Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine 2001;26:2467-2471.

Question 14

Figures 18a through 18c show the clinical photograph, radiograph, and CT scan of a 21-year-old man who reports persistent pain after injuring his right shoulder 4 months ago. What is the most likely factor associated with this patient’s diagnosis?

Explanation

The more severe the trauma, the higher the rate of subsequent clavicular nonunion. Neither duration nor type of immobilization has been clearly demonstrated to be a causative factor in the development of nonunion. Similarly, closed reduction has not been found to alter the healing course in midshaft clavicular fractures.

Question 15

A 38-year-old man who is an avid runner reports a several month history of right hip pain. Based on the radiograph and cross-sectional CT scan shown in Figures 33a and 33b, what is the most likely diagnosis for the lesions seen on the femoral neck?

Explanation

DISCUSSION: Synovial herniation pits or Pitt’s pits are tumor simulators and are incidentally identified on radiographs obtained for either pain or trauma. The main diagnostic pitfall with this lesion is mistakenly identifying it as an osteoid osteoma. Accurate diagnosis is achieved by knowledge of the location and the characteristic imaging appearance. These are common lesions in individuals with femoroacetabular impingement.
REFERENCES: Pitt MJ, Graham AR, Shipman JH, et al: Herniation pit of the femoral neck. Am J Roentgenol 1982;138:1115-1121.
Daenen B, Preidler KW, Padmanabhan S, et al: Symptomatic herniation pits of the femoral neck: Anatomic and clinical study. Am J Roentgenol 1997;168:149-153.

Question 16

A 26-year-old mixed martial arts fighter sustains a posterolateral elbow dislocation. The primary stabilizers of the elbow joint are the

Explanation

The primary stabilizers of the elbow are the ulnohumeral joint, the lateral collateral ligament (lateral epicondyle to the crista supinatoris), and the anterior band of the medial collateral ligament (anterior inferior medial epicondyle to the sublime tubercle). Secondary stabilizers are the radial head, the common flexor and
extensor origins, and the joint capsule. The muscles that cross the elbow joint act as dynamic stabilizers.

Question 17

7 weeks from injury at a union rate of 94.5%. They concluded that functional bracing has many known benefits and remains a reliable treatment however certain parameters such as functional outcome, residual deformity, and loss of joint motion remain unclear and require further research.

Explanation

OrthoCash 2020
A patient presents with the injury shown in figures A and B. What has been associated with the technique depicted in figures C and D?

Longer operative times
Increased deep surgical infection rates
Unacceptably high malunion/nonunion rates
Slower early return to function
Longer hospital stays Corrent answer: 3
Treatment of Shatzker V and VI tibial plateau fractures with hybrid external fixation is associated with increased malunion and nonunion rates.
Hybrid external fixation for treating tibial plateau fractures involves the use of an external fixator to achieve reduction through ligamentotaxis. Additional fracture reduction is achieved through limited open incisions with fixation augmented through percutaneous cannulated screws. Definitive treatment with this technique avoids soft tissue complications that have been associated with traditional open reduction and internal fixation with bicondylar plating.
However, studies have reported high malunion and nonunion rates due to a lack of rigid fixation.
Bertrand et al. performed a prospective cohort study of patients undergoing either open reduction and internal fixation versus hybrid external fixation for Schatzker V and VI tibial plateau fractures. Hybrid external fixation was associated with significantly shorter operative times but insignificantly increased complication rates. They concluded that there were limited statistically differences between these techniques, but further studies are required before advising hybrid external fixation for higher Schatzker tibial plateau fractures.
Gross et al. performed a retrospective study of patients treated with hybrid external fixation for Shatzker V and VI tibial plateau fractures. The authors found there was an 80% union rate, a 70% satisfactory reduction rate, and a 52% rate of malunion. The development of osteoarthritis was associated with plateau widening, articular comminution, articular step-off, and incorrect mechanical alignment. The authors concluded that hybrid external fixation is an effective means for the treatment of tibial plateau fractures that minimizes tissue dissection, with decreased blood loss, and shorter operative times, but associated with a very high malunion rate.
Hall et al. performed a multicenter randomized controlled trial comparing the treatment of Schatzker V and VI fractures with open reduction and internal fixation with hybrid external fixation. Patients with hybrid external fixation had less intraoperative blood loss, fewer unanticipated secondary procedures, slightly faster return to pre-injury activity at 6 months and 1 year, and shorter
hospital stay. They concluded that both hybrid external fixation and open reduction and internal fixation provide effective means for fracture treatment, but hybrid external fixation avoids soft tissue complications with deleterious consequences.
Figure A is an AP radiograph of the right knee with a Schatzker VI tibial plateau fracture. Figure B is an axial CT slice of the articular surface of the tibia with extensive comminution. Figures C and D are the AP and lateral radiographs of the knee with a hybrid external fixation construct for a tibial plateau fracture
Incorrect answers:
OrthoCash 2020
An 89-year-old female sustained the injury shown in Figure A and underwent a hemiarthroplasty. Which of the following has been associated with increased rates of post-operative dislocation?

Posterior approach
Anterior approach
Anterolateral approach
Use of a bipolar implant
Use of a monopolar implant
The incidence of dislocation after hemiarthroplasty is highest when using a posterior approach.
Elderly femoral neck fractures are one of the most common fractures encountered by orthopaedists and will only become more common as the population continues to age. The displacement of the femoral head is associated with delayed union or nonunion, an increased risk of femoral head necrosis due to disrupted blood flow at the femoral neck, and failure of internal fixation devices. For this reason, displaced femoral neck fractures in older patients are often treated with hemiarthroplasty. Three approaches to hemiarthroplasty have been described: a lateral approach, a posterior approach, and an anterior approach. The posterior approach has been used more historically; however, its use has been called into question as it has been associated with increased dislocation rates.
Parker performed a trial on all patients with intracapsular femoral neck fractures being treated with hemiarthroplasty. Patients were randomized to surgery using either a lateral or posterior approach. They found that there were no statistically significant differences observed for any of the outcome measures including mortality, degree of residual pain and regain of walking ability. They concluded that both surgical approaches appear to produce comparable functional outcomes.
van der Sijp et al. performed a meta-analysis to compare the outcomes based on approaches for hemiarthroplasty in the treatment of proximal femur fractures. They found 21 studies and found that the posterior approach poses an increased risk of dislocation and reoperation compared to the lateral approach and anterior approaches. They conclude that there are no evident advantages of the posterior approach and its routine use for fracture-related hemiarthroplasty should be questioned.
Figure A is an AP pelvis radiograph demonstrating a displaced right femoral neck fracture.
Incorrect Answers:
OrthoCash 2020
A 50-year-old male sustained a humeral shaft fracture treated operatively 6 months ago. He denies medical problems but smokes 10 cigarettes per day. His current radiograph is shown in Figure A. He continues to have pain in his arm that is affecting his quality of life. On physical examination, there is motion at the fracture site. C-reactive protein and erythrocyte sedimentation rate are within normal limits. Which is the most appropriate definitive treatment for this fracture?

Exchange humeral nailing
Augmentative plating
Nail removal with open reduction compression plating
Smoking cessation and medical optimization
Nail removal with open reduction and compression plating with bone grafting
This patient has sustained an atrophic nonunion of a humeral shaft fracture treated with an intramedullary nail. The most appropriate definitive treatment is nail removal with open reduction and compression plating with bone grafting.
Most diaphyseal humeral fractures can be managed non-operatively with functional bracing. Operative treatment is indicated under a number of circumstances including open fractures, associated neurovascular injury, proximal and distal articular extension of the fracture, and in patients with other multiple injuries. Surgical stabilization can be accomplished with different implants and techniques. The two most common are plate and screw fixation and intramedullary nailing. Plate fixation has the advantages of potential absolute stability and sparing the rotator cuff from an incision. Intramedullary nailing has to be inserted proximally with potential damage to the rotator cuff. It, however, can be inserted with small incisions. If a nonunion develops after intramedullary nailing, nail removal and compression plating is the preferred treatment choice.
Heineman et al. performed a metanalysis on plate fixation or intramedullary nailing of humeral shaft fractures. They performed a literature search from 1967-2007 comparing nails and plates in patients with humeral shaft fractures that reported complications due to surgery. They found that the risk of a complication is lower when plating a fracture of the humeral shaft than when using an intramedullary nail.
Gerwin et al. performed an anatomical study to define the course of the radial nerve in the posterior aspect of the arm, with particular reference to its relationship to operative exposures of the posterior aspect of the humeral diaphysis. They found that the radial nerve crosses the posterior aspect of the humerus from an average of 20.7 +/- 1.2 centimeters proximal to the medial epicondyle to 14.2 +/- 0.6 centimeters proximal to the lateral epicondyle. They found the approach to permit the most visualization was the triceps reflecting approach.
Figure A is a lateral radiograph of an atrophic nonunion of a humeral shaft being stabilized with an intramedullary nail.
Incorrect Answers:
OrthoCash 2020
A 45-year-old man is struck while crossing a major highway and sustains the injury depicted in Figure A. Which of the following statements comparing the techniques in Figure B and C is most accurate?

Technique depicted in Figure B is associated with an increased risk of septic arthritis
Technique depicted in Figure B is associated with increased rate of anterior knee pain
Technique depicted in Figure B is associated with improved postoperative fracture alignment
Technique depicted in Figure C is associated with an increased risk of septic arthritis
Technique depicted in Figure C is associated with improved postoperative fracture alignment
Compared to infrapatellar tibial nailing, suprapatellar tibial nailing is associated with improved postoperative fracture alignment.
While antegrade tibial nailing results in postoperative anterior knee pain in approximately 20% of patients, there is no significant difference in the incidence of anterior knee pain when the conventional infrapatellar approach is compared to suprapatellar approaches. In open tibial shaft fractures, no difference has been observed in the incidence of knee sepsis with either approach. However, several studies have demonstrated that intramedullary nail fixation through a suprapatellar approach is associated with a more accurate entry position and a more accurate fracture reduction when compared with an infrapatellar technique, particularly in more proximal and distal shaft
fractures, without evidence of a functional impact on the patellofemoral joint. Lastly, intraoperative radiography is generally less cumbersome with suprapatellar nailing.
Marecek et al. performed a multicenter comparison study of suprapatellar and infrapatellar approaches and the risk of knee sepsis after treatment of open tibia fractures. They reported no differences in the rates of infection, deep infection, or reoperation between suprapatellar and infrapatellar nailing groups. They concluded that the risk of knee sepsis after suprapatellar nailing of open fractures is low.
Avilucea et al. performed a retrospective cohort study comparing postoperative alignment after suprapatellar versus infrapatellar nailing for distal tibial shaft fractures. They reported a significantly increased rate of primary angular malalignment of greater than 5 degrees in the infrapatellar compared to the suprapatellar nailing cohort. They concluded that in the treatment of distal tibial fractures, suprapatellar nailing results in a significantly lower rate of malalignment compared with the infrapatellar nailing.
Jones et al. performed a study comparing the radiologic outcome and patient-reported function after suprapatellar and infrapatellar intramedullary nailing. They reported no difference in anterior knee pain, however, found a more accurate fracture reduction, both in terms of angulation and translation in the coronal plane, with the use of the suprapatellar technique. They concluded that when compared with infrapatellar nailing, the suprapatellar technique was not associated with more anterior knee pain, yet more accurate nail insertion and fracture reduction.
Figure A depicts a displaced distal third tibial shaft fracture. Figure B depicts the infrapatellar tibial nailing technique. Figure C depicts the suprapatellar tibial nailing technique.
Incorrect Answers:
OrthoCash 2020
A 56-year-old woman sustains the closed injury depicted in Figures A-B. On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. She also complains of some paresthesias in her thumb and index finger. The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. What is the likely mechanism of her paresthesias and what is the most appropriate treatment?

Nerve compression; open reduction internal fixation with open carpal tunnel release
Nerve laceration; open reduction internal fixation with primary nerve repair or grafting
Decreased arterial inflow; fasciotomy with open reduction internal fixation
Reflex sympathetic dystrophy; vitamin C
Nerve compression; repeat closed reduction Corrent answer: 1
This patient is presenting with signs of acute carpal tunnel syndrome (CTS) in the setting of a displaced distal radial fracture. The pathogenesis of acute CTS is nerve compression, requiring urgent open carpal release with open reduction internal fixation (ORIF).
Acute CTS is a well-recognized phenomenon after distal radial fractures. Risk factors include ipsilateral upper extremity fractures, translation of the fracture fragments, and articular distal radius fractures (DRFs). Acute CTS can manifest with paresthesias in the median nerve distribution and opponens pollicis weakness. Acute CTS is an indication for urgent surgical decompression of the median nerve.
Odumala et al. performed a study to evaluate the role of carpal tunnel decompression in the prevention of median nerve dysfunction after buttress plating of DRFs. They reported that prophylactic decompression of the carpal tunnel results in twice the relative odds of developing median nerve dysfunction, which routinely self-resolved. They concluded that prophylactic median nerve decompression does not alter the course of median nerve dysfunction and may actually increase postoperative morbidity.
Medici et al. performed a case-control study to investigate whether carpal tunnel release (CTR) during fixation DRFs improves outcomes. They reported no statistically significant difference between the groups in VAS and Mayo Wrist Scores, however, an increased risk of subsequent CTR in the group who underwent ORIF with no CTR at the index procedure. They concluded that the release of the transverse carpal ligament during ORIF may reduce the incidence of postoperative median nerve dysfunction.
Niver et al. reviewed CTS after DRFs. They reported that acute CTS noted at the time of DRF warrants urgent surgical release of the carpal tunnel and fracture fixation, and that delayed CTS presenting after a distal radius fracture has healed may be managed in the standard fashion for CTR. They concluded that there is no role for prophylactic CTR at the time of distal radius fixation in a patient who is asymptomatic.
Figures A and B depict a displaced apex volar DRF and a mildly displaced ulnar styloid fracture.
Incorrect Answers:
OrthoCash 2020
Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury?

Improved functional outcomes with open reduction internal fixation (ORIF) through FCR approach vs. closed treatment
No difference in radiographic outcomes after ORIF vs. closed treatment
No difference in functional outcomes after ORIF vs. closed treatment
Improved functional outcomes with closed treatment vs. ORIF
Improved functional outcomes with external fixation and K wire fixation vs. ORIF
This elderly patient has sustained a closed intra-articular and shortened distal radial fracture (DRF). Many studies have reported no difference in functional outcomes when patients aged 60 and over are treated in a closed manner versus operatively for unstable fractures.
The treatment of DRFs in the elderly population is controversial. A variety of nonoperative and operative treatments are available, including closed reduction and splinting/casting, K wire stabilization, external fixation, and ORIF. While conservative management of DRFs in the elderly is common,
recent systematic reviews and meta-analyses have demonstrated that despite worse radiographic outcomes after closed treatment of unstable fractures, functional outcomes were no different between patients treated closed versus surgically in patients over the age of 60 years.
Ju et al. published a systematic review and meta-analysis comparing treatment outcomes between nonsurgical and surgical treatment of unstable DRFs in the elderly. They reported no significant differences in DASH score, VAS pain score, grip strength, wrist extension, pronation, supination, and ulnar deviation between the groups. They concluded that operative and nonoperative treatments result in similar outcomes in the treatment of unstable DRFs in the elderly, with no impact on subjective function outcome and quality of life with closed treatment.
Diaz-Garcia et al. published a systematic review of the outcomes and complications after treating unstable DRFs in the elderly, comparing various treatment techniques. They reported significant differences in wrist motion, grip strength, DASH score, although these findings may not be clinically meaningful. They concluded that although the operatively treated group had improved radiographic outcomes, functional outcomes were no different when compared to the group treated in a closed manner.
Figure A depicts an unstable intra-articular and shortened DRF. Incorrect Answers:
no difference in functional outcomes between operative and closed treatment modalities for DRF.
OrthoCash 2020
An active 60-year-old woman falls from her attic and presents with the injury in Figure A. She undergoes successful closed reduction and sling immobilization. At follow up, she is unable to move her shoulder. New radiographs are depicted in Figures B and C. What is the next best step?

Continued sling immobilization
Closed reduction percutaneous pinning
Open reduction internal fixation
Hemiarthroplasty
Reverse total shoulder arthroplasty Corrent answer: 3
This active patient presents with a greater tuberosity fracture dislocation. Open reduction internal fixation (ORIF) is indicated, particularly when the greater tuberosity fragment is displaced greater than 5mm.
Many proximal humerus fractures are minimally displaced and respond acceptably to nonoperative management. Isolated greater tuberosity fractures or rotator cuff injuries are associated with shoulder dislocations in the elderly population. The greater tuberosity fragment undergoes deforming forces by the supraspinatus and infraspinatus muscles. In active patients, it is well-accepted that greater tuberosity fracture displacement greater than 5mm is an indication for ORIF to restore their ability to perform overhead activities and prevent impingement.
Schumaier et al. published a review article on the treatment of proximal humerus fractures in the elderly. They highlighted that while bone density was a predictor of reduction quality, social independence was a better predictor of outcome. They concluded that although the majority of minimally displaced fractures can be treated successfully with early physical therapy, treatment for displaced fractures should consider the patient's level of independence, bone quality, and surgical risk factors. They emphasized that there was no clear evidence-based treatment of choice, and the surgeon should consider their comfort level during their decision-making.
George et al. published a review article on greater tuberosity humerus fractures. They reported that these fractures may occur in the setting of anterior shoulder dislocations or impaction injuries against the acromion or superior glenoid, with surgical fixation recommended for fractures with greater than 5 mm of displacement in the general population or greater than 3 mm of displacement in active patients involved in frequent overhead activity. They recommended close followup and supervised rehabilitation to increase successful outcomes.
Figure A depicts a greater tuberosity fracture dislocation of the left shoulder. Figures B and C depict reduction of the glenohumeral joint with residual displacement of the greater tuberosity. Illustrations A and B depict radiographs after ORIF.
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OrthoCash 2020
A 21-year-old football player is tackled as he falls onto an outstretched arm. He sustains the injury shown in Figure A. He undergoes successful operative treatment of his injury. In which order did his injury occur?

MCL > LCL > anterior capsule
MCL > anterior capsule > LCL
anterior capsule > MCL > LCL
LCL > anterior capsule > MCL
LCL > MCL > anterior capsule Corrent answer: 4
The patient sustained a terrible triad injury of the elbow, which progresses from the LCL to the anterior capsule and then the MCL.
Terrible triad injuries of the elbow are traumatic injuries that occur after a fall on an extended arm that results in a combination of valgus, axial, and posterolateral rotatory forces. The key features of a terrible triad injury include a radial head fracture, a coronoid fracture, and an elbow dislocation. Disruption of the structures in the elbow characteristically occurs from lateral to medial, affecting the LCL first, followed by the anterior capsule and MCL. Outcomes following terrible triad injuries have historically been poor; however, more recent literature has shown that good outcomes can be achieved with surgical stabilization of the elbow followed by an early rehabilitation protocol. Some authors use temporary immobilization, but range-of-motion exercises are typically initiated by 48 hours postoperatively. Active range of motion is particularly important, as it recruits muscles that act as dynamic stabilizers of the elbow. Depending on the injury, method of fixation, and stability that is achieved, the range of motion may be limited to 30° of extension during the early postoperative period but should allow full flexion.
Giannicola et al. (2013) performed a study to determine the critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability (CEI). They found that the first 6 months after surgery represent the critical rehabilitation period to obtain a functional elbow and that elbow flexion recovered at a rate slower than that of the other elbow movements. They recommend that, following CEI surgical treatment, a rehabilitation program should be started promptly and should be continued for at least 6 months because a significant improvement of ROM occurs in this period.
Giannicola et al. (2015) performed a study analyzing the predictability of outcomes of terrible triad injuries (TTI) treated according to current diagnostic and surgical protocols. They found that the current diagnostic and therapeutic protocols allow for satisfactory clinical outcomes in a majority of cases but a high number of major and minor unpredictable complications still persist. Low compliance, obesity, and extensive soft elbow tissue damage caused by high-energy trauma represented negative prognostic factors unrelated to surgery.
McKee et al. performed a review on their standard surgical protocol for the treatment of elbow dislocations with radial head and coronoid fractures. Their surgical protocol included fixation or replacement of the radial head; fixation of the coronoid fracture, if possible; repair of associated capsular and lateral ligamentous injuries; and, in selected cases, repair of the medial collateral ligament and/or adjuvant-hinged external fixation. They found that their surgical protocol restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. They recommend early operative repair with a standard protocol for these injuries.
Figure A is a lateral radiograph of the elbow demonstrating a terrible triad injury with a comminuted radial head/neck fracture, displaced coronoid fracture, and posterior elbow dislocation. Illustration A is a rendered image of the radiograph shown in Figure A with the components labeled.
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OrthoCash 2020
An 82-year-old female sustains the fracture shown in Figure A as the result of a ground level fall. Which of the following has been shown to be a reliable predictor of postoperative lateral wall fracture for this injury after treatment with a sliding hip screw?

Reverse obliquity fracture pattern
Lateral wall thickness
Previous contralateral hip fracture
DEXA T-score <-2.0
Calcar comminution
Lateral wall thickness has been shown to be a predictor of postoperative lateral wall fracture. As the lateral wall thickness decreases, there is an increased chance of fracture.
Lateral wall fracture creates an unstable fracture pattern and increased screw sliding/collapse. This shortens the neck and abductors, leading to worse patient outcomes (radiographic and clinical). Recognition of a thin wall should lead toward the use of an intramedullary device or adjunct use of a trochanteric stabilizing plate with a sliding hip screw device.
Baumgaertner et al. reported that the failure of peritrochanteric fractures that have been treated with a fixed-angle sliding hip-screw device is frequently related to the position of the lag screw in the femoral head. They established the tip-apex distance as the sum of the distance from the tip of the lag screw to the apex of the femoral head on an anteroposterior radiograph and this distance on a lateral radiograph, after controlling for magnification. Upon reviewing their series, none of the 120 screws with a tip-apex distance of twenty-five millimeters or less cut out, but there was a very strong statistical relationship between an increasing tip-apex distance and the rate of cutout, regardless of all other variables related to the fracture.
Socci et al. performed a literature review of relevant papers and appropriate clinical databases and concluded that fixation of AO 31A1 fractures was best achieved with a sliding hip screw device and that all other types of intertrochanteric hip fractures be fixed with an intramedullary device.
Utrilla et al. reported no difference in outcome in stable fractures, but better mobility at one year following intramedullary fixation of unstable fractures.
Hsu et al. measured the thickness of the lateral wall of patients with AO/OTA 31-A1 and 31-A2 type intertrochanteric hip fractures. They found that the lateral wall thickness was a reliable predictor of postoperative lateral wall fracture for unstable AO Type A2 fractures and concluded that the lateral wall thickness threshold value for risk of developing a secondary lateral wall fracture was found to be 20.5 mm.
Figure A shows a standard obliquity intertrochanteric hip fracture.
Illustration A from the Hsu article demonstrates the measurement of the lateral wall thickness. The distance is measured along a 135-degree angle, between a point 3cm distal to the innominate tubercle of the greater trochanter and the fracture line (midway between the two cortical lines).
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OrthoCash 2020
A 78-year-old patient presents with right hip pain and inability to bear weight after an unwitnessed fall at a nursing home. Figures A and B are the radiographs of the hip and pelvis. Which statement is true regarding the treatment of these injuries?

Smaller lateral wall thickness favors sliding hip screw constructs
Unstable fractures are best treated with sliding hip screw constructs
Avoiding distal locking screws in intramedullary implants protects against refracture
Stable fractures have no differences in outcomes between sliding hip screws and intramedullary implants
Implant stability has a greater impact on outcomes rather than reduction quality
Studies have shown that in stable intertrochanteric femur fractures there are no differences in outcomes between sliding hip screws and intramedullary implants.
Intertrochanteric femur fractures are one of the most common fractures in the geriatric population. Implant selection has been a great topic of research with most studies reporting minimal to no differences in outcomes between intramedullary and sliding hip screw constructs in stable fracture patterns.
Unstable fractures, however, are reportedly better treated with a distally locked intramedullary implant. The quality of fracture reduction has a greater impact on the overall outcome than implant selection.
Hsu et al. performed a retrospective study of risk factors for postoperative lateral wall fractures in patients treated with sliding hip screws for intertrochanteric femur fractures. They found that fracture classification and lateral wall thickness, which is measured from 3 cm distal from innominate tubercle and angled 135 degrees to the fracture line, were associated with postoperative lateral wall fracture. They recommended not treating intertrochanteric femur fractures with sliding hip screws if the lateral wall thickness is less than 20.5 mm.
Socci et al. reviewed the literature regarding the treatment of intertrochanteric femur fractures. Based on the literature, they recommend treatment of AO/OTA type 31A1 fractures with sliding hip screws, type 31A2 fractures with short intramedullary implants, and 31A3 fractures with long intramedullary implants. Simple basicervical fractures of the femoral neck can be treated with sliding hip constructs whereas comminuted fractures treated with intramedullary devices due to the inherent instability of the pattern. The most import aspect in fracture healing is the quality of the reduction rather than the choice of implant.
Lindvall et al. performed a retrospective study of refracture rates in patients treated with either long or short cephalomedullary nails. The authors found a 97% union rate with both implant types and refracture not associated with either long or short implants. Rather, refracture was associated with the lack of a distal locking screw. The authors recommended locking intramedullary implants to avoid refracture.
Utrilla et al. performed a randomized control trial of elderly patients treated
with compression hip screw or Trochanteric Gamma Nail for intertrochanteric femur fractures. They reported the only differences between the two implants were quicker operating time, less fluoroscopy use, and better walking with unstable fractures treated with intramedullary implants. The authors recommended either construct for stable fractures, but intramedullary implants for unstable fractures.
Figures A and B are the AP and lateral radiographs of the right hip radiographs demonstrating a simple and minimally displaced intertrochanteric femur fracture, classified as an AO/OTA 31A1 fracture. Illustration A depicts the AO/OTA classification system for proximal femur fractures.
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OrthoCash 2020
A 28-year-old male that sustained a closed left femoral shaft fracture 12 months ago and underwent intramedullary nailing presents with persistent pain in the right thigh. The patient walks with an antalgic gait. He denies any fevers or chills. His surgical sites are well healed and there are no signs of drainage. Serum ESR and CRP are 12 mm/hr (reference <20 mm/hr) and 0.9 mg/L (reference <2.5 mg/L), respectively. Figures A and B are the AP and lateral radiographs of the left femur. Which treatment option offers the highest chance of union and enables immediate weight-bearing?

Nail removal with compression plating and open bone grafting
Closed reamed exchange nailing
Nail dynamization
Nail retention with plate augmentation and bone grafting
Electrical bone stimulator Corrent answer: 4
The patient is presenting with a hypertrophic nonunion of the femur below the isthmus, which studies have shown to have a higher union rate when treated with plate augmentation. Retention of the nail allows for full weight-bearing postop.
Hypertrophic nonunion of the femur is the result of fracture site hypermobility with sufficient biology for healing. This is demonstrated with abundant callus formation without bridging trabeculae. Traditionally, this is treated with closed reamed exchange nailing which increased construct stiffness with a larger diameter nail, improved isthmic fit, and extrusion of reaming contents to the nonunion site. However, studies have demonstrated a higher union rate with open plate augmentation, bone grafting, and nail retention. This is due to the ability to correct nonunion site deformity, provide added compression at the nonunion site, and increase fracture site biology with bone graft.
Lynch et al. reviewed the literature regarding the treatment options for femoral nonunions. The literature suggests high union rates when hypertrophic nonunions are treated with exchanged reamed nailing. However, the use of augmentative plate fixation allows for further deformity correction. The proposed mechanism by which exchange reamed nailing is increased construct stiffness with a large diameter nail, usually by 1-2 mm, increased isthmic fit, and autogenous bone graft extrusion into the nonunion site.
Somford et al. performed a systematic review of the surgical treatment of femoral nonunions. Results demonstrate that exchange nailing provides a 73% union rate compared to plate augmentation of 96%. They speculated that there were increased indications for exchange nailing for oligotrophic nonunions in many of the included studies, which may have reduced the union rate. Further, plate augmentation does allow for deformity correction, which can further improve the union rate.
Figures A and B are the AP and lateral radiographs of the femur with hypertrophic nonunion as suggested with the abundant callus formation and broken distal interlock screws. Illustration A and B are the AP and lateral radiographs of the distal femur subsequent plate augmentation and fracture healing.
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OrthoCash 2020
A 25-year-old male sustains the injury depicted in Figure A. He is splinted in the field, but on arrival to the emergency room, he complains of painful "tightness" around the leg and severe uncontrolled pain despite maximum dose narcotics. His pain is exacerbated when the toes and ankle are passively stretched in flexion and extension. What is the most appropriate next step in treatment?

External fixation with serial doppler examinations
Intramedullary nailing
Open reduction internal fixation using plates and screws
Immediate 2-compartment fasciotomies and external fixation
Immediate 4-compartment fasciotomies and external fixation Corrent answer: 5
This patient has clinical symptoms and signs of leg compartment syndrome and should undergo immediate fasciotomies of all 4 leg compartments, followed by external fixation for fracture stabilization.
Tibial fractures are among the most common reasons for compartment syndromes of the leg. A clinical assessment is key in the diagnosis of acute compartment syndrome. If there is uncertainty, intracompartmental pressure measurement has been advocated to help confirm the diagnosis. An absolute
compartment pressure >30 mm Hg or a difference in diastolic pressure and compartment pressure (delta p) <30 mmHg may help to confirm the necessity for fasciotomy.
McQueen et al. published a report of 25 patients with tibial diaphyseal fractures which had been complicated by an acute compartment syndrome. They reported significant differences in any sequelae of acute compartment syndrome between patients who underwent compartment pressure monitoring and those who had not. They recommended that all patients with tibial fractures should have continuous compartment monitoring to minimize the incidence of acute compartment syndrome.
Mawhinney et al. reported on three cases of tibial compartment syndrome after closed intramedullary nailing of the tibia. They reported that the only predisposing factors for the development of compartment syndrome were the surgery and the fracture itself. They concluded that tibial compartment syndrome is a relatively rare but significant complication of tibial nailing.
Figure A is an AP and lateral radiograph of the leg with displaced, comminuted middle third tibia and fibula fractures.
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OrthoCash 2020
A 24-year-old male is brought to the ED after an MVC. He is found to have a closed comminuted segmental fibula fracture after a prolonged extraction from the vehicle. Several hours after arrival, the patient reports increasing pain and is noted to have an exacerbation of his pain with passive stretching of the ankle. He has a heart rate of 103 and a blood pressure of 141/87. Compartment pressures are obtained and are 27 mmHg in the anterior compartment, 47 mmHg in the lateral compartment, 28 mmHg in the superficial posterior compartment, and 27 mmHg in the deep posterior compartment. Which of the following correctly describes the initial pathophysiology of compartment syndrome and the neurologic deficit that would likely occur in this patient if left untreated?
Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the first webspace
Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes
Decreased arterial inflow; inability to dorsiflex his ankle
Decreased venous outflow; decreased sensation on the dorsum of his foot involving the first webspace
Decreased venous outflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes
Compartment syndrome initially results from a decrease in venous outflow relative to arterial inflow. This patient has elevated pressures in the lateral compartment of the leg, which is where the superficial peroneal nerve runs to supply sensation to the dorsum of the foot including the hallux and 3rd and 4th toes.
Compartment syndrome results from compromised venous outflow from the leg relative to the arterial inflow. This venous congestion leads to elevated compartment pressures that ultimately lead to compromised arterial inflow without compartment release. There are 4 compartments in the leg: anterior, lateral, superficial posterior, and deep posterior. The anterior compartment contains the deep peroneal nerve, the lateral compartment of the leg contains the superficial peroneal nerve, and the deep posterior compartment contains the tibial nerve.
McQueen et al. performed a study to determine risk factors for acute compartment syndrome. They found that young patients, especially men, were most at risk of acute compartment syndrome after injury. They recommend that, when treating such injured patients, the diagnosis should be made early, utilizing measurements of tissue pressure.
Olson et al. published a review on acute compartment syndrome in lower extremity musculoskeletal trauma. They reported that acute compartment syndrome is a potentially devastating condition in which the pressure within an osseofascial compartment rises to a level that decreases the perfusion gradient across tissue capillary beds, leading to cellular anoxia, muscle ischemia, and death. They report that recognizing compartment syndromes requires having and maintaining a high index of suspicion, performing serial examinations in patients at risk, and carefully documenting changes over time.
Illustration A is a diagram depicting the compartments of the leg and its contents.
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OrthoCash 2020
Which of the following amputations results in an approximate 40% increase in energy expenditure for ambulation?
Syme
Traumatic transtibial
Vascular transtibial
Traumatic transfemoral
Vascular transfemoral
The energy expenditure of a vascular transtibial amputation is approximately 40% greater.
The energy expenditure for ambulation increases with lower extremity amputation. Diabetics and vasculopathic patients who undergo amputation
have significantly increased energy requirements compared with nondiabetic patients undergoing amputations for trauma. The metabolic cost for a vascular transtibial amputation is 40% compared to a 25% increase in normal patients who sustain a traumatic amputation.
Huang et al. used a mobile instrument system to measure energy consumption by indirect calorimetry at rest and during ambulation in 25 unimpaired subjects, 6 unilateral below-knee (BK) amputee patients, 6 unilateral above-knee (AK) amputee patients and 4 bilateral AK amputee patients. They found that in comparison to unimpaired subjects, the mean oxygen consumption was 9% higher in unilateral BK amputee patients, 49% higher in unilateral AK amputee patients and 280% higher in bilateral AK amputee patients.
Pinzur et al. performed a study to measure cardiac function and oxygen consumption in 25 patients who underwent amputation for peripheral vascular disease (PVD), and in five similarly aged control patients without PVD. They found Normal walking speed and cadence decreased and oxygen consumption per meter walked increased with more proximal amputation. They conclude that peripheral vascular insufficiency amputees function at a level approaching their maximum functional capacity and more proximal amputation levels, the capacity to walk short or long distances is greatly impaired.
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OrthoCash 2020
A 25-year-old man sustains the injury shown in Figures A-C. What is the primary advantage of using a trochanteric flip osteotomy (TFO) in treating this injury?

It may be performed in a minimally invasive manner
It involves minimal soft tissue stripping
It leads to higher union rates
It allows the surgeon to address all sites of injury through one approach
This patient has sustained a right hip fracture-dislocation with fractures of the femoral head and posterior wall. The TFO allows the surgeon to address all sites of injury through a single approach.
Femoral head fracture-dislocations are a result of high-energy trauma. Treatment ranges from closed reduction and conservative management to total hip arthroplasty. Intermediate options include open reduction and internal fixation or excision of fracture fragments. Complications of this injury include post-traumatic hip arthritis, avascular necrosis, and heterotopic ossification.
The injury is further complicated when a fracture of the acetabulum is concomitantly present. There has been no consensus treatment on this injury constellation as it presents quite rarely. The TFO is one approach that allows the surgeon to treat and stabilize both injuries concurrently. It should be noted that a surgical hip dislocation is performed in conjunction with the TFO to allow access to the femoral head.
Solberg et al. performed a retrospective study of patients sustaining Pipkin IV fracture/dislocations with a TFO. They had 12 patients over a 6 month period. They found that all patients healed radiologically and one patient developed osteonecrosis. 10 out of 12 patients had good to excellent outcomes. They concluded that using a surgical protocol with TFO rendered clinical results
comparable to previously reported outcomes in a series of isolated femoral head fractures.
Giannoudis et al. performed a systematic review to investigate data regarding femoral head fractures, particularly focusing on their management, complications and clinical results. They reported that fracture-dislocations were managed with emergent closed reduction, followed by definite treatment, aiming at an anatomic restoration of both fracture and joint incongruity. They concluded that neither the TFO nor an anterior approach seems to endanger femoral head blood supply compared to the posterior one, with the TFO possibly providing better long-term functional results and lower incidence of major complication rates.
Henle et al. reported on the result of 12 patients of femoral head fractures with associated posterior wall fractures treated with a TFO. They found good to excellent results in 10 patients. The two patients with poor outcome developed avascular necrosis of the femoral head and underwent total hip arthroplasty.
Heterotopic ossification was seen in five patients. They concluded that the TFO may lead to favorable outcomes in this injury constellation.
Figure A is an AP radiograph of the right hip demonstrating a femoral head fracture-dislocation. Figure B is an axial CT image demonstrating a posterior wall fracture. Figure C is an axial CT image demonstrating a femoral head fragment within the acetabulum. Illustration A is the Pipkin classification of femoral head fractures: Type I is below the fovea, Type II is above the fovea, Type III is associated with a femoral neck fracture, and Type IV is associated with an acetabular fracture.
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OrthoCash 2020
A 30-year-old male is brought to your emergency department following a motor vehicle collision at high speed. He is intubated in the field for airway protection but is hemodynamically stable. Subsequent workup shows a displaced acetabular fracture, in addition to an intracranial bleed and liver laceration which do not require surgery. When placing an antegrade anterior column screw, what radiographic view should be used to avoid intra-pelvic screw penetration?
Iliac oblique view with hip and knee flexed
Iliac oblique inlet view
Obturator oblique view with hip and knee flexed
Obturator oblique outlet view
Obturator oblique inlet view Corrent answer: 2
The iliac oblique inlet view will best show the the anterior-posterior placement of an anterior column ramus screw.
Percutaneous and limited-open acetabular fixation is becoming increasingly common as it avoids the morbidity of extensile pelvic dissection and allows early mobilization. However, it relies heavily on a mastery of radiographic landmarks and ability to interpret these images to reduce fracture fragments without direct visualization. Slight deviations of the fluoroscopy beam and/or fracture displacement will distort the radiographic image. Without a facile ability to interpret these and make appropriate adjustments, percutaneous fixation will be extremely onerous.
Starr et al. described their early techniques for percutaneous and limited-open acetabular fixation. They first implemented this for minimally displaced fracture patterns but have expanded these to a wider range of pathology. They cite the benefit of earlier mobilization in the poly-traumatized patient as great use for this technique.
Mauffrey et al. reviewed radiograph utilization during acetabular fracture care. Though CT has added tremendously to demonstrating subtleties of acetabular fractures, they state the use of AP and orthogonal iliac and obturator oblique Judet views cannot be overlooked. Interpreting these radiographs allows the surgeon to recreate 2-dimensional images into a 3-dimensional fracture pattern and better understand the character of the injury.
Illustrations A and B demonstrate the iliac oblique inlet view and obturator oblique outlet views, respectively.
Illustration C demonstrates the relationship of the critical structures at risk of injury during anterior column screw placement. Illustrations D and E show the starting point with screw trajectory, and position of the hip during posterior column screw.
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OrthoCash 2020
A 34-year-old male sustains the injury shown in Figures A and B. Which factor has been found to be elevated in the synovial fluid and contributes to post-traumatic arthritis?

TGF-Beta
RANKL
IL-2
IL-6
cAMP
The patient has sustained a tibial plafond or pilon fracture as depicted in Figures A and B. IL-6 is one of many inflammatory molecules that has been found to be elevated in the synovial fluid following an intra-articular ankle fracture.
Post-traumatic arthritis following intra-articular fractures is a known complication. It commonly appears 1-2 years following injury and is related to chondrocyte death at the margins. There has not been shown to be any association between prolonged non-weight bearing, poor patient compliance with weight-bearing restrictions, and hardware reactions with the development of post-traumatic arthritis. However, literature has shown that the inflammatory molecules present in the synovial fluid can have a significant effect on the development of posttraumatic arthritis. Important inflammatory factors that have been found to be elevated include IL-6, IL-8, MMP-1, MMP-2, MMP-3, MMP-9 and MMP-10.
Adams et al. looked at the synovial fluid of 21 patients with an intra-articular ankle fracture and used the un-injured ankle as a control. They found the inflammatory molecules of GM-CSF, IL-10, IL-1 beta, IL-6, IL-8, IL-10, IL-12p70, TNF-alpha, MMP-1, MMP-2, MMP-3, MMP-9, MMP-10 were all elevated. They concluded that these inflammatory molecules may play a role in posttraumatic arthritis development.
Adams et al. looked at the synovial fluid of 7 patients from his previous 21 patients that had intra-articular ankle fractures. They found that IL-6, IL-8, MMP-1, MMP-2, and MMP-3 were significantly elevated in comparison to the uninjured ankle. They concluded that the sustained elevated intra-articular inflammatory environment is a potential contributor to post-traumatic arthritis.
Figures A and B are sagittal and axial CT slices, respectively, that depict a tibial plafond or pilon fracture.
Incorrect Answers:
immune system.
OrthoCash 2020
A 29-year-old female presents to the trauma bay from the scene of a high-speed motor vehicle accident. She is found to have a closed intraarticular distal radius fracture with a concomitant ulnar styloid base fracture. She subsequently undergoes ORIF of the distal radius fracture with a volar locking plate. The ulnar styloid fracture is not addressed. Which of the following, if present, is least likely to affect functional outcomes?
Ulnar styloid nonunion
DRUJ instability
Articular step-off >3mm
Radial shortening
Workers compensation claim Corrent answer: 1
Ulnar styloid non-unions do not affect the overall outcome of hand or wrist function following ORIF of distal radius fractures.
Ulnar styloid base fractures can be associated with DRUJ disruption and TFCC rupture. The DRUJ should be independently evaluated following ORIF of the distal radius. Without instability, unlar styloid fractures do not need to be addressed. If instability exists, the DRUJ should be treated as a separate entity, typically cross-pinned using k-wires. The result of ulnar styloid nonunions are inconsequential to the overall outcome of patients undergoing distal radius ORIF.
Daneshvar et al review the effects of ulnar styloid fractures on patients sustaining distal radius fractures. They report that patients with a concomitant ulnar styloid fracture had a slower recovery of wrist flexion and grip strength compared to those with an isolated distal radius fracture. They conclude, however, that even the presence of an ulnar styloid nonunion did not significantly affect outcomes.
Buijze et al review the clinical impact of united versus non-united fractures of the proximal half of the ulnar styloid following volar plate fixation of the distal radius. They report no difference in motion, strength or outcome scores
between the united and non-united groups at 6 months follow up. They conclude that nonunion of the ulnar styloid does not have an effect on the overall outcome of hand or wrist function.
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OrthoCash 2020
Which of the following proximal humerus fractures has the highest likelihood of developing humeral head ischemia?

Posteromedial calcar length of the humeral head less than 8 mm and a loss of medial hinge are among the most reliable predictors of ischemia in the surgical management of humeral head fractures.
Proximal humerus fractures are classified based on the Neer classification, in which 4 parts are described: greater tuberosity, lesser tuberosity, articular surface, and the shaft. A fragment is considered a part if it is greater than 45 degrees angulated or displaced >1cm. The posterior humeral circumflex artery is the main blood supply to the humeral head. Following ORIF, humeral head ischemia may occur and is associated with the initial fracture pattern. Several factors including <8mm of calcar length attached to the articular segment, disruption of the medial hinge, displacement >10mm and angulation >45 degrees have been associated with a disruption of the vascular supply to the humeral head.
Campochiaro et al review Hertel’s criteria of calcar length and medial hinge integrity and its reliability in predicting humeral head necrosis. They reported a 3.7% incidence of ischemia across all 267 fractures evaluated. In those patients that developed AVN, 30% had all of the predictors described by Hertel, however, in the non-AVN group, only 4.7% had these same findings.
They concluded that while Hertel’s criteria are helpful, they may not be sufficient and the authors recommended 3-dimensional evaluation of any fracture involving the calcar.
Xu et al reviewed avascular necrosis in patients with proximal humerus fractures who were treated surgically. They reported on 291 patients throughout 7 studies in which there was no difference in the incidence of AVN for those treated surgically or nonoperatively. However, they concluded through subgroup analysis looking at different fixation constructs that, plate fixation specifically was associated with a higher risk of AVN than conservative management of proximal humerus fractures.
Figure A demonstrates a proximal humerus fracture with a medial calcar length of >8mm attached to the articular segment. Figure B is a proximal humerus fracture with a displaced greater tuberosity fragment. Figure C demonstrates a proximal humerus fracture with a medial calcar length of <8mm attached to the articular segment. Figure D is a displaced metadiaphyseal proximal humerus fracture in a skeletally immature patient. Figure E is a radiograph of a metadiaphyseal proximal humerus fracture in a skeletally mature patient with a medial calcar length >8mm.
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OrthoCash 2020
A 34-year-old man presents with the closed injury depicted in Figure A after a high energy twisting injury. Which of the other injuries below is most commonly associated with his known injury?

Nondisplaced medial malleolus vertical shear fracture
Nondisplaced Volkmann's fragment
Nondisplaced Chaput's fragment
Nondisplaced lateral wall talar fracture
Posterior inferior tibiofibular ligament disruption Corrent answer: 2
This patient has sustained a distal third tibial shaft spiral fracture, which is commonly associated with nondisplaced posterior tibial plafond fractures, with the classic Volkmann's fragment.
Prior to operative management, distal third spiral tibial shaft fractures should always be evaluated for intra-articular extension. As this commonly associated injury can be missed on plain radiographs, an ankle CT is often recommended. This is especially important when intramedullary fixation is used for definitive management of the tibial shaft fracture, as nail insertion can displace a
previously nondisplaced intraarticular fracture. Anterior to posterior lag screw fixation prior to nailing may be useful in these cases.
Sobol et al. investigated the incidence of concomitant posterior malleolar fractures (PMFs) in operative distal third spiral tibial shaft fractures. They reported that spiral distal third tibial shaft fractures were identified with an ipsilateral posterior malleolus fracture in 92.3% of cases. They recommended a preoperative ankle CT in all cases with this specific fracture morphology to properly diagnose this commonly associated injury.
Hou et al. investigated the posterior malleolar fracture association with spiral tibial shaft fractures. They reported that plain radiography (both preoperative and intraoperative) resulted in rare identification of these associated injuries, which resulted in missed injuries. They concluded that a CT or MRI ankle may be a higher yield method to detect these injuries.
Figure A demonstrates a distal third spiral tibial shaft fracture. Illustration A is a schematic demonstrating the Volkmann, Chaput, and medial malleoli intraarticular fragments of the distal tibia.
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OrthoCash 2020
An 18-year-old male is admitted for a diaphyseal, open, tibial shaft fracture after falling off a motorcycle. He has a past medical history of nicotine dependence and obesity. He undergoes provisional splinting by the resident on call and is noted to be "neurovascularly intact" following splint placement. Throughout the evening, however, the patient has an increasing narcotic requirement and develops pain with passive stretch of his toes. What factor listed below is most associated with his progressive symptoms overnight?
Age < 20
Male gender
Body mass index >/ 30 kg/m^2
Open fracture
Nicotine use
The highest prevalence of compartment syndrome is found in patients aged 12-19 years, followed by 20-29 years.
One theory for the higher prevalence of compartment syndrome in younger patients is increased muscle mass in this cohort. If there is more muscle in a compartment, there is less room for swelling. On the flip side, elderly or deconditioned patients who have less muscle or fatty atrophy may be better able to accommodate muscle swelling. Additionally, a diaphyseal fracture location is associated with a higher risk of compartment syndrome. Again, this may be due to the fact that there is more muscle than tendon, and thus more swelling, in the proximal leg.
Shadgan et al. retrospectively reviewed 1,125 patients with diaphyseal tibia fractures to look for risk factors associated with the development of compartment syndrome. Compartment syndrome occurred in approximately 8% of patients with this injury. They concluded that younger patients were at a higher risk of developing compartment syndrome and that male gender, open fracture, and intramedullary nailing were not risk factors.
Beebe et al. set out to determine the correlation between the OTA/AO classification of tibia fractures and the development of compartment syndrome. they conducted a retrospective review of a prospectively collected database comprising 2,885 fractures. They concluded that age, sex, and the OTA/AO classification were highly predictive for the development of compartment syndrome in this cohort.
McQueen et al. similarly looked at predictors of compartment syndrome after tibial fractures in a retrospective cohort study. There were 1,388 patients in their study with ages ranging from 12-98; identical to the Shadgan study, 69% of patients were male. They concluded the strongest risk factor was age, with the highest prevalence in 12 to 19-year-olds.
Park et al. additionally analyzed 414 patients with tibia fractures in a retrospective cohort study. The main outcome measure of this study was the rate of clinically determined compartment syndromes requiring fasciotomy by anatomic region. The found that diaphyseal fractures were more frequently associated with the development of compartment syndrome than proximal (next most common site) and distal tibia fractures, specifically in younger patients.
Incorrect Answers:
OrthoCash 2020
Figure A is the radiograph of a 79-year-old female with elbow pain following a fall. Compared with a total elbow artrhoplasty, open reduction and internal fixation would most likely result in?

Greater Mayo Elbow Performance Score
Greater Disabilities of the Arm, Shoulder and Hand Score
Increased flexion-extension arc
Increased reoperation rate
Decreased complication rate Corrent answer: 4
This patient sustained a comminuted distal humerus fracture. Open reduction and internal fixation (ORIF) is found to have higher repoeration rates compared with total elbow arthroplasty (TEA) in the elderly: 27% versus 12%, respectively.
Distal humerus fractures account for approximately 30% of elbow fractures. There is often a low energy mechanism of injury in the elderly patient. While ORIF and TEA may be utilized in bicolumnar distal humerus fractures in the elderly patient, recent literature has demonstrated favorable outcomes with TEA in this aged cohort. TEA is indicated in the low demand osteoporotic patients with bicolumnar distal humerus fractures that are not amendable to ORIF. Utilization of TEA has demonstrated greater functional outcome scores, greater motion, less complications, and a lower revision rate.
Mckee et al. conducted a prospective, randomized, controlled trial comparing functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with ORIF or primary semiconstrained TEA. They reports that patients who underwent TEA had significantly better motion, performance and outcome scores, lower reoperation rates compared with the ORIF group. They concluded that TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF and that TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation.
Githens et al. performed a systematic review and meta-analysis to analyze outcomes and complication rates in elderly patients with intra-articular distal humerus fractures being treated with either TEA or ORIF with locking plates. They report that TEA and ORIF for the treatment of geriatric distal humerus fractures produced similar functional outcome scores and range of motion.
However, they found a non-statistical trend toward a higher rate of major complications and reoperation after ORIF. They conclude that the quality of study methodology was generally weak and ongoing research including prospective trials and cost analysis is indicated.
Figure A is the AP radiograph of a comminuted bicolumnar distal humerus
fracture. Illustration A are the radiographs of a comminuted distal humerus fracture in an elderly patient treated with a TEA. Illustration B is the postoperative radiographs of a comminuted distal humerus fracture treated with ORIF.
Incorrect Answers:

OrthoCash 2020
Figure A is the postoperative radiograph of an 82-year-old female who was treated with a cephalomedually nail for a left intertrochanteric hip fracture. Which of the following is the most common complication following use of this device?

Anterior perforation of distal femur
Breakage of the screw
Implant cutout
Malunion
Nonunion
Intertrochanteric hip fractures are most commonly treated with a cephalomedullary nail. The most common complication following utilization of a cephalomedullary nail is implant failure and cutout.
Intertrochanteric hip fractures are extra-capsular injuries that are common in the elderly osteoporotic patient. These injuries carrry a 20-30% mortality rate in the first year following fracture. Femoral cephalomedullary nails are often used to treat these injuries. Often a helical blade or screw may be used to provide fixation within the femoral neck. Overall, the most common complication following use of this device is implant failure and cutout, which occurs most commonly within 3 months following surgery. A known risk factor of this complication is an increased tip-apex distance, with a 60% failure rate reported with a distance exceeding 45mm.
Gardner et al. reviewed the use of a helical blade device to stabilize
intertrochanteric hip fractures. They reported a mean telescoping in unstable and stable fractures of 4.3 mm and 2.6 mm, respectively. They also found that blade migration within the femoral head averaged 2.2 mm overall, with no difference between stable and unstable fractures. They concluded that position changes occurred within the first 6 weeks postoperatively, with no subsequent detectable migration or telescoping.
Haidukewych et al. reviewed patients with failed internal fixation of a hip fracture. They report that salvage options are dependent on the anatomic site of the nonunion, the quality of the remaining bone and articular surface, and patient factors such as age and activity level. They conclude that in younger patients with either a femoral neck or intertrochanteric fracture nonunion with a satisfactory hip joint, treatment typically involves revision internal fixation with or without osteotomy or bone grafting. Conversely, in older patients with poor remaining proximal bone stock or a badly damaged hip joint, conversion to hip arthroplasty is recommended.
Figure A is the AP radiograph of the right hip treated with a cephalomedullary nail. Illustration A demonstrates screw cutout.
Incorrect Answers:

OrthoCash 2020
Figure A is the radiograph of a 42-year-old female who presents to the trauma bay following a motor vehicle collision. She subsequently undergoes ORIF through a posterior approach. Iatrogenic injury to which nerve in Figure B is most likely with this approach?

Question 18

A 52-year-old woman who underwent cheilectomy 1 year ago for hallux rigidus now reports continued pain in the first metatarsophalangeal joint. She did not have any incision healing problems, and has not had any fevers, erythema, or drainage. Which of the following procedures will provide the best combination of pain relief and function?

Explanation

DISCUSSION: All but the Moberg osteotomy are capable of providing pain relief; however, arthrodesis offers the best long-term results and restores weight bearing and propulsion function to the first ray.
REFERENCES: Machacek F Jr, Easley ME, Gruber F, et al: Salvage of a failed Keller resection arthroplasty. J Bone Joint Surg Am 2004;86:1131-1138.
Myerson MS, Schon LC, McGuigan FX, et al: Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int

2000;21:297-306.

Question 19

Methicillin-resistant staphylococcus aureus (MRSA) develops its resistance to penicillinase-stable antibiotics via which of the following actions?

Explanation

After the introduction of penicillins, bacteria developed the ability to hydrolyze these antibiotics using B-lactamase. In response, penicillinase-stable antibiotics were developed, the first of which was methicillin, since replaced with oxacillin and nafcillin. Drug resistance to this class of antibiotics is achieved via a genetic mutation of mecA encoding an altered penicillin binding protein. The gene product of this mutation, PBPa has a low affinity for these antibiotics and cannot be inhibited by them. Altering cell wall permeability is found in resistance to tetracyclines, quinolones, and trimethoprim, as well as B-lactam antibiotics. Biofilm barriers are produced by bacteria such as salmonella. Active efflux pumps provide resistance to erythromycin and tetracycline, and altering the peptidoglycan subunit is found in resistance to vancomycin.

Question 20

A 50-year-old woman with a 2-part surgical neck proximal humerus fracture and metaphyseal comminution

Explanation

DISCUSSION
Proximal humerus fractures account for approximately 5% of all fractures, with incidence increasing to reflect an aging population and related osteoporosis. Treatment is dependent upon the mechanism of injury, the patient’s physiologic age and activity level, the fracture pattern, and rotator cuff integrity. Most of these injuries are nondisplaced or minimally displaced and are associated with a good overall prognosis with nonsurgical treatment and temporary impairment. A patient with a nondisplaced surgical neck fracture should be treated without surgery. K-wire stabilization, although technically difficult to achieve, is an option for compliant patients with 2-part, 3-part, and valgus-impacted 4-part fractures who have adequate bone stock. Valgus-impacted 4-part fractures pose reduced risk for osteonecrosis because of the preserved blood supply through the medial hinge, which allows for this technique. For displaced 2-part fractures accompanied by
metaphyseal comminution, K-wire fixation cannot provide adequate stability to initiate a graduated home exercise or outpatient physical therapy program. Formal open reduction with intramedullary or plate fixation in addition to bone grafting (fibular strut allograft) is the best surgical option for the clinical scenario involving a displaced surgical neck fracture with comminution. Osteosynthesis of 3-part fractures may be feasible for physiologically young and active patients without humeral head involvement and osteoporosis.
Current indications for primary hemiarthroplasty include most 4-part fractures, 3-part fractures and dislocations in elderly patients with osteoporotic bone, head-splitting articular segment fractures, and chronic anterior or posterior humeral head dislocations with more than 40% of articular surface involvement. Because of the intra-articular nature of this patient’s 4-part injury in this scenario, hemiarthroplasty with anatomic reconstruction of the greater and lesser tuberosities is most appropriate. Relative indications for hemiarthroplasty also include fractures with more than 20 degrees of varus, associated moderate to severe osteopenia, and revision surgery for failed osteosynthesis. Currently accepted indications for rTSA include scenarios in which the fracture pattern, level of comminution, bone quality, and rotator cuff deficiency preclude plate fixation or hemiarthroplasty. Scenarios involving 4-part fractures and associated rotator cuff tears and tuberosity comminution are best served with a reverse shoulder prosthesis. One of the positive attributes of this implant is the ability to achieve functional forward flexion and abduction regardless of tuberosity healing, position, and degree of comminution. Caution is warranted with this surgical technique because complication rates are higher than for hemiarthroplasty reconstruction. Acute, irreducible 2-part fracture-dislocations of the proximal humerus necessitate open reduction and internal fixation of the affected tuberosities (posterior, lesser tuberosity; anterior, greater tuberosity) through screw, anchor, and/or suture fixation. These fracture-dislocations can be managed with this technique because of the integrity of the vascular supply, which is maintained by the soft-tissue attachments to the intact tuberosities. Repeated attempts at a closed reduction in the 37-year-old with the posterior fracture-dislocation could result in neurovascular injury and myositis ossificans and should be avoided. Arthroplasty reconstruction in this scenario should not be the index procedure in light of concerns regarding implant survivorship in patients of this age and their assumed elevated activity levels.
RECOMMENDED READINGS
Harrison AK, Gruson KI, Zmistowski B, Keener J, Galatz L, Williams G, Parsons BO, Flatow EL. Intermediate outcomes following percutaneous fixation of proximal humeral fractures. J Bone Joint Surg Am. 2012 Jul 3;94(13):1223-8. doi: 10.2106/JBJS.J.01371. View Abstract at PubMed
Iannotti JP, Ramsey ML, Williams GR Jr, Warner JJ. Nonprosthetic management of proximal humeral fractures. Instr Course Lect. 2004;53:403-16. Review. View Abstract at PubMed
Mata-Fink A, Meinke M, Jones C, Kim B, Bell JE. Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review. J Shoulder Elbow Surg. 2013 Dec;22(12):1737-48. doi: 10.1016/j.jse.2013.08.021. Review. View Abstract at PubMed
Jobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg. 2015 Mar;23(3):190-201. doi: 10.5435/JAAOS-D-13-00190. Epub 2015 Jan 28. Review. View Abstract at PubMed
Bae JH, Oh JK, Chon CS, Oh CW, Hwang JH, Yoon YC. The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus. J Bone Joint Surg Br. 2011 Jul;93(7):937-41. View Abstract at PubMed
Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. 2008 Nov;90(11):1407-13. doi: 10.1302/0301-620X.90B11.21070. Review. PubMed PMID: 18978256. View Abstract at PubMed
Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004 Jul-Aug;13(4):427-33. PubMed PMID: 15220884. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 67 THROUGH 70
Figure 67 is the radiograph of a right-hand-dominant 70-year-old woman who arrives at the emergency department with acute left shoulder pain following a fall down a flight of stairs. She expresses acute diffuse left shoulder pain and swelling. Prior to her injury, she had full active painless shoulder range of motion.

Question 21

Which of the following best describes the relationship of the anterior tibial artery and dorsalis pedis artery to the extensor hallucis longus (EHL) tendon as they progress from the level of the ankle to the dorsum of the foot?

Explanation

DISCUSSION: At the ankle level, the anterior tibial artery lies medial to the EHL tendon. The artery becomes the dorsalis pedis after crossing onto the dorsum of the foot. At this point, the artery lies lateral to the tendon.
REFERENCES: Resch S: Functional anatomy and topography of the foot and ankle, in Myerson M (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 1, pp 25-49.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 22

Of the following clinical situations, which is most likely to lead to osteonecrosis associated with a slipped capital femoral epiphysis (SCFE)?

Explanation

DISCUSSION: Osteonecrosis of the femoral head is the most devastating complication of SCFE. There is a 47% incidence of ischemic necrosis associated with an unstable SCFE. By definition, the patient with an unstable SCFE is unable to bear weight even with crutches. Osteonecrosis is most likely associated with the initial femoral head displacement rather than the result of either tamponade from hemarthrosis or from gentle repositioning prior to stabilization. Age, sex, and obesity are not risk factors for osteonecrosis.
REFERENCES: Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 2, pp 711-745.

Question 23

All of the following techniques can help to prevent apex-anterior angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT:

Explanation

DISCUSSION: Sagittal malalignment is commonly seen after nailing proximal tibia fractures. The start point as well as the direction of the nail can lead to sagittal deformity. Freedman found in nailing tibia fractures that malalignment was seen in 58% of proximal third fractures, 7% of middle third fractures, and 8% of distal third fractures. Of the malaligned fractures, 83% were either segmental or comminuted. Lang found that a medialized nail entry point and a posteriorly and laterally directed nail insertion angle contributed to malalignment. It is logical that a fracture that is reamed and then nailed in the posterior direction will lead to a gap anteriorly, and that posterior comminution will lead to anterior angulation as the fracture hinges on the intact cortex anteriorly. An anterior starting hole will tend to lead to more of a posterior nail direction. Tornetta found that using only 15 degrees knee flexion (semi extended) eliminated the extension force of the quadriceps on the proximal fragment, which otherwise would have tended to cause anterior angulation at the fracture site; therefore interlocking in flexion leads to anterior angulation. Krettek found that a posteriorly placed blocking screw is meant to prevent posterior placement of the nail and therefore encourages decreased anterior angulation of the fracture. Henley found that if the fracture is high and the nail bend is within the distal fracture fragment, as the nail is inserted, the nail will drive the distal fragment posteriorly.

Question 24

Metal-on-metal articulation has been reintroduced because of concern about polyethylene wear. This type of articulation is considered favorable because

Explanation

DISCUSSION: The improvements in metal-on-metal bearing surfaces come from the nonlinear wear rate and smaller particle size of the high carbon wrought material. Extremely low rates of wear have been demonstrated with high carbon metal-on-metal implants. There is no significant electrochemical effect of mating two like materials in vivo.
REFERENCE: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 25-34.

Question 25

A 17-year-old male lacrosse player sustains an ACL tear. Imaging reveals closed physes and you recommend a transphyseal ACL reconstruction. His mother asks whether a “cadaver tendon” can be used to reconstruct his ACL instead of using his own tendon. What is the most appropriate response regarding the use of allograft compared to autograft for ACL reconstruction in an active adolescent? Review Topic

Explanation

In an active adolescent, anterior cruciate ligament reconstruction (ACLR) with allograft has a significantly higher risk of graft failure and need for revision surgery compared to ACLR with autograft.
The incidence of anterior cruciate ligament (ACL) injuries in adolescent athletes has significantly increased over the recent years, now comprising 24.5% of all ligamentous knee injuries in high school athletes. In skeletally mature adolescents, transphyseal ACLR is often performed, similar to adult patients. Proposed advantages of allograft reconstruction in patients of all ages include lack of donor-site morbidity, absence of size limitation, preservation of knee flexor/extensor mechanism, less risk of postoperative knee stiffness/pain and cosmetic appearance. Benefits of autografts include strong structural and fixation properties as well as optimal biologic incorporation.
Kraeutler et al. performed a meta-analysis comparing bone-patellar tendon-bone (BPTB) autograft to allograft for ACLR. Patients who underwent ACLR with BPTB autograft demonstrated lower rates of graft rupture, lower levels of knee laxity, improved single-legged hop test results and were more satisfied postoperatively compared to ACLR with BPTB allograft. The authors therefore recommended BPTB
autograft
ACLR,
particularly
in
young
active
patients.
Engelman et al. performed a case-control study comparing ACLR in an adolescent cohort using autograft or allograft. Postoperative knee laxity and use of allograft were significantly related to graft failure and need for revision surgery. There was no difference in functional outcome scores, knee range of motion, infection or growth disturbance. There was no difference in graft survival between low-dose (<2 Mrad) gamma-irradiated allografts and nonirradiated allografts.
Pallis et al reported a prospective cohort study of 122 ACLR performed in cadets prior to matriculation at the United States Military Academy (USMA). Cadets who entered the USMA with an allograft ACLR were 7.7 times more likely to experience graft failure compared to BPTB and hamstring (HS) autograft groups. There was no significant difference in failure between the BPTB and HS autograft groups. The authors recommend autograft ACLR for young, active individuals.
Incorrect
Responses:

Question 26

Figures 1a through 1c show the radiograph and MRI scans of a 16-year-old patient who has a painful hip. Examination reveals a significant limp, limited abduction and internal rotation, and severe pain with internal rotation and adduction. A biopsy specimen is shown in Figure 1d. What is the deposited pigment observed in this condition?

Explanation

DISCUSSION: Pigmented villonodular synovitis (PVNS) is a synovial proliferative disorder that remains a diagnostic difficulty. The most common clinical features are mechanical pain and limited joint motion. On radiographs, the classic finding is often a large lesion, associated with multiple lucencies. Other findings may include a normal radiographic appearance, loss of joint space, osteonecrosis of the femoral head, or acetabular protrusion. MRI is the imaging modality of choice and will show the characteristic findings of a joint effusion, synovial proliferation, and bulging of the hip. The synovial lining has a low signal on T₁- and T₂-weighted images, secondary to hemosiderin deposition. Copper deposition occurs in patients with Wilson’s disease, which mainly affects the liver.
REFERENCES: Bhimani MA, Wenz JF, Frassica FJ: Pigmented villonodular synovitis: Keys to early diagnosis. Clin Orthop 2001;386:197-202.
Cotten A, Flipo RM, Chastanet P, et al: Pigmented villonodular synovitis of the hip: Review of radiographic features in 58 patients. Skeletal Radiol 1995;24:1-6.

Question 27

What is the most frequent location of entrapment of the deep peroneal nerve?

Explanation

DISCUSSION: The most frequently described entrapment of the deep peroneal nerve is the anterior tarsal tunnel syndrome. This syndrome refers to entrapment of the deep peroneal nerve under the inferior extensor retinaculum. Entrapment can also occur as the nerve passes under the tendon of the extensor hallucis brevis. Compression by underlying dorsal osteophytes of the talonavicular joint and an os intermetatarseum (between the bases of the first and second metatarsals) have previously been described in runners.
REFERENCES: Kopell HP, Thompson WA: Peripheral entrapment neuropathies of the lower extremity. N Engl J Med 1960;262:56-60.
Schon LC, Mann RA: Diseases of the nerves, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 1, pp 675-677.

Question 28

A 62-year-old active man returns for routine follow-up 16 years after hip replacement. He has no hip pain. Radiographs reveal a well-circumscribed osteolytic lesion around a single acetabular screw. All hip components are perfectly positioned. Comparison radiographs obtained 6 months later show an increase in the size of the osteolytic lesion. CT depicts a well-described lesion that is 3 cm at its largest diameter and is localized around one screw hole with an eccentric femoral head. What treatment is appropriate, assuming that well-fixed cementless total hip components are in place?

Explanation

DISCUSSION:
Given a well-fixed acetabular metal shell and a localized osteolytic lesion, good outcomes can be expected from liner revision in this clinical scenario with retention of the metal socket, assuming no damage to the components or other unexpected findings arise during revision surgery. Here, complete cup revision is not warranted, considering the appropriate implant position. Beaulé and associates reviewed 83 consecutive patients (90 hips) in whom a well-fixed acetabular component was retained in a clinical scenario such as the one described. No hip showed recurrence or expansion of periacetabular osteolytic lesions. If the metal cup is unstable, acetabular component revision may be indicated.

Question 29

A 30-year-old man sustained an acute injury to his left shoulder while lifting weights. He reports pain with abduction and external rotation of the shoulder, and he has weakness with internal rotation. Inspection shows loss of contour of the axillary fold. Definitive management should consist of Review Topic

Explanation

Pectoralis major muscle injuries occur primarily in weightlifting, football, and wrestling activities. Initial swelling, pain, and ecchymosis often make diagnosis difficult in the acute setting. Over time, chest ecchymosis, loss of axillary contour, and asymmetry of the anterior chest wall can be diagnostic. MRI can aid in the diagnosis, especially to differentiate between complete and incomplete injuries. Surgical intervention is indicated for most complete tears, especially in the younger, athletic population. Acute repair is technically easier with less surrounding scar tissue, and it minimizes the potential need for late reconstruction and possible allograft use.

Question 30

A 45-year-old woman with a long-standing history of diabetes mellitus has a large draining plantar ulcer of the right foot. Examination reveals some local cellulitis and erythema surrounding the ulcer. A clinical photograph is shown in Figure 7. Based on these findings, what is the most appropriate antibiotic?

Explanation

DISCUSSION: Combination drugs with activity against both aerobic and anaerobic organisms have been determined to be the best approach. The first-generation cephalosporins do not provide adequate coverage for gram-negative and anaerobic organisms. Gentamicin alone would not provide adequate activity against anaerobes, and there is the risk of renal and auditory toxicity.
REFERENCES: Pinzur MS, Slovenkai MD, Trepman E: Guidelines for diabetic foot care. Foot Ankle Int 1999;20:695-702.
Eckman MH, Greenfield S, Mackey WC, et al: Foot infections in diabetic patients: Decision and cost-effectiveness analyses. JAMA 1995;273:712-720.

Question 31

A 10-year-old boy has had a prominent scapula for the past year. He reports crepitus and aching over the area, but only when he is active. A radiograph and CT scans are shown in Figures 37a through 37c. What is the most likely diagnosis?

Explanation

DISCUSSION: 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.

Question 32

The pharmacologic action of botulinum-A toxin can be best described as

Explanation

DISCUSSION: BotulinumA toxin acts by interfering with presynaptic acetylcholine release at cholinergic nerve terminals without destroying nerve endings, nerve terminals, or neuromuscular junctions. Thus, the toxin blocks neuromuscular control and functionally denervates the muscle.

Question 33

A 78-year-old woman undergoes an uneventful semiconstrained total elbow arthroplasty through a Bryan-Morrey approach. Her immediate postoperative management should include which of the following? Review Topic

Explanation

Postoperative management of total elbow arthroplasty patients is directed to avoidance of complications commonly associated with this procedure. Following total elbow arthroplasty, 24 hours of perioperative antibiotics should be given, consistent with other arthroplasty procedures. Because of the relatively thin soft-tissue envelope surrounding the elbow, particularly in patients with rheumatoid arthritis, consideration must be given to the surrounding soft tissues postoperatively. The surgical wound should be given several days of quiescence prior to initiation of motion to minimize wound healing complications. Splinting at 60 to 90 degrees allows tension to be removed from the soft tissues. Immediate motion places these tissues under immediate stress; immobilization of the elbow for 6 to 8 weeks until the triceps has healed would result in significant stiffness. Splinting should not be used more than 10 days to avoid stiffness of the elbow.

Question 34

-Ten or more years after severe polytrauma, premenopausal women, compared to men

Explanation

Question 35

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

Explanation

DISCUSSION: Radiation therapy is commonly used as an adjuvant in the treatment of soft-tissue sarcomas, but a controversy exists whether it should be preoperative or postoperative. Radiation therapy can be given prior to or following resection of the tumor. Postoperative radiation is usually given in a higher dose to a larger treatment field. This commonly results in a higher incidence of fibrosis and lymphedema. There is no statistical difference in local recurrence rate between the two radiation treatment plans. Neuropathy is more commonly a complication of chemotherapy. Preoperative radiation therapy has been shown to have a higher wound complication rate than postoperative radiation.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.
Davis AM, O’Sullivan B, Turcotte R, et al: Late radiation morbidity following randomization to preoperative versus postoperative radiotherapy in extremity soft tissue sarcoma. Radiother Oncol 2005;75:48-53.

Question 36

Video 1 shows a 20-year-old right-hand dominant man with a 6-month history of left wrist pain and popping that has failed nonsurgical measures. No other positive findings upon examination are noted. What is the most appropriate course of treatment?

Explanation

A 53-year-old woman is experiencing thumb weakness. She has a remote history of a wrist fracture treated with a cast. She cannot lift her thumb off of a table when her hand is lying flat, palm-down. What is the most appropriate course of treatment?
A. Abductor pollicis longus reconstruction with palmaris autograft
B. Extensor pollicis brevis repair
C. Extensor pollicis longus (EPL) repair
D. Extensor indicis proprius (EIP) to extensor pollicis longus tendon transfer
The EPL is the only tendon that will lift a thumb off of a table as described. It is the most frequently ruptured tendon associated with distal radius fractures. Rupture is more common with nondisplaced fractures. Rupture after a nondisplaced or minimally displaced fracture suggests an ischemic etiology. The patient will not be able to lift her thumb off of a table with her hand lying flat, palm-down. Direct repair is often difficult because of retraction of tendon ends, atrophy, and fraying. The EIP has a similar amplitude and direction of pull. Prerequisites for the use of the EIP to EPL tendon transfer include independent extension of the index finger.
15- Figure 1 is the clinical photograph of a very functional 17-year-old boy with cerebral palsy and quadriplegia. He has no active supination but has full passive supination. His ability to determine position and sensibility without visual input are good. Radiographs show no osseous malalignment. Which treatment can best improve this patient's function?
A. Physical therapy for supination strengthening
1- Figures 1 through 3 are the radiographs of a 40-year-old woman who sustained a minor injury to her left ring finger. Prior to this injury she was asymptomatic, but she now notes pain and swelling. What is the best course of treatment?

A. Observation only
B. Fluoroscopic-guided intralesional steroid injection followed by serial radiographs
C. Immediate curettage without bone grafting
D. Splint immobilization with curettage and possible grafting after the fracture has healed
This patient has a fracture of the middle phalanx attributable to the presence of an enchondroma. Enchondromas are the most common benign bone tumor affecting the hand. This particular enchondroma has thinned the cortices extensively so that even minor trauma can cause a pathologic fracture. Observation is not the best treatment because a fracture is present, and, at a minimum, the digit should be immobilized.

Question 37

During an ilioinguinal approach for fixation of the anterior pelvic ring, brisk bleeding is encountered as the dissection is extended along the superior pubic ramus approximately 5 cm from the midline. What structure has most likely been injured?

Explanation

The corona mortis, or "crown of death," is a common anatomic variant that consists of an anastomosis between the obturator and the external iliac or inferior epigastric arteries or veins. Its reported incidence is over 80%. It is located behind the superior pubic ramus at a variable distance from the symphysis pubis (3 cm to 9 cm). It is at risk during surgical approaches to the anterior pelvic ring. If accidentally cut, the vessel can retract making control of hemorrhage difficult.

Question 38

Sex-linked recessive Pseudohypoparathyroidism (AHO) - end-organ insensitivity; in AHO, germline mutation that leads to loss of function of Galpha S (GNAS1); causes end-organ resistance to PTH

Explanation

Which of the following is the defect in pseudohypoparathyroidism (Albright Hereditary Osteodystrophy [AHO]):

Question 39

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

Explanation

DISCUSSION: Revision anterior exposure within 2 weeks of total disk replacement incurs relatively little additional morbidity because adhesion formation is minimal. Surgeons should have a low threshold for revising implants that are clearly dangerously malpositioned or show early migration within this 2-week window. Beyond this time period, a revision strategy must be individualized to the particular clinical situation. A posterior fusion with instrumentation with or without a laminectomy is currently the most effective salvage procedure.
REFERENCE: Tortolani JP, McAfee PC, Saiedy S: Failures of lumbar disc replacement. Sem Spine Surg 2006;18:78-86.

Question 40

Which of the following ligaments provides the major static restraint to lateral patellar displacement?

Explanation

The medial patellofemoral ligament is found to arise from the adductor tubercle and pass deep to the VMO and inserts on the proximal aspect of the medial patella and on the undersurface of the distal aspect of the quadriceps mechanism. The ligament varies in size in each patient but is the major soft tissue restraint to lateral displacement of the patella. Conlin and Garth, et al. found that the medial patellofemoral ligament contributed 53% of the total force against lateral displacement of the patella.
The medial patellotibial band was found to be functionally unimportant and the medial patellomeniscal ligament was found to contribute 22% to the lateral displacement force.

Question 41

A 58-year-old woman with rheumatoid arthritis has progressive neck pain, upper extremity and lower extremity weakness, and difficulty with fine motor movements. Examination reveals hyperreflexia with mild to moderate objective weakness but the patient has no difficulty with ambulation for short distances. What is the most important preoperative imaging finding that predicts full neurologic recovery with surgical stabilization?

Explanation

DISCUSSION: Boden and associates’ article presents compelling evidence that patients with rheumatoid arthritis and neurologic deterioration in C1-2 instability are more likely to achieve some improvement if the posterior atlanto-dens interval is greater than 10 mm on preoperative studies. All the patients in their series who had neurologic deterioration and a preoperative posterior atlanto-dens interval of greater than 14 mm achieved complete motor recovery.
REFERENCES: Boden SD, Dodge LD, Bohlman HH, et al: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.
Boden SD, Clark CR: Rheumatoid arthritis of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 755-764.
Monsey RD: Rheumatoid arthritis of the cervical spine. J Am Acad Orthop Surg 1997;5:240-248.

Question 42

When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?

Explanation

DISCUSSION: As the chance of success of lumbosacral fusion increases with the stiffness and rigidity of the construct, fixation and stiffness improve with fixation into both the upper sacrum and the ilium. In a review of individuals treated with long constructs to the pelvis for adult scoliosis, Islam and associates reported that the rate of pseudarthrosis was significantly lower with sacral and iliac fixation compared with sacral fixation alone or iliac fixation alone. Iliac screws provide significant fixation anterior to the instantaneous axis of rotation for flexion and extension, as well as provides resistance to lateral bending and rotational forces. Numerous biomechanical studies support the concept of increasing biomechanical stabilization with increased fixation from the sacrum to the ilium.
REFERENCES: Islam NC, Wood KB, Transfeldt EE, et al: Extension of fusions to the pelvis in idiopathic scoliosis. Spine 2001;26:166-173.
O’Brien N, et al: Sacral pelvic fixation and spinal deformity, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 601-614.
McCord DH, Cunningham BW, Shono Y, et al: Biomechanical analysis of lumbosacral fixation. Spine 1992;17:S235-S243.

Question 43

Tendons should have what ratio of matrix protein?

Explanation

Tendons consist of mainly type I collagen (95%); a small amount of collagen types III, V, VI; and proteoglycans (< 5%). Proteoglycans have highly charged glycosaminoglycan side chains that attract water and help keep tendons well hydrated. Decorin is the most common proteoglycan in tendons and has been shown to bind to collagen. Tenascin-C is a glycoprotein upregulated in tendinopathy.

Question 44

A 52-year-old woman has bicompartmental osteoarthritis following patellectomy. Treatment should consist of

Explanation

DISCUSSION: The patient has extensive degenerative changes in both the medial and lateral compartments within the knee; therefore, arthroscopic debridement or an osteotomy will not be helpful. A patellar arthroplasty will not address the medial and lateral compartments. Because the extensor mechanism provides a significant amount of anteroposterior stability, a posterior cruciate-substituting total knee arthroplasty is the treatment of choice for this patient.
REFERENCES: Martin SD, Haas SB, Insall JN: Primary total knee arthroplasty after patellectomy. J Bone Joint Surg Am 1995;77:1323-1330.
Pagnano MW, Cushner FD, Scott WN: Role of the posterior cruciate ligament in total knee arthroplasty. J Am Acad Orthop Surg 1998;6:176-187.

Question 45

A hip compression screw is placed in a test jig and a bending load is applied to the tip of the screw. After the load is released, the screw returns completely to its original shape. What is this type of deformation called?

Explanation

When an implant is loaded below the yield point, by definition, it undergoes elastic deformation, meaning that all of the deformation recovers when the load is removed. If it is loaded above the yield point, then plastic or permanent deformation occurs. Fatigue is the gradual accumulation and progression of cracks in the material, which, after many cycles of loading, can lead to gross failure. Creep is the gradual accumulation of permanent (plastic) deformation over time, which may occur with polymeric materials but is not typical of metals or ceramics. Torsion refers to a torque being applied about the long axis of a bone or an implant. In general, the materials and dimensions of an implant are chosen to avoid plastic deformation or fatigue failure during typical clinical use.

Question 46

A 12-year-old boy is emergently transported to the emergency department following a motor vehicle accident. He was restrained in the back seat with a lap belt. On a physical exam bruising is noted across his abdomen as shown in Figure A. Lateral radiographs are shown in Figure B. Which of the following injuries are most frequently associated with this injury pattern? Review Topic

Explanation

Soft cervical orthosis because his gender puts him at a low risk of nonunion.
Halo vest immobilization because the degree of fracture displacement puts him at a low risk of nonunion.
Anterior screw fixation because his delayed time to treatment puts him at an high risk of nonunion.
Posterior C1-C2 fusion with rigid instrumentation because his age puts him at a high risk of nonunion.
Posterior C1-C2 fusion with sublaminar wiring because the degree of fracture angulation puts him at a high risk of nonunion.
The patient has a type II odontoid fracture and should be managed with halo vest immobilization as he has minimal fracture displacement (< 5mm) and no other risk factors for nonunion.
Type II odontoid fractures comprise 35% of all C2 fractures and have the highest nonunion rate. Commonly cited risk factors for nonunion include posterior displacement, posterior angulation, delayed initiation of treatment, fracture comminution and advanced age. Patients without these risk factors can often be successfully managed with halo vest immobilization. Elderly patients are frequently unable to tolerate halo vest immobilization and can be placed in a rigid cervical orthosis. Patients at high risk for nonunion are generally managed surgically with either anterior screw fixation, posterior rigid fixation (C1-C2 transarticular screw construct versus C1 lateral mass screw + C2 pedicle screw construct), or posterior C1-C2 sublaminar wiring.
Greene et al found that type II odonotoid fractures that were displaced >/= 6mm had a nonunion rate of 86% compared to 18% in patients with < 6mm displacement. This was statistically significant regardless of direction of displacement. Age was not significantly associated with nonunion.
Koivikko et al performed a retrospective review of conservatively treated type II odontoid fractures and identified risk factors for nonunion. Fracture gap > 1mm, posterior displacement > 5mm, posterior angulation > 20°, delayed start of treatment
> 4 days and posterior redisplacement > 2mm were all correlated with nonunion. In this study, anterior displacement, gender and age were unrelated to nonunion.
Figures A and B are coronal and sagittal CT scans of the cervical spine, respectively, demonstrating a noncomminuted type II odontoid fracture with minimal posterior displacement and angulation.
Incorrect
Responses:

Question 47

The posterior approach to the proximal radius uses what intermuscular interval?

Explanation

DISCUSSION: Knowledge of intermuscular and internervous planes allows safe exposures throughout the body. The posterior (Thompson) approach to the proximal forearm uses the interval between the extensor carpi radialis brevis and extensor digitorum communis. The anterior (Henry) approach to the proximal forearm uses the interval between the brachioradialis and the flexor carpi radialis.
REFERENCES: Spinner M: Injuries to the Major Branches of Peripheral Nerves of the Forearm, ed 2. Philadelphia, PA, WB Saunders, 1978, pp 66-77.
Henry AK: Extensile Exposure, ed 3. New York, NY, Churchill Livingstone, 1995.

Question 48

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

Explanation

DISCUSSION: Sexual dysfunction is a common condition after extensive anterior lumbar surgical dissection. Erectile dysfunction usually is nonorganic but may be related to parasympathetic injury. The parasympathetic nerves are deep in the pelvis at the level of S2-3 and S3-4 and usually are not involved in the surgical field for anterior L4-5 and L5-S1 procedures. Retrograde ejaculation is the result of injury to the sympathetic chain on the anterior surface of the major vessels crossing the L4-5 level and at the L5-S1 interspace. Erectile function and orgasm are not affected by sympathetic injury. The pudendal nerve is primarily a somatic nerve and is not located in the surgical field.
REFERENCES: Flynn JC, Price CT: Sexual complications of anterior fusion of the lumbar spine. Spine 1984;9:489-492.
Johnson RM, McGuire EJ: Urogenital complications of anterior approaches to the lumbar spine. Clin Orthop 1981;154:114-118.

Question 49

A 20-year-old football player has immediate pain in the midfoot and is unable to bear weight after an opposing player lands on the back of his plantar flexed foot. AP and lateral radiographs are shown in Figures 4a and 4b. Management should consist of

Explanation

DISCUSSION: The history and radiographs indicate a Lisfranc fracture-dislocation of the foot. The radiographs show the classic “fleck sign,” which is an avulsion of the Lisfranc ligament from the base of the second metatarsal. Most authors recommend open reduction and internal fixation of this injury. Closed reduction can be attempted, but anatomic reduction is unlikely because of the interposed bone fragments and soft tissues. Standard radiographs are not reliable in identifying 1 to 2 mm of subluxation of the tarsometatarsal joint. The tarsometatarsal joint has a poor tolerance to even mild subluxation, and the resulting decrease in joint contact area increases the likelihood of posttraumatic arthritis. Open reduction with the joint visible allows more anatomic reduction and internal fixation of larger osteochondral fragments or excision of smaller interposed fragments.
REFERENCES: Bellabarba C, Sanders R: Dislocations of the foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 2, pp 1539-1558.
Murphy GA: Fractures and dislocations of the foot, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 9. St Louis, MO, Mosby, 1998, vol 2, pp 1956-1960.

Question 50

Figure 199 is the clinical photograph of a 68-year-old man with a history of atrial fibrillation who was treated with warfarin. Nine days after undergoing elective total hip arthroplasty, he has a swollen left thigh. His wound remains dry and he is afebrile. His erythrocyte sedimentation rate (ESR) is 25 mm/h (reference range [rr], 0-20 mm/h) and C-reactive protein (CRP) level is 6.1 mg/L (rr, 0.08-3.1 mg/L). Aspiration reveals 3246 white blood cells (WBCs)/µL with 47% polymorphonucleocytes. Treatment at this time should consist of

Explanation

DISCUSSION
This patient has a large postsurgical hematoma. Although his ESR and CRP level are elevated, they are not considered elevated given his recent surgery. Additionally, the hip aspiration reveals a synovial cell count lower than 10000 WBC/µL along with a low percentage of polymorphonucleocytes. Treatment at this time should consist of observation. The hematoma is likely attributable to postsurgical anticoagulation, considering his history of atrial fibrillation.

Question 51

In a patient with vertebral tuberculosis, which of the following characteristics is most predictive of progression of the kyphosis?

Explanation

DISCUSSION: In patients with vertebral tuberculosis, involvement of the anterior and posterior elements creates an instability and severe kyphotic collapse can occur. This characteristic has been shown to have a stronger association than level of involvement, age, or pretreatment degree of deformity. In the absence of instability, anterior growth can resume after treatment, leading to a decrease in the deformity.
REFERENCES: Rajasekaran S: The natural history of post-tubercular kyphosis in children: Radiological signs which predict late increase in deformity. J Bone Joint Surg Br

2001;83:954-962.
Rajasekaran S, Shanmagasundaram TK, Prabhakar R, Dheenadhayalan J, Shetty AP, Shetty DK: Tuberculous lesions of the lumbosacral region: A 15-year follow-up of patients treated by ambulant chemotherapy. Spine 1998;23:1163-1167.

Question 52

A woman with a neck and chest tumor has weakness in the biceps and paresthesias in the thumb. Brachioradialis and infraspinatus function are normal. The lesion is affecting which of the following structures?

Explanation

DISCUSSION: The lateral cord terminates as the musculocutaneous nerve and also contributes sensory fibers to the median nerve. Involvement of the C6 root or upper trunk could potentially cause weakness of the infraspinatus and the brachioradialis. The middle trunk and the posterior cord do not contribute motor fibers to the thumb or sensory fibers to the thumb.
REFERENCE: Kline DG, Hudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries, Entrapments and Tumors. Philadelphia, PA, WB Saunders, 1995, p 334.

Question 53

A 21-year-old pitcher reports shoulder pain with hard throwing. He notes that the pain occurs in the early acceleration phase of his throw. Given his history, what structures are at greatest risk for injury?

Explanation

DISCUSSION: Internal impingement in the thrower’s shoulder occurs in the abducted, externally rotated position as described by Walch and associates. The injury is thought to occur from repetitive contact between the posterosuperior portion of the labrum and glenoid against the articular side of the rotator cuff and greater tuberosity.
REFERENCES: Paley KJ, Jobe FW, Pink MM, et al: Arthroscopic findings in the overhand throwing athlete: Evidence for posterior internal impingement of the rotator cuff. Arthroscopy 2000;16:35-40.
Jazrawi LM, McCluskey GM III, Andrews JR: Superior labral anterior and posterior lesions and internal impingement in the overhead athlete. Instr Course Lect 2003;52:43-63.
Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg

1992;1:238-245.

Question 54

A 44-year-old patient who has had a proximal first metatarsal osteotomy has recurrent pain and difficulty wearing many types of shoes. Radiographs show a large 1-2 intermetatarsal angle (IMA).

Explanation

Question 55

Mirror therapy is indicated for which of the following clinical conditions?

Explanation

Mirror therapy is a useful technique to improve phantom pain in amputees. Phantom limb pain is a painful sensation that is perceived within a body part that no longer exists.
Under mirror therapy, a patient is allowed to feel the imaginary movement of the removed body part behaving as normal body movement through a mirror. The mirror
image of the normal body part helps reorganize and integrate the mismatch between proprioception and visual feedback of the amputated segment.
Tilak et al. performed a randomized controlled trial of 26 patients with phantom limb pain, and found that mirror therapy as well as transcutaneous electrical nerve stimulation both significantly improved pain scores, but no difference was seen between the two groups. They recommend use of both modalities in treatment of phantom limb pain, as they are noninvasive and inexpensive.
Chan et al. reviewed 22 patients utilizing mirror therapy for amputation related phantom limb pain, and found that patients reported a significant decrease in pain when utilizing this treatment modality as compared to covered mirror therapy or mental imagery therapy.
Illustration A shows a patient with an upper extremity amputation using a mirror to perform movements during a mirror therapy session.
Incorrect Answers:

Question 56

Figure 1 is the MR image of a 43-year-old man who has left shoulder pain and weakness after a fall. An examination reveals active forward elevation at 120° and positive Yergason and lift-off test examination findings. Arthroscopy reveals that the articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment at this time?

Explanation

The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove. Biceps tendon subluxation is most frequently associated with subscapularis tendon pathology, which is indicated by the MRI and by a positive lift-off test. The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer.

Question 57

When performing a bunionectomy with a release of the lateral soft-tissue structures, the surgeon is cautioned against releasing the conjoined tendon that inserts along the lateral base of the proximal phalanx of the great toe. This conjoined tendon is made up of what two muscles?

Explanation

DISCUSSION: Owens and Thordardson cautioned surgeons not to release the conjoined tendon from the base of the proximal phalanx of the great toe because of an increased risk of iatrogenic hallux varus. Release of the transverse and oblique heads of the adductor hallucis is largely accomplished by releasing the soft tissue adjacent to the lateral sesamoid, without releasing tissue from the base of the proximal phalanx. The conjoined tendon is made up of the flexor hallucis brevis and the adductor hallucis.
REFERENCES: Owens S, Thordardson DB: The adductor hallucis revisited. Foot Ankle Int 2001;22:186-191.
Sarrafian SK: Anatomy of the Foot and Ankle. Philadelphia, PA, JB Lippincott, 1983, chapter 5.

Question 58

Figures 23a and 23b show the radiographs of a 75-year-old woman who sustained an injury to her nondominant hand. Initial treatment should consist of

Explanation

DISCUSSION: Definitive treatment decisions for displaced distal radius fractures in the elderly are based on a number of factors related to the fracture pattern and patient demographics. The first step in any treatment algorithm is a closed reduction and splinting with reassessment of alignment parameters. This is an extra-articular fracture with dorsal angulation. Low-demand elderly patients can be treated well with accepted minor malreduction.
REFERENCES: Handoll HH, Madhok R: Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;2:CD000314.
Young CF, Nanu AM, Checketts RG: Seven-year outcome following Colles’ type distal radial fracture: A comparison of two treatment methods. J Hand Surg Br 2003;28:422-426.

Question 59

Figure 35 is the radiograph of a 37-year-old woman who began having right forefoot pain about 4 weeks ago after increasing her daily running mileage. She denies any specific injury. Upon examination she has tenderness over the medial forefoot with mild swelling. In addition to her activity level, what is the primary etiology of the radiograph finding?

Explanation

DISCUSSION
Stress fractures are the result of physiological bone response to increased stress. Increased stress on bone triggers an increase in remodeling, which begins with resorption of bone at the site of stress. Ongoing stress can overwhelm bone strength, resulting in a fracture. In the foot this most commonly is seen in the second metatarsal at the junction of the middle and distal thirds. Contributing factors to increased loading of the second metatarsal include hallux valgus (decreased hallux loading transfers to the second metatarsal head), hallux rigidus (offloading of the hallux attributable to pain increases second metatarsal loading), and a long second metatarsal (increased duration of contact during push-off in the stance phase).
RECOMMENDED READINGS
Shindle MK, Endo Y, Warren RF, Lane JM, Helfet DL, Schwartz EN, Ellis SJ.
Stress fractures about the tibia, foot, and ankle. J Am Acad Orthop Surg. 2012 Mar;20(3):167-

Question 60

A 13-year-old girl sustained an isolated midshaft left femoral fracture in a motor vehicle accident. The fracture was treated with a rigid, antegrade intramedullary nail placed through the piriformis fossa. The fracture healed uneventfully, as shown in Figure 46a; however, at 12 months postoperatively she now reports left hip pain. A current AP radiograph and MRI scan are shown in Figures 46b and 46c. What complication occurred in this patient? Review Topic

Explanation

The development of femoral head ischemic necrosis is the iatrogenically created complication in this skeletally immature patient. Placement of a rigid, antegrade intramedullary nail through the piriformis fossa is likely to damage the vascular supply to the femoral head as the vessels ascend the femoral neck on the way to the femoral head. The MRI scan reveals ischemic necrosis with early collapse of the femoral head. The joint space is preserved on the MRI scan, ruling out chondrolysis.

Question 61

.Figures 41a through 41c are the radiograph and MRI scans of a 76-year-old woman who has intractable left shoulder pain. She was given 2 cortisone injections and oral pain medication without experiencing lasting relief. Examination reveals 60 degrees of active forward elevation (120 degrees passively), 30 degrees of external rotation lag, and a positive Hornblower sign. Pain relief and improved functionality will most likely be achieved with

Explanation

Question 62

A 59-year-old woman with a history of osteoporosis is involved in a high-speed motor vehicle accident, resulting in left hip pain and deformity. The initial radiograph from the trauma bay is shown in Figure 1. Postreduction CT is shown in Figures 2 through 4. What is the most appropriate definitive surgical treatment?

Explanation

DISCUSSION:
The radiograph shows a posterior wall acetabular fracture-dislocation. Post reduction CT indicates a large comminuted posterior wall fracture with marginal impaction of the articular surface. A comminuted femoral head fracture also is seen extending to the superior weight-bearing surface. Given the marginal
impaction of the acetabulum and the considerable comminution of the femoral head (which is likely unreconstructible), this injury would have a high risk of causing posttraumatic arthritis if treated with ORIF of the fractures alone. Considering this fact and the patient’s age, ORIF of the posterior wall and acute total hip arthroplasty would likely have the best functional result and the lowest risk of reoperation. Hemiarthroplasty is inappropriate for this injury considering the acetabular fracture. Skeletal traction currently plays a limited role in the definitive treatment of acetabular fractures.

Question 63

Where is the most common site for tuberculosis (TB) spondylitis in children?

Explanation

DISCUSSION: In children, the main route of infection in skeletal TB is through hematogenous spread from a primary source. The mycobacterium is deposited in the end arterials in the vertebral body adjacent to the anterior aspect of the vertebral end plate. Thus, the anterior portion of the vertebral body is most commonly involved. The lower thoracic region is the most common segment; next in decreasing order of frequency are the lumbar, upper thoracic, cervical, and sacral regions.
REFERENCES: Teo HE, Peh WC: Skeletal tuberculosis in children. Pediatric Radiol 2004;34:853-860.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 1831-1835.

Question 64

A 23-year-old right-hand dominant professional baseball pitcher has right shoulder pain when releasing the ball. He has noticed his velocity has decreased over the past 2 months. Examination reveals supine abducted external rotation of 110 degrees compared to 100 degrees on the left side. His internal rotation is 30 degrees on the right compared to 70 degrees on the left side. Rotator cuff strength is normal. All other clinical tests are normal. MRI with contrast reveals no intra-articular lesions. What is the best course of treatment?

Explanation

DISCUSSION: The examination reveals that the patient has posterior capsular tightness. Surgery should not be considered until the patient has failed to respond to nonsurgical management. The internal rotation contracture (GIRD - glenohumeral internal rotation deficit) should be addressed with appropriate posterior capsular stretching. This should then be followed by appropriate rotator cuff and scapular stabilization exercises. Only if this management fails to relieve the patient’s symptoms should surgery be considered. This patient clearly does not need external rotation stretching given the fact that he has normal external rotation.
REFERENCES: Meister K: Injuries to the shoulder in the throwing athlete. Part two: evaluation/ treatment. Am J Sports Med 2000;28:587-601.
Liu SH, Boynton E: Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete. Arthroscopy 1993;9:697-699.
Tyler TF, Nicholas SJ, Roy T, et al: Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. Am J Sports Med 2000;28:668-673.
2010 Sports Medicine Examination Answer Book • 21

Question 65

A 68-year-old man with no significant medical history underwent a total knee arthroplasty 4 years ago. A radiograph is shown in Figure 55. He reports that he had no problems with the knee until 6 weeks ago when he noted the gradual onset of pain following a colonoscopy. Examination reveals a painful, swollen knee. Knee aspiration reveals a WBC count of 40,000/mm 3 . Management should consist of

Explanation

DISCUSSION: The treatment of choice for a late hematogenous infection is two-stage resection arthroplasty and reimplantation, with parenteral antibiotics prior to reimplantation. This is particularly true when septic loosening has occurred as in this patient. Open irrigation and debridement with polyethylene exchange has been used successfully when the duration of symptoms is 3 weeks or less. Long-term suppressive antibiotics are most commonly used when the patient’s medical condition precludes further surgery. Delayed reimplantation has been shown to be superior to immediate reimplantation in multiple studies. Little data support the use of arthroscopic irrigation and debridement.
REFERENCES: Swanson KC, Windsor RE: Diagnosis of infection after total knee arthroplasty, in Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA, JB Lippincott, 2003, vol 2, pp 1485-1491.
Hanssen AD, Rand JA, Osmon DR: Management of the infected total knee arthroplasty, in Morrey BF (ed): Joint Replacement Arthroplasty, ed 3. Philadelphia, PA, Churchill-Livingstone, 2003, pp 1070-1089.

Question 66

A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and 49b, respectively. Which of the following best explains the 8-week postinjury clinical findings seen in Figure 49c?

Explanation

DISCUSSION: Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 273-284.
Neviaser RJ, Neviaser TJ, Neviaser JS: Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orthop Relat Res 1993;291:103-106.

Question 67

A 34-year-old man presents to clinic with 4 months of right elbow pain. He began going to the gym and playing squash about 3 months ago. On exam, he is tender over the lateral aspect of the elbow and has pain with resisted wrist extension. Which of the following choices lists the correct compartment of the muscle typically involved in this disease and then lists its antagonist muscle? Review Topic

Explanation

The patient presents with lateral epicondylitis, which typically involves the origin of the extensor carpi radialis brevis (ECRB). ECRB is in the mobile wad compartment and its antagonist muscle is flexor carpi ulnaris.
Lateral epicondylitis is an overuse injury, typically secondary to repetitive pronation and supination motion in extension, that leads to inflammation of the ECRB origin at the elbow. Histological analysis typically shows vascular hyperplasia and disorganized collagen. Clinically, patients will have pain over the lateral elbow exacerbated by resisted wrist extension. ECRB, the most commonly involved muscle origin, is innervated by the deep branch of the radial nerve and inserts on the base of the 3rd metacarpal. As it is radial wrist extensor, its antagonist is the ulnar sided wrist flexor.
Brummel et al. reviewed the clinical presentation and management options for lateral epicondylitis. They report acute symptoms in younger patients and chronic symptoms in older patients. NSAIDs, extensor stretching and activity modification are the mainstay of nonsurgical treatment.
Bunata et al. studies 85 cadavar elbows to determine anatomic factors contributing to tennis elbow. They found that the ECRB undersurface rubs against the lateral capitellium in elbow extension leading to tendinosis.
Illustration A is cross-sectional diagram of the forearm with muscle bellies labeled. Notice the location of ECRB in the mobile wad. Illustration B is a coronal T2 MRI showing fluid signal and undersurface tearing near the extensor origin as can be seen in lateral epicondylitis.
Incorrect Answers:
1-4: The ECRB is in the mobile wad and its antagonist is flexor carpi ulnaris. All other answers are incorrect.

Question 68

A 17-year-old basketball player has a soft-tissue abscess over the anterior aspect of his left knee. The team physician prescribes amoxicillin and the infection resolves. The next week the patient develops fevers and significantly increased pain at the site of the previous infection. What is the most likely diagnosis? Review Topic

Explanation

Skin and soft-tissue abscesses should be drained and cultured by the treating physician whenever possible. Antibiotic therapy should be guided by antibiotic sensitivities derived from the cultures to identify cases of CA-MRSA and prevent severe recurrent infections. These infections have been associated with significant morbidity, with up to 70% of players requiring hospitalization. A high index of suspicion in at-risk populations is necessary, and empiric treatment with an antibiotic effective against MRSA should be considered until sensitivity results are available. Tinea corporis is a general term for a cutaneous fungal infection. The lesion appears as a well-demarcated erythematous plaque with a raised border and central hypopigmentation, giving it a ring-like appearance. Primary infection with herpes simplex virus can produce constitutional symptoms with burning, tingling, or stinging at the site. Grouped vesicles with clear fluid 1 mm to 2 mm in size form on an erythematous base and then rupture, leaving moist ulcers or crusted plaques. Amoxicillin is appropriate empiric antibiotic therapy for group A Streptococcus, so a recurrent infection is less likely with this organism.

Question 69

Metal-on-metal lumbar disk arthroplasty devices may generate cobalt and chromium ions into the serum of patients after implantation into the lumbar spine. Which of the following statements best represents the levels of the serum ion levels in these patients? Review Topic

Explanation

According to two studies looking at patients with a cobalt-chrome metal-on-metal lumbar disk arthroplasty, serum ion levels in these patients were similar to values measured in patients with total hip arthroplasty metal-on-metal prostheses.

Question 70

A 39-year-old woman jammed her long finger playing softball 24 hours ago. She is unable to actively extend the proximal interphalangeal joint; however, when the joint is brought passively into full extension, she is able to maintain that position. Management should consist of

Explanation

Disruption of the central slip of the extensor tendon at the PIP joint with volar migration of the lateral bands will result in the so-called boutonniere deformity, which includes loss of extension at the PIP joint and compensatory hyperextension at the DIP joint. The lesion is most often secondary to closed blunt trauma with acute forceful flexion at the PIP joint. This produces avulsion of the central slip from its insertion on the dorsal base of the middle phalanx with or without fracture and/or laceration of the extensor tendon at its insertion. In closed injuries the characteristic boutonniere deformity may not be apparent at the time of injury and may not be noted until 10 to 21 days after injury. Two diagnostic tests that are useful in early recognition of this lesion are: (1) a 15 deg to 20 deg or greater loss of active extension of the PIP joint when the wrist and MP joint are fully flexed and (2) extravasation of intraarticular radiopaque dye dorsal and distal to the PIP joint. Weak extension against resistance has also been noted to be a helpful diagnostic finding. Treatment in acute cases before fixed contractures have occurred may be achieved by progressively splinting the PIP joint into full extension and at the same time performing active and passive flexion exercises of the DIP joint. In a closed boutonniere deformity operative intervention is indicated under two circumstances. (1) when the central slip has been avulsed with a bone fragment which is lying free over the PIP joint and (2) a long-standing boutonniere deformity in a young person.

Question 71

What is the most common complication following metatarsal osteotomy for a bunion deformity in an adolescent?

Explanation

Hallux varus-The question does not specify proximal or distal osteotomies, however it is the most common complication with overcorrection of proximal 1st metatarsal osteotomies. Mann. Pg. 329. “Transfer” 2nd metatarsaglia-most significant, not most common, complication of the Mitchell Osteotomy.Mann pg. 319.
Physeal arrest of the first metatarsal-“While an open epiphysis cannot be considered an absolute contraindication to an osteotomy in either the proximal phalanx, or proximal first metatarsal, it is
important at surgery to determine the exact location of the metaphyseal epiphysis to avoid injury.” Pg. 307 Mann, Surgery of Foot and Ankle.
In studies performed by Blais et. Al. A females full foot growth is usually achieved by 14 years and at 12 years an average less than 1 cm of total foot growth remains with less than 50% of this growth at the proximal epiphysis. Males’ terminal growth expected at 16 years of age with 3cm left at 12 years and approximately 1.5 cm of metatarsal growth.
Most studies show recurrence of Hallux Valgus deformity after surgical correction in the juvenile as inordinately high.

Question 72

Which specific legislative Act in the United States was created to require reporting of annual monetary gifts or compensation of more than $10 by orthopaedic implant companies to physicians?

Explanation

The Physician Payments Sunshine Act requires all payments by corporations to physicians beyond $10 per year to be reported to the Centers for Medicare and Medicaid Services.
Under this Act, all manufacturers of drugs and devices covered under Medicare, Medicaid, and SCHIP are obliged to federally report payments beyond $10 annually to physicians and academic centers. The Act was first introduced in 2007, enacted in 2010, and in 2014 the first data (from 2012) was reported publicly online in the Open Payment Program of the Centers for Medicare and Medicaid Services website.
Samuel et al analyze orthopedic surgeons available data from the Sunshine Act regarding industry payments and find over 110 million USD paid to approximately 15,000 orthopedic surgeons over the 5-month study period. No long term data exists to determine if these payments have any affect in healthcare.
Incorrect Answers:

Question 73

Which of the following studies best increases the ability to diagnose femoral neck fractures in patients with femoral shaft fractures?

Explanation

DISCUSSION: Tornetta and associates and Yang and associates found that nearly half of all femoral neck fractures associated with femoral shaft fractures were being missed at their institution. On the basis of the delayed diagnosis of these injuries, a best-practice protocol was developed by the attending trauma surgeons for the evaluation of the femoral neck in patients with a femoral shaft fracture. This protocol includes a preoperative AP internal rotation radiograph of the hip, a fine-cut (2-mm) CT scan through the femoral neck (as a part of the initial trauma scan), and an intraoperative fluoroscopic lateral evaluation of the hip just prior to fixation of the femoral shaft. In addition, postoperative AP and lateral radiographs of the hip are made in the operating room to specifically evaluate the femoral neck before the patient is awakened. They found that fine-cut CT (2 mm was the best screening tool in this group of patients) identified 12 of the 13 fractures, whereas 8 of the 13 fractures were visible on the dedicated preoperative AP internal rotation hip radiographs.
REFERENCES: Tornetta P III, Kain MS, Creevy WR: Diagnosis of femoral neck fractures in patients with a femoral shaft fracture: Improvement with a standard protocol. J Bone Joint Surg Am 2007;89:39-43.
Yang KH, Han DY, Park HW, et al: Fracture of the ipsilateral neck of the femur in shaft nailing: The role of CT in diagnosis. J Bone Joint Surg Br 1998;80:673-678.

Question 74

Overgrowth of a limb in a patient with neurofibromatosis type 1 (NF1) is most likely associated with the presence of

Explanation

DISCUSSION: Plexiform neurofibromas are lesions found in patients with NF1. Clinical reports show the prevalence of plexiform neurofibroma to be 20% to 30% but increases to 40% when imaging studies are routinely obtained. The lesions are characterized by diffuse hypertrophy of the involved nerves but with preservation of the nerves’ fascicular organization. The lesions may involve the dermis or may arise in the deeper structures. Palpation of a dermal lesion provokes an image of a “bag of worms.” Plexiform neurofibromas may cause disfigurement and hyperpigmentation of the overlying skin. The lesions also can cause diffuse hypertrophy of the soft tissue and bone, with resultant changes ranging from a relatively minor limb-length discrepancy to gigantism of the entire extremity. Dural ectasia is frequently found in patients with NF1. Therefore, MRI should be obtained prior to planning spinal procedures in these patients; however, dural ectasia is not the cause of limb overgrowth. Lisch nodules are benign hamartomas of the iris. The lesions are uncommon during early childhood but are found in all adults with NF1. Juvenile xanthogranuloma has a low occurrence rate in patients with NF1; its presence is associated with juvenile chronic myeloid leukemia. Malignant peripheral nerve sheath tumors, formally called neurofibrosarcoma, result from malignant degeneration of a plexiform neurofibroma. This condition occurs in up to 4% of patients with NF1. Localized pain, an enlarging mass, or progressive neurologic symptoms suggest a malignant peripheral nerve sheath tumor in a patient with NF1. However, progressive neurologic symptoms also may occur with benign growth of a plexiform neurofibroma.
REFERENCES: Alman BA, Goldberg MJ: Syndromes of orthopaedic importance, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 287-338.
Greene WB: Neurofibromatosis type I, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1584-1588.

Question 75

What is the most significant benefit of percutaneous transforaminal lumbar interbody fusion (TLIF) vs open posterior lumbar interbody fusion (PLIF)?

Explanation

DISCUSSION
Humphreys and associates in a retrospective review of TLIF vs PLIF found fusion rates, surgical time, and length of hospital stay were similar with both procedures. The only benefits associated with TLIF were less blood loss and preservation of the paraspinal muscle sleeve. Manos and associates in a cadaver study found no difference in the volume of disk material evacuated or the area of endplate exposed in either procedure.
RECOMMENDED READINGS
Humphreys SC, Hodges SD, Patwardhan AG, Eck JC, Murphy RB, Covington LA. Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine (Phila Pa 1976). 2001 Mar 1;26(5):567-71. PubMed PMID: 11242386. View Abstract at PubMed
Manos R, Sukovich W, Weistroffer J: Transforaminal lumbar interbody fusion: Minimally invasive versus open disc excision and endplate preparation. Presented at the 12th International Meeting of Advanced Spine Techniques, Banff, Alberta, Canada, July 7-9, 2005.

Question 76

03 A 37 year-old woman with thoracic back pain has had hemoptysis and dyspnea for the past month. A thoracic spine radiograph shows a compression fracture of T-9 and a mass in the right lung. What is the best course of action?

Explanation

Here is an algorithm from OKU 6 Tumors of the Spine pp 723-736

This question gives you the history, skips right over physical exam and goes into plain films. With this patient’s history of hemoptysis and dyspnea and a lung mass, the next steps in this patients work-up would include the competion of initial work-up, metastatic work-up, then pre-operative planning. Goals of treatment are to 1) protect or restore neurologic function, 2) control pain,

Question 77

What is the mechanism of action of bisphosphonates?

Explanation

DISCUSSION: Bisphosphonates are stable analogues of pyrophosphate that have a strong affinity for bone hydroxyapatite; these agents inhibit bone resorption by reducing the recruitment and activity of osteoclasts and increasing apoptosis. Bone formed while patients are receiving bisphosphonate treatment is histologically normal. Bisphosphonates have been shown to be effective in decreasing pathologic fractures, bone pain, and the need for radiation therapy in patients with multiple myeloma and metastatic carcinoma to bone. The most effective method of administration is via monthly intravenous infusion. Osteonecrosis of the mandible is sometimes a complication of this treatment.
REFERENCES: Gass M, Dawson-Hughes B: Preventing osteoporosis-related fractures: An overview. Am J Med 2006;119:S3-S11.
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 226-227.

Question 78

A 12-year-old boy with an ankle fracture undergoes closed reduction under sedation in the emergency department. Figure 27 shows a lateral radiograph of the ankle after two attempts at closed reduction. Based on these findings, treatment should now consist of Review Topic

Explanation

The widening of the physis associated with incomplete reduction of this fracture suggests that periosteum is interposed at the fracture site. Clinical and animal study findings suggest that the interposed periosteum may lead to premature physeal closure. Repeated forceful attempts at reduction may subject the physis to further injury and should be avoided. Growth problems are common in children with Salter-Harris type I fractures of the lower extremities. Nonunions are rare in children with Salter-Harris type I fractures.

Question 79

Figure A is the lateral view of a left knee cadaveric specimen that has the extensor mechanism removed. Which two structures labeled provide the most rotational stability in knee flexion? Review Topic

Explanation

The politeus tendon (C) and the popliteofibular ligament (D) are the lateral knee structures that provide the most rotational stability in knee flexion. The lateral collateral ligament (B) provides varus stability and rotational stability in knee
extension.
The lateral knee is stabilized by 28 unique static and dynamic structures. These structures work in concert to resist varus gapping and rotational knee instability. The three primary stabilizers include the fibular or lateral collateral ligament (LCL), the popliteus tendon (PT) and the popliteofibular ligament (PFL). Injury to these ligaments results in increased forces seen on ACL and PCL ligament reconstruction grafts with combined posterolateral corner (PLC) injuries, which can result in graft failure if the PLC is not reconstructed as well.
James et al reviewed the anatomy and biomechanics of the lateral knee stabilizers, detailing the specific functional contributions of the individual structures. The LCL is the primary restraint to varus instability, the highest forces occurring at knee extension (0°-30°). The PT and PFL serve as restraints to rotational instability, the highest forces occurring at knee flexion (60°-90°).
LaPrade et al reviewed the anatomy and biomechanics of the medial knee stabilizers. The three key static stabilizers are the superficial medial collateral ligament (sMCL), the deep medial collateral ligament (dMCL), and the posterior oblique ligament (POL). The sMCL is the primary restraint to valgus instability (proximal sMCL) and secondary restraint to rotational instability (distal sMCL) at all knee flexion angles. The dMCL is a secondary restraint to valgus and rotational instability. The POL is the primary restraint to rotational instability.
Figure A depicts the lateral knee structures in a cadaver specimen (A = lateral meniscus, B = LCL, C = PT, D = PFL, E = lateral head of gastrocnemius). Illustration A is a labeled picture of the lateral knee structures. Illustration B is a table from James et al demonstrating the change in forces experienced by the different lateral stabilizers at varying degrees of knee flexion. You see the LCL resists rotation at 0°-30° (extension) while the PT and PFL resist rotation at 60°-90° (flexion).
Incorrect Responses:

Question 80

A 70-year-old woman had poliomyelitis as a young child, and the residual weakness she has as an adult principally involves the lower extremities. She now notes progressive weakness in both legs and she tires easily. What is the best course of action?

Explanation

DISCUSSION: The most likely diagnosis is postpolio syndrome, which is characterized by increasing weakness in both the paretic and previously normal muscles. Fatigability, joint pain, muscle atrophy, respiratory insufficiency, dysphagia, and sleep apnea are also seen. Gentle exercise and modification in lifestyle demands are generally recommended. Vigorous rehabilitation is likely to be detrimental in this condition. Further diagnostic work-up is not indicated at this time.
REFERENCES: Dalakas MC, Elder G, Hallett M, et al: A long-term follow-up study of patients with post-poliomyelitis neuromuscular symptoms. N Eng J Med 1986;314:959-963.
Kasser JE (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 683-687.

Question 81

A 38-year-old man reports a 6-week history of shoulder pain and stiffness after falling on the stairs and landing onto the affected side. Radiographs are shown in Figures 54a and 54b. What is the most appropriate treatment? Review Topic

Explanation

The patient has a chronic posterior shoulder dislocation of 6-weeks duration. A CT scan will provide preoperative information regarding the size of the McLaughlin or reverse Hill-Sachs lesion. Open glenohumeral reduction with transfer of the lesser tuberosity and attached subscapularis has been shown to be successful in stabilizing a posterior dislocation. Closed reduction is highly unlikely to achieve a reduction and may cause displacement of an unrecognized humeral surgical neck fracture. Hemiarthroplasty would be considered for lesions involving more than 50% of the humeral head or when the joint has been dislocated for several months and late collapse of the head postreduction is likely. Rotator cuff tears are not commonly associated with posterior shoulder dislocation.

Question 82

A 70-year-old man reports symptomatic medial knee pain that has become progressively worse during the past year. MRI reveals a complex, posterior horn medial meniscus tear with associated medial lateral and patellofemoral cartilage defects. Radiographs reveal medial joint space narrowing and osteophytes in the other compartments. What treatment is most likely to provide long-term, durable relief of symptoms?

Explanation

DISCUSSION:
Total knee replacement is a well-established surgery for diffuse, symptomatic osteoarthritis of the knee joint, and its efficacy has been shown in many studies. According to the 2008 AAOS Clinical Practice Guideline, Treatment of Osteoarthritis of the Knee, arthroscopy in the setting of existing osteoarthritis is efficacious for relieving the signs and symptoms of a torn meniscus but not for osteoarthritis. Likewise, in young and active patients, clinical outcomes show improvement after realignment osteotomy for single- compartment osteoarthritis. Unicondylar knee replacement is not indicated for tricompartmental disease
of the knee.

Question 83

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

Explanation

DISCUSSION: The radiograph shows widening between the scaphoid and lunate. The normal variance is up to 5 mm. Although several ligaments may be torn, the scapholunate interosseous ligament must be torn for this widening to occur.
REFERENCES: Cooney WP, Linscheid RL, Dobyns JH: The Wrist: Diagnosis and Operative Treatment. St Louis, MO, Mosby-Year Book, 1998, vol 1, pp 503-506.
Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 884-885.

Question 84

View Abstract at PubMed Figures 87a and 87b are sagittal and coronal MR images of the affected elbow of a 36-year-old man who has a history of painful mechanical symptoms in his dominant arm when extending his elbow in full supination. What is the most likely cause of his painful snapping? A B

Explanation

DISCUSSION
The MRI studies show a radiocapitellar plica. This anomalous structure has been associated with symptomatic snapping. Lacertus fibrosis contracture will not cause painful snapping. An intra-articular pathology such as loose bodies is not present on these imaging studies. Olecranon fossa impingement causes posterior pain in extension and is not shown in the images.
RECOMMENDED READINGS
Antuna SA, O'Driscoll SW. Snapping plicae associated with radiocapitellar chondromalacia. Arthroscopy. 2001 May;17(5):491-5. PubMed 11337715. View Abstract at PubMed
Ruch DS, Papadonikolakis A, Campolattaro RM. The posterolateral plica: a cause of refractory lateral elbow pain. J Shoulder Elbow Surg. 2006 May-Jun;15(3):367-70. PubMed PMID: 16679240. View Abstract at PubMed

Question 85

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?

Explanation

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.

Question 86

An otherwise healthy 15-year-old wrestler has a 6-cm cutaneous lesion on the posterior aspect of his right elbow that he reports as a spider bite. What is the most likely diagnosis? Review Topic

Explanation

Patients who have skin and soft-tissue infections caused by CA-MRSA often describe the lesion as a spider bite. The cytotoxin Panton-Valentine leukocidin that is produced by many strains of CA-MRSA causes tissue necrosis, resulting in rapid development of an abscess and the appearance of a spider bite. Patients with psoriasis have thick, red skin with flaky, silver-white patches. Tinea corporis is a general term for a cutaneous fungal infection. The lesion appears as a well-demarcated erythematous plaque with a raised border and central hypopigmentation, giving it a ring-like appearance. Primary infection with herpes simplex virus can produce constitutional symptoms with burning, tingling, or stinging at the site. Grouped vesicles with clear fluid 1 to 2 mm in size form on an erythematous base and then rupture, leaving moist ulcers or crusted plaques.
(SBQ07SM.48) Carbohydrate loading is a common practice among endurance athletes that works by what mechanism? Review Topic
Increasing serum fructose levels
Maximizing stored muscle glycogen for endurance after 90 minutes of exercise
Diuresis
Decreasing serum glucose levels
Maximizing stored liver glycogen for endurance after 60 minutes of exercise
Carbohydrate loading is a strategy that involves changes to training and nutrition which can maximize muscle glycogen stores prior to endurance exercise lasting longer than 90 minutes.
There continues to be varying scientific opinions as to whether athletes should eat low vs. high glycemic index foods, and how this will affect the amount that the serum glucose levels rise. Fructose is able to be converted to glycogen in the liver but not muscle, therefore high-fructose containing foods are suboptimal. This practice is recommended for athletes participating in events that are longer than 90 minutes (after the bodies normal supply of glycogen is depleted).
Coyle et al. analyzed 10 trained cyclists who performed two bicycle ergometer exercise tests 1 wk apart. They found that blood glucose concentration was 20-40% higher during the exercise after carbohydrate ingestion than during the exercise without carbohydrate feeding. The exercise-induced decrease in plasma insulin was prevented by carbohydrate feeding. Ultimately, fatigue was postponed by carbohydrate feeding during exercise in seven out of the ten subjects.
Costill et al. examined the effect of carbohydrates on muscle glycogen resynthesis in trained runners and found that muscle glycogen levels could be normalized with the proper use of carbohydrates after strenuous activity.
Sherman et al. used muscle biopsies to determine the effects of moderate- or high-carbohydrate diets on muscle glycogen and performance in runners and cyclists over 7 consecutive days of training. They found that a high carbohydrate diet restored muscle glycogen to more normal levels than a moderate carbohydrate diet but did not find any difference in the effect on performance.
Illustration A is a graph depicting the typical carbohydrate depletion/loading regimen that endurance athletes utilize to maximize muscle glycogen stores prior to endurance exercise. This typically involves a hard workout followed by three days of a low-carb diet, another hard workout, and another three days of a high-carb diet.
Incorrect

Question 87

An active 36-year-old woman with rheumatoid arthritis has continued forefoot discomfort despite the use of orthotics and shoe wear modifications. A radiograph and a clinical photograph are shown in Figures 26a and 26b. Treatment at this point should consist of

Explanation

DISCUSSION: In a patient with inflammatory arthritis, advanced hallux valgus deformity in conjunction with lesser metatarsophalangeal joint destruction and subluxation warrants fusion of the first metatarsophalangeal joint and lesser metatarsal head resections. Hallux valgus correction will fail because of incompetent soft tissues. A Keller resection arthroplasty is not indicated in this age group. Synovectomy is contraindicated because of evidence of erosive changes of the lesser metatarsophalangeal joints.
REFERENCES: Ouzounian T: Rheumatoid arthritis of the foot & ankle, in Myerson MS (ed): Foot & Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 2, pp 1189-1204.
Mann RA, Thompson FM: Arthrodesis of the first metatarsophalangeal joint for hallux valgus in rheumatoid arthritis. J Bone Joint Surg Am 1984;66:687-692.
Coughlin MJ: Rheumatoid forefoot reconstruction: A long-term followup study. J Bone Joint Surg Am 2000;82:322-341.

Question 88

Figures 42a through 42c show the clinical photographs and radiograph of a patient with diabetes mellitus who lives independently. The patient was admitted to the hospital late yesterday afternoon with clinical signs of sepsis. Parenteral antibiotic therapy resolved the sepsis, and blood glucose levels are now well controlled. The patient has no palpable pulses. The ankle-brachial index is 0.70. Laboratory studies show a WBC count of 8,500/mm 3 , a serum albumin of 1.9 g/dL, and a total lymphocyte count of 1,500/mm 3 . What treatment has the best potential to optimize his survival and independence?

Explanation

DISCUSSION: The patient was admitted to the hospital with sepsis. The sepsis has resolved, leaving the patient with a negative nitrogen balance. Now that the patient is stable, metabolic support should be used to optimize his nutrition. If the serum albumin can be increased to 2.5 g/dL, he has an excellent potential to heal an amputation at the Syme ankle disarticulation level; a level that will optimize his functional independence.
REFERENCES: Pinzur MS, Stuck RR, Sage R, et al: Syme ankle disarticulation in patients with diabetes. J Bone Joint Surg Am 2003;85:1667-1672.
Pinzur MS, Smith D, Osterman H: Syme ankle disarticulation in peripheral vascular disease and diabetic foot infection: The one-stage versus two-stage procedure. Foot Ankle Int 1995;16:124-127.

Question 89

An 83-year-old right-hand-dominant woman sustains a displaced right extra-articular distal radius fracture and is treated with closed reduction and casting. At her 4-week follow-up visit, radiographs demonstrate a volar tilt of -5 degrees and 4 mm of positive ulnar variance. Which treatment is recommended?

Explanation

DISCUSSION
Studies demonstrate that surgical treatment of distal radius fractures in elderly people does not result in improved outcomes. Although nonsurgical treatment resulted in worse radiographic findings for this patient, these findings did not translate into worse functional outcomes.
RECOMMENDED READINGS
Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011 May;36(5):824-35.e2. doi: 10.1016/j.jhsa.2011.02.005. Review. PubMed PMID: 21527140.
View Abstract at PubMed
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53. doi: 10.2106/JBJS.J.01597. PubMed PMID: 22159849. View Abstract
at PubMed
American Academy of Orthopaedic Surgeons: Treatment of Distal Radius Fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons, March 2013. Available at http://www.aaos.org/research/Appropriate_Use/drfauc.asp Accessed {10/8/14}. Last Accessed on 10/8/14

Question 90

Figure 3 shows the radiographs of a 32-year-old man who fell 12 feet onto his outstretched arm and sustained a fracture-dislocation of the elbow. Initial management consisted of closed reduction of the dislocation. Surgical treatment should now include repair or reduction and fixation of the

Explanation

DISCUSSION: The radiographs show fractures of the coronoid and radial head. The medial collateral ligament has been avulsed from the ulnar insertion, and there is a valgus opening on the medial side. The lateral collateral ligament is always disrupted in elbow dislocations and fracture-dislocations that occur secondary to falls. This is known as the terrible triad injury (dislocation and fractures of the coronoid and radial head); it has a very poor prognosis because of its propensity for recurrent or persistent instability and late arthritis. The principle in treating this injury is to repair all of the injured parts or protect them with a hinged external fixator until they heal.
REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354.
Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.
O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF: The unstable elbow. Instr Course Lect 2001;50:89-102.

Question 91

A 9-year-old boy has lateral right knee pain. An MRI scan shows a discoid lateral meniscus with a partial tear in its central portion. Treatment should consist of Review Topic

Explanation

A tear of the mid portion of a stable discoid lateral meniscus should be treated with a partial menisectomy with saucerization. Lateral total menisectomy is contraindicated because of the poor long-term results following this procedure. Meniscal transplant and casting do not have a role in this scenario, although meniscal repairs may be needed for peripheral meniscal instability.

Question 92

When making a comparison to autograft incorporation, the inflammatory process in allograft tissue anterior cruciate ligament (ACL) reconstruction

Explanation

Compared to similar autograft, allograft tissue demonstrates a prolonged inflammatory response, slower rate of biological incorporation and remodeling, and a higher proportion of large-diameter collagen fibrils. Native ACL inserts into bone through a transition of 4 distinct zones: tendon, unmineralized fibrocartilage, mineralized fibrocartilage, and bone. This transition is not reproduced with tendon grafts, which instead heal with interposed fibrovascular scar at the graft-tunnel interface. The scar rapidly remodels to form perpendicular fibers resembling Sharpey fibers and, eventually, mature bone growth into the outer portion of the graft. The intra-articular portion of allograft undergoes an initial phase of necrosis followed by repopulation by host synovial cells into the acellular collagen scaffold. Revascularization and maturation complete the ligamentization of graft tissue.

Question 93

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared with a standard parapatellar approach, what is the expected outcome?

Explanation

DISCUSSION:
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

Question 94

Figure 30a is the anteroposterior radiograph of a 20-year-old woman with mild right groin pain and intermittent “catching” in the hip region. What is the most appropriate next step? tear

Explanation

DISCUSSION
Because this patient is young, substantial bilateral acetabular dysplasia is present, and the joint space is well preserved, periacetabular osteotomy is the treatment of choice (Figure 30b). Arthroscopic evaluation and treatment is insufficient to address the mechanical deformity. Although a hip injection can be diagnostically helpful, it would not alter the treatment plan in this scenario. The patient’s young age would make observation and subsequent THA less desirable. Femoral osteotomies also were performed to address rotational deformity.

Question 95

What is the primary intracellular signaling mediator for bone morphogenetic protein (BMP) activity?

Explanation

DISCUSSION: BMPs signal through the activation of a transmembrane serine/threonine kinase receptor that leads to the activation of intracellular signaling molecules called SMADs. There are currently eight known SMADs, and the activation of different SMADs within a cell leads to different cellular responses. The other mediators are not believed to be directly involved with BMP signaling.
REFERENCES: Lieberman J, Daluiski A, Einhorn TA: The role of growth factors in the repair of bone: Biology and clinical applications. J Bone Joint Surg Am 2002;84:1032-1044.
Li J, Sandell LJ: Transcriptional regulation of cartilage-specific genes, in Rosier RN, Evans C (eds): Molecular Biology in Orthoapedics, Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 21-24.
Zuscik MJ, Drissi MH, Reynolds PR, et al: Molecular and cell biology in orthopaedics, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006,

in press.

Question 96

A 71-year-old woman with coronary artery disease underwent an uncomplicated right total hip arthroplasty for osteoarthritis 12 years ago. Her hip has functioned well until approximately 18 months ago when she noted the spontaneous onset of groin, buttock, and proximal thigh pain that is present at rest and made worse with activity. A radiograph is shown in Figure 15. What is the recommended management at this point?

Explanation

DISCUSSION: The radiograph shows significant osteolysis with loosening of the femoral component. The patient is symptomatic and surgery is indicated because of the extent of osteolysis and the loose femoral component.
Reassurance and follow-up if symptoms worsen places the patient at risk for further bone loss and periprosthetic fracture. Emergent surgery is not required because the symptoms have been present for more than a year; however, urgent revision hip arthroplasty is recommended when the patient is medically cleared. While there is data to suggest that bisphosphonates may slow the progression of osteolysis in animal modes, there is no clear evidence that bisphosphonate treatment prevents the progression of osteolysis in humans. Additionally, this patient has a loose symptomatic femoral component.
REFERENCES: Chiang PP, Burke DW, Freiberg AA, et al: Osteolysis of the pelvis: Evaluation and treatment. Clin Orthop Relat Res 2003;417:164-174.
Dunbar MJ, Blackley HR, Bourne RB: Osteolysis of the femur: Principles of management. Instr Course Lect 2001;50:197-209.
Rubash HE, Dorr LD, Jacobs JJ, et al: Does alendronate inhibit the progression of periprosthetic osteolysis? Trans
Orthop Res Soc 2004;29:1888.
)
Figure 16a Figure 16b

Question 97

Figures 191a and 191b are the radiographs of an 18-year-old man who had an ankle fracture requiring open reduction and internal fixation 2 years ago. He has a progressive symptomatic ankle deformity.Surgical intervention should consist of

Explanation

Question 98

What is the most common non-anesthetic-related reversible cause of sustained changes in intraoperative neurophysiologic monitoring signals during spinal surgery? Review Topic

Explanation

Patient positioning that results in local nerve compression, plexus traction, or improper neck alignment is the most common non-anesthetic-related cause of changes in intraoperative neurophysiologic monitoring data during spinal surgery. Pedicle screw malpositioning, spinal cord ischemia, and retractor placement are all less common causes. Hypotension, not hypertension, can be a cause of intraoperative neurophysiologic changes.

Question 99

Figure 82 is the MRI scan of a 15-year-old boy who has had knee pain with running for 5 months. Radiographs show an osteochondritis dissecans (OCD) lesion of the medial femoral condyle. What is the most appropriate treatment? Review Topic

Explanation

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

Question 100

-What leads to muscle hypertrophy?

Explanation

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Chondroblastoma
Enchondroma
Giant cell tumor
Fibrous dysplasia
Osteoblastoma

Correct Answer: Fibrous dysplasia

Explanation:

DISCUSSION: The radiographs reveal a geographic lesion of the proximal femur with the classic “ground glass” appearance noted in fibrous dysplasia. This intramedullary lesion is modestly expansile, demonstrates some minimal cortical thinning, and has no aggressive features. Chondroblastoma, giant cell tumor, and osteoblastoma are more lytic in appearance, and the location is not typical for giant cell tumor or chondroblastoma. While enchondroma may be considered, the uniform ground glass appearance, lack of punctuate mineralization, and distinct margination of the lesion make that diagnosis less likely.
REFERENCE: Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 2:

Which of the following bones is most frequently involved in stress fractures in athletes? Review Topic

Options:

Femur
Tibia
Fibula
Navicular
Fifth metatarsal

Correct Answer: Tibia

Explanation:

Question 3:

Options:

- Superior gluteal artery
- Branch of the external iliac artery
- Branch of the pudendal artery
- Branch of the femoral artery

Correct Answer: - Branch of the pudendal artery

Explanation:

DISCUSSION
Pelvic bleeding occurs predominantly from disruption of the posterior venous plexus and bleeding from the fractured bone. Occasionally arterial bleeding is seen, with injury to the superior gluteal artery most common. Anterior pelvic bleeding occurs from injury to the obturator artery (commonly from a pubic bone fracture laceration) and less frequently from the pudendal artery near the symphysis. The location of the bleeding on CT and angiography images does not correspond to the superior gluteal, external iliac, or femoral arteries.
RECOMMENDED READINGS
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009 Apr;40(4):343-53. Epub 2009 Mar 17. Review.PubMed PMID: 19278678.
View Abstract at PubMed
Loffroy R, Yeguiayan JM, Guiu B, Cercueil JP, Krausé D. Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization. CJEM. 2008 Jul;10(4):392-5. PubMed PMID: 18652733.
View
Abstract at PubMed
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures.Injury. 2009 Oct;40(10):1023-30. Epub 2009 Apr 16. Review. PubMed PMID:19371871.
View Abstract at
PubMed
RESPONSES FOR QUESTIONS 5 THROUGH 8
5A
5B
- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation
Please choose from the responses to identify the most likely complication in each scenario.

Question 4:

Which of the following best describes the course of the ulnar nerve in the midforearm?

Options:

Travels deep to the flexor carpi ulnaris muscle, radial to the ulnar artery, superficial to the flexor digitorum profundus muscle
Travels deep to the flexor carpi ulnaris muscle, radial to the ulnar artery, deep to the flexor digitorum profundus muscle
Travels deep to the flexor carpi ulnaris muscle, ulnar to the ulnar artery, superficial to the flexor digitorum profundus muscle
Travels superficial to the flexor carpi ulnaris muscle, ulnar to the ulnar artery, superficial to the flexor digitorum profundus muscle
Travels superficial to the flexor carpi ulnaris muscle, radial to the ulnar artery, superficial to the flexor digitorum profundus muscle

Correct Answer: Travels deep to the flexor carpi ulnaris muscle, ulnar to the ulnar artery, superficial to the flexor digitorum profundus muscle

Explanation:

Question 5:

Options:

fusion of the DIP joint with no reconstruction of the tendon.
advancement and repair of the tendon to the base of the distal phalanx.
two-stage reconstruction of the profundus tendon.
Z-plasty advancement of the profundus tendon.
tenodesis of the distal tendon remnant with the flexor digitorum sublimis.

Correct Answer: advancement and repair of the tendon to the base of the distal phalanx.

Explanation:

DISCUSSION: Flexor digitorum profundus ruptures are classified into three types. In type I, the tendon retracts into the palm. In type II, the tendon retracts to the level of the proximal phalanx, the vinculum remains intact, and the blood supply is preserved to the tendon. A small fleck of bony fragment observed at the A2 pulley is pathognomonic for a type II rupture. Successful primary repair of the type II rupture has been reported as late as 2 months after the injury. Type III injuries have large fragments of the distal phalanx attached and are caught distally by the A1 pulley. Type III ruptures can be repaired up to several months after the injury.
REFERENCES: Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin
1985;1:77-83.
Kiefhaber TR: Closed tendon injuries in the hand. Oper Tech Sports Med 1996;4:227-241.

Question 6:

Options:

normal postoperative orders with frequent neurologic evaluations for the first 24 hours.
administration of IV steroids and placement of a soft cervical collar for 24 hours.
placement of both deep and superficial surgical drains prior to wound closure.
administration of IV mannitol and placement of a soft collar.
maintaining intubation for up to 24 to 48 hours.

Correct Answer: maintaining intubation for up to 24 to 48 hours.

Explanation:

Question 7:

Options:

Oncogenic rickets
Calcium sequestration by the tumor
Elevated alkaline phosphatase level
Tumor cachexia
L5 neuropathy

Correct Answer: Oncogenic rickets

Explanation:

Question 8:

Options:

Site A is the apical ectodermal ridge (AER). Site A tissue expresses Shh protein.
Site A is the AER. Site A tissue expresses FGF8.
Site A is the zone of polarizing activity (ZPA). Site A tissue expresses Shh protein.
Site A is the zone of polarizing activity (ZPA). Site A tissue expresses FGF8 protein.
Site A is non-AER ectoderm. Site A tissue expresses WNT7a.

Correct Answer: Site A is the apical ectodermal ridge (AER). Site A tissue expresses Shh protein.

Explanation:

Question 9:

Options:

0% if bracing is used
25%
50%
75%
90% or greater

Correct Answer: 90% or greater

Explanation:

Question 10:

Options:

A Vancouver type B1 fracture
Residual leg-length discrepancy
Loosening and subsidence of the femoral stem into anteversion
Loosening and subsidence of the femoral stem into retroversion

Correct Answer: Loosening and subsidence of the femoral stem into retroversion

Explanation:

Question 11:

Revision of failed hip resurfacing arthroplasty should involve

Options:

the acetabular component only.
the femoral component only.
both femoral and acetabular components.
only components that are loose or malpositioned.

Correct Answer: both femoral and acetabular components.

Explanation:

Question 12:

Options:

Types I and II
Types II and III
Types I and III
Types III and IV

Correct Answer: Types I and III

Explanation:

EXPLANATION:
Type II collagen is the predominant type found in articular cartilage. Type IV collagen is the predominant type found in the basement membranes of neurovascular structures. Collagenase
Clostridium
histolyticum
injection targets type I and type III collagen.

Question 13:

What structure is most at risk with anterior penetration of C1 lateral mass screws?

Options:

Vertebral artery
External carotid artery
Internal carotid artery
Pharynx
Glossopharyngeal nerve

Correct Answer: Internal carotid artery

Explanation:

DISCUSSION: Posterior screw fixation of the upper cervical spine has gained a great deal of popularity due to its stable fixation, obviating the use of halo vest immobilization, and its high fusion rates. The use of screws in this location, however, has introduced a whole new set of potential complications. Vertebral artery injury is one of the most feared complications associated with screws in the C1/C2 region. This structure, however, is lateral and posterior at the C2 level and then penetrates the foramen transversarium of C1 to lie cephalad to the arch of C1 before entering the foramen magnum. It is the internal carotid artery that lies immediately anterior to the arch of C1 that is particularly at risk by anterior penetration of C1 lateral mass or C1-C2 transarticular screws as demonstrated by Currier and associates. The internal carotid artery lies posterior to the pharynx. The external carotid artery and the glossopharyngeal nerve are not at risk with this method of fixation.
REFERENCES: Currier BL, Todd LT, Maus TP, et al: Anatomic relationship of the internal carotid artery to the C1 vertebra: A case report of cervical reconstruction for chordoma and pilot study to assess the risk of screw fixation of the atlas. Spine 2003;28:E461-E467.
Grant JC: Grant’s Atlas of Anatomy, ed 6. Baltimore, MD, Williams & Wilkins, 1972.
Harms J, Melcher RP: Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine 2001;26:2467-2471.

Question 14:

Options:

Shortening of 3 cm
Severity of trauma
Duration of immobilization
Type of immobilization
Closed reduction

Correct Answer: Severity of trauma

Explanation:

Question 15:

Options:

Synovial herniation pits
Osteoid osteoma
Fibrous dysplasia
Metastatic bone disease
Multiple enchondromas

Correct Answer: Synovial herniation pits

Explanation:

DISCUSSION: Synovial herniation pits or Pitt’s pits are tumor simulators and are incidentally identified on radiographs obtained for either pain or trauma. The main diagnostic pitfall with this lesion is mistakenly identifying it as an osteoid osteoma. Accurate diagnosis is achieved by knowledge of the location and the characteristic imaging appearance. These are common lesions in individuals with femoroacetabular impingement.
REFERENCES: Pitt MJ, Graham AR, Shipman JH, et al: Herniation pit of the femoral neck. Am J Roentgenol 1982;138:1115-1121.
Daenen B, Preidler KW, Padmanabhan S, et al: Symptomatic herniation pits of the femoral neck: Anatomic and clinical study. Am J Roentgenol 1997;168:149-153.

Question 16:

A 26-year-old mixed martial arts fighter sustains a posterolateral elbow dislocation. The primary stabilizers of the elbow joint are the

Options:

radiocapitellar joint, the posterior band of the medial collateral ligament, and the annular ligament.
ulnohumeral joint, the anterior band of the medial collateral ligament, and the lateral ulnar collateral ligament.
radiocapitellar joint, the anterior band of the medial collateral ligament, and the radial collateral ligament.
ulnohumeral joint, the anterior band of the medial collateral ligament, and the posterior band of the medial collateral ligament.

Correct Answer: ulnohumeral joint, the anterior band of the medial collateral ligament, and the lateral ulnar collateral ligament.

Explanation:

Question 17:

Options:

Driesman et al. followed 84 consecutive patients with diaphyseal humeral shaft fractures treated nonoperatively. They found that mobile fracture sites at 6 weeks from injury predicted nonunion with 82% sensitivity and 99% specificity. They concluded that knowledge of fracture motion can help in determining the appropriate management in decision making in nonoperatively treated humeral shaft fractures.
Figures A and B show AP and transthoracic lateral radiographs of a mid diaphyseal spiral humeral shaft fracture, respectively.
Incorrect Answers:

Correct Answer: Driesman et al. followed 84 consecutive patients with diaphyseal humeral shaft fractures treated nonoperatively. They found that mobile fracture sites at 6 weeks from injury predicted nonunion with 82% sensitivity and 99% specificity. They concluded that knowledge of fracture motion can help in determining the appropriate management in decision making in nonoperatively treated humeral shaft fractures.

Explanation:

OrthoCash 2020
A patient presents with the injury shown in figures A and B. What has been associated with the technique depicted in figures C and D?
Longer operative times
Increased deep surgical infection rates
Unacceptably high malunion/nonunion rates
Slower early return to function
Longer hospital stays
Corrent answer: 3
Treatment of Shatzker V and VI tibial plateau fractures with hybrid external fixation is associated with increased malunion and nonunion rates.
Hybrid external fixation for treating tibial plateau fractures involves the use of an external fixator to achieve reduction through ligamentotaxis. Additional fracture reduction is achieved through limited open incisions with fixation augmented through percutaneous cannulated screws. Definitive treatment with this technique avoids soft tissue complications that have been associated with traditional open reduction and internal fixation with bicondylar plating.
However, studies have reported high malunion and nonunion rates due to a lack of rigid fixation.
Bertrand et al. performed a prospective cohort study of patients undergoing either open reduction and internal fixation versus hybrid external fixation for Schatzker V and VI tibial plateau fractures. Hybrid external fixation was associated with significantly shorter operative times but insignificantly increased complication rates. They concluded that there were limited statistically differences between these techniques, but further studies are required before advising hybrid external fixation for higher Schatzker tibial plateau fractures.
Gross et al. performed a retrospective study of patients treated with hybrid external fixation for Shatzker V and VI tibial plateau fractures. The authors found there was an 80% union rate, a 70% satisfactory reduction rate, and a 52% rate of malunion. The development of osteoarthritis was associated with plateau widening, articular comminution, articular step-off, and incorrect mechanical alignment. The authors concluded that hybrid external fixation is an effective means for the treatment of tibial plateau fractures that minimizes tissue dissection, with decreased blood loss, and shorter operative times, but associated with a very high malunion rate.
Hall et al. performed a multicenter randomized controlled trial comparing the treatment of Schatzker V and VI fractures with open reduction and internal fixation with hybrid external fixation. Patients with hybrid external fixation had less intraoperative blood loss, fewer unanticipated secondary procedures, slightly faster return to pre-injury activity at 6 months and 1 year, and shorter
hospital stay. They concluded that both hybrid external fixation and open reduction and internal fixation provide effective means for fracture treatment, but hybrid external fixation avoids soft tissue complications with deleterious consequences.
Figure A is an AP radiograph of the right knee with a Schatzker VI tibial plateau fracture. Figure B is an axial CT slice of the articular surface of the tibia with extensive comminution. Figures C and D are the AP and lateral radiographs of the knee with a hybrid external fixation construct for a tibial plateau fracture
Incorrect answers:
OrthoCash 2020
An 89-year-old female sustained the injury shown in Figure A and underwent a hemiarthroplasty. Which of the following has been associated with increased rates of post-operative dislocation?
Posterior approach
Anterior approach
Anterolateral approach
Use of a bipolar implant
Use of a monopolar implant
The incidence of dislocation after hemiarthroplasty is highest when using a posterior approach.
Elderly femoral neck fractures are one of the most common fractures encountered by orthopaedists and will only become more common as the population continues to age. The displacement of the femoral head is associated with delayed union or nonunion, an increased risk of femoral head necrosis due to disrupted blood flow at the femoral neck, and failure of internal fixation devices. For this reason, displaced femoral neck fractures in older patients are often treated with hemiarthroplasty. Three approaches to hemiarthroplasty have been described: a lateral approach, a posterior approach, and an anterior approach. The posterior approach has been used more historically; however, its use has been called into question as it has been associated with increased dislocation rates.
Parker performed a trial on all patients with intracapsular femoral neck fractures being treated with hemiarthroplasty. Patients were randomized to surgery using either a lateral or posterior approach. They found that there were no statistically significant differences observed for any of the outcome measures including mortality, degree of residual pain and regain of walking ability. They concluded that both surgical approaches appear to produce comparable functional outcomes.
van der Sijp et al. performed a meta-analysis to compare the outcomes based on approaches for hemiarthroplasty in the treatment of proximal femur fractures. They found 21 studies and found that the posterior approach poses an increased risk of dislocation and reoperation compared to the lateral approach and anterior approaches. They conclude that there are no evident advantages of the posterior approach and its routine use for fracture-related hemiarthroplasty should be questioned.
Figure A is an AP pelvis radiograph demonstrating a displaced right femoral neck fracture.
Incorrect Answers:
OrthoCash 2020
A 50-year-old male sustained a humeral shaft fracture treated operatively 6 months ago. He denies medical problems but smokes 10 cigarettes per day. His current radiograph is shown in Figure A. He continues to have pain in his arm that is affecting his quality of life. On physical examination, there is motion at the fracture site. C-reactive protein and erythrocyte sedimentation rate are within normal limits. Which is the most appropriate definitive treatment for this fracture?
Exchange humeral nailing
Augmentative plating
Nail removal with open reduction compression plating
Smoking cessation and medical optimization
Nail removal with open reduction and compression plating with bone grafting
This patient has sustained an atrophic nonunion of a humeral shaft fracture treated with an intramedullary nail. The most appropriate definitive treatment is nail removal with open reduction and compression plating with bone grafting.
Most diaphyseal humeral fractures can be managed non-operatively with functional bracing. Operative treatment is indicated under a number of circumstances including open fractures, associated neurovascular injury, proximal and distal articular extension of the fracture, and in patients with other multiple injuries. Surgical stabilization can be accomplished with different implants and techniques. The two most common are plate and screw fixation and intramedullary nailing. Plate fixation has the advantages of potential absolute stability and sparing the rotator cuff from an incision. Intramedullary nailing has to be inserted proximally with potential damage to the rotator cuff. It, however, can be inserted with small incisions. If a nonunion develops after intramedullary nailing, nail removal and compression plating is the preferred treatment choice.
Heineman et al. performed a metanalysis on plate fixation or intramedullary nailing of humeral shaft fractures. They performed a literature search from 1967-2007 comparing nails and plates in patients with humeral shaft fractures that reported complications due to surgery. They found that the risk of a complication is lower when plating a fracture of the humeral shaft than when using an intramedullary nail.
Gerwin et al. performed an anatomical study to define the course of the radial nerve in the posterior aspect of the arm, with particular reference to its relationship to operative exposures of the posterior aspect of the humeral diaphysis. They found that the radial nerve crosses the posterior aspect of the humerus from an average of 20.7 +/- 1.2 centimeters proximal to the medial epicondyle to 14.2 +/- 0.6 centimeters proximal to the lateral epicondyle. They found the approach to permit the most visualization was the triceps reflecting approach.
Figure A is a lateral radiograph of an atrophic nonunion of a humeral shaft being stabilized with an intramedullary nail.
Incorrect Answers:
OrthoCash 2020
A 45-year-old man is struck while crossing a major highway and sustains the injury depicted in Figure A. Which of the following statements comparing the techniques in Figure B and C is most accurate?
Technique depicted in Figure B is associated with an increased risk of septic arthritis
Technique depicted in Figure B is associated with increased rate of anterior knee pain
Technique depicted in Figure B is associated with improved postoperative fracture alignment
Technique depicted in Figure C is associated with an increased risk of septic arthritis
Technique depicted in Figure C is associated with improved postoperative fracture alignment
Compared to infrapatellar tibial nailing, suprapatellar tibial nailing is associated with improved postoperative fracture alignment.
While antegrade tibial nailing results in postoperative anterior knee pain in approximately 20% of patients, there is no significant difference in the incidence of anterior knee pain when the conventional infrapatellar approach is compared to suprapatellar approaches. In open tibial shaft fractures, no difference has been observed in the incidence of knee sepsis with either approach. However, several studies have demonstrated that intramedullary nail fixation through a suprapatellar approach is associated with a more accurate entry position and a more accurate fracture reduction when compared with an infrapatellar technique, particularly in more proximal and distal shaft
fractures, without evidence of a functional impact on the patellofemoral joint. Lastly, intraoperative radiography is generally less cumbersome with suprapatellar nailing.
Marecek et al. performed a multicenter comparison study of suprapatellar and infrapatellar approaches and the risk of knee sepsis after treatment of open tibia fractures. They reported no differences in the rates of infection, deep infection, or reoperation between suprapatellar and infrapatellar nailing groups. They concluded that the risk of knee sepsis after suprapatellar nailing of open fractures is low.
Avilucea et al. performed a retrospective cohort study comparing postoperative alignment after suprapatellar versus infrapatellar nailing for distal tibial shaft fractures. They reported a significantly increased rate of primary angular malalignment of greater than 5 degrees in the infrapatellar compared to the suprapatellar nailing cohort. They concluded that in the treatment of distal tibial fractures, suprapatellar nailing results in a significantly lower rate of malalignment compared with the infrapatellar nailing.
Jones et al. performed a study comparing the radiologic outcome and patient-reported function after suprapatellar and infrapatellar intramedullary nailing. They reported no difference in anterior knee pain, however, found a more accurate fracture reduction, both in terms of angulation and translation in the coronal plane, with the use of the suprapatellar technique. They concluded that when compared with infrapatellar nailing, the suprapatellar technique was not associated with more anterior knee pain, yet more accurate nail insertion and fracture reduction.
Figure A depicts a displaced distal third tibial shaft fracture. Figure B depicts the infrapatellar tibial nailing technique. Figure C depicts the suprapatellar tibial nailing technique.
Incorrect Answers:
OrthoCash 2020
A 56-year-old woman sustains the closed injury depicted in Figures A-B. On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. She also complains of some paresthesias in her thumb and index finger. The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. What is the likely mechanism of her paresthesias and what is the most appropriate treatment?
Nerve compression; open reduction internal fixation with open carpal tunnel release
Nerve laceration; open reduction internal fixation with primary nerve repair or grafting
Decreased arterial inflow; fasciotomy with open reduction internal fixation
Reflex sympathetic dystrophy; vitamin C
Nerve compression; repeat closed reduction
Corrent answer: 1
This patient is presenting with signs of acute carpal tunnel syndrome (CTS) in the setting of a displaced distal radial fracture. The pathogenesis of acute CTS is nerve compression, requiring urgent open carpal release with open reduction internal fixation (ORIF).
Acute CTS is a well-recognized phenomenon after distal radial fractures. Risk factors include ipsilateral upper extremity fractures, translation of the fracture fragments, and articular distal radius fractures (DRFs). Acute CTS can manifest with paresthesias in the median nerve distribution and opponens pollicis weakness. Acute CTS is an indication for urgent surgical decompression of the median nerve.
Odumala et al. performed a study to evaluate the role of carpal tunnel decompression in the prevention of median nerve dysfunction after buttress plating of DRFs. They reported that prophylactic decompression of the carpal tunnel results in twice the relative odds of developing median nerve dysfunction, which routinely self-resolved. They concluded that prophylactic median nerve decompression does not alter the course of median nerve dysfunction and may actually increase postoperative morbidity.
Medici et al. performed a case-control study to investigate whether carpal tunnel release (CTR) during fixation DRFs improves outcomes. They reported no statistically significant difference between the groups in VAS and Mayo Wrist Scores, however, an increased risk of subsequent CTR in the group who underwent ORIF with no CTR at the index procedure. They concluded that the release of the transverse carpal ligament during ORIF may reduce the incidence of postoperative median nerve dysfunction.
Niver et al. reviewed CTS after DRFs. They reported that acute CTS noted at the time of DRF warrants urgent surgical release of the carpal tunnel and fracture fixation, and that delayed CTS presenting after a distal radius fracture has healed may be managed in the standard fashion for CTR. They concluded that there is no role for prophylactic CTR at the time of distal radius fixation in a patient who is asymptomatic.
Figures A and B depict a displaced apex volar DRF and a mildly displaced ulnar styloid fracture.
Incorrect Answers:
OrthoCash 2020
Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury?
Improved functional outcomes with open reduction internal fixation (ORIF) through FCR approach vs. closed treatment
No difference in radiographic outcomes after ORIF vs. closed treatment
No difference in functional outcomes after ORIF vs. closed treatment
Improved functional outcomes with closed treatment vs. ORIF
Improved functional outcomes with external fixation and K wire fixation vs. ORIF
This elderly patient has sustained a closed intra-articular and shortened distal radial fracture (DRF). Many studies have reported no difference in functional outcomes when patients aged 60 and over are treated in a closed manner versus operatively for unstable fractures.
The treatment of DRFs in the elderly population is controversial. A variety of nonoperative and operative treatments are available, including closed reduction and splinting/casting, K wire stabilization, external fixation, and ORIF. While conservative management of DRFs in the elderly is common,
recent systematic reviews and meta-analyses have demonstrated that despite worse radiographic outcomes after closed treatment of unstable fractures, functional outcomes were no different between patients treated closed versus surgically in patients over the age of 60 years.
Ju et al. published a systematic review and meta-analysis comparing treatment outcomes between nonsurgical and surgical treatment of unstable DRFs in the elderly. They reported no significant differences in DASH score, VAS pain score, grip strength, wrist extension, pronation, supination, and ulnar deviation between the groups. They concluded that operative and nonoperative treatments result in similar outcomes in the treatment of unstable DRFs in the elderly, with no impact on subjective function outcome and quality of life with closed treatment.
Diaz-Garcia et al. published a systematic review of the outcomes and complications after treating unstable DRFs in the elderly, comparing various treatment techniques. They reported significant differences in wrist motion, grip strength, DASH score, although these findings may not be clinically meaningful. They concluded that although the operatively treated group had improved radiographic outcomes, functional outcomes were no different when compared to the group treated in a closed manner.
Figure A depicts an unstable intra-articular and shortened DRF. Incorrect Answers:
no difference in functional outcomes between operative and closed treatment modalities for DRF.
OrthoCash 2020
An active 60-year-old woman falls from her attic and presents with the injury in Figure A. She undergoes successful closed reduction and sling immobilization. At follow up, she is unable to move her shoulder. New radiographs are depicted in Figures B and C. What is the next best step?
Continued sling immobilization
Closed reduction percutaneous pinning
Open reduction internal fixation
Hemiarthroplasty
Reverse total shoulder arthroplasty
Corrent answer: 3
This active patient presents with a greater tuberosity fracture dislocation. Open reduction internal fixation (ORIF) is indicated, particularly when the greater tuberosity fragment is displaced greater than 5mm.
Many proximal humerus fractures are minimally displaced and respond acceptably to nonoperative management. Isolated greater tuberosity fractures or rotator cuff injuries are associated with shoulder dislocations in the elderly population. The greater tuberosity fragment undergoes deforming forces by the supraspinatus and infraspinatus muscles. In active patients, it is well-accepted that greater tuberosity fracture displacement greater than 5mm is an indication for ORIF to restore their ability to perform overhead activities and prevent impingement.
Schumaier et al. published a review article on the treatment of proximal humerus fractures in the elderly. They highlighted that while bone density was a predictor of reduction quality, social independence was a better predictor of outcome. They concluded that although the majority of minimally displaced fractures can be treated successfully with early physical therapy, treatment for displaced fractures should consider the patient's level of independence, bone quality, and surgical risk factors. They emphasized that there was no clear evidence-based treatment of choice, and the surgeon should consider their comfort level during their decision-making.
George et al. published a review article on greater tuberosity humerus fractures. They reported that these fractures may occur in the setting of anterior shoulder dislocations or impaction injuries against the acromion or superior glenoid, with surgical fixation recommended for fractures with greater than 5 mm of displacement in the general population or greater than 3 mm of displacement in active patients involved in frequent overhead activity. They recommended close followup and supervised rehabilitation to increase successful outcomes.
Figure A depicts a greater tuberosity fracture dislocation of the left shoulder. Figures B and C depict reduction of the glenohumeral joint with residual displacement of the greater tuberosity. Illustrations A and B depict radiographs after ORIF.
Incorrect Answers:
OrthoCash 2020
A 21-year-old football player is tackled as he falls onto an outstretched arm. He sustains the injury shown in Figure A. He undergoes successful operative treatment of his injury. In which order did his injury occur?
MCL > LCL > anterior capsule
MCL > anterior capsule > LCL
anterior capsule > MCL > LCL
LCL > anterior capsule > MCL
LCL > MCL > anterior capsule
Corrent answer: 4
The patient sustained a terrible triad injury of the elbow, which progresses from the LCL to the anterior capsule and then the MCL.
Terrible triad injuries of the elbow are traumatic injuries that occur after a fall on an extended arm that results in a combination of valgus, axial, and posterolateral rotatory forces. The key features of a terrible triad injury include a radial head fracture, a coronoid fracture, and an elbow dislocation. Disruption of the structures in the elbow characteristically occurs from lateral to medial, affecting the LCL first, followed by the anterior capsule and MCL. Outcomes following terrible triad injuries have historically been poor; however, more recent literature has shown that good outcomes can be achieved with surgical stabilization of the elbow followed by an early rehabilitation protocol. Some authors use temporary immobilization, but range-of-motion exercises are typically initiated by 48 hours postoperatively. Active range of motion is particularly important, as it recruits muscles that act as dynamic stabilizers of the elbow. Depending on the injury, method of fixation, and stability that is achieved, the range of motion may be limited to 30° of extension during the early postoperative period but should allow full flexion.
Giannicola et al. (2013) performed a study to determine the critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability (CEI). They found that the first 6 months after surgery represent the critical rehabilitation period to obtain a functional elbow and that elbow flexion recovered at a rate slower than that of the other elbow movements. They recommend that, following CEI surgical treatment, a rehabilitation program should be started promptly and should be continued for at least 6 months because a significant improvement of ROM occurs in this period.
Giannicola et al. (2015) performed a study analyzing the predictability of outcomes of terrible triad injuries (TTI) treated according to current diagnostic and surgical protocols. They found that the current diagnostic and therapeutic protocols allow for satisfactory clinical outcomes in a majority of cases but a high number of major and minor unpredictable complications still persist. Low compliance, obesity, and extensive soft elbow tissue damage caused by high-energy trauma represented negative prognostic factors unrelated to surgery.
McKee et al. performed a review on their standard surgical protocol for the treatment of elbow dislocations with radial head and coronoid fractures. Their surgical protocol included fixation or replacement of the radial head; fixation of the coronoid fracture, if possible; repair of associated capsular and lateral ligamentous injuries; and, in selected cases, repair of the medial collateral ligament and/or adjuvant-hinged external fixation. They found that their surgical protocol restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. They recommend early operative repair with a standard protocol for these injuries.
Figure A is a lateral radiograph of the elbow demonstrating a terrible triad injury with a comminuted radial head/neck fracture, displaced coronoid fracture, and posterior elbow dislocation. Illustration A is a rendered image of the radiograph shown in Figure A with the components labeled.
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OrthoCash 2020
An 82-year-old female sustains the fracture shown in Figure A as the result of a ground level fall. Which of the following has been shown to be a reliable predictor of postoperative lateral wall fracture for this injury after treatment with a sliding hip screw?
Reverse obliquity fracture pattern
Lateral wall thickness
Previous contralateral hip fracture
DEXA T-score <-2.0
Calcar comminution
Lateral wall thickness has been shown to be a predictor of postoperative lateral wall fracture. As the lateral wall thickness decreases, there is an increased chance of fracture.
Lateral wall fracture creates an unstable fracture pattern and increased screw sliding/collapse. This shortens the neck and abductors, leading to worse patient outcomes (radiographic and clinical). Recognition of a thin wall should lead toward the use of an intramedullary device or adjunct use of a trochanteric stabilizing plate with a sliding hip screw device.
Baumgaertner et al. reported that the failure of peritrochanteric fractures that have been treated with a fixed-angle sliding hip-screw device is frequently related to the position of the lag screw in the femoral head. They established the tip-apex distance as the sum of the distance from the tip of the lag screw to the apex of the femoral head on an anteroposterior radiograph and this distance on a lateral radiograph, after controlling for magnification. Upon reviewing their series, none of the 120 screws with a tip-apex distance of twenty-five millimeters or less cut out, but there was a very strong statistical relationship between an increasing tip-apex distance and the rate of cutout, regardless of all other variables related to the fracture.
Socci et al. performed a literature review of relevant papers and appropriate clinical databases and concluded that fixation of AO 31A1 fractures was best achieved with a sliding hip screw device and that all other types of intertrochanteric hip fractures be fixed with an intramedullary device.
Utrilla et al. reported no difference in outcome in stable fractures, but better mobility at one year following intramedullary fixation of unstable fractures.
Hsu et al. measured the thickness of the lateral wall of patients with AO/OTA 31-A1 and 31-A2 type intertrochanteric hip fractures. They found that the lateral wall thickness was a reliable predictor of postoperative lateral wall fracture for unstable AO Type A2 fractures and concluded that the lateral wall thickness threshold value for risk of developing a secondary lateral wall fracture was found to be 20.5 mm.
Figure A shows a standard obliquity intertrochanteric hip fracture.
Illustration A from the Hsu article demonstrates the measurement of the lateral wall thickness. The distance is measured along a 135-degree angle, between a point 3cm distal to the innominate tubercle of the greater trochanter and the fracture line (midway between the two cortical lines).
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OrthoCash 2020
A 78-year-old patient presents with right hip pain and inability to bear weight after an unwitnessed fall at a nursing home. Figures A and B are the radiographs of the hip and pelvis. Which statement is true regarding the treatment of these injuries?
Smaller lateral wall thickness favors sliding hip screw constructs
Unstable fractures are best treated with sliding hip screw constructs
Avoiding distal locking screws in intramedullary implants protects against refracture
Stable fractures have no differences in outcomes between sliding hip screws and intramedullary implants
Implant stability has a greater impact on outcomes rather than reduction quality
Studies have shown that in stable intertrochanteric femur fractures there are no differences in outcomes between sliding hip screws and intramedullary implants.
Intertrochanteric femur fractures are one of the most common fractures in the geriatric population. Implant selection has been a great topic of research with most studies reporting minimal to no differences in outcomes between intramedullary and sliding hip screw constructs in stable fracture patterns.
Unstable fractures, however, are reportedly better treated with a distally locked intramedullary implant. The quality of fracture reduction has a greater impact on the overall outcome than implant selection.
Hsu et al. performed a retrospective study of risk factors for postoperative lateral wall fractures in patients treated with sliding hip screws for intertrochanteric femur fractures. They found that fracture classification and lateral wall thickness, which is measured from 3 cm distal from innominate tubercle and angled 135 degrees to the fracture line, were associated with postoperative lateral wall fracture. They recommended not treating intertrochanteric femur fractures with sliding hip screws if the lateral wall thickness is less than 20.5 mm.
Socci et al. reviewed the literature regarding the treatment of intertrochanteric femur fractures. Based on the literature, they recommend treatment of AO/OTA type 31A1 fractures with sliding hip screws, type 31A2 fractures with short intramedullary implants, and 31A3 fractures with long intramedullary implants. Simple basicervical fractures of the femoral neck can be treated with sliding hip constructs whereas comminuted fractures treated with intramedullary devices due to the inherent instability of the pattern. The most import aspect in fracture healing is the quality of the reduction rather than the choice of implant.
Lindvall et al. performed a retrospective study of refracture rates in patients treated with either long or short cephalomedullary nails. The authors found a 97% union rate with both implant types and refracture not associated with either long or short implants. Rather, refracture was associated with the lack of a distal locking screw. The authors recommended locking intramedullary implants to avoid refracture.
Utrilla et al. performed a randomized control trial of elderly patients treated
with compression hip screw or Trochanteric Gamma Nail for intertrochanteric femur fractures. They reported the only differences between the two implants were quicker operating time, less fluoroscopy use, and better walking with unstable fractures treated with intramedullary implants. The authors recommended either construct for stable fractures, but intramedullary implants for unstable fractures.
Figures A and B are the AP and lateral radiographs of the right hip radiographs demonstrating a simple and minimally displaced intertrochanteric femur fracture, classified as an AO/OTA 31A1 fracture. Illustration A depicts the AO/OTA classification system for proximal femur fractures.
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OrthoCash 2020
A 28-year-old male that sustained a closed left femoral shaft fracture 12 months ago and underwent intramedullary nailing presents with persistent pain in the right thigh. The patient walks with an antalgic gait. He denies any fevers or chills. His surgical sites are well healed and there are no signs of drainage. Serum ESR and CRP are 12 mm/hr (reference <20 mm/hr) and 0.9 mg/L (reference <2.5 mg/L), respectively. Figures A and B are the AP and lateral radiographs of the left femur. Which treatment option offers the highest chance of union and enables immediate weight-bearing?
Nail removal with compression plating and open bone grafting
Closed reamed exchange nailing
Nail dynamization
Nail retention with plate augmentation and bone grafting
Electrical bone stimulator
Corrent answer: 4
The patient is presenting with a hypertrophic nonunion of the femur below the isthmus, which studies have shown to have a higher union rate when treated with plate augmentation. Retention of the nail allows for full weight-bearing postop.
Hypertrophic nonunion of the femur is the result of fracture site hypermobility with sufficient biology for healing. This is demonstrated with abundant callus formation without bridging trabeculae. Traditionally, this is treated with closed reamed exchange nailing which increased construct stiffness with a larger diameter nail, improved isthmic fit, and extrusion of reaming contents to the nonunion site. However, studies have demonstrated a higher union rate with open plate augmentation, bone grafting, and nail retention. This is due to the ability to correct nonunion site deformity, provide added compression at the nonunion site, and increase fracture site biology with bone graft.
Lynch et al. reviewed the literature regarding the treatment options for femoral nonunions. The literature suggests high union rates when hypertrophic nonunions are treated with exchanged reamed nailing. However, the use of augmentative plate fixation allows for further deformity correction. The proposed mechanism by which exchange reamed nailing is increased construct stiffness with a large diameter nail, usually by 1-2 mm, increased isthmic fit, and autogenous bone graft extrusion into the nonunion site.
Somford et al. performed a systematic review of the surgical treatment of femoral nonunions. Results demonstrate that exchange nailing provides a 73% union rate compared to plate augmentation of 96%. They speculated that there were increased indications for exchange nailing for oligotrophic nonunions in many of the included studies, which may have reduced the union rate. Further, plate augmentation does allow for deformity correction, which can further improve the union rate.
Figures A and B are the AP and lateral radiographs of the femur with hypertrophic nonunion as suggested with the abundant callus formation and broken distal interlock screws. Illustration A and B are the AP and lateral radiographs of the distal femur subsequent plate augmentation and fracture healing.
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OrthoCash 2020
A 25-year-old male sustains the injury depicted in Figure A. He is splinted in the field, but on arrival to the emergency room, he complains of painful "tightness" around the leg and severe uncontrolled pain despite maximum dose narcotics. His pain is exacerbated when the toes and ankle are passively stretched in flexion and extension. What is the most appropriate next step in treatment?
External fixation with serial doppler examinations
Intramedullary nailing
Open reduction internal fixation using plates and screws
Immediate 2-compartment fasciotomies and external fixation
Immediate 4-compartment fasciotomies and external fixation
Corrent answer: 5
This patient has clinical symptoms and signs of leg compartment syndrome and should undergo immediate fasciotomies of all 4 leg compartments, followed by external fixation for fracture stabilization.
Tibial fractures are among the most common reasons for compartment syndromes of the leg. A clinical assessment is key in the diagnosis of acute compartment syndrome. If there is uncertainty, intracompartmental pressure measurement has been advocated to help confirm the diagnosis. An absolute
compartment pressure >30 mm Hg or a difference in diastolic pressure and compartment pressure (delta p) <30 mmHg may help to confirm the necessity for fasciotomy.
McQueen et al. published a report of 25 patients with tibial diaphyseal fractures which had been complicated by an acute compartment syndrome. They reported significant differences in any sequelae of acute compartment syndrome between patients who underwent compartment pressure monitoring and those who had not. They recommended that all patients with tibial fractures should have continuous compartment monitoring to minimize the incidence of acute compartment syndrome.
Mawhinney et al. reported on three cases of tibial compartment syndrome after closed intramedullary nailing of the tibia. They reported that the only predisposing factors for the development of compartment syndrome were the surgery and the fracture itself. They concluded that tibial compartment syndrome is a relatively rare but significant complication of tibial nailing.
Figure A is an AP and lateral radiograph of the leg with displaced, comminuted middle third tibia and fibula fractures.
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OrthoCash 2020
A 24-year-old male is brought to the ED after an MVC. He is found to have a closed comminuted segmental fibula fracture after a prolonged extraction from the vehicle. Several hours after arrival, the patient reports increasing pain and is noted to have an exacerbation of his pain with passive stretching of the ankle. He has a heart rate of 103 and a blood pressure of 141/87. Compartment pressures are obtained and are 27 mmHg in the anterior compartment, 47 mmHg in the lateral compartment, 28 mmHg in the superficial posterior compartment, and 27 mmHg in the deep posterior compartment. Which of the following correctly describes the initial pathophysiology of compartment syndrome and the neurologic deficit that would likely occur in this patient if left untreated?
Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the first webspace
Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes
Decreased arterial inflow; inability to dorsiflex his ankle
Decreased venous outflow; decreased sensation on the dorsum of his foot involving the first webspace
Decreased venous outflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes
Compartment syndrome initially results from a decrease in venous outflow relative to arterial inflow. This patient has elevated pressures in the lateral compartment of the leg, which is where the superficial peroneal nerve runs to supply sensation to the dorsum of the foot including the hallux and 3rd and 4th toes.
Compartment syndrome results from compromised venous outflow from the leg relative to the arterial inflow. This venous congestion leads to elevated compartment pressures that ultimately lead to compromised arterial inflow without compartment release. There are 4 compartments in the leg: anterior, lateral, superficial posterior, and deep posterior. The anterior compartment contains the deep peroneal nerve, the lateral compartment of the leg contains the superficial peroneal nerve, and the deep posterior compartment contains the tibial nerve.
McQueen et al. performed a study to determine risk factors for acute compartment syndrome. They found that young patients, especially men, were most at risk of acute compartment syndrome after injury. They recommend that, when treating such injured patients, the diagnosis should be made early, utilizing measurements of tissue pressure.
Olson et al. published a review on acute compartment syndrome in lower extremity musculoskeletal trauma. They reported that acute compartment syndrome is a potentially devastating condition in which the pressure within an osseofascial compartment rises to a level that decreases the perfusion gradient across tissue capillary beds, leading to cellular anoxia, muscle ischemia, and death. They report that recognizing compartment syndromes requires having and maintaining a high index of suspicion, performing serial examinations in patients at risk, and carefully documenting changes over time.
Illustration A is a diagram depicting the compartments of the leg and its contents.
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OrthoCash 2020
Which of the following amputations results in an approximate 40% increase in energy expenditure for ambulation?
Syme
Traumatic transtibial
Vascular transtibial
Traumatic transfemoral
Vascular transfemoral
The energy expenditure of a vascular transtibial amputation is approximately 40% greater.
The energy expenditure for ambulation increases with lower extremity amputation. Diabetics and vasculopathic patients who undergo amputation
have significantly increased energy requirements compared with nondiabetic patients undergoing amputations for trauma. The metabolic cost for a vascular transtibial amputation is 40% compared to a 25% increase in normal patients who sustain a traumatic amputation.
Huang et al. used a mobile instrument system to measure energy consumption by indirect calorimetry at rest and during ambulation in 25 unimpaired subjects, 6 unilateral below-knee (BK) amputee patients, 6 unilateral above-knee (AK) amputee patients and 4 bilateral AK amputee patients. They found that in comparison to unimpaired subjects, the mean oxygen consumption was 9% higher in unilateral BK amputee patients, 49% higher in unilateral AK amputee patients and 280% higher in bilateral AK amputee patients.
Pinzur et al. performed a study to measure cardiac function and oxygen consumption in 25 patients who underwent amputation for peripheral vascular disease (PVD), and in five similarly aged control patients without PVD. They found Normal walking speed and cadence decreased and oxygen consumption per meter walked increased with more proximal amputation. They conclude that peripheral vascular insufficiency amputees function at a level approaching their maximum functional capacity and more proximal amputation levels, the capacity to walk short or long distances is greatly impaired.
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OrthoCash 2020
A 25-year-old man sustains the injury shown in Figures A-C. What is the primary advantage of using a trochanteric flip osteotomy (TFO) in treating this injury?
It may be performed in a minimally invasive manner
It involves minimal soft tissue stripping
It leads to higher union rates
It allows the surgeon to address all sites of injury through one approach
This patient has sustained a right hip fracture-dislocation with fractures of the femoral head and posterior wall. The TFO allows the surgeon to address all sites of injury through a single approach.
Femoral head fracture-dislocations are a result of high-energy trauma. Treatment ranges from closed reduction and conservative management to total hip arthroplasty. Intermediate options include open reduction and internal fixation or excision of fracture fragments. Complications of this injury include post-traumatic hip arthritis, avascular necrosis, and heterotopic ossification.
The injury is further complicated when a fracture of the acetabulum is concomitantly present. There has been no consensus treatment on this injury constellation as it presents quite rarely. The TFO is one approach that allows the surgeon to treat and stabilize both injuries concurrently. It should be noted that a surgical hip dislocation is performed in conjunction with the TFO to allow access to the femoral head.
Solberg et al. performed a retrospective study of patients sustaining Pipkin IV fracture/dislocations with a TFO. They had 12 patients over a 6 month period. They found that all patients healed radiologically and one patient developed osteonecrosis. 10 out of 12 patients had good to excellent outcomes. They concluded that using a surgical protocol with TFO rendered clinical results
comparable to previously reported outcomes in a series of isolated femoral head fractures.
Giannoudis et al. performed a systematic review to investigate data regarding femoral head fractures, particularly focusing on their management, complications and clinical results. They reported that fracture-dislocations were managed with emergent closed reduction, followed by definite treatment, aiming at an anatomic restoration of both fracture and joint incongruity. They concluded that neither the TFO nor an anterior approach seems to endanger femoral head blood supply compared to the posterior one, with the TFO possibly providing better long-term functional results and lower incidence of major complication rates.
Henle et al. reported on the result of 12 patients of femoral head fractures with associated posterior wall fractures treated with a TFO. They found good to excellent results in 10 patients. The two patients with poor outcome developed avascular necrosis of the femoral head and underwent total hip arthroplasty.
Heterotopic ossification was seen in five patients. They concluded that the TFO may lead to favorable outcomes in this injury constellation.
Figure A is an AP radiograph of the right hip demonstrating a femoral head fracture-dislocation. Figure B is an axial CT image demonstrating a posterior wall fracture. Figure C is an axial CT image demonstrating a femoral head fragment within the acetabulum. Illustration A is the Pipkin classification of femoral head fractures: Type I is below the fovea, Type II is above the fovea, Type III is associated with a femoral neck fracture, and Type IV is associated with an acetabular fracture.
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OrthoCash 2020
A 30-year-old male is brought to your emergency department following a motor vehicle collision at high speed. He is intubated in the field for airway protection but is hemodynamically stable. Subsequent workup shows a displaced acetabular fracture, in addition to an intracranial bleed and liver laceration which do not require surgery. When placing an antegrade anterior column screw, what radiographic view should be used to avoid intra-pelvic screw penetration?
Iliac oblique view with hip and knee flexed
Iliac oblique inlet view
Obturator oblique view with hip and knee flexed
Obturator oblique outlet view
Obturator oblique inlet view
Corrent answer: 2
The iliac oblique inlet view will best show the the anterior-posterior placement of an anterior column ramus screw.
Percutaneous and limited-open acetabular fixation is becoming increasingly common as it avoids the morbidity of extensile pelvic dissection and allows early mobilization. However, it relies heavily on a mastery of radiographic landmarks and ability to interpret these images to reduce fracture fragments without direct visualization. Slight deviations of the fluoroscopy beam and/or fracture displacement will distort the radiographic image. Without a facile ability to interpret these and make appropriate adjustments, percutaneous fixation will be extremely onerous.
Starr et al. described their early techniques for percutaneous and limited-open acetabular fixation. They first implemented this for minimally displaced fracture patterns but have expanded these to a wider range of pathology. They cite the benefit of earlier mobilization in the poly-traumatized patient as great use for this technique.
Mauffrey et al. reviewed radiograph utilization during acetabular fracture care. Though CT has added tremendously to demonstrating subtleties of acetabular fractures, they state the use of AP and orthogonal iliac and obturator oblique Judet views cannot be overlooked. Interpreting these radiographs allows the surgeon to recreate 2-dimensional images into a 3-dimensional fracture pattern and better understand the character of the injury.
Illustrations A and B demonstrate the iliac oblique inlet view and obturator oblique outlet views, respectively.
Illustration C demonstrates the relationship of the critical structures at risk of injury during anterior column screw placement. Illustrations D and E show the starting point with screw trajectory, and position of the hip during posterior column screw.
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OrthoCash 2020
A 34-year-old male sustains the injury shown in Figures A and B. Which factor has been found to be elevated in the synovial fluid and contributes to post-traumatic arthritis?
TGF-Beta
RANKL
IL-2
IL-6
cAMP
The patient has sustained a tibial plafond or pilon fracture as depicted in Figures A and B. IL-6 is one of many inflammatory molecules that has been found to be elevated in the synovial fluid following an intra-articular ankle fracture.
Post-traumatic arthritis following intra-articular fractures is a known complication. It commonly appears 1-2 years following injury and is related to chondrocyte death at the margins. There has not been shown to be any association between prolonged non-weight bearing, poor patient compliance with weight-bearing restrictions, and hardware reactions with the development of post-traumatic arthritis. However, literature has shown that the inflammatory molecules present in the synovial fluid can have a significant effect on the development of posttraumatic arthritis. Important inflammatory factors that have been found to be elevated include IL-6, IL-8, MMP-1, MMP-2, MMP-3, MMP-9 and MMP-10.
Adams et al. looked at the synovial fluid of 21 patients with an intra-articular ankle fracture and used the un-injured ankle as a control. They found the inflammatory molecules of GM-CSF, IL-10, IL-1 beta, IL-6, IL-8, IL-10, IL-12p70, TNF-alpha, MMP-1, MMP-2, MMP-3, MMP-9, MMP-10 were all elevated. They concluded that these inflammatory molecules may play a role in posttraumatic arthritis development.
Adams et al. looked at the synovial fluid of 7 patients from his previous 21 patients that had intra-articular ankle fractures. They found that IL-6, IL-8, MMP-1, MMP-2, and MMP-3 were significantly elevated in comparison to the uninjured ankle. They concluded that the sustained elevated intra-articular inflammatory environment is a potential contributor to post-traumatic arthritis.
Figures A and B are sagittal and axial CT slices, respectively, that depict a tibial plafond or pilon fracture.
Incorrect Answers:
immune system.
OrthoCash 2020
A 29-year-old female presents to the trauma bay from the scene of a high-speed motor vehicle accident. She is found to have a closed intraarticular distal radius fracture with a concomitant ulnar styloid base fracture. She subsequently undergoes ORIF of the distal radius fracture with a volar locking plate. The ulnar styloid fracture is not addressed. Which of the following, if present, is least likely to affect functional outcomes?
Ulnar styloid nonunion
DRUJ instability
Articular step-off >3mm
Radial shortening
Workers compensation claim
Corrent answer: 1
Ulnar styloid non-unions do not affect the overall outcome of hand or wrist function following ORIF of distal radius fractures.
Ulnar styloid base fractures can be associated with DRUJ disruption and TFCC rupture. The DRUJ should be independently evaluated following ORIF of the distal radius. Without instability, unlar styloid fractures do not need to be addressed. If instability exists, the DRUJ should be treated as a separate entity, typically cross-pinned using k-wires. The result of ulnar styloid nonunions are inconsequential to the overall outcome of patients undergoing distal radius ORIF.
Daneshvar et al review the effects of ulnar styloid fractures on patients sustaining distal radius fractures. They report that patients with a concomitant ulnar styloid fracture had a slower recovery of wrist flexion and grip strength compared to those with an isolated distal radius fracture. They conclude, however, that even the presence of an ulnar styloid nonunion did not significantly affect outcomes.
Buijze et al review the clinical impact of united versus non-united fractures of the proximal half of the ulnar styloid following volar plate fixation of the distal radius. They report no difference in motion, strength or outcome scores
between the united and non-united groups at 6 months follow up. They conclude that nonunion of the ulnar styloid does not have an effect on the overall outcome of hand or wrist function.
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OrthoCash 2020
Which of the following proximal humerus fractures has the highest likelihood of developing humeral head ischemia?
Posteromedial calcar length of the humeral head less than 8 mm and a loss of medial hinge are among the most reliable predictors of ischemia in the surgical management of humeral head fractures.
Proximal humerus fractures are classified based on the Neer classification, in which 4 parts are described: greater tuberosity, lesser tuberosity, articular surface, and the shaft. A fragment is considered a part if it is greater than 45 degrees angulated or displaced >1cm. The posterior humeral circumflex artery is the main blood supply to the humeral head. Following ORIF, humeral head ischemia may occur and is associated with the initial fracture pattern. Several factors including <8mm of calcar length attached to the articular segment, disruption of the medial hinge, displacement >10mm and angulation >45 degrees have been associated with a disruption of the vascular supply to the humeral head.
Campochiaro et al review Hertel’s criteria of calcar length and medial hinge integrity and its reliability in predicting humeral head necrosis. They reported a 3.7% incidence of ischemia across all 267 fractures evaluated. In those patients that developed AVN, 30% had all of the predictors described by Hertel, however, in the non-AVN group, only 4.7% had these same findings.
They concluded that while Hertel’s criteria are helpful, they may not be sufficient and the authors recommended 3-dimensional evaluation of any fracture involving the calcar.
Xu et al reviewed avascular necrosis in patients with proximal humerus fractures who were treated surgically. They reported on 291 patients throughout 7 studies in which there was no difference in the incidence of AVN for those treated surgically or nonoperatively. However, they concluded through subgroup analysis looking at different fixation constructs that, plate fixation specifically was associated with a higher risk of AVN than conservative management of proximal humerus fractures.
Figure A demonstrates a proximal humerus fracture with a medial calcar length of >8mm attached to the articular segment. Figure B is a proximal humerus fracture with a displaced greater tuberosity fragment. Figure C demonstrates a proximal humerus fracture with a medial calcar length of <8mm attached to the articular segment. Figure D is a displaced metadiaphyseal proximal humerus fracture in a skeletally immature patient. Figure E is a radiograph of a metadiaphyseal proximal humerus fracture in a skeletally mature patient with a medial calcar length >8mm.
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OrthoCash 2020
A 34-year-old man presents with the closed injury depicted in Figure A after a high energy twisting injury. Which of the other injuries below is most commonly associated with his known injury?
Nondisplaced medial malleolus vertical shear fracture
Nondisplaced Volkmann's fragment
Nondisplaced Chaput's fragment
Nondisplaced lateral wall talar fracture
Posterior inferior tibiofibular ligament disruption
Corrent answer: 2
This patient has sustained a distal third tibial shaft spiral fracture, which is commonly associated with nondisplaced posterior tibial plafond fractures, with the classic Volkmann's fragment.
Prior to operative management, distal third spiral tibial shaft fractures should always be evaluated for intra-articular extension. As this commonly associated injury can be missed on plain radiographs, an ankle CT is often recommended. This is especially important when intramedullary fixation is used for definitive management of the tibial shaft fracture, as nail insertion can displace a
previously nondisplaced intraarticular fracture. Anterior to posterior lag screw fixation prior to nailing may be useful in these cases.
Sobol et al. investigated the incidence of concomitant posterior malleolar fractures (PMFs) in operative distal third spiral tibial shaft fractures. They reported that spiral distal third tibial shaft fractures were identified with an ipsilateral posterior malleolus fracture in 92.3% of cases. They recommended a preoperative ankle CT in all cases with this specific fracture morphology to properly diagnose this commonly associated injury.
Hou et al. investigated the posterior malleolar fracture association with spiral tibial shaft fractures. They reported that plain radiography (both preoperative and intraoperative) resulted in rare identification of these associated injuries, which resulted in missed injuries. They concluded that a CT or MRI ankle may be a higher yield method to detect these injuries.
Figure A demonstrates a distal third spiral tibial shaft fracture. Illustration A is a schematic demonstrating the Volkmann, Chaput, and medial malleoli intraarticular fragments of the distal tibia.
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OrthoCash 2020
An 18-year-old male is admitted for a diaphyseal, open, tibial shaft fracture after falling off a motorcycle. He has a past medical history of nicotine dependence and obesity. He undergoes provisional splinting by the resident on call and is noted to be "neurovascularly intact" following splint placement. Throughout the evening, however, the patient has an increasing narcotic requirement and develops pain with passive stretch of his toes. What factor listed below is most associated with his progressive symptoms overnight?
Age < 20
Male gender
Body mass index >/ 30 kg/m^2
Open fracture
Nicotine use
The highest prevalence of compartment syndrome is found in patients aged 12-19 years, followed by 20-29 years.
One theory for the higher prevalence of compartment syndrome in younger patients is increased muscle mass in this cohort. If there is more muscle in a compartment, there is less room for swelling. On the flip side, elderly or deconditioned patients who have less muscle or fatty atrophy may be better able to accommodate muscle swelling. Additionally, a diaphyseal fracture location is associated with a higher risk of compartment syndrome. Again, this may be due to the fact that there is more muscle than tendon, and thus more swelling, in the proximal leg.
Shadgan et al. retrospectively reviewed 1,125 patients with diaphyseal tibia fractures to look for risk factors associated with the development of compartment syndrome. Compartment syndrome occurred in approximately 8% of patients with this injury. They concluded that younger patients were at a higher risk of developing compartment syndrome and that male gender, open fracture, and intramedullary nailing were not risk factors.
Beebe et al. set out to determine the correlation between the OTA/AO classification of tibia fractures and the development of compartment syndrome. they conducted a retrospective review of a prospectively collected database comprising 2,885 fractures. They concluded that age, sex, and the OTA/AO classification were highly predictive for the development of compartment syndrome in this cohort.
McQueen et al. similarly looked at predictors of compartment syndrome after tibial fractures in a retrospective cohort study. There were 1,388 patients in their study with ages ranging from 12-98; identical to the Shadgan study, 69% of patients were male. They concluded the strongest risk factor was age, with the highest prevalence in 12 to 19-year-olds.
Park et al. additionally analyzed 414 patients with tibia fractures in a retrospective cohort study. The main outcome measure of this study was the rate of clinically determined compartment syndromes requiring fasciotomy by anatomic region. The found that diaphyseal fractures were more frequently associated with the development of compartment syndrome than proximal (next most common site) and distal tibia fractures, specifically in younger patients.
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OrthoCash 2020
Figure A is the radiograph of a 79-year-old female with elbow pain following a fall. Compared with a total elbow artrhoplasty, open reduction and internal fixation would most likely result in?
Greater Mayo Elbow Performance Score
Greater Disabilities of the Arm, Shoulder and Hand Score
Increased flexion-extension arc
Increased reoperation rate
Decreased complication rate
Corrent answer: 4
This patient sustained a comminuted distal humerus fracture. Open reduction and internal fixation (ORIF) is found to have higher repoeration rates compared with total elbow arthroplasty (TEA) in the elderly: 27% versus 12%, respectively.
Distal humerus fractures account for approximately 30% of elbow fractures. There is often a low energy mechanism of injury in the elderly patient. While ORIF and TEA may be utilized in bicolumnar distal humerus fractures in the elderly patient, recent literature has demonstrated favorable outcomes with TEA in this aged cohort. TEA is indicated in the low demand osteoporotic patients with bicolumnar distal humerus fractures that are not amendable to ORIF. Utilization of TEA has demonstrated greater functional outcome scores, greater motion, less complications, and a lower revision rate.
Mckee et al. conducted a prospective, randomized, controlled trial comparing functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with ORIF or primary semiconstrained TEA. They reports that patients who underwent TEA had significantly better motion, performance and outcome scores, lower reoperation rates compared with the ORIF group. They concluded that TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF and that TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation.
Githens et al. performed a systematic review and meta-analysis to analyze outcomes and complication rates in elderly patients with intra-articular distal humerus fractures being treated with either TEA or ORIF with locking plates. They report that TEA and ORIF for the treatment of geriatric distal humerus fractures produced similar functional outcome scores and range of motion.
However, they found a non-statistical trend toward a higher rate of major complications and reoperation after ORIF. They conclude that the quality of study methodology was generally weak and ongoing research including prospective trials and cost analysis is indicated.
Figure A is the AP radiograph of a comminuted bicolumnar distal humerus
fracture. Illustration A are the radiographs of a comminuted distal humerus fracture in an elderly patient treated with a TEA. Illustration B is the postoperative radiographs of a comminuted distal humerus fracture treated with ORIF.
Incorrect Answers:
OrthoCash 2020
Figure A is the postoperative radiograph of an 82-year-old female who was treated with a cephalomedually nail for a left intertrochanteric hip fracture. Which of the following is the most common complication following use of this device?
Anterior perforation of distal femur
Breakage of the screw
Implant cutout
Malunion
Nonunion
Intertrochanteric hip fractures are most commonly treated with a cephalomedullary nail. The most common complication following utilization of a cephalomedullary nail is implant failure and cutout.
Intertrochanteric hip fractures are extra-capsular injuries that are common in the elderly osteoporotic patient. These injuries carrry a 20-30% mortality rate in the first year following fracture. Femoral cephalomedullary nails are often used to treat these injuries. Often a helical blade or screw may be used to provide fixation within the femoral neck. Overall, the most common complication following use of this device is implant failure and cutout, which occurs most commonly within 3 months following surgery. A known risk factor of this complication is an increased tip-apex distance, with a 60% failure rate reported with a distance exceeding 45mm.
Gardner et al. reviewed the use of a helical blade device to stabilize
intertrochanteric hip fractures. They reported a mean telescoping in unstable and stable fractures of 4.3 mm and 2.6 mm, respectively. They also found that blade migration within the femoral head averaged 2.2 mm overall, with no difference between stable and unstable fractures. They concluded that position changes occurred within the first 6 weeks postoperatively, with no subsequent detectable migration or telescoping.
Haidukewych et al. reviewed patients with failed internal fixation of a hip fracture. They report that salvage options are dependent on the anatomic site of the nonunion, the quality of the remaining bone and articular surface, and patient factors such as age and activity level. They conclude that in younger patients with either a femoral neck or intertrochanteric fracture nonunion with a satisfactory hip joint, treatment typically involves revision internal fixation with or without osteotomy or bone grafting. Conversely, in older patients with poor remaining proximal bone stock or a badly damaged hip joint, conversion to hip arthroplasty is recommended.
Figure A is the AP radiograph of the right hip treated with a cephalomedullary nail. Illustration A demonstrates screw cutout.
Incorrect Answers:
OrthoCash 2020
Figure A is the radiograph of a 42-year-old female who presents to the trauma bay following a motor vehicle collision. She subsequently undergoes ORIF through a posterior approach. Iatrogenic injury to which nerve in Figure B is most likely with this approach?

Question 18:

Options:

First metatarsophalangeal arthrodesis
Soft-tissue interposition arthroplasty
First metatarsophalangeal total joint arthroplasty
First metatarsophalangeal resurfacing hemiarthroplasty
Proximal phalanx dorsiflexion osteotomy (Moberg)

Correct Answer: First metatarsophalangeal arthrodesis

Explanation:

DISCUSSION: All but the Moberg osteotomy are capable of providing pain relief; however, arthrodesis offers the best long-term results and restores weight bearing and propulsion function to the first ray.
REFERENCES: Machacek F Jr, Easley ME, Gruber F, et al: Salvage of a failed Keller resection arthroplasty. J Bone Joint Surg Am 2004;86:1131-1138.
Myerson MS, Schon LC, McGuigan FX, et al: Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int
2000;21:297-306.

Question 19:

Methicillin-resistant staphylococcus aureus (MRSA) develops its resistance to penicillinase-stable antibiotics via which of the following actions?

Options:

Alterations in cell wall permeability
Genetic mutation
Creation of a biofilm barrier
Production of active efflux pump
Altering peptidoglycan subunits

Correct Answer: Genetic mutation

Explanation:

Question 20:

A 50-year-old woman with a 2-part surgical neck proximal humerus fracture and metaphyseal comminution

Options:

Initial period of sling immobilization followed by physical therapy
Open reduction and internal fixation with or without bone grafting
Reverse total shoulder arthroplasty (rTSA)
Hemiarthroplasty
Unconstrained (TSA)
Closed reduction and Kirschner wire (K-wire) stabilization

Correct Answer: Open reduction and internal fixation with or without bone grafting

Explanation:

DISCUSSION
Proximal humerus fractures account for approximately 5% of all fractures, with incidence increasing to reflect an aging population and related osteoporosis. Treatment is dependent upon the mechanism of injury, the patient’s physiologic age and activity level, the fracture pattern, and rotator cuff integrity. Most of these injuries are nondisplaced or minimally displaced and are associated with a good overall prognosis with nonsurgical treatment and temporary impairment. A patient with a nondisplaced surgical neck fracture should be treated without surgery. K-wire stabilization, although technically difficult to achieve, is an option for compliant patients with 2-part, 3-part, and valgus-impacted 4-part fractures who have adequate bone stock. Valgus-impacted 4-part fractures pose reduced risk for osteonecrosis because of the preserved blood supply through the medial hinge, which allows for this technique. For displaced 2-part fractures accompanied by
metaphyseal comminution, K-wire fixation cannot provide adequate stability to initiate a graduated home exercise or outpatient physical therapy program. Formal open reduction with intramedullary or plate fixation in addition to bone grafting (fibular strut allograft) is the best surgical option for the clinical scenario involving a displaced surgical neck fracture with comminution. Osteosynthesis of 3-part fractures may be feasible for physiologically young and active patients without humeral head involvement and osteoporosis.
Current indications for primary hemiarthroplasty include most 4-part fractures, 3-part fractures and dislocations in elderly patients with osteoporotic bone, head-splitting articular segment fractures, and chronic anterior or posterior humeral head dislocations with more than 40% of articular surface involvement. Because of the intra-articular nature of this patient’s 4-part injury in this scenario, hemiarthroplasty with anatomic reconstruction of the greater and lesser tuberosities is most appropriate. Relative indications for hemiarthroplasty also include fractures with more than 20 degrees of varus, associated moderate to severe osteopenia, and revision surgery for failed osteosynthesis. Currently accepted indications for rTSA include scenarios in which the fracture pattern, level of comminution, bone quality, and rotator cuff deficiency preclude plate fixation or hemiarthroplasty. Scenarios involving 4-part fractures and associated rotator cuff tears and tuberosity comminution are best served with a reverse shoulder prosthesis. One of the positive attributes of this implant is the ability to achieve functional forward flexion and abduction regardless of tuberosity healing, position, and degree of comminution. Caution is warranted with this surgical technique because complication rates are higher than for hemiarthroplasty reconstruction. Acute, irreducible 2-part fracture-dislocations of the proximal humerus necessitate open reduction and internal fixation of the affected tuberosities (posterior, lesser tuberosity; anterior, greater tuberosity) through screw, anchor, and/or suture fixation. These fracture-dislocations can be managed with this technique because of the integrity of the vascular supply, which is maintained by the soft-tissue attachments to the intact tuberosities. Repeated attempts at a closed reduction in the 37-year-old with the posterior fracture-dislocation could result in neurovascular injury and myositis ossificans and should be avoided. Arthroplasty reconstruction in this scenario should not be the index procedure in light of concerns regarding implant survivorship in patients of this age and their assumed elevated activity levels.
RECOMMENDED READINGS
Harrison AK, Gruson KI, Zmistowski B, Keener J, Galatz L, Williams G, Parsons BO, Flatow EL. Intermediate outcomes following percutaneous fixation of proximal humeral fractures. J Bone Joint Surg Am. 2012 Jul 3;94(13):1223-8. doi: 10.2106/JBJS.J.01371.
View Abstract at PubMed
Iannotti JP, Ramsey ML, Williams GR Jr, Warner JJ. Nonprosthetic management of proximal humeral fractures. Instr Course Lect. 2004;53:403-16. Review.
View Abstract at PubMed
Mata-Fink A, Meinke M, Jones C, Kim B, Bell JE. Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review. J Shoulder Elbow Surg. 2013 Dec;22(12):1737-48. doi: 10.1016/j.jse.2013.08.021. Review.
View Abstract at PubMed
Jobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg. 2015 Mar;23(3):190-201. doi: 10.5435/JAAOS-D-13-00190. Epub 2015 Jan 28. Review.
View Abstract at PubMed
Bae JH, Oh JK, Chon CS, Oh CW, Hwang JH, Yoon YC. The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus. J Bone Joint Surg Br. 2011 Jul;93(7):937-41.
View Abstract at PubMed
Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. 2008 Nov;90(11):1407-13. doi: 10.1302/0301-620X.90B11.21070. Review. PubMed PMID: 18978256.
View Abstract at PubMed
Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004 Jul-Aug;13(4):427-33. PubMed PMID: 15220884.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 67 THROUGH 70
Figure 67 is the radiograph of a right-hand-dominant 70-year-old woman who arrives at the emergency department with acute left shoulder pain following a fall down a flight of stairs. She expresses acute diffuse left shoulder pain and swelling. Prior to her injury, she had full active painless shoulder range of motion.

Question 21:

Options:

Artery medial, then lateral
Artery lateral, then medial
Artery always medial
Artery always lateral
Artery always deep

Correct Answer: Artery medial, then lateral

Explanation:

DISCUSSION: At the ankle level, the anterior tibial artery lies medial to the EHL tendon. The artery becomes the dorsalis pedis after crossing onto the dorsum of the foot. At this point, the artery lies lateral to the tendon.
REFERENCES: Resch S: Functional anatomy and topography of the foot and ankle, in Myerson M (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 1, pp 25-49.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 22:

Of the following clinical situations, which is most likely to lead to osteonecrosis associated with a slipped capital femoral epiphysis (SCFE)?

Options:

A girl younger than age 15 years
A boy younger than age 15 years
An unstable SCFE
A stable SCFE
A stable SCFE associated with morbid obesity

Correct Answer: An unstable SCFE

Explanation:

DISCUSSION: Osteonecrosis of the femoral head is the most devastating complication of SCFE. There is a 47% incidence of ischemic necrosis associated with an unstable SCFE. By definition, the patient with an unstable SCFE is unable to bear weight even with crutches. Osteonecrosis is most likely associated with the initial femoral head displacement rather than the result of either tamponade from hemarthrosis or from gentle repositioning prior to stabilization. Age, sex, and obesity are not risk factors for osteonecrosis.
REFERENCES: Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 2, pp 711-745.

Question 23:

All of the following techniques can help to prevent apex-anterior angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT:

Options:

posterior blocking screw
posterior starting hole
interlocking the nail in a semi-extended knee position
anteriorly directing the nail
anterior blocking screw

Correct Answer: posterior blocking screw

Explanation:

Question 24:

Metal-on-metal articulation has been reintroduced because of concern about polyethylene wear. This type of articulation is considered favorable because

Options:

metal particles are inert.
metal particles are larger than polyethylene particles.
the surfaces can now be fabricated with low carbon, machined cobalt-chromium.
less than 0.6 mm 3 of metallic debris are generated per year.
electrochemical problems of the articulation have now been solved through passivation.

Correct Answer: less than 0.6 mm 3 of metallic debris are generated per year.

Explanation:

Question 25:

Options:

There is a significantly higher risk of infection.
There is a significantly higher risk of growth disturbance.
There is a significantly higher risk of arthrofibrosis and loss of knee motion.
There is a significantly higher risk of graft failure and need for revision surgery.
There is a significantly higher risk of graft failure in low-dose (<2 Mrad) gamma-irradiated allografts only.

Correct Answer: There is a significantly higher risk of infection.

Explanation:

Question 26:

Options:

Hemoglobin
Myoglobin
Melanin
Copper
Hemosiderin

Correct Answer: Hemosiderin

Explanation:

DISCUSSION: Pigmented villonodular synovitis (PVNS) is a synovial proliferative disorder that remains a diagnostic difficulty. The most common clinical features are mechanical pain and limited joint motion. On radiographs, the classic finding is often a large lesion, associated with multiple lucencies. Other findings may include a normal radiographic appearance, loss of joint space, osteonecrosis of the femoral head, or acetabular protrusion. MRI is the imaging modality of choice and will show the characteristic findings of a joint effusion, synovial proliferation, and bulging of the hip. The synovial lining has a low signal on T
1
- and T
2
-weighted images, secondary to hemosiderin deposition. Copper deposition occurs in patients with Wilson’s disease, which mainly affects the liver.
REFERENCES: Bhimani MA, Wenz JF, Frassica FJ: Pigmented villonodular synovitis: Keys to early diagnosis. Clin Orthop 2001;386:197-202.
Cotten A, Flipo RM, Chastanet P, et al: Pigmented villonodular synovitis of the hip: Review of radiographic features in 58 patients. Skeletal Radiol 1995;24:1-6.

Question 27:

What is the most frequent location of entrapment of the deep peroneal nerve?

Options:

Tendon of the extensor hallucis brevis
Inferior extensor retinaculum
Osteophytes of the talonavicular joint
Os intermetatarseum
Base of the fifth metatarsal

Correct Answer: Inferior extensor retinaculum

Explanation:

DISCUSSION: The most frequently described entrapment of the deep peroneal nerve is the anterior tarsal tunnel syndrome. This syndrome refers to entrapment of the deep peroneal nerve under the inferior extensor retinaculum. Entrapment can also occur as the nerve passes under the tendon of the extensor hallucis brevis. Compression by underlying dorsal osteophytes of the talonavicular joint and an os intermetatarseum (between the bases of the first and second metatarsals) have previously been described in runners.
REFERENCES: Kopell HP, Thompson WA: Peripheral entrapment neuropathies of the lower extremity. N Engl J Med 1960;262:56-60.
Schon LC, Mann RA: Diseases of the nerves, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 1, pp 675-677.

Question 28:

Options:

Revision of the polyethylene liner, removal of the screw, and debridement of the osteolytic lesion with or without bone grafting
Revision of the acetabular component to a newer design without screws
Removal of the screw, revision of the polyethylene liner, and stem cell injection into the lytic lesion
Removal of the offending screw from the metal socket and placement of a new polyethylene liner in the existing socket

Correct Answer: Revision of the polyethylene liner, removal of the screw, and debridement of the osteolytic lesion with or without bone grafting

Explanation:

Question 29:

Options:

rest, ice, anti-inflammatory drugs, and a gradual return to physical activity.
primary acute surgical repair.
delayed repair after failed nonsurgical management.
a steroid injection.
referral for immediate physical therapy.

Correct Answer: primary acute surgical repair.

Explanation:

Question 30:

Options:

Penicillin G
Cefazolin sodium
Oxacillin
Ampicillin sodium/sulbactam sodium
Gentamicin

Correct Answer: Ampicillin sodium/sulbactam sodium

Explanation:

Question 31:

Options:

Enchondroma
Osteochondroma
Chondroblastoma
Ewing’s sarcoma
Chondrosarcoma

Correct Answer: Osteochondroma

Explanation:

Question 32:

- The pharmacologic action of botulinum-A toxin can be best described as

Options:

Prevention of presynaptic release of acetylcholine
Prevention of synthesis of presynaptic acetylcholine
Activation of acetylcholinesterase at the motor end-plate
Blockage of postsynaptic action of acetylcholine until reserves are depleted
Stimulation of release of presynaptic acetylcholine until reserves are depleted

Correct Answer: Prevention of presynaptic release of acetylcholine

Explanation:

Question 33:

Options:

Five days of intravenous antibiotics for perioperative prophylaxis
Use of continuous passive motion beginning on postoperative day one
Immediate initiation of active flexion and gravity-assisted passive extension
Splinting at 60 to 90 degrees of flexion for 5 to 10 days, followed by initiation of active flexion and gravity-assisted passive extension
Splinting at 60 to 90 degrees of flexion until the triceps has healed, followed by initiation of active flexion and extension

Correct Answer: Splinting at 60 to 90 degrees of flexion for 5 to 10 days, followed by initiation of active flexion and gravity-assisted passive extension

Explanation:

Question 34:

-Ten or more years after severe polytrauma, premenopausal women, compared to men

Options:

need less psychological support.
are less likely to feel well rehabilitated.
have a shorter duration of rehabilitation.
show no difference in quality-of-life scores.
show higher rates of posttraumatic stress disorder and take more sick leave time.

Correct Answer: show higher rates of posttraumatic stress disorder and take more sick leave time.

Question 35:

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

Options:

Fibrosis
Lymphedema
Wound necrosis
Local recurrence
Neuropathy

Correct Answer: Wound necrosis

Explanation:

DISCUSSION: Radiation therapy is commonly used as an adjuvant in the treatment of soft-tissue sarcomas, but a controversy exists whether it should be preoperative or postoperative. Radiation therapy can be given prior to or following resection of the tumor. Postoperative radiation is usually given in a higher dose to a larger treatment field. This commonly results in a higher incidence of fibrosis and lymphedema. There is no statistical difference in local recurrence rate between the two radiation treatment plans. Neuropathy is more commonly a complication of chemotherapy. Preoperative radiation therapy has been shown to have a higher wound complication rate than postoperative radiation.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.
Davis AM, O’Sullivan B, Turcotte R, et al: Late radiation morbidity following randomization to preoperative versus postoperative radiotherapy in extremity soft tissue sarcoma. Radiother Oncol 2005;75:48-53.

Question 36:

Options:

Lunotriquetral fusion
Distal radioulnar joint (DRUJ) tenodesis
Triangular fibrocartilage complex (TFCC) repair
Extensor carpi ulnaris (ECU) tendon sheath reconstruction Upon examination, this patient is exhibiting dislocation of the ECU tendon because of a disrupted sheath. He has failed nonsurgical measures, so surgery that would involve either direct repair or reconstruction of the tendon sheath is indicated. An option for reconstruction is to use a portion of the extensor retinaculum as a sheath substitute. Deepening of the ECU tendon groove at the distal ulna with direct repair of the sheath is another option, although a 2016 paper by Ghatan and associates did not find depth of the groove as a risk factor for subluxation. TFCC repair, lunotriquetral fusion, and DRUJ tenodesis are not appropriate because the examination clearly shows ECU tendon dislocation. TFCC and lunotriquetral ligament tears can occur along with ECU tendon dislocation, but no other examination findings suggest these conditions for this patient.

Correct Answer: Extensor carpi ulnaris (ECU) tendon sheath reconstruction Upon examination, this patient is exhibiting dislocation of the ECU tendon because of a disrupted sheath. He has failed nonsurgical measures, so surgery that would involve either direct repair or reconstruction of the tendon sheath is indicated. An option for reconstruction is to use a portion of the extensor retinaculum as a sheath substitute. Deepening of the ECU tendon groove at the distal ulna with direct repair of the sheath is another option, although a 2016 paper by Ghatan and associates did not find depth of the groove as a risk factor for subluxation. TFCC repair, lunotriquetral fusion, and DRUJ tenodesis are not appropriate because the examination clearly shows ECU tendon dislocation. TFCC and lunotriquetral ligament tears can occur along with ECU tendon dislocation, but no other examination findings suggest these conditions for this patient.

Explanation:

Question 37:

Options:

A branch of the femoral artery
An anastomosis between the external iliac artery and obturator artery
An anastomosis between the external iliac and femoral artery
Internal iliac artery
External iliac artery

Correct Answer: An anastomosis between the external iliac artery and obturator artery

Explanation:

Question 38:

Sex-linked recessive Pseudohypoparathyroidism (AHO) - end-organ insensitivity; in AHO, germline mutation that leads to loss of function of Galpha S (GNAS1); causes end-organ resistance to PTH

Options:

PHP - short stature, short metacarpals (4th and 5th), rounded facies
Mental retardation, tetany
Sex-linked dominant
Laboratory features
Hypocalcemia
Hyperphopshatemia
Normal PTH

Correct Answer: Sex-linked dominant

Explanation:

Which of the following is the defect in pseudohypoparathyroidism (Albright Hereditary Osteodystrophy [AHO]):

Question 39:

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

Options:

3 days
1 week
10 days
2 weeks
6 weeks

Correct Answer: 2 weeks

Explanation:

DISCUSSION: Revision anterior exposure within 2 weeks of total disk replacement incurs relatively little additional morbidity because adhesion formation is minimal. Surgeons should have a low threshold for revising implants that are clearly dangerously malpositioned or show early migration within this 2-week window. Beyond this time period, a revision strategy must be individualized to the particular clinical situation. A posterior fusion with instrumentation with or without a laminectomy is currently the most effective salvage procedure.
REFERENCE: Tortolani JP, McAfee PC, Saiedy S: Failures of lumbar disc replacement. Sem Spine Surg 2006;18:78-86.

Question 40:

Which of the following ligaments provides the major static restraint to lateral patellar displacement?

Options:

Medial patellotibial
Medial patellofemoral
Medial patellomeniscal
Lateral patellofemoral
Lateral patellotibial

Correct Answer: Medial patellofemoral

Explanation:

Question 41:

Options:

Basilar invagination of less than 1 cm
Anterior atlanto-dens interval of 4 mm
Posterior atlanto-dens interval of greater than 14 mm
Rotatory subluxation of less than 10 degrees
Subaxial subluxation of less than 3.5 mm

Correct Answer: Posterior atlanto-dens interval of greater than 14 mm

Explanation:

DISCUSSION: Boden and associates’ article presents compelling evidence that patients with rheumatoid arthritis and neurologic deterioration in C1-2 instability are more likely to achieve some improvement if the posterior atlanto-dens interval is greater than 10 mm on preoperative studies. All the patients in their series who had neurologic deterioration and a preoperative posterior atlanto-dens interval of greater than 14 mm achieved complete motor recovery.
REFERENCES: Boden SD, Dodge LD, Bohlman HH, et al: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.
Boden SD, Clark CR: Rheumatoid arthritis of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 755-764.
Monsey RD: Rheumatoid arthritis of the cervical spine. J Am Acad Orthop Surg 1997;5:240-248.

Question 42:

When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?

Options:

Addition of sublaminar wires to the midlumbar spine
Cross-linking of the longitudinal rods
Use of multiple claw hook fixation in the upper thoracic spine
Use of large-diameter rods and pedicle screws
Fixation into both the ilium and the sacrum

Correct Answer: Fixation into both the ilium and the sacrum

Explanation:

Question 43:

Tendons should have what ratio of matrix protein?

Options:

65% collagen type I and 35% proteoglycans
80% collagen type I and 20% collagen type VI
95% collagen type I and less than 5% collagen type III
95% proteglycans and 5% tenascin

Correct Answer: 95% collagen type I and less than 5% collagen type III

Explanation:

Question 44:

A 52-year-old woman has bicompartmental osteoarthritis following patellectomy. Treatment should consist of

Options:

high tibial osteotomy.
arthroscopic debridement.
patella arthroplasty.
total knee arthroplasty.
knee arthrodesis.

Correct Answer: total knee arthroplasty.

Explanation:

Question 45:

Options:

Plastic
Elastic
Fatigue
Creep
Torsion

Correct Answer: Elastic

Explanation:

Question 46:

Options:

Cardiac tamponade
Pulmonary contusion
Colonic rupture
Bladder rupture
Acute cholecystitis

Correct Answer: Acute cholecystitis

Explanation:

The clinical presentation is consistent with a Chance fracture of the spine. These fractures are often associated with concomitant bowel injury.
A Chance fracture injury is a flexion-distraction injury of the spine. The anterior column (vertebral body) collapses under compression and the posterior elements fail under tension (rupture of the interspinous ligaments or avulsion fracture of the spinous process). A common mechanism is a MVA where the child is wearing a seatbelt, leading to a "seatbelt sign". In the presence of a "seatbelt" sign, on should have a high suspicion for a bowel injury.
Reid et al. reported seven cases of pediatric patients with Chance fractures. All had associated intraabdominal bowel injury.
Holland et al. retrospectively reviewed 28 pediatric patients with Chance fractures, 71% sustained following road trauma. Eleven percent had associated small bowel injury, but all patients had abnormal abdominal CT scans.
Figure A is a clinical photo of a 'seatbelt sign' following a motor vehicle accident. Figure B exhibits a "bony" Chance fracture where the spinous process has been avulsed. Illustration A depict the failure of the anterior column under compression and failure of the posterior column under tension.
Incorrect answers:
(SBQ12SP.32) A 48-year-old man is involved in a motor vehicle accident and is taken to an outside hospital where he undergoes CT imaging, displayed in Figures A-B. Approximately 36 hours later he is transferred to your hospital for further evaluation and management. On exam, he has tenderness over his upper cervical spine and is neurologically intact with no myelopathic signs. What is the most appropriate treatment method for this patient and why?
Review
Topic
Soft cervical orthosis because his gender puts him at a low risk of nonunion.
Halo vest immobilization because the degree of fracture displacement puts him at a low risk of nonunion.
Anterior screw fixation because his delayed time to treatment puts him at an high risk of nonunion.
Posterior C1-C2 fusion with rigid instrumentation because his age puts him at a high risk of nonunion.
Posterior C1-C2 fusion with sublaminar wiring because the degree of fracture angulation puts him at a high risk of nonunion.
The patient has a type II odontoid fracture and should be managed with halo vest immobilization as he has minimal fracture displacement (< 5mm) and no other risk factors for nonunion.
Type II odontoid fractures comprise 35% of all C2 fractures and have the highest nonunion rate. Commonly cited risk factors for nonunion include posterior displacement, posterior angulation, delayed initiation of treatment, fracture comminution and advanced age. Patients without these risk factors can often be successfully managed with halo vest immobilization. Elderly patients are frequently unable to tolerate halo vest immobilization and can be placed in a rigid cervical orthosis. Patients at high risk for nonunion are generally managed surgically with either anterior screw fixation, posterior rigid fixation (C1-C2 transarticular screw construct versus C1 lateral mass screw + C2 pedicle screw construct), or posterior C1-C2 sublaminar wiring.
Greene et al found that type II odonotoid fractures that were displaced >/= 6mm had a nonunion rate of 86% compared to 18% in patients with < 6mm displacement. This was statistically significant regardless of direction of displacement. Age was not significantly associated with nonunion.
Koivikko et al performed a retrospective review of conservatively treated type II odontoid fractures and identified risk factors for nonunion. Fracture gap > 1mm, posterior displacement > 5mm, posterior angulation > 20°, delayed start of treatment
> 4 days and posterior redisplacement > 2mm were all correlated with nonunion. In this study, anterior displacement, gender and age were unrelated to nonunion.
Figures A and B are coronal and sagittal CT scans of the cervical spine, respectively, demonstrating a noncomminuted type II odontoid fracture with minimal posterior displacement and angulation.
Incorrect
Responses:

Question 47:

The posterior approach to the proximal radius uses what intermuscular interval?

Options:

Extensor carpi radialis brevis and extensor digitorum communis
Extensor carpi radialis longus and extensor digitorum communis
Extensor digitorum communis and extensor pollicis brevis
Brachioradialis and flexor carpi radialis
Anconeus and extensor carpi ulnaris

Correct Answer: Extensor carpi radialis brevis and extensor digitorum communis

Explanation:

DISCUSSION: Knowledge of intermuscular and internervous planes allows safe exposures throughout the body. The posterior (Thompson) approach to the proximal forearm uses the interval between the extensor carpi radialis brevis and extensor digitorum communis. The anterior (Henry) approach to the proximal forearm uses the interval between the brachioradialis and the flexor carpi radialis.
REFERENCES: Spinner M: Injuries to the Major Branches of Peripheral Nerves of the Forearm, ed 2. Philadelphia, PA, WB Saunders, 1978, pp 66-77.
Henry AK: Extensile Exposure, ed 3. New York, NY, Churchill Livingstone, 1995.

Question 48:

Options:

disruption of the sympathetic nerves during anterior lumbar exposure.
traction on the parasympathetic nerve at the L4-5 level.
not related to the surgical dissection.
injury to the pudendal nerves in the anterior sacral region during dissection at the L5-S1 level.
sexual dysfunction secondary to retrograde ejaculation.

Correct Answer: not related to the surgical dissection.

Explanation:

Question 49:

Options:

closed reduction and a non-weight-bearing cast.
closed reduction and a weight-bearing cast.
closed reduction and percutaneous pinning.
open reduction and casting.
open reduction and internal fixation.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 50:

Options:

irrigation and debridement.
single-stage exchange.
stage exchange.
observation.

Correct Answer: observation.

Explanation:

Question 51:

In a patient with vertebral tuberculosis, which of the following characteristics is most predictive of progression of the kyphosis?

Options:

Involvement of the vertebral body and posterior elements
Involvement of the thoracic vertebrae
Involvement of the lumbar vertebrae
Age of the patient
Pretreatment degree of kyphosis

Correct Answer: Involvement of the vertebral body and posterior elements

Explanation:

DISCUSSION: In patients with vertebral tuberculosis, involvement of the anterior and posterior elements creates an instability and severe kyphotic collapse can occur. This characteristic has been shown to have a stronger association than level of involvement, age, or pretreatment degree of deformity. In the absence of instability, anterior growth can resume after treatment, leading to a decrease in the deformity.
REFERENCES: Rajasekaran S: The natural history of post-tubercular kyphosis in children: Radiological signs which predict late increase in deformity. J Bone Joint Surg Br
2001;83:954-962.
Rajasekaran S, Shanmagasundaram TK, Prabhakar R, Dheenadhayalan J, Shetty AP, Shetty DK: Tuberculous lesions of the lumbosacral region: A 15-year follow-up of patients treated by ambulant chemotherapy. Spine 1998;23:1163-1167.

Question 52:

Options:

C6
Upper trunk
Middle trunk
Posterior cord
Lateral cord

Correct Answer: Lateral cord

Explanation:

DISCUSSION: The lateral cord terminates as the musculocutaneous nerve and also contributes sensory fibers to the median nerve. Involvement of the C6 root or upper trunk could potentially cause weakness of the infraspinatus and the brachioradialis. The middle trunk and the posterior cord do not contribute motor fibers to the thumb or sensory fibers to the thumb.
REFERENCE: Kline DG, Hudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries, Entrapments and Tumors. Philadelphia, PA, WB Saunders, 1995, p 334.

Question 53:

Options:

Posterosuperior labrum, greater tuberosity, articular side of the rotator cuff
Posterior glenoid, humeral head, bursal side of the rotator cuff
Biceps anchor, articular side of the rotator cuff, supraspinatus tendon
Biceps tendon, bursal side of the rotator cuff, superior labrum
Subscapularis, anterior labrum, humeral head

Correct Answer: Posterosuperior labrum, greater tuberosity, articular side of the rotator cuff

Explanation:

Question 54:

A 44-year-old patient who has had a proximal first metatarsal osteotomy has recurrent pain and difficulty wearing many types of shoes. Radiographs show a large 1-2 intermetatarsal angle (IMA).

Options:

Lapidus procedure
First metatarsophalangeal (MTP) joint arthrodesis and lesser metatarsal head resection
Proximal first metatarsal osteotomy
Distal first metatarsal chevron osteotomy
Biplanar distal first metatarsal osteotomy

Correct Answer: Lapidus procedure

Question 55:

Mirror therapy is indicated for which of the following clinical conditions?

Options:

Impaired proprioception after lower extremity injury
Two-stage flexor tendon reconstruction
Plumbism
Anterior cruciate ligament reconstruction
Phantom pain

Correct Answer: Impaired proprioception after lower extremity injury

Explanation:

Question 56:

Options:

Rotator cuff repair and biceps tenodesis
Rotator cuff repair and loose body removal
Latissimus dorsi transfer
Bankart repair

Correct Answer: Rotator cuff repair and biceps tenodesis

Explanation:

The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove. Biceps tendon subluxation is most frequently associated with subscapularis tendon pathology, which is indicated by the MRI and by a positive lift-off test. The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor
may experience a better functional result with latissimus dorsi transfer.

Question 57:

Options:

Flexor hallucis longus and flexor hallucis brevis
Flexor hallucis longus and adductor hallucis
Flexor hallucis brevis and adductor hallucis
Flexor hallucis longus and abductor hallucis
Flexor hallucis brevis and abductor hallucis

Correct Answer: Flexor hallucis brevis and adductor hallucis

Explanation:

DISCUSSION: Owens and Thordardson cautioned surgeons not to release the conjoined tendon from the base of the proximal phalanx of the great toe because of an increased risk of iatrogenic hallux varus. Release of the transverse and oblique heads of the adductor hallucis is largely accomplished by releasing the soft tissue adjacent to the lateral sesamoid, without releasing tissue from the base of the proximal phalanx. The conjoined tendon is made up of the flexor hallucis brevis and the adductor hallucis.
REFERENCES: Owens S, Thordardson DB: The adductor hallucis revisited. Foot Ankle Int 2001;22:186-191.
Sarrafian SK: Anatomy of the Foot and Ankle. Philadelphia, PA, JB Lippincott, 1983, chapter 5.

Question 58:

Figures 23a and 23b show the radiographs of a 75-year-old woman who sustained an injury to her nondominant hand. Initial treatment should consist of

Options:

closed reduction and splinting.
open reduction and internal fixation through a volar approach.
external fixation and Kirschner wire fixation.
intrafocal pinning and casting.
acceptance of alignment and bracing.

Correct Answer: closed reduction and splinting.

Explanation:

DISCUSSION: Definitive treatment decisions for displaced distal radius fractures in the elderly are based on a number of factors related to the fracture pattern and patient demographics. The first step in any treatment algorithm is a closed reduction and splinting with reassessment of alignment parameters. This is an extra-articular fracture with dorsal angulation. Low-demand elderly patients can be treated well with accepted minor malreduction.
REFERENCES: Handoll HH, Madhok R: Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;2:CD000314.
Young CF, Nanu AM, Checketts RG: Seven-year outcome following Colles’ type distal radial fracture: A comparison of two treatment methods. J Hand Surg Br 2003;28:422-426.

Question 59:

Options:

Osteoporosis
Hallux valgus deformity
Hallux rigidus
A relatively long second metatarsal

Correct Answer: A relatively long second metatarsal

Explanation:

Question 60:

Options:

Chondrolysis
Ischemic necrosis of the femoral head
Ischemic necrosis of the greater trochanter
Femoral neck fracture
Trochanteric overgrowth

Correct Answer: Ischemic necrosis of the femoral head

Explanation:

Question 61:

Options:

continued nonsurgical treatment.
hemiarthroplasty with partial rotator cuff repair.
reverse total shoulder arthroplasty with latissimus dorsi transfer.
rotator cuff repair without acromioplasty, preserving the coracoacromial ligament.
limited-goals debridement of the rotator cuff and glenohumeral joint without rotator cuff repair.

Correct Answer: reverse total shoulder arthroplasty with latissimus dorsi transfer.

Question 62:

Options:

Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty
ORIF of the acetabular fracture and ORIF of the femoral head fracture fragments
ORIF of the acetabular fracture and hemiarthroplasty
Skeletal traction with delayed total hip arthroplasty after the acetabular fracture has healed

Correct Answer: Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty

Explanation:

Question 63:

Where is the most common site for tuberculosis (TB) spondylitis in children?

Options:

Anterior aspect of the lower thoracic region
Anterior aspect of the cervical spine
Posterior elements of the lower thoracic region
Posterior elements of the cervical spine
Transverse process of the lower lumbar spine

Correct Answer: Anterior aspect of the lower thoracic region

Explanation:

DISCUSSION: In children, the main route of infection in skeletal TB is through hematogenous spread from a primary source. The mycobacterium is deposited in the end arterials in the vertebral body adjacent to the anterior aspect of the vertebral end plate. Thus, the anterior portion of the vertebral body is most commonly involved. The lower thoracic region is the most common segment; next in decreasing order of frequency are the lumbar, upper thoracic, cervical, and sacral regions.
REFERENCES: Teo HE, Peh WC: Skeletal tuberculosis in children. Pediatric Radiol 2004;34:853-860.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 1831-1835.

Question 64:

Options:

Arthroscopic capsular plication
Arthroscopic thermal shift
Arthroscopic subacromial decompression
Posterior capsular stretching
Selective external rotation stretching

Correct Answer: Posterior capsular stretching

Explanation:

DISCUSSION
: The examination reveals that the patient has posterior capsular tightness. Surgery should not be considered until the patient has failed to respond to nonsurgical management. The internal rotation contracture (GIRD - glenohumeral internal rotation deficit) should be addressed with appropriate posterior capsular stretching. This should then be followed by appropriate rotator cuff and scapular stabilization exercises. Only if this management fails to relieve the patient’s symptoms should surgery be considered. This patient clearly does not need external rotation stretching given the fact that he has normal external rotation.
REFERENCES
: Meister K: Injuries to the shoulder in the throwing athlete. Part two: evaluation/ treatment. Am J Sports Med 2000;28:587-601.
Liu SH, Boynton E: Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete. Arthroscopy 1993;9:697-699.
Tyler TF, Nicholas SJ, Roy T, et al: Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. Am J Sports Med 2000;28:668-673.
2010 Sports Medicine Examination Answer Book • 21

Question 65:

Options:

suppressive antibiotics.
open irrigation and debridement with polyethylene exchange.
one-stage resection arthroplasty and reimplantation.
two-stage resection arthroplasty and reimplantation.
arthroscopic irrigation and debridement.

Correct Answer: two-stage resection arthroplasty and reimplantation.

Explanation:

Question 66:

Options:

Axillary nerve palsy
Spinal accessory nerve palsy
Deltoid avulsion
Rotator cuff tear
Unreduced posterior glenohumeral dislocation

Correct Answer: Rotator cuff tear

Explanation:

DISCUSSION: Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 273-284.
Neviaser RJ, Neviaser TJ, Neviaser JS: Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orthop Relat Res 1993;291:103-106.

Question 67:

Options:

posterior; flexor carpi radialis
posterior; flexor carpi ulnaris
posterior; flexor digitorum superficialis to the long finger
mobile wad; flexor carpi radialis
mobile wad; flexor carpi ulnaris

Correct Answer: mobile wad; flexor carpi ulnaris

Explanation:

Question 68:

Options:

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA)
Tinea corporis
Herpes simplex virus
Group A Streptococcus

Correct Answer: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA)

Explanation:

Skin and soft-tissue abscesses should be drained and cultured by the treating physician whenever possible. Antibiotic therapy should be guided by antibiotic sensitivities derived from the cultures to identify cases of CA-MRSA and prevent severe recurrent infections. These infections have been associated with significant morbidity, with up to 70% of players requiring hospitalization. A high index of suspicion in at-risk populations is necessary, and empiric treatment with an antibiotic effective against MRSA should be considered until sensitivity results are available. Tinea corporis is a general term for a cutaneous fungal infection. The lesion appears as a well-demarcated erythematous plaque with a raised border and central hypopigmentation, giving it a ring-like appearance. Primary infection with herpes simplex virus can produce constitutional symptoms with burning, tingling, or stinging at the site. Grouped vesicles with clear fluid 1 mm to 2 mm in size form on an erythematous base and then rupture, leaving moist ulcers or crusted plaques. Amoxicillin is appropriate empiric antibiotic therapy for group A
Streptococcus
, so a recurrent infection is less likely with this organism.

Question 69:

Options:

The serum ion levels are not measureable in these patients.
The serum ion levels are measureable, but are of negligible value in these patients.
The serum ion levels measured equal the values measured in the local tissues in total hip arthroplasty metal-on-metal prostheses.
The serum ion levels measured are much lower in terms of their level to the values measured in total hip arthroplasty metal-on-metal prostheses.
The serum ion levels measured are similar in terms of their level to the values measured in total hip arthroplasty metal-on-metal prostheses.

Correct Answer: The serum ion levels measured are similar in terms of their level to the values measured in total hip arthroplasty metal-on-metal prostheses.

Explanation:

Question 70:

- A 39-year-old woman jammed her long finger playing softball 24 hours ago. She is unable to actively extend the proximal interphalangeal joint; however, when the joint is brought passively into full extension, she is able to maintain that position. Management should consist of

Options:

Open repair of the central slip of the extensor mechanism
Open repair of the terminal tendon of the extensor mechanism
Closed splinting with the proximal interphalangeal joint
Closed splinting with the proximal interphalangeal joint in 30 degrees of flexion
Closed splinting with the proximal interphalangeal joint in 45 degrees of flexion

Correct Answer: Closed splinting with the proximal interphalangeal joint

Explanation:

Question 71:

What is the most common complication following metatarsal osteotomy for a bunion deformity in an adolescent?

Options:

Hallux varus
Osteonecrosis
Recurrence of the hallux valgus
“Transfer” second metatarsalgia
Physeal arrest of the first metatarsal

Correct Answer: Recurrence of the hallux valgus

Explanation:

Question 72:

Which specific legislative Act in the United States was created to require reporting of annual monetary gifts or compensation of more than $10 by orthopaedic implant companies to physicians?

Options:

Patient Protection and Affordable Care Act
Medicare Payment Reform Act
Physician Financial Transparency Act
Physician Payments Sunshine Act
Health Insurance Portability and Accountability Act

Correct Answer: Physician Financial Transparency Act

Explanation:

Question 73:

Which of the following studies best increases the ability to diagnose femoral neck fractures in patients with femoral shaft fractures?

Options:

MRI
Fine-cut CT scan
Bone scan
AP radiograph of the femur
AP radiograph of the pelvis

Correct Answer: Fine-cut CT scan

Explanation:

DISCUSSION: Tornetta and associates and Yang and associates found that nearly half of all femoral neck fractures associated with femoral shaft fractures were being missed at their institution. On the basis of the delayed diagnosis of these injuries, a best-practice protocol was developed by the attending trauma surgeons for the evaluation of the femoral neck in patients with a femoral shaft fracture. This protocol includes a preoperative AP internal rotation radiograph of the hip, a fine-cut (2-mm) CT scan through the femoral neck (as a part of the initial trauma scan), and an intraoperative fluoroscopic lateral evaluation of the hip just prior to fixation of the femoral shaft. In addition, postoperative AP and lateral radiographs of the hip are made in the operating room to specifically evaluate the femoral neck before the patient is awakened. They found that fine-cut CT (2 mm was the best screening tool in this group of patients) identified 12 of the 13 fractures, whereas 8 of the 13 fractures were visible on the dedicated preoperative AP internal rotation hip radiographs.
REFERENCES: Tornetta P III, Kain MS, Creevy WR: Diagnosis of femoral neck fractures in patients with a femoral shaft fracture: Improvement with a standard protocol. J Bone Joint Surg Am 2007;89:39-43.
Yang KH, Han DY, Park HW, et al: Fracture of the ipsilateral neck of the femur in shaft nailing: The role of CT in diagnosis. J Bone Joint Surg Br 1998;80:673-678.

Question 74:

Overgrowth of a limb in a patient with neurofibromatosis type 1 (NF1) is most likely associated with the presence of

Options:

dural ectasia.
Lisch nodules.
juvenile xanthogranuloma.
malignant peripheral nerve sheath tumor.
plexiform neurofibroma.

Correct Answer: plexiform neurofibroma.

Explanation:

Question 75:

What is the most significant benefit of percutaneous transforaminal lumbar interbody fusion (TLIF) vs open posterior lumbar interbody fusion (PLIF)?

Options:

Preservation of the paraspinal muscle sleeve
Higher fusion rate
More measurable intraoperative blood loss
Improved ability to evacuate the disk space

Correct Answer: Preservation of the paraspinal muscle sleeve

Explanation:

DISCUSSION
Humphreys and associates in a retrospective review of TLIF vs PLIF found fusion rates, surgical time, and length of hospital stay were similar with both procedures. The only benefits associated with TLIF were less blood loss and preservation of the paraspinal muscle sleeve. Manos and associates in a cadaver study found no difference in the volume of disk material evacuated or the area of endplate exposed in either procedure.
RECOMMENDED READINGS
Humphreys SC, Hodges SD, Patwardhan AG, Eck JC, Murphy RB, Covington LA. Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine (Phila Pa 1976). 2001 Mar 1;26(5):567-71. PubMed PMID: 11242386.
View Abstract at PubMed
Manos R, Sukovich W, Weistroffer J: Transforaminal lumbar interbody fusion: Minimally invasive versus open disc excision and endplate preparation. Presented at the 12th International Meeting of Advanced Spine Techniques, Banff, Alberta, Canada, July 7-9, 2005.

Question 76:

Options:

Metastatic work-up
Physical therapy
Transpedicular biopsy
Thoracotomy with partial resection of the mass
T9 corpectomy with anterior column reconstruction 76.03

Correct Answer: Metastatic work-up

Explanation:

Here is an algorithm from OKU 6 Tumors of the Spine pp 723-736
This question gives you the history, skips right over physical exam and goes into plain films. With this patient’s history of hemoptysis and dyspnea and a lung mass, the next steps in this patients work-up would include the competion of initial work-up, metastatic work-up, then pre-operative planning. Goals of treatment are to 1) protect or restore neurologic function, 2) control pain,

Question 77:

What is the mechanism of action of bisphosphonates?

Options:

Directly stimulating osteoblastic new bone formation
Increasing gut absorption of calcium
Increasing efficiency of 1,25 dihydroxylation of vitamin D in the kidney
Inhibiting bone resorption by osteoclasts
Decreasing release of parathyroid hormone

Correct Answer: Inhibiting bone resorption by osteoclasts

Explanation:

DISCUSSION: Bisphosphonates are stable analogues of pyrophosphate that have a strong affinity for bone hydroxyapatite; these agents inhibit bone resorption by reducing the recruitment and activity of osteoclasts and increasing apoptosis. Bone formed while patients are receiving bisphosphonate treatment is histologically normal. Bisphosphonates have been shown to be effective in decreasing pathologic fractures, bone pain, and the need for radiation therapy in patients with multiple myeloma and metastatic carcinoma to bone. The most effective method of administration is via monthly intravenous infusion. Osteonecrosis of the mandible is sometimes a complication of this treatment.
REFERENCES: Gass M, Dawson-Hughes B: Preventing osteoporosis-related fractures: An overview. Am J Med 2006;119:S3-S11.
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 226-227.

Question 78:

Options:

at least two more attempts at closed reduction in the emergency department before the patient’s sedation wears off.
at least two attempts at closed reduction in the operating room under general anesthesia with muscle relaxation.
acceptance of the reduction because the alignment is satisfactory and growth problems are rare with Salter-Harris type I fractures.
open reduction, extraction of any interposed periosteum, and smooth wire fixation to prevent nonunion.
open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

Correct Answer: open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

Explanation:

Question 79:

Options:

A + C
B + C
B + D
C + D
C + E

Correct Answer: A + C

Explanation:

Question 80:

Options:

Gentle physical therapy and lifestyle modification to reduce demands on the symptomatic muscles
Vigorous physical therapy to rehabilitate the weak muscle groups
Muscle biopsy
MRI of the lumbosacral spine
Electromyography and nerve conduction velocity studies

Correct Answer: Gentle physical therapy and lifestyle modification to reduce demands on the symptomatic muscles

Explanation:

Question 81:

Options:

Physical therapy including ultrasound and gentle stretches
Closed manipulation of the shoulder
MRI and possible rotator cuff repair
Open glenohumeral reduction, with possible lesser tuberosity transfer
Shoulder hemiarthroplasty

Correct Answer: Open glenohumeral reduction, with possible lesser tuberosity transfer

Explanation:

Question 82:

Options:

High tibial osteotomy
Total knee replacement
Unicondylar knee replacement
Arthroscopic partial meniscectomy

Correct Answer: Total knee replacement

Explanation:

Question 83:

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

Options:

Distal radioulnar ligament
Radioscapholunate ligament
Radioscaphocapitate ligament
Scapholunate interosseous ligament
Triangular fibrocartilage

Correct Answer: Scapholunate interosseous ligament

Explanation:

Question 84:

Options:

Lacertus fibrosis contracture
Intra-articular loose bodies 74
Olecranon fossa impingement
Radiocapitellar plica

Correct Answer: Radiocapitellar plica

Explanation:

DISCUSSION
The MRI studies show a radiocapitellar plica. This anomalous structure has been associated with symptomatic snapping. Lacertus fibrosis contracture will not cause painful snapping. An intra-articular pathology such as loose bodies is not present on these imaging studies. Olecranon fossa impingement causes posterior pain in extension and is not shown in the images.
RECOMMENDED READINGS
Antuna SA, O'Driscoll SW. Snapping plicae associated with radiocapitellar chondromalacia. Arthroscopy. 2001 May;17(5):491-5. PubMed 11337715.
View Abstract
at PubMed
Ruch DS, Papadonikolakis A, Campolattaro RM. The posterolateral plica: a cause of refractory lateral elbow pain. J Shoulder Elbow Surg. 2006 May-Jun;15(3):367-70. PubMed PMID: 16679240.
View Abstract at PubMed

Question 85:

Options:

Unreamed intramedullary nail
Reamed statically locked intramedullary nail
External fixation
Plate fixation and interfragmentary compression
Bridge plate stabilization

Correct Answer: Plate fixation and interfragmentary compression

Explanation:

Question 86:

An otherwise healthy 15-year-old wrestler has a 6-cm cutaneous lesion on the posterior aspect of his right elbow that he reports as a spider bite. What is the most likely diagnosis? Review Topic

Options:

Psoriasis
Tinea corporis
Herpes simplex virus
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA)

Correct Answer: Psoriasis

Explanation:

Patients who have skin and soft-tissue infections caused by CA-MRSA often describe the lesion as a spider bite. The cytotoxin Panton-Valentine leukocidin that is produced by many strains of CA-MRSA causes tissue necrosis, resulting in rapid development of an abscess and the appearance of a spider bite. Patients with psoriasis have thick, red skin with flaky, silver-white patches. Tinea corporis is a general term for a cutaneous fungal infection. The lesion appears as a well-demarcated erythematous plaque with a raised border and central hypopigmentation, giving it a ring-like appearance. Primary infection with herpes simplex virus can produce constitutional symptoms with burning, tingling, or stinging at the site. Grouped vesicles with clear fluid 1 to 2 mm in size form on an erythematous base and then rupture, leaving moist ulcers or crusted plaques.
(SBQ07SM.48) Carbohydrate loading is a common practice among endurance athletes that works by what mechanism?
Review Topic
Increasing serum fructose levels
Maximizing stored muscle glycogen for endurance after 90 minutes of exercise
Diuresis
Decreasing serum glucose levels
Maximizing stored liver glycogen for endurance after 60 minutes of exercise
Carbohydrate loading is a strategy that involves changes to training and nutrition which can maximize muscle glycogen stores prior to endurance exercise lasting longer than 90 minutes.
There continues to be varying scientific opinions as to whether athletes should eat low vs. high glycemic index foods, and how this will affect the amount that the serum glucose levels rise. Fructose is able to be converted to glycogen in the liver but not muscle, therefore high-fructose containing foods are suboptimal. This practice is recommended for athletes participating in events that are longer than 90 minutes (after the bodies normal supply of glycogen is depleted).
Coyle et al. analyzed 10 trained cyclists who performed two bicycle ergometer exercise tests 1 wk apart. They found that blood glucose concentration was 20-40% higher during the exercise after carbohydrate ingestion than during the exercise without carbohydrate feeding. The exercise-induced decrease in plasma insulin was prevented by carbohydrate feeding. Ultimately, fatigue was postponed by carbohydrate feeding during exercise in seven out of the ten subjects.
Costill et al. examined the effect of carbohydrates on muscle glycogen resynthesis in trained runners and found that muscle glycogen levels could be normalized with the proper use of carbohydrates after strenuous activity.
Sherman et al. used muscle biopsies to determine the effects of moderate- or high-carbohydrate diets on muscle glycogen and performance in runners and cyclists over 7 consecutive days of training. They found that a high carbohydrate diet restored muscle glycogen to more normal levels than a moderate carbohydrate diet but did not find any difference in the effect on performance.
Illustration A is a graph depicting the typical carbohydrate depletion/loading regimen that endurance athletes utilize to maximize muscle glycogen stores prior to endurance exercise. This typically involves a hard workout followed by three days of a low-carb diet, another hard workout, and another three days of a high-carb diet.
Incorrect

Question 87:

Options:

hallux valgus correction and lesser metatarsophalangeal joint synovectomies.
hallux valgus correction and lesser metatarsal head resections.
first metatarsophalangeal joint fusion and lesser metatarsal head resections.
first metatarsophalangeal joint fusion and lesser metatarsophalangeal joint synovectomies.
Keller resection arthroplasty and lesser metatarsal head resections.

Correct Answer: first metatarsophalangeal joint fusion and lesser metatarsal head resections.

Explanation:

Question 88:

Options:

Local wound care, parenteral antibiotic therapy, metabolic support, and reevaluation in 1 week
Vascular consultation for a bypass operation
Syme ankle disarticulation
Guillotine transtibial amputation
Closed transtibial amputation

Correct Answer: Local wound care, parenteral antibiotic therapy, metabolic support, and reevaluation in 1 week

Explanation:

DISCUSSION: The patient was admitted to the hospital with sepsis. The sepsis has resolved, leaving the patient with a negative nitrogen balance. Now that the patient is stable, metabolic support should be used to optimize his nutrition. If the serum albumin can be increased to 2.5 g/dL, he has an excellent potential to heal an amputation at the Syme ankle disarticulation level; a level that will optimize his functional independence.
REFERENCES: Pinzur MS, Stuck RR, Sage R, et al: Syme ankle disarticulation in patients with diabetes. J Bone Joint Surg Am 2003;85:1667-1672.
Pinzur MS, Smith D, Osterman H: Syme ankle disarticulation in peripheral vascular disease and diabetic foot infection: The one-stage versus two-stage procedure. Foot Ankle Int 1995;16:124-127.

Question 89:

Options:

- No additional reduction and continued treatment in the cast
- Repeat closed reduction and cast application
- Closed reduction and percutaneous skeletal fixation
- Open reduction and internal fixation

Correct Answer: - No additional reduction and continued treatment in the cast

Explanation:

DISCUSSION
Studies demonstrate that surgical treatment of distal radius fractures in elderly people does not result in improved outcomes. Although nonsurgical treatment resulted in worse radiographic findings for this patient, these findings did not translate into worse functional outcomes.
RECOMMENDED READINGS
Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011 May;36(5):824-35.e2. doi: 10.1016/j.jhsa.2011.02.005. Review. PubMed PMID: 21527140.
View Abstract at PubMed
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53. doi: 10.2106/JBJS.J.01597. PubMed PMID: 22159849.
View
Abstract
at PubMed
American Academy of Orthopaedic Surgeons: Treatment of Distal Radius Fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons, March 2013. Available at
http://www.aaos.org/research/Appropriate_Use/drfauc.asp Accessed {10/8/14}. Last Accessed on 10/8/14

Question 90:

Options:

medial and lateral collateral ligaments, radial head, and coronoid.
medial collateral ligament and coronoid.
lateral collateral ligament and radial head.
medial and lateral collateral ligaments.
radial head and coronoid.

Correct Answer: medial and lateral collateral ligaments, radial head, and coronoid.

Explanation:

Question 91:

A 9-year-old boy has lateral right knee pain. An MRI scan shows a discoid lateral meniscus with a partial tear in its central portion. Treatment should consist of Review Topic

Options:

arthroscopic saucerization of the meniscus.
lateral total menisectomy.
meniscal transplant.
arthroscopy and repair of the central tear.
casting for 6 weeks followed by physical therapy.

Correct Answer: arthroscopic saucerization of the meniscus.

Explanation:

Question 92:

When making a comparison to autograft incorporation, the inflammatory process in allograft tissue anterior cruciate ligament (ACL) reconstruction

Options:

occurs earlier.
occurs later.
is prolonged.
is shortened.

Correct Answer: is prolonged.

Explanation:

Question 93:

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared with a standard parapatellar approach, what is the expected outcome?

Options:

Improvement in range of motion
Reduction in range of motion
Increase in extensor mechanism lag
No differences in motion and strength

Correct Answer: No differences in motion and strength

Explanation:

DISCUSSION:
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

Question 94:

Figure 30a is the anteroposterior radiograph of a 20-year-old woman with mild right groin pain and intermittent “catching” in the hip region. What is the most appropriate next step? tear

Options:

Arthroscopic evaluation and treatment of the hypertrophic labrum and a possible labral
A hip injection to confirm an intra-articular source of the pain
Nonsurgical treatment and subsequent total hip arthroplasty (THA) when the patient is
sufficiently symptomatic
Periacetabular osteotomy

Correct Answer: sufficiently symptomatic

Explanation:

Question 95:

What is the primary intracellular signaling mediator for bone morphogenetic protein (BMP) activity?

Options:

Interleukin-1 (IL-1)
Runx2
NFK-B
SMADS
P53

Correct Answer: SMADS

Explanation:

Question 96:

Options:

Immediate admission to the hospital and emergent revision hip arthroplasty
Reassurance and follow-up if symptoms worsen
Repeat radiographs in 1 month
Protected weight bearing with urgent revision hip arthroplasty when the patient is medically cleared
A prescription for alendronate and reevaluation in 1 year

Correct Answer: Protected weight bearing with urgent revision hip arthroplasty when the patient is medically cleared

Explanation:

Question 97:

Options:

ankle arthrodesis.
total ankle arthroplasty.
supramalleolar tibial osteotomy.
valgus-producing calcaneal osteotomy.
epiphyseodesis of the distal tibial physis.

Correct Answer: supramalleolar tibial osteotomy.

Question 98:

What is the most common non-anesthetic-related reversible cause of sustained changes in intraoperative neurophysiologic monitoring signals during spinal surgery? Review Topic

Options:

Pedicle screw misplacement
Patient positioning
Spinal cord ischemia
Retractor placement
Hypertension

Correct Answer: Patient positioning

Explanation:

Question 99:

Options:

Arthroscopic or open reduction and internal fixation
Arthroscopic loose body removal
Activity restriction for up to 9 months
Subchondral drilling

Correct Answer: Arthroscopic or open reduction and internal fixation

Explanation:

Question 100:

-What leads to muscle hypertrophy?

Options:

Neural recruitment
Active stretching
Passive stretching
Proprioceptive training
Progressive overloading

Correct Answer: Progressive overloading

Orthopedic Surgery MCQs: Arthroplasty, Fracture & Hip Exam Prep | Part 18

Orthopedic Surgery Board Exam MCQs: Trauma, Hip & Peripheral Nerve | Part 75

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 75

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index