Orthopedic Board Review MCQs: Adult Reconstruction, Trauma & Ankle Part 97

A 21-year-old collegiate track athlete increased her training 4 months ago in anticipation of starting the season. Two months into her training program, she reported pain followed by a 1-month history of diffuse pain in the first metatarsophalangeal joint that was aggravated by weight bearing. A removable walker boot partially relieved the pain, and she was able to complete the season. Her pain has now returned; however, she denies any history of injury. Examination reveals tenderness over the medial sesamoid but no deformities. A radiograph and bone scan are shown in Figures 22a and 22b. What is the best treatment option at this time?

Which of the following methodologies has been proven to be effective in reducing the use of homologous blood transfusion following total hip arthroplasty (THA)?

Figures 36a and 36b show the radiographs of a 48-year-old woman who smokes cigarettes and sustained a segmental femoral shaft fracture in a motor vehicle accident 9 months ago. Initial management consisted of stabilization with a reamed statically locked intramedullary nail. She now reports lower leg pain that increases with activity. In addition to advising the patient to quit smoking, management should include

Figure 70 is the radiograph of a 14-year-old girl with increasing posterior ankle pain, especially during pointe technique exercises. Nonsurgical measures such as modification, stretching, and injection have been unsuccessful. Which nerve is most vulnerable to injury during endoscopic excision of this lesion?

Figures below show the radiographs obtained from an 86-year-old-woman who has had chronic left hip pain for several years. She now uses a walker and a wheelchair for ambulation. She is medically healthy. What is the most appropriate surgical intervention?

What is the most important consideration in the preoperative evaluation of a child with polyarticular or systemic juvenile rheumatoid arthritis (JRA)?

Figures 42a and 42b show the radiographs of a 52-year-old man who sustained a fall from a motorcycle 6 months ago and now reports pain and stiffness in his left shoulder. What is the most reliable treatment to improve function and comfort of the shoulder?

Figure 48 shows a current lateral radiograph of a 23-year-old man who sustained a closed femoral diaphyseal fracture 5 months ago. Treatment consisted of placement of a retrograde femoral nail for the femoral fracture. The patient now reports a sudden onset of pain in the midthigh and cannot bear weight on his leg. Management should consist of

A medial plate is best used to treat tibial plateau fractures when there is

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

Figures 33a and 33b show the standing posteroanterior and lateral radiographs of a 59-year-old woman with adult idiopathic scoliosis. She underwent a prior decompressive laminectomy and fusion at L4-S1 to address lumbar stenosis. She now reports progressive lower back pain and a feeling of being shifted to the right. If surgical intervention is considered, what is the most important goal in improving her health-related quality of life (HRQL) outcomes? Review Topic

An 18-year-old football player is injured after making a tackle with his left shoulder. He has decreased sensation over the lateral aspect of the left shoulder and radial aspect of the forearm. Motor examination reveals weakness to shoulder abduction and external rotation as well as elbow flexion. He has decreased reflexes of the biceps tendon on the left side but full, nontender range of motion of the cervical spine. What anatomic site has been injured? Review Topic

A 17-year-old high school football player reports wrist pain 5 months after the conclusion of the football season. A radiograph and MRI scan are shown in Figures 29a and 29b. What is the recommended intervention?

A 64-year-old man who underwent total shoulder arthroplasty 4 weeks ago is making satisfactory progress in physical therapy, but his therapist notes limitations in external rotation to neutral. A stretching program is started, and the patient suddenly gains 90 degrees of external rotation but now reports increased pain and weakness. What is the best course of action?

A 12-year-old male sustains a ulnar fracture with an associated posterior-lateral radial head dislocation. After undergoing closed reduction, the radiocapitellar joint is noted to remain non-concentric. What is the most likely finding?

The use of bisphosphonates in children with osteogenesis imperfecta is becoming more widely accepted as treatment to improve quality of life and to decrease the risks of fracture. What is the mechanism by which bisphosphonates work?

Placing a plate too anteriorly against the lateral aspect of the bicipital groove while performing open reduction and internal fixation (ORIF) of a proximal humerus fracture has an increased risk of what complication?

A 65-year-old female presents with the injury seen in Figures A and B after a motor vehicle collision. She is hemodynamically unstable and undergoes emergent pelvic supra-acetabular external fixation followed by laparotomy. She is now hemodynamically stable and cleared for surgery. She has no evidence of neurologic deficit on examination. Which of the following factors is a relative contraindication to open reduction and plating of her posterior pelvic injury from an anterior approach?

Six weeks after onset, what is the most clearly accepted indication for surgical management for lumbar disk herniation?

A patient with a transverse femur fracture undergoes statically locked antegrade intramedullary nailing. Postoperatively, the patient appears to have a

Figures 128a and 128b show the radiograph and MRI scan of a 74-year-old woman with severe neck pain and upper extremity numbness, tingling, and clumsiness. She also reports that she has balance problems and sustained a distal radius fracture in a fall 6 months ago. Examination reveals hyperreflexia in bilateral quadriceps and Achilles reflexes, bilateral Hoffman's signs, and eight beats of clonus in both lower extremities. What is the best treatment option? Review Topic

A 59-year-old active woman undergoes elective total hip replacement in which a posterior approach is used.  She  has  minimal  pain  and  is  discharged  to  home  2  days  after  surgery.  Four  weeks  later,  she dislocates her hip while shaving her legs. She undergoes a closed reduction in the emergency department. Postreduction  radiographs  show  a  reduced  hip  with  well-fixed  components  in  satisfactory  alignment. What is the most appropriate management of this condition from this point forward?

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

An otherwise healthy 16-year-old boy who has had thoracolumbar pain with an increasingly worse deformity for the past 2 years now reports that the pain is worse at night. He responded well to nonsteroidal anti-inflammatory drugs initially, but they have become less effective. He denies any neurologic or constitutional symptoms. Examination is consistent with a mild thoracolumbar scoliosis and is otherwise normal. Laboratory studies show a normal CBC, erythrocyte sedimentation rate, and C-reactive protein. Standing radiographs show a 20 degrees left thoracolumbar scoliosis, and he has a Risser stage of 4. A bone scan shows increased uptake at L2; a CT scan through this level is shown in Figure 18. Management should now consist of

A 58-year-old woman has had a slowly progressing mass over the distal interphalangeal (DIP) joint of her dominant hand with a worsening deformity of her nail. She has no significant medical history but underwent bilateral knee arthroplasties 1 year ago. Radiographs reveal a small osteophyte at the DIP joint dorsally. A clinical photograph and a biopsy specimen are shown in Figures 76a and 76b. What is the most likely diagnosis?

A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals that the knee is held in 45 degrees of flexion, and any attempt to actively or passively extend the knee produces pain and muscle spasms. A lateral radiograph is shown in Figure 4. What is the most likely diagnosis?

Amphotericin exerts antifungal activity by

During treatment of rupture of the subscapularis tendon with associated biceps instability, treatment of the biceps tendon should include which of the following?

A 30-year-old man reports pain and weakness in his right arm. Examination reveals grade 4 strength in wrist flexion and elbow extension, decreased sensation over the middle finger, and decreased triceps reflex. These symptoms are most compatible with impingement on what spinal nerve root?

Figure 33 shows the MRI scan of a 55-year-old woman who has had a 6-week history of back and leg pain. Which of the following clinical scenarios is most consistent with the MRI scan findings at L4-L5?

A 5-year-old girl sustains an isolated injury to the right shoulder area after falling off the monkey bars. Examination reveals intact neurovascular function in the extremity distally, but she is quite uncomfortable. An AP radiograph of the proximal humerus is shown in Figure 24. Her parents state that she is a very talented gymnast. Considering her age and potential athletic career, management should consist of

-Which type of cells has been implicated in the process shown inFigure?

A 42-year-old woman reports that she has low back pain and had a transient loss of consciousness after falling off a horse. She denies having neck pain but notes that she was involved in a motor vehicle accident 2 years ago and had neck pain at that time. Examination reveals full range of motion of the neck and no localized tenderness. The neurologic examination is normal. A lateral radiograph of the cervical spine is obtained. Figures 41a and 41b show CT and MRI scans. What is the most likely diagnosis?

• In revision hip arthroplasty, which of the following is the 5- to 10-year reported graft failure rate when using structural acetabular allografts in the repair of acetabular deficiencies?

What is the principal advantage of surgical repair for the lesion shown in Figure 19?

Figures 36a and 36b show the radiographs of a 3-year old child who has a congenital upper extremity deformity. Which of the following features would be a major contraindication to a centralization procedure?

A 26-year-old man has had a 2-year history of pain and stiffness after sustaining a comminuted olecranon fracture. Treatment at the time of injury consisted of open reduction and internal fixation with tension band wiring. Examination reveals motion of 45 degrees to 110 degrees and pain throughout the arc of motion. Resisted flexion and extension are painful. Forearm rotation is normal. Radiographs are shown in Figure 51. Treatment should consist of

..Figures 87a through 87e are the radiograph, MRI scans, and biopsy specimen of an 83-year-old woman who is experiencing pain in her distal thigh with activity and at night. She has undergone total hip arthroplasty for hip osteoarthritis. The most appropriate treatment is

Figures 136a through 136c are the weight-bearing anteroposterior and lateral radiographs of a 28-year-old construction worker who has had 6 months of progressive knee pain isolated to the medial aspect of his right knee. The pain has not responded to nonsurgical treatment. His body mass index is 26. He has knee range of motion from 0 to 125 degrees, and his knee is stable to ligament examination. What is the most appropriate surgical treatment?

Figures 24a and 24b are the radiographs of a 7-year-old boy who fell off the monkey bars and has a closed injury. His hand appears warm and well perfused with an absent radial pulse. What is the best initial treatment?

A 52-year-old man has had groin and deep buttock pain for the past 2 months. Examination reveals that hip range of motion is mildly restricted, and he has pain with both weight bearing and at rest. An MRI scan is shown in Figure 28. Management should consist of

A 22-year-old patient has had severe groin pain for many months and is unable to engage in any physical activity. The AP radiograph of the pelvis shows minimal arthritis. The lateral radiograph of the hip is shown in Figure 33a. An MR-arthrogram is shown in Figure 33b. What is the most appropriate treatment at this stage? Review Topic

A 23-year-old man has had right posterolateral knee pain and occasional lateral calf dysesthesias for the past 8 months. A radiograph, CT scan, MRI scans, and a biopsy specimen are shown in Figures 62a through 62e. What is the most likely diagnosis?

During the application of halo skeletal fixation, the most appropriate position for the placement of the anterior halo pins is approximately 1 cm above the superior orbital rim and Review Topic

A lO'/z-year-old boy sustained the injury shown in Figure 72 when he fell out of a tree. This is a closed, neurologically intact injury and the patient has no head injury or loss of consciousness. He weighs 115 pounds and is otherwise healthy. What is the optimal treatment option for this injury?

An elite gymnast injured her ankle in an awkward dismount 36 hours ago. Examination reveals weakness on single leg step-up. A clinical photograph of the medial ankle is shown in Figure 15. Plain radiographs are normal. To help confirm the diagnosis, the next step in evaluation should consist of

A 20-year-old girl reports a shoulder dislocation while reaching for a high shelf. Her history reveals multiple past dislocations with spontaneous reduction and no obvious traumatic event at onset. A photograph of her hand is shown in figure

Figure 50 shows the cross table lateral radiograph of a 31-year-old paratrooper who has recalcitrant groin pain. The pain is worse after activities such as standing or sitting (driving). Examination reveals that pain can be reproduced by internal rotation of the leg with the hip and knee in 90 degrees of flexion. Extensive nonsurgical management has failed to provide relief. What is the treatment of choice?

A 32-year-old man underwent a total medial meniscectomy 2 years ago. He now reports pain and recurrent swelling for the past 3 months. Work-up includes full standing hip-knee-ankle radiographs, standing AP radiographs of both knees in full extension, an axial view of the patellofemoral joint, and a 45-degree flexion AP radiograph. Contraindication to meniscus allograft transplantation includes which of the following? Review Topic

A 55-year-old woman has slowly increasing pain at the distal end of her little finger that is exacerbated by cold temperatures. She denies any history of trauma to her hands and is employed as a school teacher. The histology of the resected specimen is shown in Figure 71. What is the most likely diagnosis?

Nutritional rickets in the US occurs more frequently in infants older than 6 months of age who do not receive vitamin D supplementation and are Review Topic

At a minimum 2-year follow-up and compared with the metacarpophalangeal (MCP) joint, pyrolytic carbon resurfacing arthroplasties of the proximal interphalangeal (PIP) joint

Figures 21a and 21b show the radiographs of a 12-year-old patient with an L4-level myelomeningocele who has scoliosis that has been slowly progressing for the past several years. There has been no loss of motor function. An MRI scan shows no syringomyelia or increased hydrocephalus. Management should consist of

Which of the following tumors have characteristic chromosomal translocations?

A 12-year-old boy falls from a bicycle. A radiograph of his injured shoulder is shown in Figure 41. What is the optimal method of treatment?

An 18-year-old football player is injured after making a tackle with his left shoulder. He has decreased sensation over the lateral aspect of the left shoulder and radial aspect of the forearm. Motor examination reveals weakness to shoulder abduction and external rotation as well as elbow flexion. He has decreased reflexes of the biceps tendon on the left side but full, nontender range of motion of the cervical spine. What anatomic site has been injured?

Figure 1 shows the radiograph of a 68-year-old man who underwent revision hip arthroplasty with impaction grafting of the femur and cementing of a tapered component into the graft 2 years ago. The patient remains symptom-free. Which of the following best describes the most likely histologic appearance of the proximal femur if a biopsy was performed?

Figures 38a and 38b show the CT scans of a 64-year-old woman. What is the most likely diagnosis?

Which of the following is more likely to occur with use of a bone patellar bone allograft instead of a bone patellar bone autograft for anterior cruciate ligament (ACL) reconstruction in an 18-year-old high school or collegiate athlete? Review Topic

A previously healthy 35-year-old man was involved in a rollover motor vehicle accident 2 days ago. He was placed in a semi-rigid cervical orthosis. He now reports mostly axial neck pain with attempted range of motion. Examination reveals the mechanical neck pain but no obvious neurologic deficits. AP, flexion, and extension radiographs are shown in Figures 10a through 10c, and sagittal and coronal CT scans are shown in Figures 10d and 10e. What is the most appropriate management at this time?

Which local treatment option is most appropriate?

When performing a flexor tendon repair of a digit other than the thumb, what structures of the flexor tendon sheath should be preserved?

To control most spontaneous bleeding into the knee in children with hemophilia, factor VIII must be replaced to what percentage of normal?

The natural history of cervical spondylolytic myelopathy is best described as

A 12-year-old boy has a head-on head collision while playing soccer. He had no loss of consciousness but has persistent headaches for 2 weeks. The patient is now back to school and has no headaches. What is the best next step?

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

After open reduction and internal fixation of long bone fractures, at what time period should C-reactive protein start to decrease?

Examination of a 12-year-old girl with a painful flatfoot deformity reveals tenderness in the region of the sinus tarsi and no appreciable subtalar motion. Radiographs are shown in Figures 48a through 48c. Two attempts to relieve her symptoms by cast immobilization fail to relieve the pain. Management should now consist of

-Thirty minutes later the gymnast is experiencing headache and difficulty concentrating. If her symptoms persist 1 week later, the next treatment step should be

Figure 1 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain?

An otherwise healthy 26-year-old woman is involved in a high speed motor vehicle accident and sustains the injury shown in Figure 54 to her dominant right arm. Appropriate treatment of this injury complex includes

A 46-year-old woman reports pain and a shortened appearance of her toe after undergoing a Keller resection arthroplasty 2 years ago for hallux rigidus. Examination reveals mild swelling and motion limited to 25 degrees at the metatarsophalangeal joint. Radiographs show large dorsal osteophytes on the first metatarsal head, 50% resection of the proximal phalanx, and complete loss of the metatarsophalangeal joint space. Which of the following is considered the most reliable procedure to improve her pain and the appearance of her toe?

A previously asymptomatic 40-year-old man injures his shoulder in a fall. Examination shows that he is unable to lift the hand away from his back while maximally internally rotated. An axial MRI scan of the shoulder is shown in Figure 14. What is the most likely diagnosis?

A young male patient underwent intramedullary nail fixation for a diaphyseal femur fracture. A post-operative CT scanogram is performed to assess rotational alignment between the surgical and non-surgical femur. Which of the following measurement(s) are considered acceptable differences in regards to femoral rotational malreduction after intramedullary nail fixation as compared to the uninjured femur?

A 25-year-old woman returns for her first postoperative visit after arthroscopic thermal capsulorrhaphy for recurrent multidirectional instability. Examination reveals that the portals are healed, there is no swelling; and passive range of motion is within the normal range. However, she is unable to actively raise her arm. Shoulder radiographs are normal. What is the most likely cause of these findings?

A direct lateral (Hardinge) approach is used during total hip arthroplasty. The structure labeled A in Figure 7 is the

A 30-year-old woman sustains a transverse amputation of the distal phalanx of the index finger, leaving exposed bone. What is the most appropriate management of the soft-tissue defect?

A 4-year-old child has droopy shoulders. Examination shows that the child has a large head, short stature, and a narrow chest. Radiographs of the spine and chest show absent clavicles, delayed ossification of the pubis and ischium, and mild coxa vara. What is the inheritance pattern for this condition?

A 28-year-old woman has left shoulder pain and a tender soft-tissue mass. Based on the MRI scan and biopsy specimens shown in Figures 74a through 74c, what is the most likely diagnosis?

Figure 53 is a coronal-cut CT scan of a 63-year-old woman who has a longstanding pes planus. She is seen for lateral ankle discomfort. Upon examination she is tender over the sinus tarsi and distal to the fibula. She has painless passive hindfoot eversion with 5/5 eversion strength. The most appropriate diagnosis is

Which of the following is a contraindication to laminoplasty in a patient with cervical spondylotic myelopathy?

A 19-year-old man has had back pain with activity, especially running in soccer and baseball, for the past 4 months. He denies any history of trauma. Examination reveals no motor weakness or sensory changes in the lower extremities. Range of motion shows increased pain with extension and mild limitation with flexion. A sitting straight leg raising test is limited at approximately 60 degrees bilaterally by back and buttocks pain. Plain radiographs are normal. MRI scans are shown in Figures 13a through 13e. What is the most likely diagnosis?

A 20-year-old man has a symptomatic lesion of fibrous dysplasia in the femoral neck. Management should consist of

A 33-year-old woman reports a mass on the right hand that has been enlarging for 1 year. An intraoperative photograph is shown in Figure 28a, and a biopsy specimen is shown in Figure 28b. What is the most likely diagnosis?

What is the most common long-term complication of the fracture shown in Figure 32?

A 23-year-old male is involved in a motor vehicle accident and sustains a left open femur fracture, right open humeral shaft fracture, and an LC-II pelvic ring injury. Which of the following best describes the radiographic findings associated with this pelvic injury pattern using the Young-Burgess Classification system?

A 28-year-old woman who is an avid runner reports pain about the left hip with activities. Nonsurgical management has failed to provide relief. An MRI arthrogram is shown in Figure 47. What is the most likely diagnosis? Review Topic

What is the primary indication for performing a total wrist arthroplasty in a patient with painful rheumatoid arthritis?

Which of the following patient factors is associated with recurrent radicular pain following lumbar diskectomy for sciatica?

A 32-year-old construction worker reports a persistent burning, tingling sensation on the dorsum of his right foot and significant sensitivity on the plantar surface after a 500-lb steel beam dropped on it 8 weeks ago. Initial radiographs revealed no fractures, and the skin remained intact at the time of injury. Physical therapy, anti-inflammatory drugs, and a serotonin reuptake inhibitor have failed to provide relief. What is the next most appropriate step in management?

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

In hybrid arthroplasty, the use of a polymethylmethacrylate (PMMA) precoated femoral component has been shown to result in

A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out with his left arm to prevent the defensive player from getting around him, and, as he grabbed the player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.” He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook test result is abnormal at the elbow. The athlete undergoes repair of the injury, and postsurgical radiographs are shown in Figures 1 and 2. At his first postsurgical visit, he reports no pain but describes weakness in his hand and decreased sensation over his lateral forearm. Upon examination, he has decreased 2-point discrimination over the lateral forearm and an inability to actively extend his thumb and fingers at the metacarpophalangeal joints. He can extend at the finger interphalangeal joints. He can extend his wrist weakly, and it deviates radially as he extends. His distal sensation is intact. Considering his examination findings, which two nerves are injured?

In the initial evaluation of acute low back pain (duration of less than 4 weeks), plain radiographs are recommended in which of the following situations?

Which of the following medications inhibits release of neurotransmitters by binding to presynaptic calcium channels?

A 45-year-old IV drug abuser has sternoclavicular (SC) joint pain for the past 2 weeks. He is afebrile and physical exam findings include point tenderness and swelling. He most likely has septic arthritis of the sternoclavicular joint. If so, what is the most likely infecting organism?

A 42-year-old man reports the recent onset of right hip pain. A radiograph and MRI scan are shown in Figures 38a and 38b. A WBC count, erythrocyte sedimentation rate, and hip aspiration are within normal limits. Management should now consist of

A 28-year-old professional football player reports painless loss of ankle motion after sustaining a “severe” ankle sprain 12 months ago. A mortise radiograph is shown in Figure 1. Surgical treatment should be reserved for which of the following conditions?

Figure 21 shows the radiograph of an 18-year-old man who was brought to the emergency department with shoulder pain following a rollover accident on an all-terrain vehicle. Examination reveals a fracture with massive swelling; however, the skin is intact and not tented over the fracture. Based on these findings, initial management should consist of

An 76-year-old woman falls from standing and sustains the injury shown in Figure A. Her most recent T score was -1.9, 3 months prior to presentation. If labwork were performed, which values would be consistent with her bone density score?