ORTHO MCQS 011 FREE BANK 02

 

Question 101A 60-year-old woman with a long-standing history of diabetes mellitus with documented peripheral neuropathy has a plantar ulcer. The ulcer has been present for 3 months. Her primary care physician has treated her with saline dressing changes with no success. The ulcer is located on the plantar surface of the foot under the third metatarsophalangeal joint. On probing the wound, the metatarsal head is visualized. What is the best diagnostic test to determine the presence of bony involvement?

1. CBC count

2. C-reactive protein

3. Technetium bone scan 4- Bone biopsy

5- Weight-bearing radiographs

DISCUSSION: The presence or absence of osteomyelitis is difficult to discern. The clinical finding that has been found to be the most specific for bony involvement is the presence of an ulcer that probes directly to bone. Bone biopsy from the involved area is the most accurate method to determine the presence or absence of osteomyelitis. A bone biopsy with culture not only helps determine the presence of osteomyelitis, it helps in determining the causative pathogen in chronic osteomyelitis. The standard laboratory test such as a complete blood count with differential is not very helpful because of the immunocompromised condition and vascular insufficiency in many of these patients. C- reactive protein elevation and erythrocyte sedimentation rate can be helpful but are not diagnostic for bone involvement. Standard radiographs can show erosive changes consistent with osteomyelitis but in a neuropathic patient, this can be confused with Charcot neuroarthropathic changes. The Preferred Response to Question # 101 is 4.

 

Question 102Figures 102a and 102b are the radiographs of a 10-year-old boy who sustained an injury to his elbow in a fall. He is neurovascularly intact. What is the most appropriate treatment?

1. Open reduction and internal fixation

2. Closed reduction and percutaneous pinning

3. Closed reduction and casting for 4 weeks in full pronation

4. Closed reduction and casting for 4 weeks in full supination

5. Splinting for 2 weeks, followed by early motion

 

DISCUSSION: The patient has a medial condyle fracture. These are uncommon injuries and are often confused with fractures of the medial epicondyle. However, unlike medial epicondyle fractures, medial condyle fractures involve the articular surface and require anatomic reduction and fixation. This fracture is rotated radiographically. Open reduction and internal fixation is likely to be necessary to achieve anatomic restoration of anatomy. Closed reduction or splinting will not restore the joint surface adequately.

The Preferred Response to Question # 102 is 1.

 

Question 103Results of a study demonstrating no difference between treatments when a difference truly exists is an example of which of the following?

1- Statistical insignificance 2- Type I error

3. Type II error

4. Fragile p-values

5. Negative predictive value

 

DISCUSSION: A type II error (also known as a beta error) occurs when results demonstrate that two groups are similar when, in reality, they are different (with regard to the statistic being measured). Type I errors show that a difference exists when, in reality, no difference exists. A statistically insignificant result may lead an investigator to conclude that no difference exists between two groups; this may be correct (and therefore not a type II error). The concept of `fragile` p-values is that small sample sizes may result in wide variability of p-values with only one change in a data point for a given group. This singular change could be a chance occurrence, but it still can affect the statistical significance of the outcomes analysis. Fragility of p-values is limited by increasing sample sizes. Negative predictive value is the proportion of patients with negative test results who are correctly diagnosed. The Preferred Response to Question # 103 is 3.

 

Question 104Among patients with lumbar degenerative disk disease and low back pain, what factor is most predictive of clinical outcomes after surgical management?

1- Duration of symptoms 2- Workers' compensation 3- Use of disk arthroplasty

4. Severity of disk degeneration

5. Number of spinal segments treated

 

DISCUSSION: The treatment of low back pain ranges from nonsurgical management to surgical management. Whereas many other treatment modalities have been investigated, lumbar arthrodesis remains the primary surgical treatment of lumbar diskogenic pain. Outcomes of surgical management vary but are consistently impacted negatively by workers' compensation status. Neither the radiographic severity of disease, number of spinal segments, nor duration of disease has been correlated with clinical outcomes. While total disk arthroplasty was hoped to be an improvement over fusion, the evidence available to date has shown no significant differences over arthrodesis.

The Preferred Response to Question # 104 is 2.

 

Question 105A 57-year-old woman sustains a posterolateral elbow dislocation. Following closed reduction, a displaced radial head fracture of 40% of the joint surface is noted. At surgery, the fragment is found to be comminuted into four pieces. What is the best choice for treatment?

 

1- Partial radial head excision 2- Radial head excision

3- Radial head replacement 4- Total elbow arthroplasty

5- Open reduction and internal fixation with prolonged postoperative immobilization

 

DISCUSSION: The injury described is a ligamentous injury because of the dislocation with the radial head fracture. Therefore, the surgical goals are to restore stability to the elbow and allow early range of motion. Only radial head replacement will restore stability and allow early range of motion of the elbow. Radial head excision is not recommended in the setting of any instability because the radial capitellar joint is an important secondary stabilizer of the elbow. Total elbow arthroplasty is not needed because the ulnohumeral joint is normal. Partial excision of fragments over 30% will likely cause degeneration of the capitellum and will not restore the secondary stabilizing effect of the radial head.

Attempts to repair the radial head that cannot achieve rigid fixation are not recommended because they do not restore stability or allow early range of motion.

 

The Preferred Response to Question # 105 is 3.

 

Question 106A patient with a transverse femur fracture undergoes statically locked antegrade intramedullary nailing. Postoperatively, the patient appears to have a rotational deformity of greater than 25 degrees. The surgeon informs the patient, who chooses to undergo corrective treatment with removal of distal interlocking screws, rotational correction, and relocking of the screws. The patient goes on to heal but has persistent hip pain and a limp that does not improve completely after extensive rehabilitation. There is complete healing, no evidence of infection, no hardware issues, no ectopic bone, and rotational studies indicate less than 2 degrees of malrotation.

Functional capacity testing reveals the affected abductor and quadriceps function to be about 85% of the uninjured side and the patient returns to work and most of his recreational activities except rock climbing. Two days before the statute of limitations, the patient files a malpractice suit alleging negligence of surgery, loss of function, consortium, and pain and suffering due to the surgeon's efforts. What action should the surgeon and the defense team take?

1. Settle the case because the surgeon made an error that resulted in unnecessary surgery, and thus the case is indefensible.

2. Settle the case because they are likely to lose the case, and it would be cheaper to settle than to defend.

3. Defend the case alleging that there was no error, and no damages, and that the patient is malingering.

4. Defend the case because despite there being an error, the error was corrected and there were little or no damages compared with expected outcomes.

5. Contact the patient directly to discuss why he is suing and attempt an amicable resolution.

 

DISCUSSION: To establish negligence, certain criteria must be met. 1) A duty was owed by the surgeon (in this case, yes, a relationship was established). 2) The duty was breached, where the provider failed to meet the standard of care (there was a technical error, but it was corrected). 3) The breach caused an injury. In this case, the patient had an outcome that was very acceptable, as documented with outcome studies, for femur fractures.

Also, the rotational error and locking distally would have had little impact on the hip, whereas antegrade nailing itself is expected to result in some objective impairment of the hip in some patients. 4) Damages were incurred as a result. In this case, the patient returned to work and could not rock climb which could be reasonably expected with a femur fracture in some patients, and cannot be causally linked to the corrective surgery.

 

For all practical purposes, the patient had a very acceptable outcome. Thus, settling the case for an error would be rather permissive and the important issue is that the surgeon recognized the problem, addressed it, and fulfilled his or her postoperative responsibility. The case is very defendable, and thus it is unlikely to be lost. Defending the case and alleging no error is incorrect because there was an error. The surgeon should never function outside of his or her legal counsel once a suit is filed.

 

The Preferred Response to Question # 106 is 4.

 

Question 107 Five weeks following total knee arthroplasty, a woman has intermittent knee drainage for 1 week. Clear serous drainage is coming from her wound from a small area in the central portion of her incision. Her medical comorbidities include hypertension and a BMI of 50. Fluid aspirated from the knee shows a WBC of 11,500/mm3 with 92% polymorphonuclear cells. Methicillin-resistant Staphylococcus aureus grows from an aspirate on day 2. What is the next step in management?

 

1- One-stage revision using antibiotic-containing cement 2- Two-stage revision using an antibiotic cement spacer

3. Irrigation and debridement with polyethylene exchange

4. Infectious disease consult and appropriate oral antibiotics for 6 weeks 5- Infectious disease consult and appropriate IV antibiotics for 6 weeks

 

DISCUSSION: Infections that are diagnosed early have historically been treated with irrigation and debridement and IV antibiotics. However, published literature shows that this treatment is associated with success rates of less than 50%. The presence of resistant bacteria in the setting of morbid obesity and persistent drainage further decreases the success rate. A recent paper presented at the AAOS in 2010 showed poorer outcomes following two-stage revision in those patients in whom an attempt at component retention with irrigation and debridement had been performed first. Therefore, a two- stage revision with the use of an antibiotic cement spacer is likely to give a better outcome in this patient.

 

The Preferred Response to Question # 107 is 2.

 

Question 108Figures 108a through 108c are the radiographs of a 38-year-old man who fell on an outstretched hand 1 week ago and now reports severe left elbow pain.

Examination of the wrist reveals normal range of motion with no tenderness or swelling. Pain limits examination of his elbow. What is the most appropriate management to determine if surgery is indicated?

 

1- CT of the elbow 2- MRI of the elbow

3. Apply a long-arm splint and schedule a follow-up examination in 2 to 3 weeks when less painful

4. Examination under general anesthesia

5. Intra-articular lidocaine injection followed by repeat examination

 

DISCUSSION: Whereas there is controversy regarding the best treatment for comminuted radial head fractures, nondisplaced and minimally displaced fractures in which there is no block to motion can be treated nonsurgically. At the time of initial examination, it is important to determine that there is no block to range of motion. If pain limits the ability to examine the patient's range of motion, local analgesia with intra-articular lidocaine is most appropriate. Whereas general anesthesia would be useful for open reduction and internal fixation, the necessity for open reduction and internal fixation is best determined first before scheduling surgery. Neither a CT or MRI scan is necessary if the patient has no block to range of motion. Early range of motion is the best treatment for radial head fractures treated nonsurgically. After immobilization for 2 weeks, it may be difficult to determine whether there is a block to motion because the patient will likely have decreased elbow pronation and supination.

The Preferred Response # 108 is 5.

 

Question 109You design a research study in which you ask patients who have a nonunion of the tibia to fill out a questionnaire in which they report on a variety of medical conditions and social/behavioral practices. You compare these findings to a similar group who did not develop a nonunion in order to identify medical and/or social conditions that might be risk factors for the development of tibial nonunions. This would be an example of what type of study?

1. Case series

2. Meta-analysis

3. Case control study

4. Retrospective cohort study 5- Prospective cohort study

 

DISCUSSION: A case control series starts with the occurrence of a specific disease or observation, and then compares data on those individuals to a similar group without the disease (control group) in order to identify potential risk factors for the development of the disorder. A case series is an observational study in which an investigator follows a series of patients who received a specific treatment, recording the results and outcomes of that treatment. A meta-analysis is the combination of several separate studies that look at similar hypotheses in an effort to create a larger patient population for analysis. A cohort study looks for the incidence of a specific outcome in two groups (cohorts) of patients who are similar with the exception of a particular research variable (risk factor). The Preferred Response to Question # 109 is 3.

Question 110Figures 110a and 110b are the radiographs of a 13-year-old boy who has right lower extremity deformity, pain, and is unable to walk. He fell from the back of a moving pickup truck. What is the most likely complication associated with this injury? 1- Growth arrest

2- Medial collateral ligament injury 3- Anterior cruciate ligament injury 4- Nonunion

5- Loss of knee motion

 

DISCUSSION: The radiographs show a distal femoral Salter type II injury. The most likely

complication is a complete or partial growth arrest. Growth arrest is related to the severity of displacement. This injury can cause growth arrest in 50% to 80% of patients.

 

The older the patient, the more likely growth arrest will occur. Medial collateral and anterior cruciate ligament injuries are not associated with these fractures because the bone fails at the physis and not at the joint level. The fractures virtually always heal; therefore, nonunion is not an issue. Loss of motion is only transient and is not a permanent complication. The Preferred Response to Question # 110 is 1.

 

Question 111Figures 111a and 111b show axial MRI scans of a 24-year-old man who injured his right shoulder several years ago and now reports continued difficulty with the shoulder and has pain with activity. He reports that when the injury occurred, he felt that his shoulder "popped" but he never required closed reduction. He wore a sling for about 6 weeks and went through several months of physical therapy. Which of the following activities is most likely to cause him pain?

 

1. Reaching back to hit a forehand in tennis

2. External rotating the shoulder to spike a volleyball

3. Performing a bench press with large amounts of weight 4- Performing a biceps curl with large amounts of weights

5- Throwing a baseball at the point of late cocking/early acceleration

 

DISCUSSION: Performing a bench press with large amounts of weight is most likely to cause pain for a patient with a posterior labral tear. A patient who sustains a first-time posterior dislocation is less likely to have recurrent dislocations compared with first-time anterior dislocations. Patients often do have problems with loading the shoulder in a forward flexed position, such as during a bench press. The other activities listed here might be difficult, but are not as likely to be problematic. A biceps curl might bother a person with a SLAP tear. The late cocking/early acceleration phase of throwing, the overhead portion of a tennis serve, and spiking a volleyball places the shoulder in an abduction/external rotation position, which is likely to be problematic for a person with anterior instability.

The Preferred Response to Question # 111 is 3.

 

Question 112A 29-year-old man sustained an open humeral fracture and underwent surgical fixation 1 year ago. At that time, the radial nerve was transected and repaired primarily. He now haspersistent wrist drop and is unable to extend his digits. Nerve conduction velocity studies show no evidence of re-innervation. While discussing surgical options, the patient states that one of his hobbies is playing football. The most appropriate surgical reconstruction should include pronator teres transfer to the extensor carpi radialis brevis

1. alone.

2. and the flexor carpi radialis to the extensor digitorum communis. 3- and the flexor carpi ulnaris to the extensor digitorum communis.

4. and the flexor carpi radialis to the extensor digitorum communis, and the palmaris longus to the extensor pollicis longus.

5. and the flexor carpi ulnaris to the extensor digitorum communis, and the palmaris longus to the extensor pollicis longus.

 

DISCUSSION: The standard transfers for radial nerve palsy involve the pronator teres to the extensor carpi radialis brevis for central line of pull wrist extension. To power the extensor digitorum communis, the choice is between the flexor carpi radialis and the flexor carpi ulnaris. In a patient who needs power in throwing and needs to generate ulnarly directed flexion, it is important to preserve the flexor carpi ulnaris function; therefore, the flexor carpi radialis is the better choice. Furthermore, the thumb extension deficit should be corrected and the palmaris longus makes a good choice. Pr Re# 112 is 4.

 

Question 113Compared with myodesis, osteomyoplasty offers which of the following advantages in transtibial amputation?

1- Enhanced end-bearing 2- Early prosthetic fitting

3- Immediate weight bearing 4- Fibular abduction

5- Decreased surgical morbidity

 

DISCUSSION: Osteomyoplasty in transtibial amputation, originally described by Ertl in 1949, features creation of a bone bridge between the distal tibia and fibula, which is theorized to enhance bony stability and increase end-bearing of the residual limb, and may enhance patient-perceived functional outcomes relative to myodesis. Fibular

 

abduction is a known complication of traditional myodesis techniques, and is believed to represent syndesmotic instability. Osteomyoplasty requires additional surgical time and increased surgical morbidity, and because the success of the procedure is dependent on achieving bony union, early prosthetic fitting and immediate weight bearing are typically contraindicated. The Preferred Response to Question # 113 is 1.

 

Question 114Which of the following factors is considered to be the strongest predictor of outcome following arthroscopic partial meniscectomy?

1. Patient age

2. Patient body mass index

3. Amount of meniscal resection 4- Location of the meniscal tear

5- Modified Outerbridge cartilage score

 

DISCUSSION: In a recent evidence-based review of the literature, the only consistent factor predicting outcome after arthroscopic partial meniscectomy was the extent of osteoarthritis as classified by the modified Outerbridge cartilage score at the time of surgery. All other factors listed (ie, location of meniscal tear, patient age, patient BMI, and amount of meniscal resection) were shown to not predict outcome following partial meniscectomy. While not provided as an answer choice, female gender was shown to be a predictor for slower recovery in the short term. The Preferred Respon # 114 is 5.

 

Question 115A 72-year-old woman has chronic effusions and pain in her right knee. She has been treated with physical therapy and periodic epidural steroid injections for back pain for several years. Radiographs are unrevealing and the MRI scans shown in Figures 115a through 115c reveal evidence of osteonecrosis. The patient has been treated nonsurgically for the past 6 months without benefit and is now confined to limited ambulation around the home, has chronic night pain, and requires narcotic medications for comfort. What is the most appropriate management?

 

1- Observation for an additional 6 months 2- Diagnostic arthroscopy

3- Core biopsy and drilling procedure 4- Total knee arthroplasty

5- Physical therapy

 

DISCUSSION: The patient's condition raises several important issues. Although evidence remains anecdotal, chronic repeated cortisone injections may be a cause of chronic osteonecrosis in the hip and knee joints. The patient had chronic effusions, joint pain, and a classic appearance seen on the MRI scans. With extensive involvement as noted on the MRI scans, diagnostic arthroscopy and core drilling procedures are unlikely to offer much benefit. For a patient younger than age 50, temporizing for another 6 months would be beneficial in the hope that some resolution might occur. However, in a patient with severe pain and functional disability, total knee arthroplasty is the best alternative.

The Preferred Response to Question # 115 is 4.

 

Question 116A workers' compensation carrier for a local manufacturing company requests a second opinion on a 59-year-old man who sustained a crush injury to his foot and leg at work 6 months ago. His leg and foot were pinned between a forklift and a wall when an employee he was supervising lost control of the forklift. The employer suspects that the injured worker is malingering because the treating physician released him to work, but he has not returned to work. Which of the following elements of your history will best help you determine that the injured worker does not want to return to work out of fear of a confrontation with the employee he was supervising?

1. Formality

2. Empathy

3. Yes-no questions

4. Taking copious notes

5. Sitting leaning back in a chair

 

DISCUSSION: Empathy during the interview demonstrates compassion and earns the patient's trust; which, in turn, enables the patient to discuss any agenda or concerns he or she may otherwise feel uncomfortable revealing. It is also important to engage the patient to establish a trusting relationship and thus understand all the factors impacting the patient. A formal attitude toward the patient makes it difficult to engage the patient to be "drawn in." An engaged patient is more comfortable, reliable, and thorough when providing a history. Closed-end, yes-no questions do not allow the patient to detail all of the subtle nuances of their condition and its effect on their life. Taking copious notes likewise prevents engagement of the patient and the distraction of taking notes may cause the physician to miss an important detail. It is better to lean forward in a chair when interviewing a patient because this suggests the physician is genuinely interested,

 

whereas leaning back in a chair suggests the physician is simply waiting for the patient to finish talking. Avoid interrupting the patient when talking.

The Preferred Res# 116 is 2.

 

Question 117 Figures 117a through 117e are the radiographs and CT scans of a 32-year- old man who fell from a height of 8 feet and now reports pain and is unable to bear weight on his left lower extremity. The limb has no neurovascular impairment and the soft tissues are soft and intact. The preferred fixation construct should include which of the following?

 

1- A medially applied uniaxial locking plate 2- A laterally applied uniaxial locking plate 3- A laterally applied polyaxial locking plate

4. Anterolateral and posteromedially applied plates via two incisions

5. Anterolateral and medially applied plates via a single anterior incision

 

DISCUSSION: The injury represents a bicondylar tibial plateau fracture with an associated posteromedial fragment of considerable size. The posteromedial fragment can go unrecognized and undertreated, resulting in loss of knee motion, instability, and arthritis. A laterally applied plate is required to treat the bicondylar fracture. It alone, however, will not address the posteromedial fragment adequately. A second, posteromedial plate is required to adequately fix this important component of the fracture pattern. This is preferentially inserted employing a second (posteromedial) incision. The insertion of both plates through a single midline approach has resulted in unacceptable infection rates.

Any contemporary laterally applied plate (including polyaxial plates) will be insufficient by itself to address this fracture pattern. A medially applied plate alone will inadequately manage either the lateral condyle lesion or the posteromedial fragment.

The Preferred Response to Question # 117 is 4.

 

Question 118An 18-year-old football player crossing the field to make a catch is hit on the shoulder and upper chest by the tackler and falls to the ground with immediate pain throughout the shoulder region. The emergency department physician obtains the radiographs, CT scan, and 3-dimensional reconstructions seen in Figures 118a through 118e. What is the next step in management?

1. Obtain an MRI scan of the shoulder.

2. Place the arm in a sling for comfort and treat the injury nonsurgically. 3- Perform closed reduction in the emergency department.

4. Perform closed reduction in the operating room.

5. Perform open reduction using Kirschner wires to hold the joint reduced.

 

DISCUSSION: The player has sustained a posterior sternoclavicular dislocation. The CT scans show the medial end of the clavicle in close proximity to the aorta. An MRI scan will add no diagnostic information and might delay treatment. Nonsurgical management of an anterior sternoclavicular dislocation is often appropriate, but given the proximity of the clavicle to the aorta and airway, reduction of the dislocation is recommended to prevent vascular injury. While reduction is indicated, performing the reduction in the emergency department is not recommended because of the vascular injury or the need to perform an open reduction. Performing the procedure in the operating room with a thoracic surgeon available is recommended. Usually a closed reduction is stable, but if open reduction is necessary, Kirschner wires should be avoided to avoid the chance of migration of the implants. The Preferred Response to Question # 118 is 4.

 

Question 119 Internal impingement of the shoulder and posterosuperior labral pathology in throwers has been most clearly associated with which of the following? 1- Posterior capsular contracture

2. Anterior capsular laxity

3. Coracoacromial arch stenosis 4- Rotator cuff disease

5- Bennet's lesion

 

DISCUSSION: Posterior capular contracture has been recognized to be the primary pathologic process resulting in internal impingement. Internal impingement of the shoulder describes contact between the posterosuperior glenoid labrum and the undersurface of the rotator cuff at the level of the posterior supraspinatus when the shoulder comes into abduction and external rotation. This contact may be physiologic or pathologic and is frequently seen in overhead throwing athletes, possibly resulting in articular-sided rotator cuff tears, glenoid labral tears, tendinitis of the long head of the biceps, anterior instability, glenohumeral internal rotation deficit, and dysfunction of scapular rhythm. Nonsurgical management is the initial treatment of choice with an emphasis on increasing range of motion and improving scapular mechanics. Anterior capsular laxity may be present with internal impingement but is variable and less directly associated with internal impingement than posterior capsular contracture.

Coracoacromial arch stenosis is associated with subacromial impingement and unrelated to internal impingement. Bennett's lesion refers to exostosis or calcification at the posterior capsule and while potentially associated with overhead throwing athletes who may have internal impingement, a causal link between the two has not been established and therefore posterior capsular contracture is the preferred response. The Preferred Response to Question # 119 is 1.

 

Question 120Which of the following associated diagnoses is more likely to occur in a young adolescent with a displaced type III tibial tubercle fracture that occurred as a result of a noncontact basketball injury?

1- Compartment syndrome 2- Peroneal nerve palsy

3. Patella dislocation

4. Anterior cruciate ligament (ACL) and lateral collateral ligament (LCL) injuries 5- ACL and medial collateral ligament (MCL) injuries

 

DISCUSSION: Most tibial tubercle fractures occur as a result of a noncontact injury often while a skeletally immature athlete lands from a jump. The resulting zone of soft-tissue injury often exceeds that of the tibial tubercle itself, leading to the development of a compartment syndrome. Typically, tibial tubercle fractures are not associated with ACL, MCL, LCL, or patella injuries. The Preferred Response to Question # 120 is 1.

 

Question 121Figures 121a through 121d are the radiographs and CT scans of a 49-year- old woman with a history of metastatic breast cancer who has progressively severe right hip pain over the last 4 weeks. She is in a wheelchair and unable to walk.

Examination reveals she is obviously uncomfortable, has severe groin pain with any motion of the hip joint, and mild back pain. She has no motor or sensory weakness in her upper or lower extremities. A bone scan shows increased uptake in the femoral neck. Treatment should consist of

1. hemiarthroplasty.

2. radiation therapy.

3. percutaneous pinning. 4- total hip arthroplasty.

5- cephalomedullary fixation.

 

DISCUSSION: The radiographs and CT scans reveals the characteristic appearance of metastatic bone disease. Based on her sudden increase in pain and inability to walk, a nondisplaced femoral neck fracture has likely occurred. If the primary is unknown, biopsy should be considered prior to treatment. Radiation therapy can be used to treat local bony disease, but is not recommended in the setting of an acute fracture. Although the fracture is minimally displaced, percutaneous pinning is not indicated with diffusely metastatic disease. Cephalomedullary fixation would be an option, however, but may not be optimal for the fracture location. Furthermore, a small study comparing intramedullary fixation with arthroplasty in proximal femoral metastatic disease found a lower rate of implant failure and reoperation with arthroplasty (8% versus 16%).

Hemiarthroplasty could be an option, given the patient's advanced stage of disease, and likely limited lifespan; however, the cystic changes in the acetabulum indicate the presence of metastatic disease there. Additionally, studies have shown that total hip arthroplasty pain and functional outcomes at 6 months through 2 years are superior to hemiarthroplasty when the procedure is performed for elderly patients with hip

 

fractures. Total hip arthroplasty is the recommended treatment for patients with metastatic femoral neck fractures. The Preferred Response to Question # 121 is 4.

 

Question 122 A physician receives a summons that he is being sued. The first step should be to

1. call the patient and apologize.

2. notify the medical liability carrier.

3. contact an attorney with whom the physician is familiar with and have the attorney review the records.

4. be sure to discard any handwritten phone messages because they are not discoverable.

5. find a colleague with a similar subspecialty and have the colleague review the record before doing anything.

 

DISCUSSION: The most appropriate first step is to notify the medical liability carrier. The medical liability carrier will assign an attorney who is likely to be more appropriate. A review by a colleague may be requested by the defense attorney but that should be at their discretion. Patient apology is appropriate early on when and if you discover an error. Records should be reviewed, but never altered. The Preferred Respon# 122 is 2.

 

Question 123What is the most efficient pressure for use with negative pressure wound therapy?

1. 25 mm Hg

2. 75 mm Hg

3. 125 mm Hg

4. 300 mm Hg

5. 500 mm Hg

 

DISCUSSION: In animal and clinical studies, a range of pressures between 50 mm Hg to 500 mm Hg were tested; the most efficient pressure was 125 mm Hg, resulting in a fourfold increase in blood flow, 63% increase in granulation tissue with continuous pressure, and 103% increase in granulation tissue with intermittent pressure. When 125 mm Hg pressures were compared with either those less than 50, or those greater than 250, there was a decrease in granulation tissue in swine models. The Pre Res# 123 is 3.

 

Question 124Figures 124a and 124b are the radiographs of a 30-year-old man who sustained an ankle injury and has swelling with lateral tenderness. The patient denies any previous ankle injuries. After 6 weeks of rest and use of a removable ankle brace, he continues to have swelling, lateral pain, and popping. An anterior drawer test reveals a solid end point. Recommended treatment should include which of the following?

1- Ankle arthroscopy and debridement of an osteochondral lesion 2- Peroneal retinacular reconstruction

3. Brostrom-Gould lateral ligament reconstruction

4. Immobilization in a walker boot in plantar flexion 5- Ankle rehabilitation and physical therapy

DISCUSSION: The radiographs and examination reveal peroneal tendon instability requiring surgical treatment for persistent symptoms and tendon instability. The radiographs demonstrate the "fleck sign," which is an avulsion of the posterior distal fibular ridge, and represents an injury to the superior peroneal retinaculum and probable peroneal dislocation. Peroneal tendon dislocations are typically present with vague lateral ankle findings associated with swelling and tenderness over the distal fibula. The tendons may be palpated as a ridge over the lateral fibula distally. Initial management of the acute injury with cast immobilization in plantar flexion/inversion with the use of a pad in the shape of a "U" or "J" is effective in 50% of patients; the rest will require surgical treatment. The indications for surgical treatment of peroneal dislocation/subluxation include continued pain and failure of nonsurgical management.

Associated peroneal tendon tears can be found when performing retinacular reconstruction. Many techniques have been described including soft-tissue reconstructions, bone block procedures as well as fibular groove-deepening procedures. Radiographs do not reveal an osteochondral lesion. There is no evidence of lateral ankle

 

ligament instability. Ankle rehabilitation and physical therapy may further damage the unstable tendons. The Preferred Response to Question # 124 is 2.

 

Question 125 Figures 125a and 125b are the current radiographs of a 52-year-old man who sustained an injury to his dominant wrist 8 weeks ago. He is an alcoholic and does not remember the details of how he injured it. Paperwork showing what treatment he received at an urgent care facility indicates that he was given a splint for his "sprained wrist." Examination reveals the pain is getting better, but there is persistent swelling and range of motion is very limited. Recommended treatment at this time should consist of

1- discontinuation of the splint and commencement of a regimen of hand therapy. 2- casting for an additional 2 weeks and reassessment of the fracture healing at that time.

3- open reduction and internal fixation of the injury. 4- proximal row carpectomy.

5- wrist arthrodesis.

 

DISCUSSION: The injury represents a very uncommon presentation of a perilunate injury pattern. Whereas these injuries are sometimes overlooked on initial radiographic studies, they are usually recognized much sooner. In this case of a late presenting perilunate injury in a patient that is not entirely responsible, a proximal row carpectomy represents the best treatment option. Open reduction and internal fixation is generally not successful because of cartilage degeneration and contracture that has developed in the interim. No further splinting or casting is indicated, and neglecting the injury would be indicated only if the patient refused any further treatment. Wrist arthrodesis is generally indicated only as a salvage procedure if a proximal row carpectomy is unsuccessful.

The Preferred Response to Question # 125 is 4.

 

Question 126A 30-year-old man has had severe knee pain and swelling for 1 week. He reports he previously had acromioclavicular joint pain that disappeared. He denies any fever. Aspiration of a cloudy fluid from the knee reveals a WBC count of greater than 50,000 with 90% polymorphonucleocytes. While awaiting culture results, what is the most appropriate action?

1. Cortisone injection

2. Open surgical debridement

3. Immediate arthroscopic lavage

4. Intravenous vancomycin for presumptive MRSA infection

5. Obtain sexual activity history and select appropriate antibiotic

 

DISCUSSION: The patient has polyarticular gonococcal arthritis. Acute septic arthritis in adults can be separated into two major patient groups: young (age 15 to 40 years) healthy, sexually active patients with gonococcal pyogenic arthritis and elderly or immunocompromised patients with nongonococcal septic arthritis. In gonococcal septic arthritis, the infecting organism is Neisseria gonorrhea. It is the most common cause of acute joint infection in persons 15 to 40 years of age in the U.S. The clinical presentation is variable, but typically includes migratory polyarthralgias, fever, rash, urethral or vaginal discharge, and tenosynovitis. A patient with disseminated gonococcal infection may report few genital symptoms. More than 50% of these infections are polyarticular.

Because patients with gonococcal septic arthritis are healthy, prompt antibiotic treatment results in a generally good prognosis. MRSA septic arthritis would be associated with fever, more rapid onset of symptoms, and is rarely polyarticular. The Preferred Response to Question # 126 is 5.

 

Question 127A 38-year-old man sustained a complete thoracic spinal cord injury at age

14. An MRI scan of his shoulder, when compared with studies from uninjured controls, is more likely to show which of the following?

1- Hypertrophied subscapular muscle 2- Rotator cuff tear

3- Posterior glenohumeral subluxation 4- Increased bone density

5- Supraspinatus nerve compression

 

DISCUSSION: Children that sustain a spinal cord injury or otherwise use a wheelchair for mobility, and thus often have more pain and a higher incidence of structural and functional changes of the shoulder joint as an adult. MRI studies have shown a four-fold risk of rotator cuff tears in people with long-term paraplegia when compared with age- matched controls. An MRI scan would not show bone density changes. The other answer choices have not been demonstrated in higher numbers on MRI in paraplegics.

The Preferred Response to Question # 127 is 2.

 

Question 128Figures 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?

1. Posterior laminectomy

2. Posterior laminoplasty

3. Posterior laminectomy and fusion 4- Cervical collar and observation

5- Combined anteroposterior decompression and fusion

DISCUSSION: The patient has cervical spondylosis and symptomatic myelopathy. The radiograph reveals multilevel spinal cord compression and, most importantly, a fixed kyphosis of the cervical spine. In the setting of cord compression and kyphotic deformity, a combined anteroposterior approach allows for ventral and dorsal decompression, kyphosis correction, and stabilization. Observation in the setting of severe myelopathy will likely lead to further disease progression. In the setting of cervical kyphosis, posterior-only treatment options will not adequately address cord deformation and, therefore, not improve symptoms as reliably. The Preferred Response # 128 is 5.

 

Question 129Figures 129a and 129b show the six-month follow-up radiographs of a 62- year-old woman who sustained a hip fracture in a fall. Prior to the fall, the patient was active and had no difficulty with ambulation. The patient underwent open reduction and internal fixation with a sliding hip screw device. She has difficulty with ambulation, continues to walk with a walker, and reports startup pain. What is the most appropriate management at this time?

 

1. Valgus osteotomy

2. Removal of the hardware

3. Intramedullary fixation after removal of the hardware

4. Conversion to total hip arthroplasty with a long cementless stem

5. Conversion to total hip arthroplasty with a primary tapered stem

 

DISCUSSION: The radiographs demonstrate a healed fracture with penetration of the screw through the femoral head into the acetabulum as well as osteonecrosis and collapse of the femoral head (Figure 129b). Conversion to total hip arthroplasty with a long stem is necessary to bypass the femoral cortical defects from the screw holes. A primary tapered stem is not appropriate because of the proximal femoral deformity and the stress risers associated with the screw holes. Removal of hardware, valgus osteotomy, and revision of the internal fixation are not appropriate in the presence of the femoral head collapse and acetabular penetration.

The Preferred Resp # 129 is 4.

 

Question 130A 45-year-old man sustained the injury seen in Figure 130a 6 weeks ago. He denies any prior injury to his shoulder. After treatment of the injury in the emergency department, he was noted to have significant weakness with empty can testing and external rotation at the side. He has full passive range of motion with forward flexion, abduction, and internal and external rotation, but has difficulty initiating abduction with his arm at his side. He has negative apprehension and relocation signs. A detailed neurologic examination shows no deficits. A coronal image from a follow-up MRI scan is seen in Figure 130b. Follow-up radiographs reveal no fractures. What is the most appropriate next step in his treatment?

 

strength improvements

 

DISCUSSION: The most likely concern, in a patient older than age 40 having a first-time shoulder dislocation, is a rotator cuff tear. The MRI scan shows a tear of the supraspinatus tendon. Recurrent instability is less likely to be a problem, so an external rotation brace for an extended period of time is unnecessary. The patient already has good passive range of motion, and with a full-thickness rotator cuff tear, physical therapy alone is unlikely to return him to full function. The MRI scan shows no labral tear, so arthroscopic or open repair is not indicated.

The Preferred Response # 130 is 2.

 

Question 131During a percutaneous plating of a proximal tibia fracture requiring a 13- hole minimally invasive locking plate system, the placement of the distal most screws should be done through a small open incision to avoid injury to what structure?

 

1- Superficial peroneal nerve 2- Saphenous nerve

3- Posterior tibial artery 4- Peroneal artery

5- Peroneal tendons

 

DISCUSSION: The superficial and deep peroneal nerves are consistently at risk near the distal holes of long locking proximal tibia plates but can be avoided with a small open incision for those screws. The peroneal tendons are more posterior at that level. The saphenous nerve is medial. The peroneal artery runs behind the fibula and is not at risk. The posterior tibial artery is posterior to the tibia.

The Preferred Response # 131 is 1.

 

Question 132Figures 132a and 132b are the lateral and anteroposterior radiographs of a 15-year-old boy with a 6-month history of recurrent, activity-related posterior elbow pain when pitching. Two separate 6-week periods of rest have failed to provide relief. What is the next best step to enable him to return to play?

1. Physiotherapy

2. Long-arm cast

3. Cannulated screw fixation 4- Plate fixation of the ulna 5- Hinged-elbow bracing

 

DISCUSSION: Intramedullary screw fixation of the olecranon stress fracture is most likely to allow him to return to play. Stress

fractures through a persistent olecranon apophysis have been well described in the literature. The AP radiograph reveals the other physes of the elbow to be closed. After patients fail to respond to appropriate periods of rest and cessation from throwing followed by appropriate physiotherapy, surgical management with cannulated screw fixation is appropriate and has been demonstrated to have favorable success rates.

Hinged-elbow bracing will not facilitate healing or return to play. Long-arm casting is likely to result in stiffness and would not be unreasonable for a short duration at the onset of symptoms, but is less likely to be helpful at this point. Plate fixation is not indicated for treatment of this injury. The Preferred Response# 132 is 3.

 

Question 133Currently, what is the most common clinical study type in the orthopaedic literature?

1. Level 1 (prospective, randomized trial)

2. Level 2 (cohort trial)

3. Level 3 (retrospective case control)

4. Level 4 (retrospective case series)

5. Level 5 (expert opinion)

 

DISCUSSION: Although a recent push for prospective, randomized trials has been advocated by multiple orthopaedic journals, many studies published continue to be of Level 4 evidence (retrospective case series). Case series represented 64% of all studies

 

reviewed by Freedman and associates in 2001 from the British and American volumes of Journal of Bone and Joint Surgery and from Clinical Orthopaedics and Related Research. Obremskey and associates published that 58.1% of all studies from nine orthopaedic journals were Level 4 evidence. The Preferred Response to Question # 133 is 4.

 

Question 134A 47-year-old woman sustained a nondisplaced distal radius fracture 6 months ago and is unable to extend her thumb. When performing reconstruction using the extensor indicis proprius to the extensor pollicis longus transfer, tension is ideally determined by securing the tendons in what manner?

1- In maximum tension with the wrist and thumb in extension 2- In maximum tension with the wrist and thumb in neutral

3. In maximum tension with the wrist and thumb in flexion

4. According to the tenodesis effect with wrist flexion and extension

5. According to functional testing with the patient awake under local anesthesia

 

DISCUSSION: Extensor pollicis longus rupture can result from distal radius fractures. Synergistic tendon transfer can be achieved using the extensor pollicis longus as the motor donor. Whereas different schemes for achieving optimal tension are available, the most reliable method is to tension the repair under local anesthesia while asking the patient to perform thumb flexion and extension. Tendon transfer tension can be adjusted accordingly to achieve maximum extension without compromising active flexion range.

Other methods of tensioning are estimates at best, and maximum tensioning in patients without neuromuscular disease is rarely used in tendon transfers. The Pre Res# 134 is 5.

 

Question 135During spinal deformity surgery, which of the following is the most specific early indicator of an intraoperative injury to the spinal cord?

1. Somatosensory-evoked potentials

2. Transcranial motor-evoked potential monitoring

3. Transcutaneous electroencephalogram neuromonitoring 4- Stimulus-evoked transpedicular electromyography (EMG) 5- Brainstem auditory-evoked responses (BAERs)

 

DISCUSSION: Transcranial motor-evoked potentials provide the most specific early indicator of an intraoperative spinal cord injury. Somatosensory-evoked potentials are routinely used but do not have the sensitivity and specificity of motor-evoked potentials.

 

EMG evaluations are routinely used for root evaluation following pedicle screw placement. BAERs are typically used in monitoring brain surgery. The Pre Res# 135 is 2.

 

Question 136Figure 136 is the radiograph of a 68-year-old man who reports persistent pain after undergoing total hip arthroplasty. Examination reveals equal limb lengths and there is minimal discomfort with straight-leg raise or hip rotation. When asked to ambulate, however, he has discomfort with the first few steps, and then can walk more comfortably. C-reactive protein and erythrocyte sedimentation rates are normal.

Management should now consist of

 

1. an indium scan.

2. a three-phase bone scan.

3. revision of the femoral component with a cemented stem. 4- revision of the femoral component with a cementless stem. 5- cortical strut allografting of the femoral stress fracture.

 

DISCUSSION: The patient has a 100% radiolucent line around the femoral component as well as a distal pedestal indicating loosening of the femoral component. With these findings, there is

no need to do further workup for loosening with a bone scan. Infection is unlikely with the normal laboratory findings so an indium scan is not necessary. Allograft for the femur may improve pain with a stress fracture but not in the setting of a loose femoral component. Revision of the femoral component with a cementless stem after removing the fibrous endosteal tissue and the distal pedestal is associated with the best results.

Cemented revision stems in this setting are associated with early failure. The Preferred Response to Question # 136 is 4.

 

Question 137Figures 137a and 137b show MRI scans of a 56-year-old man who fell down the stairs and injured his elbow. He felt a pop and noted that his elbow had significant swelling. The primary care physician ordered radiographs that showed no fracture. Examination reveals moderate elbow swelling and ecchymosis. He has pain with passive range of motion, but can achieve full extension and flexion to 150 degrees. He is tender to palpation in the antecubital fossa and states that he would like to avoid surgery if possible. Which of the following statements best reflects the outcome of nonsurgical management?

 

DISCUSSION: The patient has a distal biceps tendon rupture. The MRI scans show the tendon avulsed from its insertion and the amount of retraction of the tendon. Surgical treatment to repair the tendon avulsion is often indicated, but nonsurgical management can be recommended. Whereas flexion of the elbow is a biceps function and can be decreased after this injury, the other elbow flexors often compensate adequately.

Significant decreases in forearm supination strength are frequent complaints of patients with distal biceps injuries. Loss of motion, instability, and degenerative arthritis are not common outcomes of this injury. The Preferred Response to Question # 137 is 1.

 

Question 138Figures 138a through 138c are the radiograph and CT scans of a 42-year- old man who sustained an injury to both of his ankles and underwent surgical repair 2 weeks prior to presentation to your office. One ankle is healing well. On the contralateral side, he reports pain and restricted ankle range of motion. Management should consist of

 

1- the addition of more aggressive physiotherapy. 2- observation and continued non-weight-bearing.

3. addition of an anteriorly directed "syndesmosis screw."

4. loosening the syndesmotic screws from an overtightened position.

5. removal of screws, re-reduction of the syndesmosis, and revision fixation.

 

DISCUSSION: This patient has a malreduced syndesmosis. The CT scans clearly show the fibula to be subluxated posteriorly relative to the incisura; therefore, surgical revision is warranted. Revision surgery should include either removal of the current screws with accurate reduction of the syndesmosis and new screw placement or repair of the posterior malleolar fragment, which will in turn reduce the syndesmosis. Addition of an anteriorly directed screw to the current construct will not change the malalignment.

Loosening the syndesmotic screws or addition of aggressive physiotherapy will not correct the malrotation of the distal fibula within the incisura which is seen on the CT scan. Outcomes after these injuries are related to the reduction of the ankle mortise.

 

The Preferred Response to Question # 138 is 5.

 

Question 139Which of the following substances is likely to cause the most soft-tissue damage in the long term if injected into a fingertip under high pressure?

 

1. Grease

2. Latex paint

3. Water

4. Oil-based paint

5. Chlorofluorocarbon-based refrigerant

 

DISCUSSION: This type of injury represents a difficult problem in hand surgery. The factors that most determine outcome after high-pressure injection injuries into the fingertip include: involvement of the tendon sheath, extent of proximal spread of the injected substance, pressure setting, and delay to surgical treatment. The other factor that likely is most important is the type of substance injected. Water and latex-based paints are least destructive. Grease and chlorofluorocarbon-based substances are intermediate, but aggressive surgical debridement can restore reasonable function. Oil- based paints are highly inflammatory and can cause such chronic inflammation such that amputation may be the only reasonable treatment option despite early aggressive surgical treatment.

 

The Preferred Response to Question # 139 is 4.

 

Question 140Which of the constructs seen in the Figures 140a through 140c best demonstrates buttress plating technique for the fracture shown?

 

1- Figure 140a with a nonlocked screw 2- Figure 140a with a locked screw

3- Figure 140b with a nonlocked screw 4- Figure 140b with a locked screw

5- Figure 140c with a locked screw

 

DISCUSSION: Buttress plating technique relies on an under-contoured plate secured with a

nonlocked screw near the apex of a vertical fracture. This provides an axilla to resist vertical displacement. Locked screws do not compress plate to bone and are not ideal for buttress plating technique. The Preferred Response to Question # 140 is 1.

 

Question 141The risk for remanipulation of a pediatric distal forearm fracture, after initial reduction and casting, is most closely related to

1- initial immobilization with a short-arm cast. 2- the location of the fracture.

3- initial translation of the fracture. 4- initial angulation of the fracture.

5- a single versus both bone fracture.

 

DISCUSSION: Initial fracture translation has been shown to be associated with a higher risk for remanipulation. Fracture reduction is important and if there is residual translation after reduction, consideration for fixation should be considered. The location of the fracture or single versus both bone fracture, in itself, is not a risk factor for redisplacement, nor is the use of long- versus short-arm casts. The Pre Resp# 141 is 3.

 

Question 142A 72-year-old man has a severe limp 9 months after undergoing a total hip arthroplasty. He has no pain. His straight lateral incision from an anterolateral approach healed well without prolonged antibiotics or drainage. His legs feel equal when he stands, but he ambulates with a severe Trendelenburg limp and is unable to actively abduct his hip against gravity. What is the most likely cause of his problem?

 

1. Component loosening

2. Component impingement 3- Foraminal stenosis at L3-4

4. Detached gluteus medius tendon

5. Neuropathy of the superior gluteal nerve

 

DISCUSSION: The direct lateral approach to the hip is commonly used for primary total hip arthroplasty (50% to 65% of cases). The technique requires detachment of a portion of the gluteus medius tendon and then reattachment during closure. In a small percentage of patients the repair will fail, resulting in significant abductor weakness and a Trendelenburg limp. This is often painless after the initial surgical healing time.

Component impingement can lead to early wear or dislocation but would not cause a limp. It is usually painless. Foraminal stenosis could cause isolated weakness but is much more likely to cause radicular type symptoms of pain with or without numbness or weakness. Any weakness would be in a nerve distribution pattern and because the superior gluteal nerve has components from L4, L5, and S1, weakness from root compression would be subtle and incomplete. Dissection of more than 3 cm to 4 cm from the greater trochanter can injure the superior gluteal nerve and result in weakness, but this is much less reported and has been shown to be transient in most cases. Component loosening can cause a limp but is painful and would produce weakness.

The Preferred Response to Question # 142 is 4.

 

Question 143A 22-year-old woman underwent closed reduction and percutaneous pinning with casting of a displaced extra-articular distal radius fracture. The surgery was completed with a supraclavicular regional anesthesia. After the block wears off, she reports new onset dense numbness in the palmar aspect of the thumb, index, and middle fingers as well as severe pain in the hand. What is the next step in management?

1. Bivalve the cast and follow up in 1 week

2. Return to the operating room for open carpal tunnel release 3- Compartment pressure monitoring of the hand

4. Emergent nerve conduction velocity studies

5. Exploration of the supraclavicular brachial plexus

 

DISCUSSION: The injury represents a somewhat uncommon problem after surgical treatment of distal radius fractures; however, vigilance is required to detect the acute presentation of a carpal tunnel syndrome. In this case, urgent release of the tunnel is recommended. Bivaling the cast alone is indicated when the pain is less severe, and only when the numbness is very minimal and more generalized. Compartment syndrome of the hand is almost unheard of in the setting of a distal radius fracture; rather it is more commonly associated with a crush injury to the hand. There is no role for emergent nerve conduction velocity studies or brachial plexus exploration. The Pre Res# 143 is 2.

 

Question 144Patients with multiple hereditary exostoses have a greater risk of developing what kind of mesenchymal tumor?

1. Hemangioma

2. Enchondroma

3. Chondrosarcoma

4. Extra-abdominal desmoid tumor 5- Neurofibroma

 

DISCUSSION: Patients with multiple hereditary exostosis (MHE) have an increased risk of secondary chondrosarcomas in an area of a prior exostosis. This risk is probably 1 in 10,000 MHE patients and typically is a low-grade chondrosarcoma. Mafucci's syndrome is a different disorder and is associated with hemangiomas. Ollier's patients have multiple enchondromas. Extra-abdominal desmoids are associated with Gardner's syndrome, and von Recklinghausen's disease is associated with plexiform neurofibromas.

The Preferred Response to Question # 144 is 3.

 

Question 145A 50-year-old woman with a history of type 1 diabetes has a 2-month history of pain and swelling in her left foot. Initial radiographs are seen in Figures 145a and 145b. She has been treated in a cast and has been non-weight-bearing for 2 months. Her skin is intact but her foot is swollen, warm, and erythematous. She is afebrile. Laboratory studies show a uric acid level of 4.0 mg/dL (normal 2.5-7.0 mg/dL), white blood cell count of 9,700/mm3 (normal 3,500-10,500/mm3), erythrocyte sedimentation rate of 65 mm/h (normal up to 20 mm/h), and a glucose level of 166 mg. Current radiographs are seen in Figures 145c and 145d. What is the best treatment option at this time?

 

1- Continued total contact cast immobilization 2- Medical management for gouty arthritis

3. Physical therapy to work on range of motion and strengthening

4. Immediate open reduction and internal fixation of the navicular fracture

5. Open biopsy of the left midfoot for deep cultures and a referral to infectious disease for antibiotic therapy

 

DISCUSSION: The radiographs show progressive disruption of the talonavicular joint consistent with a neuropathic arthropathy. This is clinically in the development- fragmentation stage (Eichenholtz stage 1) with the triad of erythema, warmth, and swelling, and is best treated in a non-weight-bearing cast. Cast immobilization for stage 1 has been shown to be effective in multiple studies; however, the non-weight-bearing status has not been conclusively shown to be necessary. Whereas infection is always a possibility, the lack of an open wound and signs of sepsis: fever, leukocytosis, or elevated serum glucose, make an infectious process doubtful. The uric acid level is normal and gout does not cause significant rapid bony destruction. Physical therapy would potentially aggravate the neuropathic process and is not indicated during stage 1. While a few authors have advocated early surgical intervention, there is not enough significant scientific evidence to recommend surgical management during stage 1 and thus it is usually reserved for significant deformity and impending skin breakdown.

 

The Preferred Response to Question # 145 is 1.

 

Question 146Figure 146 is the radiograph of a 72-year-old woman with a history of Parkinson's disease and a multiply revised right total hip arthroplasty with a constrained implant. She is seen in

the emergency department, reporting pain. Treatment should consist of which of the following?

1. Closed reduction

2. Open reduction

3. Open reduction with soft-tissue repair

4. Acetabular revision with a constrained implant

5. Acetabular revision with an unconstrained implant

 

DISCUSSION: The patient has a hip dislocation with a previously placed constrained acetabular component. The ring around the femoral neck is the locking ring of a constrained implant that has dissociated. The acetabular component demonstrates increased vertical inclination and retroversion. The acetabular component malposition contributed to the dislocation along with the patient's deficient abductor musculature. The appropriate treatment would be to perform an acetabular revision to improve the component position along with a constrained liner due to the deficient abductors. A closed reduction will be extremely difficult to achieve because of the presence of a constrained liner, whereas an open reduction is not advised because of the persistent problem of component malposition. The Preferred Response to Question # 146 is 4.

 

Question 147Figure 147 is an MRI scan of a 72-year-old woman admitted to the hospital 7 days ago with persistent and worsening back pain. A repeat vertebral augmentation was performed at L2 three days ago. Today she became diaphoretic, reported severe dyspnea, and collapsed during physical therapy. Examination reveals a pulse of 128/min, blood pressure of 98/55 mm Hg, and temperature of 100 degrees F (37.7 degrees C). Jugular venous distention is noted. What is the most likely complication?

 

1. Spinal shock

2. Neurogenic shock

3. Hemorrhagic shock

4. Pulmonary embolism

5. Autonomic dysreflexia

 

DISCUSSION: The patient has the classic symptoms of a pulmonary embolism. Symptoms of pulmonary embolism of polymethylmethacrylate (PMMA) following vertebral augmentation may occur with a delay. A symptomatic pulmonary embolism following vertebroplasty can occur either by migration of acrylic or the migration of fat and bone marrow cells. The MRI scan reveals a new superior endplate fracture involving L2. With this now being the third consecutive vertebral compression fracture in 2 months, one must be suspicious that these represent pathologic fractures, rather than osteoporosis. Risk factors for venous thromboembolic disease include increasing age, prolonged immobility, surgery, trauma, malignancy, pregnancy, estrogenic medications (eg, oral contraceptive pills, hormone therapy, tamoxifen [Nolvadex]), congestive heart failure, hyperhomocystinemia, diseases that alter blood viscosity (eg, polycythemia, sickle cell disease, multiple myeloma), and inherited thrombophilias. In addition to the risk associated with embolization of PMMA, the patient has been immobile for 7 days and was ultimately diagnosed with multiple myeloma. The Preferred Response # 147 is 4.

 

DISCUSSION: Patients with multiple hereditary exostosis (MHE) have an increased risk of secondary chondrosarcomas in an area of a prior exostosis. This risk is probably 1 in 10,000 MHE patients and typically is a low-grade chondrosarcoma. Mafucci's syndrome is a different disorder and is associated with hemangiomas. Ollier's patients have multiple enchondromas. Extra-abdominal desmoids are associated with Gardner's syndrome, and von Recklinghausen's disease is associated with plexiform neurofibromas.

 

Question 148Which key factor that induces osteoclastogenesis is secreted by osteoblasts in response to inflammatory stimuli?

1. Osteoprotegerin (OPG)

2. Tumor necrosis factor (TNF) 3- Insulin growth factor-1 (IGF)

4. Bone morphogenetic protein (BMP)

5. Receptor activator of nuclear factor kappa-B ligand (RANKL)

 

DISCUSSION: Osteoclasts are derived from cells of the monocyte/macrophage lineage. They are multinucleated and develop by fusion of mononuclear precursors, a process that requires receptor activator for nuclear factor kappa-B ligand (RANKL) and macrophage- colony stimulating factor (M-CSF). RANKL is secreted by osteoblasts in response to

 

inflammatory signals and is a key component of inflammation-mediated osteolysis. OPG binds to and sequesters RANKL, thus inhibiting osteoclast differentiation and activity.

BMP and IGF-1 are potent regulators of osteoblast differentiation and activation. TNF is a cytokine secreted by macrophages and degranulating platelets infiltrated in the fracture site and impacts a variety of cells, not osteoclasts. The Preferred Response # 148 is 5.

 

Question 149A 3-year-old child has the deformity seen in Figures 149a and 149b. In discussing the condition with the family, it is important to inform them that this problem is associated with

 

1. osteogenesis imperfecta.

2. neurofibromatosis.

3. limb-length discrepancy.

4. congenital pseudarthrosis.

5. renal anomalies.

 

DISCUSSION: The radiographs demonstrate congenital posterior medial bow of the tibia. It is associated with limb-length discrepancy in the older child and calcaneovalgus foot in the newborn. The bowing slowly diminishes, although a considerable limb-length discrepancy can develop (3-8 cm). It is important to differentiate this condition from anterior lateral bow of the tibia, which is associated with congenital pseudarthrosis of the tibia and neurofibromatosis. Osteogenesis imperfecta can present with various long-bone deformities secondary to fracture, but the bone quality in the figure appears normal.

Renal anomalies are not associated with posterior medial or anterior lateral bow of the tibia. The Preferred Response to Question # 149 is 3.

 

Question 150Figures 150a and 150b are the MRI scan and biopsy specimen of a 53-year- old man who has had right knee pain and swelling for the past 9 months. What is the most likely diagnosis?

1. Liposarcoma

2. Biphasic synovial sarcoma 3- Ganglion cyst

4- Pigmented villonodular synovitis 5- Myxoma

 

DISCUSSION: Soft-tissue sarcomas found near joints are very rare. The MRI scan is clearly not benign fat (lipoma) but could be consistent with any sarcoma, myxoma, or ganglion cyst. The biopsy specimen, however, is not a cyst or myxoma (generally very acellular).

This is a high-grade liposarcoma because it has high-grade cellular morphology and is not a biphasic picture. Furthermore, there are lipoblasts in the biopsy specimen. High-grade liposarcomas may have very little recognizable fat cells on the biopsy specimen. A biphasic synovial sarcoma has slit-like areas that look almost like glands and other more solid cellular areas. The name, synovial sarcoma, implies that it is found in the synovium, but that is not true. It is a misnomer concerning the pathologic appearance. A myxoma would have this MRI appearance but would be much less cellular on the biopsy specimen. The Preferred Response to Question # 150 is 1.

 

Question 151 Figures 151a and 151b are the radiographs of a 15-year-old boy who has had swelling and knee pain for several weeks. He has pain both at rest and with activity. What is the next step in management?

1. Through-knee amputation

2. MRI scan of the entire bone as soon as possible

3. Biopsy of the lesion with referral to a tumor specialist if malignant

4. Continued observation with repeated radiographs in 3 months if still painful 5- Symptomatic treatment, including rest and nonsteroidal anti-inflammatory medication, with follow-up as needed

 

DISCUSSION: The radiographs reveal a bone-forming tumor with indistinct margins that most likely represents a malignant sarcoma such as an osteosarcoma. Evaluation requires a full workup, including an MRI scan of the entire involved bone. Symptomatic treatment

 

or continued observation has no role in this treatment. A biopsy should be performed after the evaluation is complete and preferably by the surgeon that will do the definitive treatment. Most tumors, even if malignant, can be treated with limb-sparing surgery.

The Preferred Response to Question # 151 is 2.

 

Question 152Figures 152a and 152b are the radiographs of an otherwise healthy 75- year-old woman who underwent open reduction and internal fixation of a tibial plateau fracture 1 year ago. The patient now reports chronic pain that leaves her unable to walk any more than just about the home and she has great difficulty going up and down stairs. Laboratory studies show an erythrocyte sedimentation rate of 18 mm/h (normal up to 20 mm/h). She has no other lower extremity involvement. The valgus deformity of the knee measures 18 degrees. What is the best option for this patient?

1. Varus osteotomy

2. Knee arthrodesis

3. Standard total knee arthroplasty with hardware removal 4- Removal of hardware and lateral unicondylar arthroplasty

5- Total knee arthroplasty with removal of hardware and a hinged-knee prosthesis

 

DISCUSSION: The patient is an excellent candidate for a reconstructive procedure, but this is a difficult procedure for a number of issues and potential problems. The hardware is lateral and the best option for approaching hardware removal which is needed for placement is from the lateral side. The lateral approach to the knee has other benefits including the ability to directly approach lateral ligaments for balancing and to avoid disruption of the patella blood supply which may have been violated by prior procedures. The surgeon should prepare for the possibility of needing augments or stems on the components. The Preferred Response to Question # 152 is 4.

 

Question 153 A 31-year-old high school football coach has right medial knee pain that is made worse with prolonged standing. His knee is minimally painful in the morning but by the end of the school day, he must sit down. The pain often makes sleeping difficult. He states that several years ago he underwent a surgical procedure to "clean out" the cartilage of the knee; however, he only had several months of pain relief. He is noted to be an athletic male (BMI of less than 30). Knee examination is unremarkable except for medial joint line pain that is exacerbated with standing and walking. Radiographs, including a long-leg view, and MRI scans are seen in Figures 153a through 153d. He wishes to remain active and asks whether he would be a candidate for allograft meniscus transplantation. You advise him that

1. the current literature does not support allograft meniscus transplantation.

2. allograft meniscus transplantation is a surgical option; however, he is beyond the age where the procedure will provide much lasting benefit.

3. you would recommend a course of viscosupplementation.

4. based on his age and limb alignment, you would not recommend an allograft meniscus transplant but would recommend a high tibial osteotomy.

5. based on his age and limb alignment, you would recommend a high tibial osteotomy and a staged allograft meniscal transplant after the osteotomy has healed.

 

DISCUSSION: The patient's history, physical findings, and MRI scans indicate that a complete medial meniscectomy was performed. The meniscus provides an essential function in dissipating forces to the adjacent articular cartilage. Complete or partial meniscectomy has been shown to result in more rapid clinical and radiographic arthritis

 

than if the meniscus is preserved. Allograft meniscal transplantation has been shown to be effective in the young patient with an absent meniscus, no or correctable limb malalignment, and minimal or correctable articular cartilage damage. His age would be appropriate for an allograft meniscus transplant. Based on the patient's long-leg radiograph, a valgus-producing high tibial osteotomy would be appropriate but alone would not address the absent meniscus in this young patient. Viscosupplementation may provide some temporary relief but is not an

appropriate long-term solution. A staged valgus-producing osteotomy followed by an allograft meniscus transplant would be the most appropriate treatment. The Preferred Response to Question # 153 is 5.

 

Question 154A 45-year-old woman undergoes an uncomplicated total knee arthroplasty. Nine months later she has not yet returned to work because of pain and stiffness. Her range of motion is 5 to 80 degrees. She has no instability, is unable to climb stairs normally, sitting in low chairs is uncomfortable, and she no longer participates in physical therapy. She has pain with prolonged standing. Radiographs show a well-aligned, cruciate-retaining implant. Work-up for infection, including joint aspiration, is negative. What is the next step in management?

1. Dynamic splinting

2. Open release of adhesions

3. Manipulation under anesthesia

4. Revision to a cruciate-sacrificing implant

5. Arthroscopic release of adhesions and manipulation

 

DISCUSSION: Arthrofibrosis after total knee arthroplasty (TKA) affects 1% of patients. Ninety degrees of motion allows for most activities, including ascending and descending stairs. Risk factors for postoperative stiffness include preoperative stiffness, younger age, posttraumatic arthritis, and multiple prior surgeries. Whether range of motion is affected by the choice of cruciate retaining versus sacrificing implants is subject to much debate, but has not been shown to be related to arthrofibrosis following TKA. At earlier time points, physical therapy, use of dynamic splinting, and manipulation under anesthesia may be beneficial in restoring motion but at 9 months is unlikely to prove successful.

However, the patient has both pain and motion loss and is 9 months from her original surgery. Late manipulation may have an increased risk of complications such as fracture or tendon rupture. Moreover, arthroscopy would allow for lysis of adhesions and

 

assessment for other causes of pain and has been shown to be safe and effective following TKA; however, it does carry the risk of infection. Care must be taken not to scratch or otherwise damage the implants during surgery. The Preferred Resp # 154 is 5.

 

Question 155 A 30-year-old accountant and recreational softball player, who is seen at the end of his baseball season, reports a several month history of pain along the medial side of his dominant elbow. He cannot identify a specific injury and notes it only hurts when he throws the ball in from the outfield. Besides the pain, he remarks that his speed and distance while throwing have diminished considerably. Examination reveals tenderness along the medial elbow but no weakness or gross instability is found.

Radiographs are normal. Based on the history, what is the most likely diagnosis? 1- Ulnar neuritis

2. Pronator syndrome

3. Medial epicondylitis

4. Medial collateral ligament sprain 5- Varus extension overload

 

DISCUSSION: Throwing athletes frequently develop medial collateral ligament sprain related to the repeated valgus stress that occurs on the medial elbow during the acceleration phase of throwing. This has the effect of not only causing pain, but also resulting in loss of velocity and distance during the throwing activity. The injury is generally well tolerated in most activities of daily living and only becomes problematic during the vigorous, stressful act of throwing. Absence of neurologic signs or symptoms makes ulnar nerve pathology unlikely. Pronator syndrome causes pain on the volar aspect of the forearm during resisted forearm pronation and is not associated with the throwing motion in particular. Valgus extension overload may mimic medial collateral ligament injury, not varus extension injuries. Medial epicondylitis may be confused with ligament insufficiency but the examination and a history of pain only while throwing make this an unlikely diagnosis. The Preferred Response to Question # 155 is 4.

 

156 A prospective outcome study is performed at a single institution to analyze the potential differences in treating intertrochanteric hip fractures with a plate/screw device versus an intramedullary device. No specific randomization is performed because an equal number of surgeons have preferences for the use of one of these devices and they are allowed to continue their preferred method. Hip-specific and

 

general health-related outcome measures are used, an excellent follow-up rate of 85% of the patients at 2 years is accomplished, and there appears to be results that favor the intramedullary device but the confidence intervals are wide. This study would be considered to carry what level of evidence?

 

1- I 2- II 3- III 4- IV 5- V

 

DISCUSSION: This is a prospective comparative study but is not randomized or blinded and is therefore a Level II therapeutic study. To qualify as Level I, it would need to be a high-quality randomized trial with narrow confidence intervals regardless of a significant difference or no difference in outcomes. Level III would be case-control studies or retrospective comparisons. Level IV is case series and Level V is expert opinion.

The Preferred Response to Question # 156 is 2.

 

Question 157 Displaced olecranon apophyseal fractures in children are commonly associated with which of the following?

 

1. Child abuse

2. Multiple trauma

3. Noonan syndrome

4. Osteogenesis imperfecta 5- Vitamin D deficiency

 

DISCUSSION: Children with osteogenesis imperfecta often sustain numerous fractures and the differentiation between this and child abuse can be difficult. Although most fracture patterns can occur in both, olecranon apophyseal fractures do occur commonly in children with osteogenesis imperfecta, and are treated most commonly with open reduction and fixation. Children with osteogenesis imperfecta who have this fracture are at high risk for a similar fracture on the contralateral side. The fracture is not specifically associated with child abuse, multiple trauma, or Noonan's syndrome. Vitamin D deficiency is now being recognized as extremely common in children, especially those with disabilities, but it is not associated with this fracture pattern.

The Preferred Response to Question # 157 is 4.

 

Question 158 A 19-year-old college pitcher reports posterior shoulder discomfort that started recently with pitching. He is able to throw with normal velocity and control, but his pain in the early acceleration phase of throwing is getting worse. Examination reveals symmetric rotator cuff strength and no increased anterior or posterior translation of either shoulder. He has some discomfort with his shoulder in abduction and external rotation. Supine range of motion of the right shoulder in 90 degrees of abduction reveals external rotation to 100 degrees and internal rotation to 25 degrees. His left shoulder has 95 degrees of external rotation and 45 degrees of internal rotation. He is not playing the next 2 weeks and requests some exercises that he can do on his own. Which of the following exercises will most likely improve his shoulder symptoms?

 

1. Standard and low rowing exercises

2. Lying on his side with the shoulder abducted 90 degrees, elbow flexed 90 degrees, and pushing his forearm toward the table

3. Humeral head depressions while holding a ball against a wall 4- Scapular `punches` in many directions

5- Putting a rolled towel between his shoulder blades while lying supine and having a teammate push posteriorly on the shoulders

 

DISCUSSION: The patient has a glenohumeral internal rotation deficit of 20 degrees. Posterior capsular stretching would be beneficial. A sleeper stretch is a common way for patients to stretch the posterior capsule on their own. It involves lying on the side with the shoulder abducted 90 degrees and the elbow flexed 90 degrees and trying to push the forearm toward the table. Closed-chain rotator cuff exercises, such as humeral head depressions while holding a ball against a wall, pectoralis minor stretching, such as lying on a rolled towel and pushing posteriorly on the shoulders, scapular protraction, such as punches, and scapular retraction, such as row exercises, can all be helpful for the disabled throwing shoulder, but they will not restore the decreased internal rotation.

 

The Preferred Response to Question # 158 is 2.

 

Question 159 Figures 159a and 159b are the radiographs of a 40-year-old woman who sustained a twisting injury to her lower extremity. What additional information or studies are important in determining treatment options?

 

1- Full-length tibia-fibula radiographs 2- Inability to bear weight

3. History of recurrent ankle sprains

4. Presence or absence of medial tenderness 5- MRI scan

 

DISCUSSION: The radiographs reveal a medial ankle injury with a widened medial clear

space. No fibula fracture is visualized on this view; therefore, full-length radiographs looking for a proximal fibula fracture are required to determine treatment. The presence or absence of medial tenderness has been shown to not be a good predictor of unstable injuries. A history of previous injuries or ankle instability is typically lateral instability, which would not present with this radiographic appearance. An MRI scan can be used to evaluate subtle syndesmotic injuries, but there is a clear widening of the medial clear space in this case. The inability to bear weight is not helpful in determining the treatment options. The Preferred Response to Question # 159 is 1.

 

Question 160 An athletic 35-year-old man participates in competitive sports for recreation. During a weight-lifting workout, he described striding forward with his left foot on his flexed right hip. He heard an audible pop and immediately experienced pain in his right hip. Since the injury, he has had difficulty with movement and pain in the right hip. After a week of continued symptoms, he consulted an orthopaedic surgeon who ordered an MRI scan which indicated a partial tear of the right tensor fascia lata and physical therapy was recommended. Specific instructions for the therapist in the initial phase of rehabilitation to prevent hip arthrofibrosis, yet not injure the muscle further, should include which of the following?

1. Immediate active hip internal and external rotation, active hip flexion and extension, with hip strengthening beginning in 4 weeks

2. Immediate active hip internal and external rotation, active hip flexion, and passive hip extension with hip strengthening beginning in 4 weeks

 

3. Immediate active hip internal and external rotation, passive hip flexion and extension, with hip strengthening beginning in 4 weeks

4. Immediate passive hip flexion and internal rotation, active hip external rotation and hip extension, with hip strengthening beginning in 4 weeks

5. Immediate active hip internal and external rotation, and active hip flexion and extension with immediate hip strengthening

 

DISCUSSION: The patient injured his tensor fascia lata based on his symptoms, the mechanism of injury, and the MRI findings. Although various authors have described different functions of the tensor fascia lata, it has generally been agreed on that it functions as a hip flexor, hip internal rotator, and to a lesser degree, hip external rotator. Initial therapy to facilitate healing of a muscle begins with ice, compression, and initial passive range of motion. After this initial phase, active motion can commence, followed by strengthening and functional rehabilitation. Initial passive range of motion of the injured tensor fascia lata would include hip internal rotation and flexion. Answer choice 1 is incorrect because active hip internal rotation and flexion would potentially injure the tensor fascia lata before it had healed. Answer choice 2 is incorrect because immediate active hip flexion would injure the tensor fascia lata. Answer choice 3 is incorrect because active hip internal rotation would injure the tensor fascia lata before healing. Answer choice 4 is correct for the previously mentioned explanation. Answer choice 5 is incorrect because active hip flexion and internal rotation would injure the tensor fascia lata.

The Preferred Response to Question # 160 is 4.

 

Question 161Figures 161a and 161b are the AP and lateral radiographs of a 10-year-old boy with a painful left distal tibia. An MRI scan is shown in Figure 161c. Figures 161d and 161e show biopsy specimens. What is the most likely diagnosis?

 

1. Trauma

2. Osteosarcoma

3. Osteomyelitis

4. Ewing's sarcoma

5. Eosinophilic granuloma

 

DISCUSSION: The patient has a distal tibial destructive lesion with a Codman's triangle and an extensive soft-tissue mass as seen on the radiographs, which is an osteosarcoma. The pathology shows a malignant osseous-forming lesion. Eosinophilic granuloma would be characterized by a lytic lesion with variable periosteal response, but rarely ever has a soft-tissue mass. The pathology would have large histiocytes and scattered eosinophils with a variable amount of acute inflammatory cells. Osteomyelitis would not present with a soft-tissue mass, although abcesses are rarely seen. The pathology should not show malignant cells, but rather acute and chronic inflammatory cells and variable amounts of dead bone. Trauma such as stress fractures can be difficult to assess on plain radiographs, but the MRI scan should show a fracture line, best seen on a T1-weighted image. The amount of soft-tissue mass seen on the MRI scan would not be seen in a fracture, nor would the malignant cells be seen on biopsy. Ewing's sarcoma is typical of this boy's age and can be seen in the metadiaphysis of the distal tibia, but the biopsy should have shown malignant small blue round cells with indistinct cytoplasm. Osteoid seen on the biopsy specimen can be seen in small areas of Ewing's, where reactive bone occurs but should not be the prominent feature as it is in this case. The Preferred Respon# 161 is 2.

 

Question 162 A 37-year-old woman has right-hand numbness and tingling. Based on the history and examination, carpal tunnel syndrome is suspected, and electrodiagnostic tests also point to the same diagnosis. The patient has worn night splints for the last 8 weeks with continued persistent symptoms. What is the next most appropriate step in management?

1- Continue the night splinting for 1 additional month. 2- Continue the night splinting for 3 more months.

3- Switch to full-time splinting and reevaluate in 1 month. 4- Switch to full-time splinting for 3 more months.

5- Perform carpal tunnel release.

 

DISCUSSION: Various nonsurgical management options exist for carpal tunnel syndrome (local and oral steroids, splinting, and ultrasound). All effective or potentially effective nonsurgical forms of management have measureable effects on symptoms within 2 to 7 weeks of the initiation of treatment. If a treatment is not effective within that time frame, a different treatment option should be chosen. In this case, continued splinting is unlikely to improve symptoms and steroid injection or surgery is indicated.

The Preferred Response to Question # 162 is 5.

 

Question 163Figures 163a through 163c show the radiograph and MRI scans of a 45- year-old woman with severe right arm pain. She has had symptoms for 6 months without resolution despite multiple nonsurgical treatments. Examination reveals weakness in the right triceps and wrist flexors with decreased sensation in the middle finger and a positive Spurling's sign. What is the most appropriate treatment for the patient's symptoms?

1. Posterior laminoplasty

2. Posterior cervical foraminotomy 3- Anterior cervical foraminotomy

4- Anterior cervical diskectomy and arthrodesis 5- Anterior corpectomy and arthrodesis

 

DISCUSSION: The patient has symptoms and signs of cervical radiculopathy despite a long course of nonsurgical management. Therefore, surgical decompression is indicated and is best performed through an anterior cervical diskectomy and arthrodesis. Single level anterior cervical diskectomy and arthrodesis have been shown to produce significant improvements in arm pain and neurologic function. Anterior cervical foraminotomy, while reported, has insufficient data to support its use and it places the vertebral artery at significant risk. Posterior cervical foraminotomy is contraindicated given the ventral spinal cord compression; foraminotomy places the patient at risk for spinal cord injury.

The patient has one-level cervical disease, therefore a corpectomy is unnecessary.

Posterior laminoplasty is used to treat myelopathy, not radiculopathy.

The Preferred Response to Question # 163 is 4.

 

Question 164 A 5-month-old girl sustained an isolated midshaft left femur fracture when her father tripped and fell while carrying her. She has no other injuries. In addition to verifying that this was not a case of child abuse, treatment should consist of 1- application of a Pavlik harness.

2- application of a one-and-one-half spica cast. 3- flexible intramedullary nailing.

4. percutaneous submuscular plating.

5. open reduction and internal fixation with a locked plating construct.

DISCUSSION: Femur fractures in children who are not yet walking are rare, but they do occur. Any child who is not yet walking who sustains a femur fracture should be considered a victim of abuse until demonstrated otherwise. However, occasionally femur fractures that are not related to abuse do occur in this patient population. Femur fractures in the prewalking child heal reliably and rapidly; immobilization in a position that minimizes deforming forces of surrounding muscles yields comfort and allows for simpler maintenance of alignment. Pavlik harnesses are well tolerated in children younger than 6 months of age, and allow for easy diapering for parents. Spica casting is a reasonable alternative treatment, but diapering is more difficult than with a Pavlik harness. Surgical methods of fixation for femur fractures in children younger than 6 months of age are rarely used, if ever. The Preferred Response to Question # 164 is 1.

 

Question 165 A 43-year-old man who works as a plumber has a painful stiff elbow in his dominant arm. He notes that while he recalls no single event of injury, he thinks the many years of pulling wrenches and soldering pipes have resulted in his problem. He reports that he has pain with any motion in bending his arm and can no longer straighten his elbow. Examination reveals generalized swelling of the elbow, both medial and lateral with a range of motion that lacks 45 degrees of extension and flexes only to 110 degrees. Pronation and supination are also limited to 45 degrees. Audible crepitus is perceived but there is no instability. Radiographs reveal advanced osteoarthritis at the radiocapitellar and ulnohumeral joints with complete loss of articular cartilage. What is the most appropriate initial treatment option?

1. Elbow fusion

2. Radial head resection

3. Total elbow arthroplasty

4. Osteophyte resection and capsular release

5. Physical therapy with dynamic extension and flexion splints

 

DISCUSSION: Osteoarthritis of the elbow is more common in the middle-age laborer such as this plumber, whereas rheumatoid arthritis is more common in older females.

Treatment must respect the physical demands of the patient while trying to preserve joint motion and function with tolerable symptoms. Osteophyte resection and capsular release have offered many patients significant improvement in their symptoms while allowing them to return to most activities. The osteophyte resection and releases can be done effectively by an open or arthroscopic approach. Whereas total elbow arthroplasty would likely result in better and more thorough pain relief, it would not tolerate the occupational demands of this individual. There is no role for physical therapy initially in the face of advanced, painful arthritis associated with long-standing fixed joint contractures. Elbow fusion results in severe loss of function and its indication is rare and usually considered in the face of unmanageable sepsis. Radial head resection may improve symptoms related to the radial capitellar arthritis but would not improve range of motion or end range impingement pain. Also, radial head resection should be avoided in heavy laborers with elbow arthritis because it would lead to increased loads across the arthritic ulnohumeral joint. The Preferred Response to Question # 165 is 4.

 

Question 166  At what age does the lateral epicondyle normally ossify in males?

1- 2 to 4 years 2- 5 to 6 years 3- 7 to 8 years 4- 9 to 11 years 5- 12 to 14 years

 

DISCUSSION: The lateral epicondylar epiphysis is the last to ossify in the elbow at age 12 to 14 years in males. The first secondary ossification center to ossify is the capitellum, which ossifies during the first 6 months of life. Next is the radial head, ossifying between age 3 and 6 years. The medial epicondyle appears between 5 and 7 years; the trochlea and olecranon at 8 and 10 years, respectively. In females, the appearance of ossification centers is about a year earlier than males. The Preferred Response to Question # 166 is 5.

 

Question 167 Which of the following factors is predictive of a poor patient outcome after antegrade intramedullary nailing of a femoral shaft fracture?

 

1. Gait assessment

2. Manual muscle testing

3. "Time to tire" walking trial

4. Visual analog pain scale for hip

5. Radiographic appearance of fracture

 

DISCUSSION: Patients who have undergone an antegrade intramedullary nailing of a femur fracture will commonly have hip abductor weakness and a Trendelenburg gait following surgery. Patients with a short stride length and an ipsilateral trunk lean are likely to be dissatisfied with their outcomes. They will lean their trunk toward their affected side as a result of hip abductor weakness. This may result from abductor damage during surgery, prominent hardware, and/or inadequate rehabilitation. Archdeacon and associates examined eight nonconsecutive femoral shaft fractures treated with an antegrade nail. All patients were enrolled in a standardized postoperative outpatient protocol as described in the article by Paterno and associates. The authors used hip kinematics (hip and trunk coronal plane motion) and hip kinetics (hip abductor moment) and found that patients improved over time. They also found that a patient reported a dysfunction score at about 2 years postoperative correlated with the presence of an abnormal ipsilateral trunk lean at the time of initial independent ambulation as well as ambulation after complete healing had occurred. The authors commented that the clinical assessment of a shortened stride length and a lateral trunk lean may be predictive of a poorer functional outcome, and can be used at follow-up visits to assess dynamic hip abductor function. "Time to tire" is not an existing outcomes test. Visual analog hip pain, manual muscle testing, and fracture consolidation are not predictive of outcome.

The Preferred Response to Question # 167 is 1.

 

Question 168 Figures 168a and 168b are the radiograph and CT scan of a 15-year-old patient who reports a 6-month history of intermittent ankle pain that worsens with activity. The pain was temporarily relieved with 8 weeks in a walking cast. What is the next most appropriate step in

management?

 

1- Repeat use of the walking cast 2- Surgical resection

3. Custom foot orthotic

4. Non-weight-bearing casting

5. Subtalar arthrodesis

 

DISCUSSION: Pain due to tarsal coalition that recurs after appropriate nonsurgical management is best treated surgically. In this patient, the talocalcaneal coalition is fibrocartilaginous, occupies less than 50% of the joint surface, and there are no

 

degenerative changes. Therefore, surgical resection is indicated. Even if initially effective, nonsurgical management such as another walking cast, restricted weight bearing, and orthotics are rarely effective for recurrent pain. Subtalar arthrodesis is indicated when the coalition comprises greater than 50% of the talocalcaneal joint or degenerative arthritis is present. Nonsurgical management such as custom foot orthoses, activity restrictions, and over-the-counter removable boots can be helpful for the initial treatment of mild pain, but a walking cast for 4 to 6 weeks has a very high rate of successful symptom relief of any magnitude and is the most appropriate treatment for the first presentation of pain. The Preferred Response to Question # 168 is 2.

 

Question 169 Figures 169a through 169c show the radiograph and MRI scans of a 74- year-old woman who has had back and bilateral leg pain for the past 6 months.

Nonsurgical management has failed to provide relief. What is the best option for surgical treatment?

1. Posterior decompression

2. Posterior interbody arthrodesis

3. Posterior decompression and in situ arthrodesis

4. Posterior decompression and instrumented arthrodesis 5- Anterior and posterior arthrodesis

 

DISCUSSION: The patient has symptoms of lumbar spinal stenosis and radiographic evidence of a grade I degenerative spondylolisthesis at L4-5. Surgical treatment has been shown to provide better clinical outcomes than nonsurgical management. Treatment for spondylolisthesis remains somewhat controversial but posterior lumbar instrumented arthrodesis is best supported in the literature. Decompression alone places the patient at risk for recurrent stenosis and progression of deformity. Noninstrumented arthrodesis for

 

this condition results in high rates of nonunion and worsened long-term outcomes. There is insufficient evidence to support the role for interbody arthrodesis (either through an anterior or posterior approach) compared with posterior decompression and arthrodesis. The Preferred Response to Question # 169 is 4.

 

Question 170 Figures 170a through 170d show the radiograph, axial MRI scans, and sagittal MRI scan of a 60-year-old man who sustained a seizure 12 weeks ago. Since that time he has had shoulder pain and is unable to use his arm. Examination reveals pain with any motion and he has no active or passive external rotation of the arm.

What is the most appropriate next step in management?

1-Sling immobilization with gentle passive range of motion starting in 2 weeks 2-Humeral head hemiarthroplasty with subscapularis repair

3. Arthroscopic posterior labral repair

4. Open reduction and transfer of the lesser tuberosity into the defect 5-Closed reduction and early active range of motion

 

DISCUSSION: Humeral head arthroplasty with subscapularis repair is the most reliable way to fill this large anterior humeral head defect and achieve joint stability. He has a chronic locked posterior dislocation with a large reverse Hill-Sachs deformity and a displaced lesser tuberosity fracture. It has likely been dislocated for 12 weeks since his seizure. At this point, sling immobilization is not appropriate because this will not provide reduction of the joint. Closed reduction should not be attempted 12 weeks following the injury because it is highly unlikely to succeed. Arthroscopic posterior labral repair will not be successful with a large reverse Hill-Sachs deformity. Transfer of the lesser tuberosity into the defect may be successful for smaller lesions, but will be unlikely to provide enough bone to fill this large defect. In a younger patient with similar findings, an osteochondral allograft to restore humeral head deficiency with subscapularis repair is an appropriate option. The Preferred Response to Question # 170 is 2.

 

Question 171 Postoperative radiographs following a total hip arthroplasty performed through a posterior approach demonstrate that the cup has been placed in about 35 degrees of abduction. Compared with the ideal placement of 45 degrees of abduction, this more horizontal cup placement is likely to give what functional result?

1- Increased dislocation rate 2- Increased range of motion

3- Increased risk of iliopsoas impingement when using a large metal head 4- Elevated risk of squeaking in ceramic-ceramic bearing surfaces

5- No adverse effect on wear

DISCUSSION: Decreased abduction angles have no adverse effect on wear rates. The optimal placement of the acetabular cup is accepted to be 45 degrees of abduction and 20 degrees of anteversion. However, outliers to these positions are common. Increased abduction angle has been shown to markedly increase wear rates. Decreased anteversion may contribute to posterior hip dislocation, whereas increased anteversion may increase impingement. However, placing the cup at 35 degrees of abduction may decrease range of motion, especially if there is insufficient anteversion of the femoral and acetabular components. Squeaking in ceramic hips is associated with more vertical rather than horizontal cup placement. The Preferred Response to Question # 171 is 5.

 

Question 172 Randomized controlled trials can be designed in several ways. Which of the following study designs refers to a randomized controlled trial in which two interventions are compared within the same study group?

 

1- Parallel 2- Case control 3- Case series 4- Factorial 5- Crossover

 

DISCUSSION: A factorial randomized control trial design is more easily represented in a two by two table. Practically, patients are randomized to either treatment A and B, treatment A or control, treatment B or control, or no treatment. The strength of this trial design is that two interventions can be assessed with the same study population. Also, any interaction between the treatments can be determined (for example, does treatment A work differentially when combined with treatment B). The parallel design trial is the simplest and most classic design for a randomized controlled trial. In this trial design, participants are randomized to two or more groups of different treatments and each group is exposed to a different intervention and only that intervention. In the crossover design trial, both groups receive both interventions over a randomly allocated time

 

period. Group A can receive the treatment, and after a suitable washout period, can receive the placebo. Group B can receive the placebo and later can receive the treatment; this produces within-participant comparisons. The crossover trial design has a limited role in surgical interventions because it is difficult or impossible for patients to receive both treatment interventions, such as plate and nail fixation, or a cemented versus a cementless total hip arthroplasty. Case control and case series are not randomized trials, but observational studies. The Preferred Response # 172 is 4.

 

Question 173 A 46-year-old man sustains an injury to his left index finger while cleaning his paint gun with paint thinner. Examination reveals a small puncture wound at the pulp. The finger is swollen. What is the next most appropriate step in management?

 

1. Elevation and observation

2. Surgical debridement and lavage 3- Infiltration with corticosteroids

4- Infiltration with a neutralizing agent 5- Administration of antibiotics

 

DISCUSSION: High-pressure injection injuries are associated with a high risk of amputation. The risk of amputation is highest with organic solvents. The presence of infection and the use of steroids do not impact the amputation rate. Amputation risk is lower if surgical debridement is performed within 6 hours. Elevation and observation would delay necessary care. Neutralizing agents may be used in specific situations, such as hydrofluoric acid exposure or chemotherapeutic agent extravasation, but in high pressure paint thinner injection, the best outcome is achieved through early surgical lavage. The Preferred Response to Question # 173 is 2.

 

Question 174Figures 174a through 174c are the MRI scans of a 16-year-old football player who dislocated his dominant left shoulder 3 weeks ago while landing on his outstretched arm. The dislocation was reduced in the emergency department. He has since had two episodes where he felt like his shoulder slipped partially out of place.

Which of the following statements to the athlete and his parents is most accurate regarding treatment options?

 

1. Physical therapy should allow him to return to football with recurrent dislocations unlikely.

2. Immobilization of his shoulder in an external rotation brace will eliminate the chance of further dislocations.

3. Arthroscopic capsulolabral repair is a reasonable option if he wishes to undergo this procedure, despite this being a first-time dislocation.

4. Arthroscopic capsular and labral repair will likely fail in this situation. 5- Open repair definitely provides a better outcome.

 

DISCUSSION: Arthroscopic capsulolabral repair is a reasonable option despite this being a first-time dislocation. The patient has had recurrent instability episodes with two subluxations since his dislocation. Outcome studies have shown up to 90% recurrent instability rates in young, active populations. Capsulolabral repair has the best chance to reduce the risk of recurrent instability. Physical therapy is unlikely to significantly reduce the high likelihood of recurrence. While there is controversy regarding immobilization in internal or external rotation, studies have shown that immobilization may not reduce the risk of recurrent instability. While older studies did show that open repairs had lower recurrence rates than arthroscopic repairs, more recent studies have shown similar rates for arthroscopic capsulolabral plication with modern suture anchor techniques and no glenoid bone loss or engaging Hill-Sachs lesion. The Preferred Response # 174 is 3.

 

Question 175 When performing a right proximal humeral hemiarthroplasty, the relative placements of the lesser tuberosity relative to the biceps tendon is best depicted, in Figure 175, by the

1- lesser tuberosity at A, biceps at B. 2- lesser tuberosity at B, biceps at C. 3- lesser tuberosity at C, biceps at B. 4- lesser tuberosity at A, biceps at C. 5- lesser tuberosity at C, biceps at D.

 

DISCUSSION: The lesser tuberosity should be placed at position A, and the biceps tendon at position B. One of the most common errors during proximal humeral arthroplasty is the use of the lateral keel of the prosthesis as the landmark, around which the tuberosities are reconstructed. If this is done, the anterior soft tissue/bone element is stretched, while the posterior soft tissue/bone element is lax, with a resultant loss of external rotation of the arm. The biceps should be used as the proper landmark for tuberosity reconstruction and in its absence, the anterior aspect of the prosthesis, where the bicipital groove would have been, should be used as the central juncture of tuberosity reconstruction. The upper border of the pectoralis is best used to gauge appropriate height but knowing that the biceps tendon runs directly underneath the tendon insertion can also aid in estimating the proper location. The Preferred Response # 175 is 1.

 

Question 176 Which of the following rehabilitation techniques is appropriate for initial nonsurgical management of an isolated grade 2 posterior cruciate ligament injury?

1. Immobilization in full extension for 4 weeks

2. Immobilization in 30 degrees of flexion for 4 weeks

3. Relative protection for 10 to 14 days, then range of motion with progressive plyometric exercises

4. Relative protection for 10 to 14 days, then range of motion with gentle open-chain hamstring strengthening

5. Relative protection for 10 to 14 days, then range of motion with gentle closed-chain quadriceps strengthening

 

DISCUSSION: Treatment should consist of relative protection for 10 to 14 days followed by early range of motion and gentle closed-chain quadriceps strengthening. Isolated grade 1 and grade 2 posterior cruciate ligament injuries can be successfully managed nonsurgically. Progression to global knee strengthening can begin 4 to 6 weeks after the injury, with return to functional activity when full range of motion and strength is established. Plyometric exercises involve rapid alteration of contraction and loading of a muscle and should not be used in the early rehabilitation of a ligament injury of the knee because it risks further injury to the ligament. Hamstring strengthening should be avoided until the ligament has healed (4to 6 weeks) because the posterior force on the tibia will stress the injured posterior cruciate ligament. Immobilization may be used for a short time to allow swelling and pain to subside, but early range of motion is preferred to avoid unnecessary stiffness following the stable injury. The Preferred Respons # 176 is 5.

 

Question 177 Figure 177 is an intra-articular photograph taken while viewing from the anterior superior portal during arthroscopy of a right shoulder. Which of the following findings identified at the time of surgery would be the most predictive for recurrence following arthroscopic repair of the demonstrated pathology?

1- Nonengaging Hill-Sachs deformity 2- Intra-articular loose body

3- Anterior glenoid bone deficiency of 35% 4- Subacromial bursitis

5- 10% partial-thickness, articular side tear of the supraspinatous

 

DISCUSSION: Anterior glenoid bone deficiency of 35% is most predictive of recurrence. Figure 177 shows an acute tear of the anterior inferior glenoid labrum consistent with a Bankart lesion. It has been clearly shown that there is a direct relationship between failure (ie, recurrent dislocation) of arthroscopic Bankart repair and anterior glenoid bone loss. Anterior glenoid bone loss of greater than 25% in the setting of anterior glenohumeral instability is a relative contraindication to performing arthroscopic stabilization and instead is an indication to perform a bony glenoid augmentation procedure to address the articular arc deficit. Therefore, an anterior bony defect of 35% is the most predictive finding at the time of surgery for recurrent dislocation. An engaging Hill-Sachs deformity has a significant effect on the rate of redislocation, but a nonengaging one should not. An intra-articular loose body, subacromial bursitis, and a partial-thickness articular-sided supraspinatous tear should not lead to an increased risk of recurrent dislocation following Bankart repair. The Preferred Response # 177 is 3.

 

Question 178 A 12-year-old boy has severe left hip pain that is worse at night and dramatically improves with the use of nonsteroidal anti-inflammatory drugs. A radiograph and CT scan are seen in Figures 178a and 178b. Which of the following options is associated with the most rapid resolution of symptoms with the least long- term morbidity?

1. Steroid injection

2. Radiofrequency ablation

3. En bloc excision with osteoarticular allograft

4. Continued use of parenteral naproxen sodium 500 mg bid

5. Open curettage of the lesion with careful dislocation of the femoral head

 

DISCUSSION: These studies are characteristic of an osteoid osteoma. Radiofrequency ablation is the least invasive and highly successful procedure for osteoid osteomas.

Ninety-five percent of lesions are destroyed completely with one procedure. Open curettage or en bloc excisions are associated with significant late joint morbidity. Steroid injections have been reported as successful for unicameral bone cysts and eosinophilic granulomas, but not osteoid osteomas. The Preferred Response to Question # 178 is 2.

 

Question 179 A 56-year-old woman undergoes an arthroscopic rotator cuff repair for a two-tendon retracted tear (supraspinatus and infraspinatus), requiring the use of four suture anchors placed in a double row technique. At her 1 month follow-up visit, what is the appropriate recommendation for her continued rehabilitation program?

1. Initiate isometric external rotation strengthening and continue passive range of motion.

2. Initiate eccentric supraspinatus strengthening and continue passive range of motion. 3- Initiate light resistance training to minimize atrophy and continue passive range of motion.

4- Continue passive range of motion and initiate concentric deltoid strengthening. 5- Continue passive range of motion with no active strengthening of the shoulder muscles.

 

DISCUSSION: Regardless of the technique of rotator cuff repair, the biology of tendon healing remains the same. Therefore, the repaired muscle tendon(s) must be protected from stress for a minimum of 6 weeks and more likely 8 weeks in a large two-tendon tear such as this patient had repaired. Therefore, at the 1 month follow-up visit, the patient should continue strict passive motion exercises and should perform no strengthening activities. Deltoid strengthening cannot be isolated from rotator cuff strengthening; therefore, deltoid strengthening is inappropriate as well. Because the infraspinatus is the primary shoulder external rotator, it should not be strengthened for 6 to 8 weeks.

Supraspinatus strengthening at this time frame would likely ensure its disruption and result in failure of the surgery. Any resistance training at 1 month from surgery would likely result in tendon failure at the tendon-bone interface. The obligatory need to protect the muscles during healing will predictably result in atrophy but it is easier to strengthen healed muscles than it is to strengthen muscle/tendon units that have failed to heal. The Preferred Response to Question # 179 is 5.

 

Question 180 A 54-year-old woman who has a history of undergoing trapezium excision with ligament reconstruction and tendon interposition using the entire flexor carpi radialis performed by another surgeon, now reports left basilar thumb pain.

Examination reveals pain and subluxation of the carpometacarpal joint with axial loading. The metacarpophalangeal joint hyperextends to 60 degrees, but radiographs show intact joint space. What is the best option to improve function?

1- Bracing with a hand-based thumb spica splint 2- Pinning of the carpometacarpal joint

3- Pinning of the carpometacarpal and metacarpophalangeal joints 4- Carpometacarpal revision stabilization

5- Carpometacarpal revision stabilization and metacarpophalangeal joint fusion

 

DISCUSSION: The patient previously underwent ligament reconstruction and tendon interposition. However, the previous surgeon failed to address metacarpophalangeal joint hyperextension, which leads to adduction contracture and collapse of the basilar joint. With the basilar joint causing pain and instability, repeat ligament reconstruction should be performed. Splinting alone is unlikely to resolve instability problems. Because the flexor carpi radialis was used, the next option is to use the abductor pollicis longus. Additionally, the severe metacarpophalangeal joint hyperextension should be corrected by fusion. Simple pinning is unlikely to provide long-term stability when this degree of hyperextension exists. The Preferred Response to Question # 180 is 5.

 

Question 181 A 16-year-old boy has had knee pain for the past 6 months, and activity restrictions have not provided relief. An MRI scan reveals a stable 1.5 cm by 1 cm osteochondritis dissecans on the weight-bearing surface of the lateral femoral condyle. What is the best course of treatment?

1. Continued activity restrictions for 6 more months or until asymptomatic

2. An aggressive physical therapy program that includes closed chain quadriceps strengthening

3. Arthroscopic drilling of the subchondral bone 4- Open debridement and screw fixation

5- Osteochondral autograft transplant procedure

 

DISCUSSION: As a child approaches skeletal maturity, osteochondritis dissecans lesions are unlikely to heal with continued nonsurgical management. Drilling of the lesion has a

 

high success rate. The lesion is stable and an open repair or osteochondral transplant is not needed. The Preferred Response to Question # 181 is 3.

Question 182 Paget's disease of bone is considered an osteoclastic abnormality resulting in which of the following?

1. Decreased vascularity of bone

2. Decreased osteoblast bone formation

3. Decreased resorption of bone by osteoclasts 4- Focally increased remodeling of bone

5- Sclerotic bone replacing normal marrow

 

DISCUSSION: Paget's disease of bone, first described in 1877, is an osteoclastic abnormality marked by focally increased skeletal remodeling within the axial or appendicular skeleton. There is an initial wave of osteoclast-mediated bone resorption, followed by the second phase of disorganized skeletal repair. This process leads to excessively disorganized woven bone and lamellar bone, characterized by osteosclerosis and hyperostosis, respectively, and results in the characteristic findings of cement lines seen histologically. The disorganized bone is weaker and prone to fractures. The final phase of the disease is the quiescent phase in which there is little bone turnover. Because of the increased bone remodeling, there is usually an associated increased vascularity which should be taken in account when surgery is performed. There is no bony replacement of the bone marrow. The Preferred Response to Question # 182 is 4.

 

Question 183Figures 183a and 183b are the radiographs of an otherwise healthy 62- year-old man with a history of a total knee arthroplasty followed 1 year later by a periprosthetic fracture treated with open reduction and internal fixation. The surgery was complicated by multiple wound infections with a sensitive organism. He eventually had hardware and implant removal and placement of an antibiotic spacer that was subsequently removed. After a full course of antibiotics, retesting reveals persistent infection and he is referred for further treatment. His subsequent treatment should be 1- knee fusion.

2. above-knee amputation.

3. antibiotic suppression.

4. arthroscopic irrigation and debridement. 5- repeat debridement and placement of an antibiotic spacer.

 

DISCUSSION: Two-stage resection with placement of an antibiotic impregnated spacer followed by reimplantation has been demonstrated to have success rates as high as 80% and has become the standard treatment for an infected total joint arthroplasty in the United States. Failure to eradicate the infection can be due to the virulence or drug resistance of the organism, the appropriateness of the antibiotic selection, or the adequacy of the debridement. Retained metal fragments, cement, or devitalized bone can result in failure to clear the infection. Special attention should be made to the patella because the exposure for a total knee arthroplasty can remove the majority of its blood supply. A lateral release (or lateral dissection as in this case) can compromise the primary remaining vessel to the patella (the superior lateral genicular) and result in osteonecrosis. In the setting of infection, the devitalized patella may become a large sequestrum and patellectomy should be considered. Antibiotic suppression should be used rarely and would not be a viable option in an otherwise healthy 62-year-old that would require decades of treatment. Above-knee amputation is a last resort, and in most situations at least a second attempt at two-stage resection and reimplantation should be attempted first. Knee fusion would not be indicated until the infection was eradicated and is also considered a last resort. Arthroscopic irrigation and debridement would not allow for adequate debridement of the joint and should not be used in the treatment of an infected arthroplasty. The Preferred Response to Question # 183 is 5.

 

Question 184 Figures 184a and 184b are the weight-bearing radiographs of a 19-year- old college baseball player who underwent surgery 4 months ago for an unstable ankle fracture sustained while sliding into a base. Figure 184c is a CT scan of the injured side and Figure 184d is the normal uninjured side. He now reports medial ankle pain and "rolling inward" sensations of the ankle. are seen in. Based on these findings, what is the most appropriate treatment?

 

1- Revision open reduction and internal fixation of syndesmosis 2- Removal of syndesmosis screws

3. Multiplanar fibular osteotomy

4. Ankle arthroscopy and debridement 5- Deep deltoid ligament repair

 

DISCUSSION: The patient has a malalignment of the syndesmosis with persistent widening, which is best managed by revision open reduction and internal fixation. The anatomic location of the deep deltoid ligament is such that a true repair is not feasible. Although syndesmosis screws are frequently removed in competitive athletes, screw removal alone will not address the widening nor will ankle arthroscopy. Multiplanar osteotomy of the fibula is indicated in the instance of fibular malunion. In this case, fibular length and talofibular symmetry are anatomic. The Preferred Respons# 184 is 1.

 

Question 185 Since the adoption by the American Academy of Orthopaedic Surgeons in 1997 of the presurgical protocol in which the surgeon signs the surgical site and the mandate for this protocol by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) in 2003, the total number of wrong-site surgeries reported per year in the United States has

1. increased.

2. decreased.

3. decreased for orthopaedic surgery but stayed the same for other surgeries. 4- remained the same.

5- only improved for hospital-based surgery.

 

DISCUSSION: Despite the initiatives by the American Academy of Orthopaedic Surgeons and the JCAHO, the number of reported cases of wrong-site surgery has continued to increase yearly since 1997. Because reporting of these events is not mandated by JCAHO, it is possible that the continued increase is due to a greater awareness of the problem and thereby a greater level of reporting. The U.S. estimates are 12.7 wrong-site surgeries per million cases performed. Orthopaedic surgery and podiatry are the most common specialties associated with wrong-site surgery (41%) followed by general surgery (21%), neurosurgery (14%), and urologic surgery (11%). The Preferred Respons# 185 is 1.

 

Question 186 Figures 186a and 186b are the radiographs of a 10-year-old girl who sustained an injury 2 days ago after jumping off another girl's shoulders while cheerleading. She is unable to walk and has no other injuries. Examination reveals swelling below the knee and a palpable defect at the tibial tubercle. The knee is ligamentously stable medial-lateral and anterior-posterior. What is the next most appropriate step in management?

 

1-MRI scan of the knee 2-CT scan of the knee

3-Open reduction and internal fixation 4-Excision of the fragment

5-Application of a long-leg cast

 

DISCUSSION: The radiographs show the patella elevated and the patellar

ligament insertion retracted greater than 2 cm. The most appropriate treatment is repair of the patellar ligament. Excision of the fragment and application of a cast will not restore quadriceps function. A CT scan will only demonstrate what is evident on the radiographs and an MRI scan is not needed because the knee is ligamentously stable.

The Preferred Response to Question # 186 is 3.

 

Question 187 Figure 187 is the radiograph of a 65-year-old woman who underwent uneventful bipolar hip arthroplasty for a displaced femoral neck fracture 5 years ago. Although she initially did well and returned to an active lifestyle, recently she reports increasing pain with ambulation and has become sedentary. Appropriate management should consist of which of the following?

1. Removal of the trochanteric wires

2. Use of an assistive device for ambulation

3. Physical therapy for abductor strengthening

4. Conversion to a total hip arthroplasty with femoral revision and acetabular implantation

5. Conversion of the bipolar hip arthroplasty to a total hip arthroplasty with placement of an acetabular component

 

DISCUSSION: The patient has lost acetabular articular cartilage. In addition, the bipolar component is migrating superiorly and laterally. Revision to a total hip arthroplasty is necessary. Removal of trochanteric hardware and abductor strengthening is not likely to improve the patient's symptoms. The use of assistive devices for ambulation may decrease the discomfort but does not address the proximal migration of the bipolar head associated with acetabular wear. The femoral component is not loose and does not need to be revised. The Preferred Response to Question # 187 is 5.

 

Question 188 Figures 188a and 188b are the radiographs of a 6' 1" 205-lb 22-year-old female collegiate basketball player who landed awkwardly on her right leg during practice and collapsed on the ground. She immediately reported severe pain in her right leg and could not move her right knee. Examination in the emergency department reveals symmetric dorsalis pedis and posterior tibial pulses in her lower extremities. An MRI scan reveals anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner injury. What is the next most appropriate step in management?

1. Admission and observation overnight, followed by closed reduction and examination under anesthesia in the morning, splinting, discharge, and follow-up in 48 hours for delayed ligament reconstruction

2. Emergent closed reduction followed by immediate transfer to the vascular suite for an angiogram

3. Emergent closed reduction and examination under anesthesia, followed by immediate ligament reconstruction

4. Emergent closed reduction and examination under anesthesia followed by repeat neurovascular examination, observation overnight, and delayed ligament reconstruction

 

5. Emergent closed reduction and examination under anesthesia followed by repeat neurovascular examination, discharge, and follow-up in 48 hours for delayed ligament reconstruction

 

DISCUSSION: Management should include emergent closed reduction and observation overnight for neurovascular compromise and compartment syndrome. The radiographs clearly show an anterior knee dislocation. This condition can result in vascular and/or neurologic compromise and represents a true emergency. Initial treatment is emergent closed reduction followed by close observation for 24 to 48 hours. Some controversy exists regarding the indications for invasive vascular studies out of concern for occult catastrophic arterial injury. Stannard and associates and Klineberg and associates studied the incidence of vascular compromise following knee dislocation and concluded that patients with symmetric lower extremity pulses were at low risk for progression to vascular compromise. As a result, selective arteriography based on serial physical examinations is a safe and prudent policy following knee dislocation. Definitive treatment of the ligamentous injuries is not advocated in the immediate period following injury because of the need to ensure the vascular integrity of the limb. Repair versus reconstruction of damaged ligaments at a later time is controversial, with some authors advocating early repair/reconstruction while others support reconstruction in a staged fashion. The Preferred Response to Question # 188 is 4.

 

Question 189 A 68-year-old woman sustains the injury seen in Figure 189 following a fall. Careful neurologic and vascular examinations reveal no associated injury. What is the most common complication of surgical fixation with a locked plate and screw construct through a deltopectoral approach?

1. Infection

2. Axillary nerve palsy 3- Peri-implant fracture

4. Deltoid insertion detachment

5. Screw penetration of the articular surface

 

DISCUSSION: Several studies have documented screw

penetration through the articular surface as the leading complication with locked plate and screw fixation for displaced proximal humerus fractures. Axillary nerve palsy is rare but can be seen with a deltoid split approach. Whereas some loss of range of shoulder

 

motion is expected following this injury, infection rates about the shoulder are in the 1% to 5% range. While a portion of the deltoid insertion is commonly taken down, complete deltoid insertion detachment has not been described. The Preferred Response to Question # 189 is 5.

 

Question 190 When evaluating a patient with suspected purulent flexor tenosynovitis in the thumb, the distal forearm and little finger are found to be swollen as well. The most likely anatomic explanation is the existence of a potential space in which of the following?

1. Through the carpal tunnel

2. Across the midpalmar space

3. Communicating with the subcutaneous tissue 4- Superficial to the distal antebrachial fascia

5- Between the fascia of the pronator quadratus and flexor digitorum profundus conjoined tendon sheaths

 

DISCUSSION: Pyogenic flexor tenosynovitis is an infection within the flexor tendon sheath that can involve the fingers or thumb. The tendon sheaths begin at the metacarpal neck level and extend to the distal interphalangeal joint. In the little finger and the thumb, the sheaths usually communicate with the ulnar and radial bursae, respectively. The potential space of communication, Parona's space, lies between the fascia of the pronator quadratus muscle and flexor digitorum profundus conjoined tendon sheaths. Infection tracking through this space presents as a horseshoe abscess. The Pre Resp# 190 is 5.

 

Question 191What complication is most likely to occur following proximal humeral fixation with a locked plate-and-screw construct?

1- Screw penetration 2- Rotator cuff injury

3. Axillary nerve damage

4. Fracture of the humeral shaft 5- Impingement

DISCUSSION: Proximal humeral locking plates have been associated with screw penetration (incidence 23%). The rotator cuff injury is not due to the plate or its application and is associated with dislocations in the elderly. Axillary nerve damage, while possible, has a low reported incidence from open reduction and internal fixation of the

 

proximal humerus with locking constructs. Impingement and fracture of the humeral shaft are also unlikely. More likely but not offered as a choice is the problem of varus reduction which can result in failure. However, penetration of the screws remains the most commonly reported complication. The Preferred Response to Question # 191 is 1.

 

Question 192 Which of the following associated diagnoses is more likely to occur in a child with a Myers and McKeever type II tibial spine fracture?

1- Lower leg compartment syndrome 2- Patellar dislocation

3. Peroneal nerve palsy

4. Meniscal entrapment at the fracture site 5- Proximal tibial growth arrest

 

DISCUSSION: Tibia eminence, also referred to as a tibial spine fracture, occurs as a result of stress on the anterior cruciate ligament that results in an avulsion fracture at the anterior cruciate ligament's proximal tibia footprint. These avulsion injuries have a high association of meniscal entrapment of the anterior portion of the meniscus underneath the angulated or displaced tibial spine fracture fragment. Compartment syndrome is associated with tibial tubercle fractures but not tibial spine fractures. Patellar dislocation, peroneal nerve palsy, and proximal tibial growth arrest are not associated with this fracture. The Preferred Response to Question # 192 is 4.

 

Question 193 The use of evidence-based studies among professions associated with health care, including purchasing and management, is known as

1. decision analysis.

2. cost-utility analysis.

3. cost-benefit analysis.

4. cost-effectiveness analysis. 5- evidence-based health care.

 

DISCUSSION: Evidence-based health care extends the application of the principles of evidence-based medicine to all professions associated with health care. This concept is becoming more important because data will be used by the different parties for their decision making (policy makers, health insurances, hospitals, doctors, and the public). Cost-benefit analysis refers to the conversion of effects into the same monetary terms as

 

the costs and compares them. Cost-effectiveness analysis refers to the conversion of effects into health terms and describes the costs for some additional health gain (eg, cost per additional event prevented). Cost-utility analysis refers to the conversion of effects into personal preferences (or utilities) and describes how much it costs for some additional quality gain (eg, cost per additional quality-adjusted life-year). Decision analysis refers to the application of explicit, quantitative methods to analyze decisions under conditions of uncertainty. The Preferred Response to Question # 193 is 5.

 

Question 194 A 55-year-old woman has had a swollen and painful right knee for 1 year. Figures 194a and 194b show AP and lateral radiographs, and Figure 194c shows a biopsy specimen. What is the most likely diagnosis?

1- Pigmented villonodular synovitis 2- Synovial chondromatosis

3. Septic arthritis

4. Loose bodies related to osteoarthritis 5- Chondroblastoma

 

DISCUSSION: The patient has synovial chondromatosis that is characterized by multiple calcified masses seen in the radiographs and by benign chondroid masses seen in the biopsy specimen. This is a benign condition that is typically treated by open, complete synovectomy of the joint. There have been rare cases reported of late conversion to chondrosarcoma, but most patients have good local control with synovectomy.

Pigmented villonodular synovitis would not have mineralization and is characterized by recurrent bloody effusions and low-signal changes of gradient echo images on MRI. Loose bodies are usually much smaller, completely intra-articular, and can move around on examination. Septic arthritis is typically more acute in history and would not have cartilage formation on biopsy. Chondroblastoma is an osseous lesion and almost never

 

has a soft-tissue extension. The biopsy specimen would show cobblestone chondroblasts with occasional giant cell-like osteoclasts.

The Preferred Response to Question # 194 is 2.

 

Question 195 Which of the following proximal phalanx fractures can most reliably be treated with a closed reduction and avoidance of surgical measures?

 

1- Midshaft transverse diaphyseal fracture with 30 degrees of angulation 2- Long spiral diaphyseal fracture with 15 degrees of malrotation

3. Open fracture with skin loss and exposed extensor tendon

4. Distal condylar intra-articular fracture with minimal displacement

5. Proximal metaphyseal fracture location with 30 degrees of dorsal tilting

 

DISCUSSION: Proximal phalanx fractures are very common, but care must be taken to understand which injuries are reliably treated with nonsurgical measures, and which ones are prone to clinically symptomatic malunion without surgical treatment. The proximal metaphyseal location is a problematic fracture to get reduced with closed measures, and due to the forces of the extensor apparatus, is prone to collapse into the original deformity. Imaging is also frequently difficult because of the overlap of the other fingers and frequently the true angulation is underappreciated. With 30 degrees of angulation, consideration should be given to surgical treatment. Long oblique/spiral fractures with malrotation are also most reliably treated with multiple lag screws, because maintaining the reduction with nonsurgical measures is unreliable, and can lead to significant functional problems in the form of crossover of the fingers with gripping. Open fractures with skin loss clearly are treated with surgical measures. Distal condylar fractures with minimal displacement are another fracture pattern that have a high rate of loss of reduction when treated nonsurgically. Like most articular fractures, they are best treated with anatomic reduction and rigid internal fixation. By comparison, closed midshaft transverse diaphyseal fractures can usually be anatomically reduced and held in this position with closed measures.

 

The Preferred Response to Question # 195 is 1.

 

Question 196 Figures 196a through 196c are the radiographs of a 52-year-old woman who reports knee pain after falling from a standing height. Examination reveals a moderate knee effusion but no obvious instability of the knee in extension. What is the most appropriate treatment?

1. Long-leg cast

2. Open reduction and internal fixation using percutaneous screws

3. Open reduction and internal fixation using a medial buttress plate

4. Open reduction and internal fixation using a small wire Ilizarov frame

5. Strict non-weight-bearing with active range of motion from the outset for 6 weeks, followed by gradual weight bearing

 

DISCUSSION: The patient has a nondisplaced split condyle fracture of the proximal tibia that importantly does not show displacement of any significance. The conclusion is particularly clear on the lateral radiograph. Whether or not the fracture is displaced is a good predictor of eventual outcome. This relates to the damage that occurs to the cartilage surface as indicated by recent studies if significant disruption of the joint surface occurs. The patient has an excellent prognosis for recovery with nonsurgical management consisting of non-weight-bearing and early active range of motion along with careful clinical monitoring of radiographs.

 

The Preferred Response to Question # 196 is 5.

 

Question 197 Figures 197a through 197c are the radiograph and MRI scans of a 63-year- old woman who reports the insidious onset of severe right hip pain. Her pain is worse with weight bearing and alleviated with rest. She takes no medications and is otherwise healthy. What is the next best step in her treatment?

1- Bone resection and mega-prosthetic reconstruction 2- Radiation therapy

3. Prolonged course of antibiotics

4. Partial weight bearing and observation 5- Core decompression

 

DISCUSSION: The patient has transient osteoporosis, which most commonly involves the hips. The etiology is unknown but may be related to an interruption of the intraosseous blood supply. Patients have joint pain and usually have normal findings on radiographs or CT scans. The MRI scan shows complete replacement of the marrow on T1-weighted images and marked hyper-intensity of the marrow on T2-weighted sequences.

Osteonecrosis of bone would show focal marrow changes and a serpentine line of demarkation. Crescent-shaped bone collapse can later be seen on the radiographs. This case does not show radiographic changes of osteonecrosis, but does show early subchondral bone formation in the femoral head. Osteonecrosis would not show early subchondral bone healing. The findings of transient osteoporosis are commonly mistaken for metastatic bone disease; however, the MRI scan does not show a focal mass. The diagnosis of transient osteoporosis can be made by correlating the clinical history of severe pain with the markedly abnormal MRI scan in the face of a normal radiograph and CT scan. Transient osteoporosis is a self-limiting disease. Therefore, surgeons should use a treatment approach based on the clinical symptoms. Current, therapeutic strategies include partial weight bearing, mild analgesics, and administration of nonsteroidal anti- inflammatory drugs. Treatment protocols to avoid include bone resection (malignancy), radiation (malignancy), antibiotics (osteomyelitis), or core decompression (osteonecrosis). The Preferred Response to Question # 197 is 4.

 

Question 198 A 24-month-old boy with clubfoot is not walking independently. What is the most likely reason he is not walking independently?

1. Neurologic disorder

2. Hip dysplasia

3. In-toeing

4. Limb-length inequality

5. Foot deformity

 

DISCUSSION: Children should ambulate independently at about 1 year of age and although this age may vary, if not ambulating by 18 months, an underlying neurologic or developmental condition should be considered. Clubfoot does not significantly delay ambulation nor does hip dysplasia or limb-length inequality, although this is a common misconception and reason for referral. Torsional deformities, such as in-toeing, are common and do not alter the age at which a child will ambulate. The Pre Res# 198 is 1.

 

Question 199 Which of the following is the best method of initial pelvic stabilization for a patient with hemodynamic instability and the pelvic ring injury seen in Figure 199?

 

1. Symphyseal plating

2. Iliosacral screw fixation 3- Pelvic binder

4. Pelvic C-clamp

5. External fixation

 

DISCUSSION: For a patient with an unstable pelvic ring injury and hemodyamic instability, the most appropriate initial treatment method is a pelvic sheet or binder. Symphyseal plating and iliosacral screw fixation require surgical intervention and may be appropriate following initial stabilization. External fixation and the pelvic C-clamp can be applied in the emergency setting, but usually are reserved for patients who do not respond to simpler less invasive methods initially. The Preferred Response to Question # 199 is 3.

 

Question 200 A 20-year-old collegiate volleyball player has vague left, nondominant elbow pain. Five years ago, he sustained a dislocation of the same joint and, while he could participate in his sport, he notes that the elbow 'never felt quite right.` The pain is not severe but prevents him from playing sports and he cannot localize the pain to any specific location. Occasionally he will perceive a catching when pushing himself out of a chair but the elbow never locks in one position. Examination reveals full passive and active range of motion in flexion, extension, supination, and pronation. There is tenderness of the lateral elbow during elbow extension with the forearm supinated and a momentary painful `clunk` is noted. Radiographs and MRI scans are normal. What is the most likely instability?

 

1. Varus

2. Valgus

3. Longitudinal forearm

4. Posteromedial rotatory

5. Posterolateral rotatory

 

DISCUSSION: Posterolateral rotatory instability of the elbow is seen in athletes and frequently follows a previous injury such as a dislocation where the lateral ulnar collateral ligament becomes weakened and attenuated. The ulna supinates away from the humerus and the radius subluxates posteriorly on the capitellum with the forearm supinated and the elbow in extension. Posteromedial rotatory instability is more often seen in association with fracture of the coronoid process following a varus stress to the elbow.

Valgus instability occurs due to an injury to the medial ulnar collateral ligament seen most commonly in throwers from overuse. Varus instability is rare but results in lateral gapping of the elbow. Longitudinal forearm instability is seen after an Essex-Lopresti injury.

 

The Preferred Response to Question # 200 is 5.

 

 

 

Question 1A 23-year-old patient with lateral epicondylitis underwent a routine elbow arthroscopy and an anterolateral portal was used. The patient now has complications associated with nerve injury in this area. What symptoms will most likely be present?

1. Loss of digital extension

2. Weakness of the interossei

3. Decreased sensation in the ring and little fingers 4- Decreased sensation in the ulnar dorsal forearm 5- Loss of flexor pollicis longus function

 

DISCUSSION: The anterolateral portal as originally described puts the radial nerve at risk because of its close proximity to the portal. The best test to demonstrate radial nerve function is the ability to extend the metacarpophalangeal joints. Weakness of the interossei, sensation to the ring and little fingers, and ulnar forearm sensation are all ulnar nerve functions. The flexor pollicis longus is innervated by the median nerve. The Preferred Response to Question # 1 is 1

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