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Dr Mohammed Hutaif
Dr Mohammed Hutaif
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Orthopedic MCQS online Anatomy 017

Orthopedics MCQ online
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ORTHOPEDIC MCQS ONLINE ANATOMY 017

 

ANATOMY-IMAGING SELF-

SCORED SELF-ASSESSMENT EXAMINATION

AAOS 2017

 

 

Question 1 of 100

Figures 1a and 1b are the MR images of a 69-year-old woman with bilateral leg pain that is worse with ambulation. She feels better when she is sitting down or leaning on a grocery cart. Which condition or structure is indicated by the arrows?

 

 

 

  1. Disk herniation

  2. Synovial cyst

  3. Arachnoid cyst

  4. Epidural lipomatosis

     

    PREFERRED RESPONSE: 2- Synovial cyst

    DISCUSSION

    This patient has neurogenic claudication as demonstrated by her “shopping cart” sign. Typically, spinal stenosis is attributable to bony spurs and/or a thick ligamentum flavum. However, for this patient, a large synovial cyst is the main contributing factor to stenosis. A cyst typically is filled with gelatinous material. If symptomatic, surgical excision is typically recommended because success with aspiration is unreliable. The need for fusion is debatable.

    A disk herniation is not bright on T2. An arachnoid cyst is a sac filled with cerebrospinal fluid. Spinal arachnoid cysts are relatively uncommon, and typically are intradural, but they also can be extradural. Epidural lipomatosis is a condition caused by excessive accumulation of fat within the epidural space. It is not well circumscribed as seen with this lesion.

    RECOMMENDED READINGS

 

RESPONSES FOR QUESTIONS 12 THROUGH 15

  1. T-type fracture

  2. Anterior column fracture

  3. Anterior wall fracture

  4. Posterior wall fracture

  5. Posterior column and posterior wall fracture

  6. Transverse with posterior wall fracture

For each image set below, please select the correct diagnosis listed above

Question 12 of 100

Figures 12a through 12c

 

 

 

  1. T-type fracture

  2. Anterior column fracture

  3. Anterior wall fracture

  4. Posterior wall fracture

  5. Posterior column and posterior wall fracture

  6. Transverse with posterior wall fracture

 

PREFERRED RESPONSE: 5- Posterior column and posterior wall fracture

 

Question 13 of 100

Figures 13a through 13c

 

 

 

  1. T-type fracture

  2. Anterior column fracture

  3. Anterior wall fracture

  4. Posterior wall fracture

  5. Posterior column and posterior wall fracture

  6. Transverse with posterior wall fracture

 

PREFERRED RESPONSE: 4- Posterior wall fracture

 

Question 14 of 100

Figures 14a through 14c

 

 

 

  1. T-type fracture

  2. Anterior column fracture

  3. Anterior wall fracture

  4. Posterior wall fracture

  5. Posterior column and posterior wall fracture

  6. Transverse with posterior wall fracture

 

PREFERRED RESPONSE: 1- T-type fracture

 

Question 15 of 100

Figures 15a through 15d

 

 

 

  1. T-type fracture

  2. Anterior column fracture

  3. Anterior wall fracture

  4. Posterior wall fracture

  5. Posterior column and posterior wall fracture

  6. Transverse with posterior wall fracture

 

PREFERRED RESPONSE: 6- Transverse with posterior wall fracture

DISCUSSION

Plain radiographic imaging of a patient with an acetabular injury begins with 5 standard views of the pelvis (anteroposterior [AP], iliac oblique, obturator oblique, inlet, and outlet views). These views will show fractures of the acetabulum and help to evaluate for pelvic fractures and hip joint integrity. The obturator oblique view is taken with the injured side rotated 45 degrees forward with the beam centered on the patient’s affected hip. This shows the anterior column and posterior wall and will reveal if any posterior subluxation of the hip is present. The iliac oblique view is taken with the injured side of the patient rolled 45 degrees forward with the beam centered on the affected hip. This shows the posterior column and the anterior wall. Inlet and outlet pelvic radiographs may depict pelvic injuries such as sacroiliac joint fracture or widening.

Judet and Letournel have a classification system for acetabular fractures. The system consists of 5 elementary fracture patterns: anterior wall, anterior column, posterior wall, and posterior column fractures of the acetabulum and a transverse pattern. There are also 5 associated fracture patterns: posterior column/posterior wall, transverse/posterior wall, T-type, anterior column with hemitransverse fracture of the posterior column, and both-column fractures.

Figure 12b shows a fracture of the posterior column on the Iliac oblique, and Figure 12c shows a fracture of the posterior wall in the obturator oblique.

In Question 13, the figures only reveal a fracture of the posterior wall, and this is best appreciated in Figure 13c, the obturator oblique view.

The T-type fracture is a transverse fracture with a secondary fracture line extending inferiorly. This causes the anterior and posterior columns to be separated. The iliac oblique view, Figure 14b, shows a fracture extending through the posterior column. In the obturator oblique view (Figure 14c), the yellow arrow shows a fracture extending through the anterior column, and the red arrow shows a fracture extending inferiorly through the ischium.

Fractures extending through the anterior and posterior columns are seen, which represent a transverse fracture, but there is no extension inferiorly, which eliminates T-type as a possible correct response. The anterior column fracture is best seen on the inlet view (Figure 15b), but it also can be seen in Figure 15d, the obturator oblique view. Figure 15c shows the fracture through the posterior column. For this patient, a small fracture of the posterior wall is visualized on the AP view (Figure 15a).

RECOMMENDED READINGS

8. doi: 10.1097/BSD.0b013e3181a9d540. PubMed PMID: 20084033. View Abstract at PubMed

 

CLINICAL SITUATION FOR QUESTIONS 26 THROUGH 29

A 13-year-old boy has left anterior knee pain that is localized to the tibial tubercle. The pain is worse with jumping and has been getting worse during his current basketball season. Ice provides temporary symptom relief. His knee never bothered him before, and his other knee does not hurt.

 

Question 26 of 100

What is the most likely diagnosis?

  1. Osgood-Schlatter disease

  2. Sinding-Larsen-Johansson syndrome

  3. A tibia stress fracture

  4. Patellar tendonitis

 

PREFERRED RESPONSE: 1- Osgood-Schlatter disease

 

Question 27 of 100

Which pathology is associated with this condition?

  1. Degenerative changes in the patellar tendon

  2. Apophysitis of the inferior pole of the patella

  3. Apophysitis of the tibial tubercle

  4. Partial avulsion of the quadriceps tendon

PREFERRED RESPONSE: 3- Apophysitis of the tibial tubercle

 

Question 28 of 100

The patient returns 4 years later; now he is a 17-year-old boy who has anterior knee pain with jumping and kneeling (Figure 28). The pain is located at the tibial tubercle. There is soft-tissue swelling and tenderness to palpation over the tubercle. He is able to do a straight-leg raise and there is no effusion, but the pain prevents him from playing basketball. Initial treatment should include

 

 

 

  1. surgery to repair the patellar tendon.

  2. nonsurgical treatment with ice, nonsteroidal anti-inflammatory drugs (NSAIDs,) physical therapy for stretching, and an unloading brace.

  3. a cortisone injection into the patellar tendon.

  4. open reduction and internal fixation of the tibial tubercle.

 

PREFERRED RESPONSE: 2- nonsurgical treatment with ice, nonsteroidal anti-inflammatory drugs (NSAIDs,) physical therapy for stretching, and an unloading brace.

 

Question 29 of 100

The patient fails nonsurgical treatment for this condition. What is the best next step?

  1. Continued nonsurgical care with physical therapy, a brace, and stretching

  2. Activity restrictions and avoiding painful activity

  3. Surgical excision of the tibial tubercle ossicle

  4. Debridement of the ossicle and repair of the patellar tendon

    PREFERRED RESPONSE: 3- Surgical excision of the tibial tubercle ossicle

    DISCUSSION

    Osgood-Schlatter disease is an apophysitis of the tibial tubercle. This condition is present in males more than females and occurs prior to fusion of the tubercle to the epiphysis of the tibia. The apophysis is cartilaginous before 11 years of age and begins to ossify between 11 and 14 years of age. The apophysis fuses to the epiphysis between 14 and 18 years of age (females before males). Symptoms are pain and swelling, and pain is worse with jumping and running. Initial treatment should consist of activity limitation, ice, quadriceps and hamstring stretching, and possible bracing. NSAIDs may be used to control symptoms. When symptoms resolve, the athlete may return to activities. In fewer than 10% of cases, symptoms persist after skeletal maturity. For these patients, excision of the ossicle will usually resolve symptoms. The ossicle is usually not part of the tendon attachment and can be resected without detaching any of the patellar tendon.

    RECOMMENDED READINGS

RESPONSES FOR QUESTIONS 35 THROUGH 38

  1. Open reduction and internal fixation (ORIF)

  2. Walking boot and weight bearing as tolerated until pain subsides

  3. Nonweight-bearing cast for 6 weeks

  4. Physical therapy

  5. Closed reduction and weight bearing as tolerated

  6. Closed reduction and percutaneous fixation

A 23-year-old man sustains an inversion ankle injury. For each figure(s) shown below, select the most appropriate treatment listed above.

Question 35 of 100

Figure 35

 

  1. Open reduction and internal fixation (ORIF)

  2. Walking boot and weight bearing as tolerated until pain subsides

  3. Nonweight-bearing cast for 6 weeks

  4. Physical therapy

  5. Closed reduction and weight bearing as tolerated

  6. Closed reduction and percutaneous fixation

 

PREFERRED RESPONSE: 2- Walking boot and weight bearing as tolerated until pain subsides

 

Question 36 of 100

Figure 36

 

  1. Open reduction and internal fixation (ORIF)

  2. Walking boot and weight bearing as tolerated until pain subsides

  3. Nonweight-bearing cast for 6 weeks

  4. Physical therapy

  5. Closed reduction and weight bearing as tolerated

  6. Closed reduction and percutaneous fixation

 

PREFERRED RESPONSE: 1- Open reduction and internal fixation (ORIF)

 

Question 37 of 100

Figure 37

 

  1. Open reduction and internal fixation (ORIF)

  2. Walking boot and weight bearing as tolerated until pain subsides

  3. Nonweight-bearing cast for 6 weeks

  4. Physical therapy

  5. Closed reduction and weight bearing as tolerated

  6. Closed reduction and percutaneous fixation

 

PREFERRED RESPONSE: 2- Walking boot and weight bearing as tolerated until pain subsides

 

Question 38 of 100

Figures 38a and 38b

  1. Open reduction and internal fixation (ORIF)

  2. Walking boot and weight bearing as tolerated until pain subsides

  3. Nonweight-bearing cast for 6 weeks

  4. Physical therapy

  5. Closed reduction and weight bearing as tolerated

  6. Closed reduction and percutaneous fixation

     

     

     

     

     

    Figures 38a and 38b

     

    PREFERRED RESPONSE: 1- Open reduction and internal fixation (ORIF)

    DISCUSSION

    Inversion of the ankle can cause various injuries about the foot and ankle, all via the same mechanism. Fifth metatarsal base avulsion (Figure 35) fractures can be treated with use of a walking boot until pain subsides. Jones fractures (Figure 36) can be treated with surgical or nonsurgical treatment, although young, active patients are perhaps better treated with ORIF, which can decrease disability time. Treatment of an anterior process calcaneus fracture (Figure 37) is similar to that for a fifth metatarsal base avulsion fracture. Figures 38a and 38b show a calcaneal fracture-dislocation, which necessitates ORIF.

    RECOMMENDED READINGS

 

RESPONSES FOR QUESTIONS 41 THROUGH 44

  1. Tibial and/or fibular osteotomy with open reduction and internal fixation (ORIF)

  2. Ankle distraction arthroplasty

  3. Ankle fusion

  4. Total ankle arthroplasty (TAA)

For each scenario described below, select the most appropriate treatment listed above.

Question 41 of 100

A 27-year-old man who underwent ankle ORIF 5 years ago is experiencing continuous ankle pain that has worsened over time (Figures 41a and 41b).

 

 

 

  1. Tibial and/or fibular osteotomy with open reduction and internal fixation (ORIF)

  2. Ankle distraction arthroplasty

  3. Ankle fusion

  4. Total ankle arthroplasty (TAA)

 

PREFERRED RESPONSE: 2- Ankle distraction arthroplasty

 

Question 42 of 100

A 71-year-old man with long-standing ankle arthrosis who has previously had a subtalar fusion (Figure 42).

  1. Tibial and/or fibular osteotomy with open reduction and internal fixation (ORIF)

  2. Ankle distraction arthroplasty

  3. Ankle fusion

  4. Total ankle arthroplasty (TAA)

 

 

 

 

PREFERRED RESPONSE: 4- Total ankle arthroplasty (TAA)

 

Question 43 of 100

A 52-year-old woman who is an avid hiker. Her ankle pain has begun to substantially limit her activity (Figure 43).

 

 

 

  1. Tibial and/or fibular osteotomy with open reduction and internal fixation (ORIF)

  2. Ankle distraction arthroplasty

  3. Ankle fusion

  4. Total ankle arthroplasty (TAA)

PREFERRED RESPONSE: 3- Ankle fusion

 

Question 44 of 100

A 46-year-old woman had an ankle fracture and ORIF 6 years ago. She had subsequent removal of some of the hardware, but her pain has persisted (Figures 44a and 44b).

 

 

 

  1. Tibial and/or fibular osteotomy with open reduction and internal fixation (ORIF)

  2. Ankle distraction arthroplasty

  3. Ankle fusion

  4. Total ankle arthroplasty (TAA)

 

PREFERRED RESPONSE: 1- Tibial and/or fibular osteotomy with open reduction and internal fixation (ORIF)

DISCUSSION

Patients younger than 40 years of age who have ankle arthritis pose an ongoing clinical challenge. Nonsurgical treatment should be maximized, although distraction arthroplasty can be used in an effort to delay the need for fusion.

One of the strongest indications for ankle arthroplasty is a preexisting hindfoot fusion with a goal to retain some ankle/hindfoot motion. Ankle fusion is perhaps the most predictable surgical treatment for a relatively young, active patient with ankle arthritis. Moreover, there are concerns regarding implant loosening when performing TAA in active patients.

Outcome after syndesmosis ORIF has been linked to the quality of the reduction at the index procedure. Syndesmotic malreduction that is severe necessitates osteotomy and revision ORIF.

RECOMMENDED READINGS

PMID: 25888590. View Abstract at PubMed

 

RESPONSES FOR QUESTIONS 51 THROUGH 57

Figure 51 a- h

 

 

 

 

 

 

 

a b c

h

 

 

 

 

d
e
f

 

g

 

Question 51 of 100

Hip dysplasia is indicated if the measurement exceeds 10 degrees

  1. Figure 51a

  2. Figure 51b

  3. Figure 51c

  4. Figure 51d

  5. Figure 51e

  6. Figure 51f

  7. Figure 51g

  8. Figure 51h

 

PREFERRED RESPONSE: 2- Figure 51b

 

Question 52 of 100

Indicates the anterior center edge angle

  1. Figure 51a

  2. Figure 51b

  3. Figure 51c

  4. Figure 51d

  5. Figure 51e

  6. Figure 51f

  7. Figure 51g

  8. Figure 51h

 

PREFERRED RESPONSE: 4- Figure 51d

 

Question 53 of 100

Indicates the lateral center edge angle

  1. Figure 51a

  2. Figure 51b

  3. Figure 51c

  4. Figure 51d

  5. Figure 51e

  6. Figure 51f

  7. Figure 51g

  8. Figure 51h

 

PREFERRED RESPONSE: 1- Figure 51a

Question 54 of 100

The femoral head overlaps the ilioischial spine medially

  1. Figure 51a

  2. Figure 51b

  3. Figure 51c

  4. Figure 51d

  5. Figure 51e

  6. Figure 51f

  7. Figure 51g

  8. Figure 51h

 

PREFERRED RESPONSE: 6- Figure 51f

 

Question 55 of 100

The floor of the acetabular fossa touches the ilioischial line

  1. Figure 51a

  2. Figure 51b

  3. Figure 51c

  4. Figure 51d

  5. Figure 51e

  6. Figure 51f

  7. Figure 51g

  8. Figure 51h

 

PREFERRED RESPONSE: 5- Figure 51e

 

Question 56 of 100

Allows for visualization of the anterior column

  1. Figure 51a

  2. Figure 51b

  3. Figure 51c

  4. Figure 51d

  5. Figure 51e

  6. Figure 51f

  7. Figure 51g

  8. Figure 51h

PREFERRED RESPONSE: 7- Figure 51g

Question 57 of 100

Provides visualization of the ilioischial line

  1. Figure 51a

  2. Figure 51b

  3. Figure 51c

  4. Figure 51d

  5. Figure 51e

  6. Figure 51f

  7. Figure 51g

  8. Figure 51h

 

PREFERRED RESPONSE: 8- Figure 51h

DISCUSSION

Although advanced imaging techniques such as CT scan and MRI are increasingly used to evaluate hip pathology, plain radiographs remain an essential, cost-effective, and readily available means with which to assess hip pain or traumatic injury. Radiographic assessment is crucial when evaluating patients for adult sequelae of developmental dysplasia of the hip, femoroacetabular impingement, protrusion acetabuli and periacetabular fractures, and dislocations. Basic measurements are used for evaluation of patients with the conditions previously mentioned. The acetabular index is drawn using the Hilgenreiner line through the area of the triradiate cartilage and a second line intersecting the Hilgenreiner line and extending laterally and superiorly to the lateral acetabular edge. In the normal adult hip, this should measure 10 or fewer degrees. The femoral head extrusion index is measured as a percentage of the femoral head that is lateral to the lateral acetabular margin relative to the total width of the femoral head. If the measurement exceeds 25%, this indicates acetabular dysplasia. The anterior center edge angle is drawn on the faux profile view with 1 line vertical from the center of the femoral head and the other extending from the center of the femoral head to the anterior edge of the acetabulum. A value exceeding 25 degrees is considered normal, a value less than 20 degrees indicates hip dysplasia, and a value between 20 and 25 degrees is considered borderline. The lateral center edge angle is drawn on the anteroposterior (AP) view of the hip with 1 line extending vertically from the center of the femoral head and a second line extending from the center of the femoral head to the lateral margin of the acetabulum. A value exceeding 25 degrees is considered normal, a value less than 20 degrees indicates hip dysplasia, and a value between 20 and 25 degrees is borderline.

Coxa profunda is indicated when the medial line of the acetabulum is medial to the ilioischial line on a plain AP view of the hip. Protrusio acetabuli refers to the femoral head being medial to the ilioischial line.

The iliac oblique and obturator oblique (Judet) views are used along with the AP of the hip to evaluate patients who have sustained acetabular fractures. The iliac oblique view shows the anterior wall and the posterior column of the acetabulum (as seen by the ilioischial line), and the obturator oblique view shows the posterior wall and the anterior column (as seen by the iliopectineal line).

RECOMMENDED READINGS

  • Bloomfield MR, Erickson JA, McCarthy JC, Mont MA, Mulkey P, Peters CL, Pivec R, Austin MS. Hip pain in the young, active patient: surgical strategies. Instr Course Lect. 2014;63:159-76. PubMed PMID: 24720303.View Abstract at PubMed

  • Sassoon A, Haidukewyech GJ. Hip and pelvic reconstruction and arthroplasty. In: Cannada LK, ed. Orthopaedic Knowledge Update 11. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2014:489-507.

  • Nepple JJ, Prather H, Trousdale RT, Clohisy JC, Beaulé PE, Glyn-Jones S, Rakhra K, Kim YJ. Diagnostic imaging of femoroacetabular impingement. J Am Acad Orthop Surg. 2013;21 Suppl 1:S20-

    6. doi: 10.5435/JAAOS-21-07-S20. PubMed PMID: 23818187.View Abstract at PubMed

  • Tornetta P 3rd. Displaced acetabular fractures: indications for operative and nonoperative management. J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):18-28. Review. PubMed PMID: 11174160. View Abstract at PubMed

     

    Question 58 of 100

    Figure 58 is the CT scan of a 50-year-old man who has fallen from a height of 12 feet. He has a reported incomplete spinal cord injury. He is intubated and sedated prior to an examination. What are the likely neurological examination findings?

     

     

     

    1. No motor weakness, but an inability to feel throughout the entire body

    2. Motor weakness in bilateral lower extremities, sensation intact to nipples only, no bulbocavernosus reflex

    3. Motor weakness in bilateral upper and lower extremities, sensation intact to the umbilicus, no bulbocavernosus reflex

    4. Motor weakness in the ankle and foot, sensation intact to arms only, no bulbocavernosus reflex

    PREFERRED RESPONSE: 2- Motor weakness in bilateral lower extremities, sensation intact to nipples only, no bulbocavernosus reflex

    DISCUSSION

    This patient has sustained a fracture dislocation of his spine at T5. At this level of injury, the incident is unlikely to affect motor strength in the upper extremities, but it can affect motor function below T5. Sensation to the nipple line is typically at T4 and the umbilicus at T10. The absence of the bulbocavernosus reflex indicates spinal shock. Bulbocavernosus reflex refers to anal sphincter contraction in response to squeezing the glans penis or pulling on the Foley. Spinal shock usually resolves within 48 hours, and the return of the reflex signals termination of spinal shock. With this degree of fracture dislocation, it is unlikely that motor function is spared without sensation changes.

    RECOMMENDED READINGS

  • Ko HY, Ditunno JF Jr, Graziani V, Little JW. The pattern of reflex recovery during spinal shock. Spinal Cord. 1999 Jun;37(6):402-9. PubMed PMID: 10432259.View Abstract at PubMed

  • Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, Johansen M, Jones L, Krassioukov A, Mulcahey MJ, Schmidt-Read M, Waring W. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med. 2011 Nov;34(6):535-46. doi: 10.1179/204577211X13207446293695. PubMed PMID: 22330108. View Abstract at PubMed

  • American Spinal Injury Association Standards for neurological classification of spinal injured patients. Chicago, IL: ASIA; 1982.

     

    Question 59 of 100

    Which structures are often encountered and may need to be mobilized in the surgical treatment of the injury shown in Figure 59?

     

     

     

    1. Greater saphenous vein and sural nerve

    2. Saphenous nerve and sural nerve

    3. Superficial peroneal nerve and sural nerve

    4. Lesser saphenous vein and sural nerve

     

    PREFERRED RESPONSE: 4- Lesser saphenous vein and sural nerve DISCUSSION

    The CT scan shows a large posterior malleolar fracture that necessitates open reduction and internal fixation. The best approach to this fragment is posterolateral to the ankle, which necessitates an incision over the posterolateral ankle roughly halfway between the fibula and the Achilles tendon. In that interval, the sural nerve runs with the lesser saphenous vein, both of which often need to be mobilized.

    The greater saphenous vein and the saphenous nerve run along the medial aspect of the ankle. The superficial peroneal nerve is anterolateral at this level.

    RECOMMENDED READINGS

  • Jowett AJ, Sheikh FT, Carare RO, Goodwin MI. Location of the sural nerve during posterolateral approach to the ankle. Foot Ankle Int. 2010 Oct;31(10):880-3. doi: 10.3113/FAI.2010.0880. PubMed PMID: 20964966.View Abstract at PubMed

  • Franzone JM, Vosseller JT. Posterolateral approach for open reduction and internal fixation of a posterior malleolus fracture--hinging on an intact PITFL to disimpact the tibial plafond: a technical note. Foot Ankle Int. 2013 Aug;34(8):1177-81. doi: 10.1177/1071100713481455. Epub 2013 Mar 12.

    PubMed PMID: 23481092. View Abstract at PubMed

     

    Question 60 of 100

    The direct anterior approach is used to perform a total hip arthroplasty (THA). When the surgeon makes postsurgical rounds, it is noted that the patient cannot extend her knee flat into the bed. What is the most likely explanation for this finding?

    1. Neurapraxia of the obturator nerve from errant retractor placement intraoperatively

    2. Neurapraxia of the superior gluteal nerve from errant retractor placement intraoperatively

    3. Neurapraxia of the femoral nerve from errant retractor placement intraoperatively

    4. Neurapraxia of the peroneal branch of the sciatic nerve attributable to excessive retraction

     

    PREFERRED RESPONSE: 3- Neurapraxia of the femoral nerve from errant retractor placement intraoperatively

    DISCUSSION

    Neurologic injury rarely occurs during THA. The femoral nerve is just medial to the rectus femoris muscle and may be injured by placement of retractors in the anterior soft tissues while exposing the acetabulum. Injury to the nerve will result in an inability to straighten the knee or to press the knee flat into the bed with the patient supine. The most commonly injured nerve is the peroneal branch of the sciatic nerve. This injury will result in an inability to dorsiflex the foot and extend the great toe. Denervation of the anterior portion of the gluteus medius muscle may result from splitting this muscle and damaging the superior gluteal nerve during a lateral approach to the hip.

    This will result in abductor weakness. Obturator nerve injury is rare, and its clinical consequences are not usually noticed, nor are they usually clinically tested for. Injury to the femoral nerve is becoming more common with the increased use of the direct anterior approach.

    RECOMMENDED READINGS

  • Hoppenfeld S, deBoer P. The hip. In: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA: JB Lippincott; 1984:301-356.

  • Hanssen AD. Anatomy and surgical approaches. In: Morrey BF, An KN, Cofield RH, Lewallen DG, Cooney WP III, Kitaoka HB, Pagnano MW, eds. Joint Replacement Arthroplasty. 3rd ed. Philadelphia, PA: Churchill-Livingstone; 2003:566-593.

 

RESPONSES FOR QUESTIONS 61 THROUGH 66

  1. Osteonecrosis

  2. Chondrosarcoma

  3. Hip dysplasia

  4. Transient osteoporosis of the hip

  5. Femoral neck fracture

  6. Labral tear

For each image below, identify the correct diagnosis from the list above.

Question 61 of 100

 

 

 

Figure 61

  1. Osteonecrosis

  2. Chondrosarcoma

  3. Hip dysplasia

  4. Transient osteoporosis of the hip

  5. Femoral neck fracture

  6. Labral tear

PREFERRED RESPONSE: 4- Transient osteoporosis of the hip

 

Question 62 of 100

 

 

 

Figure 62

  1. Osteonecrosis

  2. Chondrosarcoma

  3. Hip dysplasia

  4. Transient osteoporosis of the hip

  5. Femoral neck fracture

  6. Labral tear

 

PREFERRED RESPONSE: 2- Chondrosarcoma

 

 

 

Question 63 of 100

 

Figure 63

  1. Osteonecrosis

  2. Chondrosarcoma

  3. Hip dysplasia

  4. Transient osteoporosis of the hip

  5. Femoral neck fracture

  6. Labral tear

 

PREFERRED RESPONSE: 6- Labral tear

 

Question 64 of 100

 

 

 

Figure 64

  1. Osteonecrosis

  2. Chondrosarcoma

  3. Hip dysplasia

  4. Transient osteoporosis of the hip

  5. Femoral neck fracture

  6. Labral tear

 

PREFERRED RESPONSE: 1- Osteonecrosis

 

Question 65 of 100

  1. Osteonecrosis

  2. Chondrosarcoma

  3. Hip dysplasia

  4. Transient osteoporosis of the hip

  5. Femoral neck fracture

  6. Labral tear

 

 

 

Figure 65

 

PREFERRED RESPONSE: 3- Hip dysplasia

 

Question 66 of 100

 

 

 

Figure 66

  1. Osteonecrosis

  2. Chondrosarcoma

  3. Hip dysplasia

  4. Transient osteoporosis of the hip

  5. Femoral neck fracture

  6. Labral tear

 

PREFERRED RESPONSE: 5- Femoral neck fracture

DISCUSSION

Figure 61 reveals transient osteoporosis of the left hip. This is a T1-weighted image of the pelvis with generalized low-intensity signal of the bone marrow in the left femoral head. A T2-weighted

image would show high-intensity signal in a similar distribution. These changes signify an increase in bone marrow edema. On occasion, a subchondral insufficiency fracture is seen, but collapse of the femoral head should not occur with transient osteoporosis of the hip. It is seen most commonly in healthy middle-age men and in women during the third trimester of pregnancy. Hip pain is the most common symptom, and this typically lasts 6 to 8 months. Complete resolution of symptoms without long-term sequelae is the rule with few exceptions.

Figure 62 shows chondrosarcoma of the pelvis. This is a T1-weighted image that reveals a large soft-tissue mass of low-signal intensity, signifying destruction of the left acetabulum with medial protrusion of the left femoral head into the pelvis. These tumors occur typically in adults and are usually located in the proximal femur, ilium, or the periacetabular regions.

Figure 63 shows a superior acetabular labral tear. This is a T2-weighted image of the left hip after administration of intra-articular contrast. The distension of the joint with contrast shows the separation of the superior labrum from the bony acetabular rim.

Figure 64 shows end-stage osteonecrosis of the left femoral head. This is a T1-weighted image of the left hip with low-intensity signal, signifying bone marrow edema and femoral head collapse. There is a bandlike low signal intensity line that is characteristically seen on T1-weighted images. This represents the zone of demarcation between the viable and necrotic bone. The most common risk factors for osteonecrosis are heavy alcohol intake and chronic glucocorticoid use.

Figure 65 shows a T1-weighted image of a dysplastic right hip. A shallow acetabulum is present with approximately 40% uncoverage of the right femoral head. A shallow fovea on the femoral head and a hyperplastic superior labrum also are seen.

Figure 66 shows a T1-weighted image of a nondisplaced right femoral neck fracture. The fracture line is seen in the subcapital region of the femoral neck, and there is low-signal intensity signifying surrounding bone edema. Plain radiographs are negative in 8% of femoral neck fractures, and MRI has been shown to be 99% sensitive.

RECOMMENDED READINGS

 

RESPONSES FOR QUESTIONS 80 THROUGH 86

  1. Well-fixed cemented stem

  2. Well-fixed uncemented stem

  3. Well-fixed uncemented stem with femoral osteolysis

  4. Well-fixed uncemented stem with stress shielding

  5. Loose cemented stem

  6. Loose uncemented stem

For each image below, select the above response that best describes the femoral component.

Question 80 of 100

 

 

 

Figure 80a

  1. Well-fixed cemented stem

  2. Well-fixed uncemented stem

  3. Well-fixed uncemented stem with femoral osteolysis

  4. Well-fixed uncemented stem with stress shielding

  5. Loose cemented stem

  6. Loose uncemented stem

 

PREFERRED RESPONSE: 5- Loose cemented stem

 

Question 81 of 100

Figure 81

 

  1. Well-fixed cemented stem

  2. Well-fixed uncemented stem

  3. Well-fixed uncemented stem with femoral osteolysis

  4. Well-fixed uncemented stem with stress shielding

  5. Loose cemented stem

  6. Loose uncemented stem

 

PREFERRED RESPONSE: 2- Well-fixed uncemented stem

 

Question 82 of 100

 

 

 

 

Figure 82

  1. Well-fixed cemented stem

  2. Well-fixed uncemented stem

  3. Well-fixed uncemented stem with femoral osteolysis

  4. Well-fixed uncemented stem with stress shielding

  5. Loose cemented stem

  6. Loose uncemented stem

 

PREFERRED RESPONSE: 6- Loose uncemented stem

 

Question 83 of 100

  1. Well-fixed cemented stem

  2. Well-fixed uncemented stem

  3. Well-fixed uncemented stem with femoral osteolysis

  4. Well-fixed uncemented stem with stress shielding

  5. Loose cemented stem

  6. Loose uncemented stem

 

 

 

Figure 83

 

PREFERRED RESPONSE: 3- Well-fixed uncemented stem with femoral osteolysis

 

Question 84 of 100

 

 

 

Figure 84

  1. Well-fixed cemented stem

  2. Well-fixed uncemented stem

  3. Well-fixed uncemented stem with femoral osteolysis

  4. Well-fixed uncemented stem with stress shielding

  5. Loose cemented stem

  6. Loose uncemented stem

 

PREFERRED RESPONSE: 4- Well-fixed uncemented stem with stress shielding

 

 

 

Question 85 of 100

 

Figure 85

  1. Well-fixed cemented stem

  2. Well-fixed uncemented stem

  3. Well-fixed uncemented stem with femoral osteolysis

  4. Well-fixed uncemented stem with stress shielding

  5. Loose cemented stem

  6. Loose uncemented stem

 

PREFERRED RESPONSE: 1- Well-fixed cemented stem

 

Question 86 of 100

  1. Well-fixed cemented stem

  2. Well-fixed uncemented stem

  3. Well-fixed uncemented stem with femoral osteolysis

  4. Well-fixed uncemented stem with stress shielding

  5. Loose cemented stem

  6. Loose uncemented stem

 

 

 

Figure 86

 

PREFERRED RESPONSE: 6- Loose uncemented stem

DISCUSSION

 

 

 

The radiographs reveal femoral stems with either cemented or uncemented fixation types. When viewing these radiographs, it is important to evaluate for the stability of the stems because a loose stem can cause pain after hip arthroplasty. Radiographic signs of stem loosening vary based on fixation type. Signs of loose uncemented stems include radiolucent lines around the porous surface, stem subsidence, pedestal formation distal to the tip of the stem, or stem fracture. Signs of a loose cemented stem include radiolucent lines at the implant-cement or bone-cement interfaces, implant subsidence, cement mantle fracture, or stem fracture. These changes are best observed on serial radiographs when available. Plain radiographs are the most accurate tool with which to evaluate for loosening; however, bone scan and CT scan can be useful when radiographs are inconclusive.

Figures 81, 83, and 84 reveal well-fixed uncemented stems and osseointegration around the porous portions of the stems without subsidence or pedestal formation. In Figure 83, there is osteolysis in the medial calcar, bony trabeculae about the lateral portion of the stem, and spot welds. Figure 84 shows proximal stress shielding around a well-fixed uncemented implant. Stress shielding is disuse

osteopenia that occurs in bone as a result of a metal prosthesis preventing bone from deformity or bending. This is an example of Wolff’s law, which states that bone will adapt to the load under which it is placed. This can be seen in the proximal femur, typically from a femoral stem that is larger in diameter; made of a stiffer material, such as cobalt and chromium; and/or is extensively porous coated. Stress shielding does not result in loosening of the implant because the osseointegration is still present.

Figures 82 and 86 show loose uncemented stems. Both figures reveal radiolucent lines around the entire implants, stem subsidence, and pedestal formation.

Figures 80a and 85 are stems with cemented fixation. Figure 85 is well fixed and has an adequate cement mantle around the entire prosthesis with interdigitation into the cancellous bone and no radiolucent lines. Figure 80b shows a fractured cement mantle and radiolucency at the bone-cement interface with poor cancellous bone integration of cement.

RECOMMENDED READINGS

  • White RE, Archibeck MJ. Evaluation of the painful total hip replacement. In: Callaghan JJ, Rosenberg AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:1343-1351.

  • MacDowell AD, Howie DW. Fixation by methyl methacrylate. In: Callaghan JJ, Rosenberg AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:184-194.

  • Jasty M, Kienapfel H, Griss P. Fixation by ingrowth. In: Callaghan JJ, Rosenberg AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:195-206.

  • Duffy P, Masri BA, Garbuz D, Duncan CP. Evaluation of patients with pain following total hip replacement. Instr Course Lect. 2006;55:223-32. Review.View Abstract at PubMed

     

    Question 87 of 100

    Which abnormality most likely is associated with the clinical photograph and radiograph findings in Figures 87a and 87b?

     

     

     

    1. Craniofacial deformity

    2. Chest wall deformity

    3. Cardiac defect

    4. Abdominal tumor

     

    PREFERRED RESPONSE: 2- Chest wall deformity

    DISCUSSION

    The clinical photograph and radiograph show the classic symbrachydactyly seen with Poland sequence. There are shortened, diminutive fingers with round middle phalanges and simple-incomplete syndactylies. Fingers also tend to be stiff at either the proximal or distal interphalangeal joints. The thumb is often unaffected. The ipsilateral chest wall often has absent or hypoplastic pectoralis muscle(s), asymmetry of the nipples, or (rarely) rib cage deformity. Most often, this is a sporadic mutation, vascular insult, or error in cell signaling rather than a genetic, inheritable defect. If the hand and chest wall deformities appear isolated, a medical genetics consultation is not necessary because there are no associated anomalies that must be screened or identified.

    Apert syndrome has associated hand and craniofacial anomalies. The congenital hand difference in Apert syndrome is complex-complete syndactyly with multiple nail and underlying distal phalangeal synostoses (acrosyndactyly).

    Many congenital hand differences involve associated cardiac defects because the heart and limbs develop simultaneously. A common example is radial dysplasia (formerly known as radial club hand) and associated cardiac defects.

    The congenital upper extremity difference known to be a harbinger for intra-abdominal malignancy is hemihyperplasia (formerly known as hemihypertrophy). Hemihyperplasia may be isolated or associated with syndromes such as Beckwith-Wiedemann syndrome. Consultation with a medical geneticist and abdominal screening ultrasounds are recommended.

    RECOMMENDED READINGS

  • Catena N, Divizia MT, Calevo MG, Baban A, Torre M, Ravazzolo R, Lerone M, Sénès FM. Hand and upper limb anomalies in Poland syndrome: a new proposal of classification. J Pediatr Orthop. 2012 Oct-Nov;32(7):727-31. doi: 10.1097/BPO.0b013e318269c898. View Abstract at PubMed

  • Wilson MR, Louis DS, Stevenson TR. Poland's syndrome: variable expression and associated anomalies. J Hand Surg Am. 1988 Nov;13(6):880-2. View Abstract at PubMed

  • Online Mendielian Inheritance in Man. http://www.omim.org/entry/173800?search=poland &highlight=poland

     

    Question 88 of 100

    A 75-year-old woman falls from standing height. She is found a few hours later by her family and is taken to the emergency department. She has more profound weakness in her upper extremities than lower. She can elevate her shoulders bilaterally but cannot grasp. Her sensation is slightly diminished in both upper extremities. What is the likely scenario?

    1. Cauda equina syndrome

    2. Brown-Séquard syndrome

    3. Anterior cord syndrome

    4. Central cord syndrome

     

    PREFERRED RESPONSE: 4- Central cord syndrome

    DISCUSSION

    Central cord syndrome typically is a result of a neck hyperextension injury in a patient with a narrow spinal canal. This results in more substantial upper extremity weakness and variable sensory deficits. It is theorized that the cause is a result of hemorrhage or vascular occlusion affecting the central part of the canal, particularly the corticospinal tract, which controls motor function. Upper extremity fibers are located more centrally than lower extremity fibers, resulting in the asymmetric involvement of the upper and lower extremities.

    Anterior cord syndrome typically is a result of injury to the anterior spinal artery. Patients develop paralysis and loss of pain and temperature sensation below the level of the lesion, sparing the touch, vibration, and proprioceptions. Brown-Séquard syndrome causes ipsilateral paralysis, and ipsilateral loss of vibration and position sense below the level of the lesion. Patients experience impaired pain and temperature sensation contralateral to the side of the lesion. Cauda equina syndrome is the result of compression of the lower lumbosacral nerve roots. This is characterized by polyradiculopathy, motor weakness, and sphincter disturbances.

    RECOMMENDED READINGS

  • Guest J, Eleraky MA, Apostolides PJ, Dickman CA, Sonntag VK. Traumatic central cord syndrome: results of surgical management. J Neurosurg. 2002 Jul;97(1 Suppl):25-32. PubMed PMID: 12120648. View Abstract at PubMed

  • Kepler CK, Kong C, Schroeder GD, Hjelm N, Sayadipour A, Vaccaro AR, Anderson DG. Early outcome and predictors of early outcome in patients treated surgically for central cord syndrome. J Neurosurg Spine. 2015 Oct;23(4):490-4. doi: 10.3171/2015.1.SPINE141013. Epub 2015 Jul 10.

PubMed PMID: 26161520. View Abstract at PubMed

 

CLINICAL SITUATION FOR QUESTIONS 89 THROUGH 93

Figures 89a and 89b are the ultrasound and CT scan of a 20-month-old girl who has a dislocated, irreducible right hip attributable to developmental dysplasia. She has failed all nonsurgical treatment and is scheduled for open surgical reduction of her right hip.

 

 

 

Question 89 of 100

Which approach will allow for the best visualization of all structures that may be impeding reduction through the interval between the pectineus and the femoral neurovascular bundle?

  1. Medial

  2. Anterior

  3. Lateral

  4. Posterior

 

PREFERRED RESPONSE: 1- Medial

 

Question 90 of 100

Numbness in the proximal lateral thigh is attributable to structure damage indicated by Figure 89b through which surgical approach?

  1. Medial

  2. Anterior

  3. Lateral

  4. Posterior

 

PREFERRED RESPONSE: 2- Anterior

Question 91 of 100

Which surgical approach is less useful for children who have reached walking age because it does not allow for capsulorrhaphy?

  1. Medial

  2. Anterior

  3. Lateral

  4. Posterior

 

PREFERRED RESPONSE: 1- Medial

 

Question 92 of 100

During a medial approach to the hip, which anatomic structure identified in the figures can help surgeons locate the true acetabulum?

  1. Medial femoral circumflex artery

  2. Acetabular labrum

  3. Ligamentum teres

  4. Femoral neurovascular bundle

 

PREFERRED RESPONSE: 3- Ligamentum teres

 

Question 93 of 100

A 30-month-old boy underwent open reduction of his right hip to address developmental hip dysplasia. The reduction was performed through an anterior approach, and a shortening femoral osteotomy was not performed. Four months after surgery, hip radiographs reveal absence of ossification of the femoral epiphysis and fragmentation of the ossific nucleus. What is the likely cause of this complication?

  1. Intraoperative damage to the medial femoral circumflex artery

  2. Intraoperative damage to the lateral femoral circumflex artery

  3. Excessive pressure on the femoral head after reduction

  4. Incarceration of the acetabular labrum in the reduction

 

PREFERRED RESPONSE: 3- Excessive pressure on the femoral head after reduction

DISCUSSION

The incidence of pediatric hip dysplasia is approximately 1 per 100 live births, with hip dislocation present in 1 in 1000 births. Two surgical approaches primarily are used for surgical reduction in the dislocated pediatric hip: the modified medial approach as described by Weinstein and the

anterior Smith-Peterson approach. The Weinstein modification of the Ludloff approach exploits the interval between the pectineus muscle and the femoral neurovascular bundles rather than the interval between the pectineus and the adductor longus and brevis. The modified “bikini” anterior Smith-Peterson approach passes between the sartorius and tensor fascia lata superficially and between the rectus and gluteus medius during deep dissection.

When using the medial approach, the neurovascular bundle is particularly at risk, including the medial circumflex femoral vessels that supply blood to the femoral head ossific nucleus. Damage to this structure increases risk for osteonecrosis of the femoral head. Unlike the anterior approach, the medial approach does not allow for the performance of a capsulorrhaphy, poses higher risk for postprocedure redislocation, and is less useful in children of walking age. Identification of the ligamentum teres during deep dissection assists in localization of the true bony acetabulum.

The anatomic structure primarily at risk during the anterior approach is the lateral femoral cutaneous nerve. Excessive traction or transection of this structure will result in numbness in the proximal lateral thigh. This surgical approach allows for identifying and addressing all potential impediments to reduction: the redundant capsule, hypertrophic labrum, hypertrophic ligamentum teres, pulvinar, iliopsoas tendon, and transverse acetabular ligament. In older children who undergo open reduction with periacetabular osteotomy without a concomitant proximal femoral shortening osteotomy, reduction may be accompanied by increased pressure on the femoral head which, in turn, may result in secondary osteonecrosis of the femoral head.

RECOMMENDED READINGS

 

RESPONSES FOR QUESTIONS 96 THROUGH 99

  1. Proximal phalangeal osteotomy alone

  2. Proximal metatarsal osteotomy with a modified McBride procedure

  3. Distal metatarsal osteotomy with a modified McBride procedure

  4. First tarsometatarsal fusion with a modified McBride procedure

  5. First metatarsophalangeal fusion

Please choose the most appropriate surgical treatment listed above to address each clinical scenario seen in the radiographs below.

 

Question 96 of 100

The patient in Figure 96 has medial pain at the first metatarsophalangeal (MTP) joint and no other pain.

  1. Proximal phalangeal osteotomy alone

  2. Proximal metatarsal osteotomy with a modified McBride procedure

  3. Distal metatarsal osteotomy with a modified McBride procedure

  4. First tarsometatarsal fusion with a modified McBride procedure

  5. First metatarsophalangeal fusion

 

 

 

PREFERRED RESPONSE: 3- Distal metatarsal osteotomy with a modified McBride procedure

 

Question 97 of 100

The patient in Figure 97 has medial pain at the first MTP joint and pain under the second metatarsal head, or transfer metatarsalgia, with a loose first tarsometatarsal joint.

 

 

 

  1. Proximal phalangeal osteotomy alone

  2. Proximal metatarsal osteotomy with a modified McBride procedure

  3. Distal metatarsal osteotomy with a modified McBride procedure

  4. First tarsometatarsal fusion with a modified McBride procedure

  5. First metatarsophalangeal fusion

 

PREFERRED RESPONSE: 4- First tarsometatarsal fusion with a modified McBride procedure

 

Question 98 of 100

The patient in Figure 98 has pain medially at the first MTP joint and no other pain.

  1. Proximal phalangeal osteotomy alone

  2. Proximal metatarsal osteotomy with a modified McBride procedure

  3. Distal metatarsal osteotomy with a modified McBride procedure

  4. First tarsometatarsal fusion with a modified McBride procedure

  5. First metatarsophalangeal fusion

 

 

 

 

PREFERRED RESPONSE: 2- Proximal metatarsal osteotomy with a modified McBride procedure

 

Question 99 of 100

The patient in Figure 99 has pain at the first MTP joint.

 

 

 

  1. Proximal phalangeal osteotomy alone

  2. Proximal metatarsal osteotomy with a modified McBride procedure

  3. Distal metatarsal osteotomy with a modified McBride procedure

  4. First tarsometatarsal fusion with a modified McBride procedure

  5. First metatarsophalangeal fusion

     

    PREFERRED RESPONSE: 5- First metatarsophalangeal fusion

    DISCUSSION

    General principles can be used as bunion surgery guidelines even though there is extensive debate on the topic. A distal metatarsal osteotomy is most appropriate for patients with mild deformity and no transfer metatarsalgia. A proximal osteotomy potentially can correct more severe

    deformities. A lapidus procedure, or tarsometatarsal fusion, provides the highest potential to correct deformity plus the advantage of stabilizing the first tarsometatarsal joint and limiting or eliminating transfer metatarsalgia. A first MTP fusion is most appropriate for patients with severe first MTP arthrosis.

    RECOMMENDED READINGS

This is the last question of the exam.

GOOD LUCK

Dr. Mohammed Hutaif

About the Author: Prof. Dr. Mohammed Hutaif

Vice Dean of the Faculty of Medicine at Sana'a University and a leading consultant in orthopedic and spinal surgery. Learn more about my expertise and achievements.

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