ORTHOPEDIC MCQS  011 Reconstruction 

Online 2011 Orthopaedic Self-Assessment Examination by Dr.Dhahirortho

 

 

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Question 1Which of the following methods of treating a vertically oriented (eg, Pauwels III) femoral neck fracture is mechanically optimal?

1. Two parallel fully threaded screws

2. Three parallel partially threaded screws

3. Three parallel fully threaded screws

4. Four parallel partially threaded screws

5. Sliding hip screw and side plate

 

DISCUSSION: Vertical fractures have a higher rate of displacement and nonunion because of shearing forces across the fracture. Biomechanical and clinical studies indicate that for the vertically oriented fracture of the femoral neck, the most stable fixation construct is a sliding hip screw and side plate. Antirotation screws may be used as well. Nonsurgical management carries a high risk of early displacement because of shear forces. Three screws are loaded as a cantilever and have less resistance to displacement compared with a fixed-angle device with a side plate. Fully threaded screws will not allow any compression and have the same drawbacks as partially threaded screws. The addition of a fourth screw has not been shown to be of benefit. The Preferred Response # 1 is 5.

 

Question 2 Figures 2a and 2b are the MR arthrograms of a 19-year-old college baseball pitcher who injured his throwing elbow during a game 5 days ago when he felt a pop. Immediately after the throw he reported significant discomfort with pitching and noted that he could not achieve his normal velocity or accuracy in location with his subsequent pitches. On further questioning, he admits to increasing medial elbow pain over the last few seasons with pitching. Examination reveals medial elbow swelling and somewhat diffuse tenderness to palpation medially. Valgus stress at 30 degrees of flexion and resisted wrist flexion produced discomfort. He notes some tingling in his fourth and fifth fingers but Tinel's test posterior to the medial epicondyle is unremarkable. Radiographs of the elbow show no fracture. Because the patient wishes to return to competitive throwing, what is the next step in management?

1. Ulnar nerve transposition

2. Ulnar collateral ligament reconstruction

3. Long arm cast for a medial epicondyle fracture

4. Open reduction and internal fixation of the medial epicondyle

5. Elbow arthroscopy and excision of a posteromedial olecranon osteophyte

 

 

 

DISCUSSION: This high level throwing athlete has a full-thickness injury to the ulnar collateral ligament and is most likely to be able to return to competitive throwing with an ulnar collateral ligament reconstruction. There is no radiographic evidence of a medial epicondyle fracture. The clinical presentation and lack of a posteromedial olecranon osteophyte makes valgus extension overload unlikely, and therefore, makes arthroscopic osteophyte excision a suboptimal choice. Whereas ulnar nerve pathology can coexist with an ulnar collateral ligament injury, isolated ulnar nerve transposition without addressing the ligament injury is not warranted in this patient. Initial nonsurgical management with activity modification and physical therapy is appropriate for partial-thickness injury to the ulnar collateral ligament in a non-throwing athlete, and in athletes whose sporting activity places them at low risk. The Preferred Response to Question # 2 is 2.

 

 

 

Question 3 Figures 3a and 3b are the radiographs of an active 59-year-old woman who has had a 5-year history of right great toe pain. Nonsurgical management, consisting of shoe modifications, an orthotic with a Morton's extension, injections, and medications, has failed to provide relief. The range of motion is 30 degrees of dorsiflexion to 10 degrees of plantar flexion with pain at each end point, but not through the midrange of motion. What is the most appropriate management?

 

1. Cheilectomy

2. Keller resection arthroplasty

3. Silastic implant arthroplasty with titanium grommets

4. Arthrodesis of the first metatarsophalangeal joint

5. Total metatarsophalangeal joint arthroplasty

 

 

 

DISCUSSION: The patient exhibits significant arthrosis of the first metatarsophalangeal joint but does not have pain at the midrange arc of motion and is, therefore, a good candidate for a cheilectomy. Easley and associates and Coughlin and associates have shown excellent mid-term and long-term results with a cheilectomy, especially in patients without preoperative pain at the midrange arc of motion. An arthrodesis of the first metatarsophalangeal joint is an acceptable choice for achieving pain relief but will somewhat limit her shoe wear choice. A Keller resection arthroplasty is only recommended for older and low-demand patients. Silastic implant or total metatarsophalangeal joint arthroplasty has not been shown to be durable in active patients.

The Preferred Response to Question # 3 is 1.

 

Question 4 If an orthopaedic surgeon receives royalties from a company for his or her participation in the design and development of a product, and uses that same product for the care of his or her patients, what is the orthopaedic surgeon's obligation?

1. Obligated to disclose only the fact that he or she was involved in the design and development

2. Obligated to disclose only the company relationship if there is a state law requiring it

3. Obligated to disclose his or her full relationship with the company, including the fact that he or she receives royalties

4. No obligation to disclose this private matter to the patient

5. Avoid this situation because it should not exist since he or she cannot use such a product

 

DISCUSSION: The AAOS has a specific code of ethics and professionalism that addresses this issue: "When an orthopaedic surgeon receives anything of value, including royalties, from a manufacturer, the orthopaedic surgeon must disclose this fact to the patient." It is derived from a broader document developed by the American Medical Association, and is applicable to all physicians. At present, this is an ethical issue receiving greater federal scrutiny. This issue has had a greater effect on the public's perception of the integrity of the orthopaedic profession.

 

The Preferred Response to Question # 4 is 3.

 

 

Question 6 Range of motion after total knee arthroplasty is best described by which of the following statements?

1. The principle predictive factor of the postoperative range of motion is the preoperative range of motion.

2. Intraoperative range of motion is not correlated with the postoperative range of motion.

3. Postoperative stiffness rarely impairs function.

4. Excess distal femoral resection with a thick tibial polyethylene is associated with a flexion contracture.

5. Inadequate distal femoral resection and a tight posterior capsule are associated with loss of flexion.

 

DISCUSSION: The cause of postoperative stiffness after total knee arthroplasty is multifactorial. Whereas there is no universally accepted definition of stiffness, 90 degrees of flexion is needed to perform tasks such as stair climbing and getting out of a chair and nearly full extension is necessary for efficient gait. Predictors of postoperative range of motion include preoperative and intraoperative range of motion. Capsule release, ligament release, osteophyte removal, and properly sized components are often necessary to optimize range of motion. Excess distal femoral resection with a thick polyethylene will cause a tight flexion gap and loss of flexion. Inadequate distal femoral resection with retained osteophytes and a tight posterior capsule will lead to a flexion contracture. The Preferred Response to Question # 6 is 1.

 

Question 7 What is the proper location for a trochanteric nail starting point?

1. At thetip of the greater trochanter

2. Just medial to the tip of the trochanter

3. Just lateral to the tip of the trochanter

4. Dependent on the position and obliquity of the fracture

5. Dependent on the relative position of the trochanter to the axis of the femoral shaft

 

DISCUSSION: Contrary to popular belief, the tip of the greater trochanter is not necessarily the proper starting location for insertion of a trochanteric femoral nail. The relative position of the tip of the trochanter and the long axis of the femoral canal varies substantially between patients. Also, the proximal lateral bend varies substantially between different nails. Therefore, the relative position of the trochanter to the axis of

 

 

the femoral shaft and the particular geometry of the selected nail must be considered. The Preferred Response to Question # 7 is 5.

 

Question 8Which of the following statements best describes the 2-year outcome of workers' compensation patients who received surgical treatment for lumbar intervertebral disk herniation compared with those who received nonsurgical management?

1. Decreased pain

2. Decreased disability

3. Improved return to work

4. No improvement with surgical treatment

5. No added benefit associated with surgical treatment

 

DISCUSSION: Workers' compensation patients demonstrated no added benefit associated with surgical treatment at 2-year follow-up, in contrast with the non-workers' compensation patients who had significantly greater improvement with surgery. Both groups of patients were shown to improve substantially during the study. However, the workers' compensation group demonstrated similar improvement with surgical and nonsurgical treatment at 2-year follow-up. Additionally, surgical treatment did not improve work or disability outcomes at 2 years in the workers' compensation group. The Preferred Response to Question # 8 is 5.

 

 

 

Question 9Figures 9a through 9c are the MRI scans of a 65-year-old woman on dialysis who has thoracic back pain, malaise, and an elevated erythrocyte sedimentation rate (ESR). The clinical history and imaging findings are most consistent with

 

1. lymphoma.

2. renal osteodystrophy.

3. osteomyelitis and diskitis.

4. metastatic breast carcinoma.

5. osteoporotic compression fracture.

 

 

DISCUSSION: The sagittal MRI scans are pathognomonic for diskitis and osteomyelitis with fluid signal and destructive changes in the disk on T2 (Figure 9a), low signal with blurring of the disk margins on T1 (Figure 9b), and on the T1 gadolinium image (Figure 9c) vertebral body enhancement on either side of the affected disk with dark signals within the disk corresponding to the bright fluid signal from the T2 image. Metastatic carcinoma tends to affect the vertebral body with relative disk sparing, and lymphoma can affect the vertebral body but often has soft tissue extending within the spinal canal. Osteoporotic fractures are contained with the vertebral body. Renal osteodystrophy can result in a diskitis picture with disk destruction but one would not expect an elevated ESR or malaise, and this is much rarer than diskitis in dialysis patients. The Pr Resp# 9 is 3.

 

 

 

Question 10 A 6-month-old child has the deformity seen in Figure 10. There are no other known associated problems. What is the etiology of this condition?

 

1. Exposure to teratogens

2. Multifactorily inherited

3. A defect of the apical ectodermal ridge

- A defect in fibroblast growth factor

5- Inherited as an autosomal dominant

 

DISCUSSION: The radiograph demonstrates a type IV radial clubhand (radial dysplasia) with complete absence of the radius. This is a pre-axial deficiency usually with complete absence of the thumb. The condition is thought to be caused by an injury to the formation of the apical ectodermal ridge early in embryology. It is not an inherited condition unless it is associated with other syndromic problems. It is not known to be associated with specific teratogens. Fibroblast growth factor is involved in angiogenesis, wound healing, and embryonic development, but is not known to be associated with radial clubhand. The Preferred Response to Question # 10 is 3.

 

Question 11 A 52-year-old man who dislocated his dominant shoulder has it reduced in the emergency department and he is placed in a sling. At his 5-day follow-up evaluation, he reports that this is his first shoulder dislocation and that the pain is mostly gone but he notes difficulty using his arm overhead and away from his body.

Examination reveals minimal pain with passive range of motion, a positive

 

 

apprehension and relocation test, and 3/5 strength with the empty can test and external rotation at the side compared with 5/5 with those tests on the contralateral side. Cutaneous sensation over the lateral aspect of the shoulder is intact. Radiographs show the glenohumeral joint is reduced with no fractures or degenerative changes.

What is the next step in management?

 

1. CT of the shoulder

2. MRI of the shoulder

3. Application of a sling for 6 weeks

4. Surgery for diagnostic shoulder arthroscopy

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

 

DISCUSSION: Obtaining an MRI scan to evaluate for a rotator cuff tear is a reasonable next step. The patient sustained a first-time shoulder dislocation, and given his age and clinical presentation, it is likely that he injured the rotator cuff. Large, full-thickness rotator cuff tears following dislocation in young individuals warrants early surgical intervention. Delay of surgical repair for large, full-thickness tears may lead to irreversible changes, including atrophy and retraction of the tendon. As a result, clinical outcomes may be compromised. CT will demonstrate bony changes, but it is not as effective as MRI for soft-tissue pathology. While in the short term a sling for comfort might be helpful, 6 weeks of immobilization is unnecessary because recurrent instability is rarely an issue.

Physical therapy can be beneficial but could potentially delay identification of an acute rotator cuff tear. In the event the MRI does not reveal a large, full-thickness rotator cuff tear, physical therapy would be an appropriate next step. There is no indication for urgent shoulder arthroscopy. The Preferred Response to Question # 11 is 2.

 

 

 

Question 12A 22-year-old woman sustains the injury seen in Figure 12 as a result of a motor vehicle crash. What factor is most closely associated with development of osteonecrosis?

 

1. Reduction quality

2. Time from injury to surgery

3. Presence or absence of a capsulotomy

4. Type of implant used for internal fixation

5. Location of the fracture within the femoral neck

 

 

 

DISCUSSION: A displaced femoral neck fracture in a young patient is considered a surgical urgency and prompt anatomic reduction and internal fixation is recommended. There are a few studies that have specifically looked at the rate of osteonecrosis in this patient population. A review of femoral neck fractures in patients ages 15 to 50 years revealed that the incidence of osteonecrosis in displaced fractures was 27% compared with 14% in nondisplaced fractures. The quality of the reduction also influenced the rate of osteonecrosis. Time to reduction, type of implant, presence or absence of capsulotomy, and location of the fracture are not associated with osteonecrosis risk.

The Preferred Response to Question # 12 is 1.

 

 

 

Question 13Figure 13 shows the radiograph of a 2-year-old boy who underwent closed reduction of a forearm fracture 1 week ago. The parents noted the arm appeared crooked after a trip to the playground but the child did not report pain. The opposite forearm appears normal. He has been recently diagnosed with which of the following conditions?

 

1. Neurofibromatosis

2. Osteopetrosis

3. Ulnar dysplasia

4. Congenital radial-ulnar synostosis

5. Vitamin D resistant rickets

 

DISCUSSION: This is a case of a `pathologic fracture` in the forearm of a very young child. All of the presentation details reveal a deformity in the forearm with little outward signs of trauma, and the forearm bones do not appear normal on the radiograph. The medullary canal disappears in the distal third of both bones and there is an associated bowing deformity. Whereas much less common than congenital pseudarthrosis of the tibia, congenital pseudarthrosis of the forearm has been well documented and is associated with neurofibromatosis in about 50% of cases. This is a typical case presentation. All of the other conditions are not associated with this forearm deformity. The Preferred Response to Question # 13 is 1.

 

 

Question 14 Which of the following postoperative rehabilitation techniques causes minimal rotator cuff muscle activation?

1. Active forward flexion

2. Passive forward flexion

3. Active-assisted forward flexion

4. Overhead pulley-assisted passive forward flexion

5. Isometric strengthening

 

DISCUSSION: Electromyography (EMG) studies have shown that the rotator cuff is least active with passive range of motion and hence this is allowed early in most postoperative rotator cuff rehabilitation protocols. Active forward flexion, active-assisted motion, and isometric strengthening all cause activation of the rotator cuff muscles (as measured by EMG) and therefore should be introduced later in rehabilitation when the repair can withstand these forces. Whereas some authors have felt that pulley-assisted range of motion exercises are safe, EMG analysis has demonstrated that these exercises do cause activation of the rotator cuff musculature and probably should be avoided early in the rehabilitation protocol. The Preferred Response to Question # 14 is 2.

 

 

 

Question 15A minimally invasive plate osteosynthesis is seen in Figure 15. The resultant fracture healing can best be attributed to a fixation construct that was

 

1. stiff and stable.

2. flexible and stable.

3. facilitating direct osteonal healing.

4. inhibitory to endochondral ossification.

5. stimulatory to intramembranous ossification.

 

DISCUSSION: Locked plating constructs with long-working lengths provide flexible but stable constructs that promote (not inhibit) endochondral ossification. Because of the longer

working length they are not stiff, and these fractures do not heal with intramembranous ossification which occurs in bones like the calvarium. Direct osteonal healing is usually seen with constructs where absolute stability is achieved through interfragmentary compression, unlike in this case. The Preferred Response # 15 is 2.

 

 

 

 

Question 16Figure 16 shows the CT scan of a 44-year-old woman who sustained a direct blow to the head after falling while snowboarding. She is unable to move her upper or lower extremities and has diffuse numbness. Examination reveals normal strength in the deltoid muscles bilaterally but 0/5 strength in the remaining upper or lower extremity muscle groups. She is absent light touch, pinprick, and proprioceptive function in her upper and lower extremities. She has decreased rectal tone and intact perirectal sensation with an intact bulbocavernosus reflex. The patient's spinal cord injury is best classified as

 

1. complete, ASIA A.

2. complete, ASIA B.

3. incomplete, ASIA B.

4. incomplete, ASIA C.

5. incomplete, ASIA D.

 

DISCUSSION: The patient has sustained a C5 tear-drop fracture with spinal cord injury. Examination demonstrated

sacral sparing with perirectal sensation; therefore, this is an incomplete injury. Given her absent motor function, she would be classified as an ASIA (American Spinal Injury Association) B. ASIA A represents a complete spinal cord injury with no motor or sensory sparing below the level of injury. ASIA B is an incomplete spinal cord injury with sacral sparing (preservation of sacral sensation). ASIA C and ASIA D injuries reveal some motor function in the lower extremities. ASIA C injuries result in grade 3/5 or less strength, while ASIA D injuries show greater than 3/5 strength.

The Preferred Response to Question # 16 is 3.

 

17A 20-year-old collegiate pitcher has had a 5-month history of shoulder pain while throwing, decreased velocity, and difficulty with location of his pitches despite multiple attempts at rest. He reports no traumatic event. Examination with his throwing arm abducted at 90 degrees reveals external rotation to 110 degrees and internal rotation to 70 degrees when compared with his nonthrowing shoulder which has external rotation to 95 degrees and internal rotation to 85 degrees. He has a positive O'Brien's sign, positive modified Jobe's relocation test, full rotator cuff strength, no obvious muscular atrophy, and no scapular winging. Radiographs of the affected shoulder show no abnormalities. What is the next most appropriate step in management?

 

 

1. Dynamic ultrasound examination of the rotator cuff

2. Electrodiagnostic testing of the throwing shoulder

3. MR arthrogram of the throwing shoulder

4. Referral to a physical therapist to concentrate on range of motion

5. Laboratory studies to evaluate C-reactive protein and erythrocyte sedimentation rate

 

DISCUSSION: The study of choice to evaluate the superior labrum is an MR arthrogram. The patient has symptoms suspicious for superior labral pathology (ie, positive O'Brien's test, Jobe's relocation test, pain with throwing, loss of velocity and location). Whereas he does have increased external rotation and decreased internal rotation of his throwing arm compared with his non-throwing arm, the total arc of motion is 180 degrees and this is considered a normal adaptive change in the overhead throwing athlete; therefore, ultrasound is not considered appropriate management. There are no signs of weakness or rotator cuff pathology to suggest suprascapular nerve compression or a full-thickness rotator cuff tear; therefore, electrodiagnostic testing or physical therapy are inappropriate. There are also no signs or symptoms suggesting infection or rheumatologic issues; therefore, laboratory studies are unnecessary. If the MR arthrogram shows a labral tear, the initial management would include posterior capsular stretching and rotator cuff strengthening. The Preferred Response to Question # 17 is 3.

 

Question 18A patient has an elbow injury that includes a coronoid fracture, medial collateral ligament injury, and a radial head fracture. When is excision of the radial head without replacement indicated as definitive treatment for the radial head injury? 1- When the elbow is stable after fixation of the coronoid and medial collateral ligament

1. When the elbow is unstable after fixation of the coronoid and medial collateral ligament

2. When the fracture is comminuted and therefore stable internal fixation is unobtainable

3. When there is preexisting radiocapitellar arthritis

4. Excision is generally not indicated in this clinical scenario

 

DISCUSSION: The injury likely represents a terrible triad injury. Restoration of the lateral column is required to restore valgus stability. A repaired or replaced radial head is also thought to be protective of the coronoid fracture repair. Therefore, excision is not

 

 

indicated. Either radial head arthroplasty or open reduction and internal fixation would be indicated. The Preferred Response to Question # 18 is 5.

 

Question 19 An orthopaedic surgeon makes an incision on a right knee and realizes that the patient was supposed to have a left total knee arthroplasty. The surgeon should do which of the following?

1. Leave the wound open and talk to the family immediately.

2. Close the wound, abort the surgery, and talk to the patient and family when the patient is awake.

3. Close the wound, complete the left knee arthroplasty, and talk to the family after the surgery is complete.

4. Complete the surgery and talk directly to the patient the following day on rounds.

5. Discuss the problem in the office the next week in a calm reassuring manner.

 

DISCUSSION: The AAOS recommendation is to complete the correct surgery, repair the incorrect surgery to as close to normal as possible, and then discuss it openly with the family after the surgery is complete. Prompt informing is necessary. Aborting the surgery then results in the patient requiring a second anesthesia and surgical time needlessly. The Preferred Response to Question # 19 is 3.

 

 

 

Question 20Figure 20 is the radiograph of a patient who underwent total hip arthroplasty 15 years ago and now reports poorly defined pain in the hip. Which of the following represents the most appropriate management?

 

1. Revision total hip arthroplasty

2. Evaluation by a physiatrist

3. Physical therapy for strengthening and gait training

4. Nonsteroidal anti-inflammatory drugs (NSAIDs) and observation

5. CBC, C-reactive protein, erythrocyte sedimentation rate, and possibly hip aspiration

 

DISCUSSION: The patient has a fractured femoral component and requires revision. Poorly defined hip pain in the absence of mechanical failure may respond to physical therapy or NSAIDs. In addition, new onset pain after total joint arthroplasty may

 

 

represent infection and workup is appropriate (CBC, C-reactive protein, erythrocyte sedimentation rate, and possibly hip aspiration). Poorly defined hip region pain may also represent lumbar spine pathology and when infection and mechanical failure have been ruled out, evaluation by a physiatrist may be appropriate. The Preferred Respon # 20 is 1.

 

Question 21 A tall 14-year-old girl with joint laxity has progressive right thoracic scoliosis and is thought to be a surgical candidate. Her neurologic examination is normal. Presurgical screening should include which of the following studies?

1. CT of the cervical spine

2. MRI of the entire spine

3. Whole body bone scan

4. Echocardiography of the heart

5. Preoperative somatosensory testing

 

DISCUSSION: The patient is likely to have Marfan syndrome and cardiac complications are more likely to occur. Therefore, an echocardiogram would be indicated to assess for valvular insufficiency or other cardiac abnormalities. MRI of the spine is indicated in rapidly progressive curves, right-sided curves, those patients with an abnormal neurologic examination, and younger patients. CT of the spine would be indicated in patients with torticollis or if evaluating a congenital spine disorder. Preoperative somatosensory testing is occasionally performed in patients with neurologic conditions in which responses may not be normal and a baseline is needed. A bone scan is not indicated. Pre Res# 21 is 4.

 

 

 

Question 22Figure 22 is the radiograph of a 55-year-old woman with progressive deformity of the great toe after undergoing bunion corrective surgery 2 years ago. What is the most likely factor associated with this deformity?

 

1. Excessive lateral soft-tissue release

2. Excessive medial eminence resection

3. Inadequate correction of the intermetatarsal 1-2 angle

4. Hypermobility of the first tarsometatarsal joint

5. Failure of pin fixation in the first metatarsal

 

DISCUSSION: The cause of hallux varus is often multifactorial

with overcorrection occurring often from a combination of excessive lateral release,

 

 

overcorrection of the intramedullary 1-2 angle, excessive medial release, excessive laxity of the soft tissues, and malalignment of the metatarsal osteotomy. In this patient, there does not appear to be an excessive medial eminence resection and of the answers available, the excessive soft-tissue release is the best response. The pins in the metatarsal have no bearing on the result. Hallux varus is not associated with hypermobility of the tarsometatarsal joint.

The Preferred Response to Question # 22 is 1.

 

Question 23 A subtrochanteric femur fracture in which the lesser trochanter is intact is associated with what deformity?

1. Adduction and extension of the proximal fragment

2. Adduction and flexion of the proximal fragment

3. Abduction and extension of the proximal fragment

4. Abduction and flexion of the proximal fragment

5. Predominantly internal rotation of the proximal fragment

 

DISCUSSION: The most commonly seen deformity in subtrochanteric femur fractures is abduction and flexion of the proximal fragment. Subtrochanteric fractures can pose challenges in reduction because of the muscle attachments proximal and distal to the fragment. The gluteus medius and gluteus minimus attach to the greater trochanter and abduct the proximal fragment. The iliopsoas attaches to the lesser trochanter, flexing and externally rotating the proximal fragment. The short external rotators (piriformis, superior and inferior gamellus) and the obturator internus also cause external rotation of the proximal fragment. The Preferred Response to Question # 23 is 4.

 

Question 24A 20-year-old unrestrained driver sustained a midshaft femur fracture in a high-speed motor vehicle accident. The femoral neck was evaluated with a CT scan with 2-mm cuts through the hip; no fracture was identified. What additional studies (if any) should be performed to minimize the risk of having an undiagnosed femoral neck fracture?

1. Postoperative MRI scan

2. Postoperative bone scan

3. Preoperative AP pelvic radiograph

4. No additional imaging studies are needed

5. Intraoperative fluoroscopic images of the femoral neck

 

 

DISCUSSION: Nondisplaced femoral neck fractures may occur concurrently with high-energy injuries of the femur. Preferably, these are identified prior to or during surgery so that the fracture can be stabilized to prevent displacement and minimize the risk of osteonecrosis. However, the diagnosis of these injuries can be difficult. Tornetta and associates reported on standardized protocol that involved preoperative radiographs and CT scans with fine cuts through the femoral head. This protocol improved the detection of femoral neck fractures compared with situations with no set protocol. Of the 16 fractures detected, 13 were identified preoperatively. Of the three fractures that were missed by the screening, one was iatrogenic, one of these was detected at the time of surgery with intraoperative internal/external views of the femoral neck, and one had a late displacement. The overall rate of nondisplaced femoral neck fractures in this study was 7.5%, of which 91% were treated at the time of initial surgery having been identified on preoperative and/or intraoperative radiographs. Care must be taken not to neglect careful scrutiny of the femoral neck at the time of surgery even if preoperative imaging studies do not detect a fracture. No one method has been shown to have a 100% success rate. Postoperative bone scans and MRI scans are not routinely used. The Pr Res# 24 is 5.

 

Question 25 Performing reconstruction of the anterior cruciate ligament by drilling the femoral tunnel via an anteromedial portal, in contrast to transtibial drilling, affords what theoretical benefit?

1. Longer femoral tunnel

2. More anatomic graft placement

3. A more vertically oriented graft

4. Diminished risk of posterior tunnel wall violation ("blowout")

5. Diminished risk to lateral femoral articular cartilage and subchondral bone posteriorly

 

DISCUSSION: Recent trends in anterior cruciate ligament reconstruction include an emphasis on anatomic rather than isometric reconstruction of the ligament. According to some studies, this more effectively restores knee kinematics and with this, rotatory stability. Transtibial drilling affords limited access to the lateral intercondylar wall and has been associated with vertical graft orientation. The anteromedial portal, in contrast, allows independent femoral tunnel drilling and more anatomic positioning of the graft. A more anatomically positioned tunnel established via an anteromedial portal may afford increased tunnel and graft obliquity. This has been suggested to resolve rotatory

 

 

instability. Knee flexion angle during the course of reaming has been studied to assess favorable and negative tunnel characteristics and hazards to regional anatomic structures. When compared with transtibial drilling, the anteromedial portal is associated with shorter femoral tunnels, posterior tunnel wall integrity compromise, and increased risk to lateral femoral articular cartilage and subchondral bone posteriorly. Pr Re# 25 is 2.

 

Question 26Figures 26a and 26b are the radiograph and MRI scan of an otherwise healthy 10-year-old girl with increasing pain in the arm. A biopsy specimen is seen in Figure 26c. Treatment now should consist of

 

 

1. amputation.

2. radiation therapy and chemotherapy.

3. limb-sparing surgery with reconstruction.

4. chemotherapy and limb-sparing surgery with reconstruction.

5. radiation therapy, chemotherapy, and limb-salvage surgery and reconstruction.

 

DISCUSSION: The girl has osteosarcoma of the upper humerus. The biopsy specimen shows malignant osteoid formation. Osteosarcoma and Ewing's sarcoma are the two most common primary malignant bone tumors in children and account for approximately 6% of all childhood malignancies. Histopathology distinguishes between the two because clinical and radiographic imaging can sometimes be similar. Treatment methods have seen significant advancements, particularly in regard to chemotherapy and limb-sparing surgery. These advancements have led to an increased survival rate. With many longterm survivors, it is important to evaluate long-term patient outcomes following treatment, including function and health-related quality of life. Osteosarcomas are not radiosensitive tumors and would, therefore, not be treated with radiation therapy.

Although limb-sparing surgery is feasible and preferred over amputation in most instances, it is best used when combined with chemotherapy. The Preferred Res# 26 is 4.

 

 

Question 27A total knee arthroplasty is recommended to a mentally competent 68-year-old woman who has disabling knee pain caused by degenerative arthritis. Her son has researched the procedure on the internet and prefers the Acme Female Knee for his mother. You have designed the Axis Woman's Knee, for which you receive royalties, and use it exclusively. Which of the following ethical principles takes precedence in guiding her treatment?

1. Informed consent

2. Patient autonomy

3. Fiduciary responsibility

4. Physician paternalism

5. Justice

 

DISCUSSION: Informed consent incorporates a number of ethical principles relevant to this case. The fundamentals of medical ethics include nonmaleficence, beneficence, autonomy, and justice. The patient is competent and capable of exercising her autonomy in choosing the Acme Female Knee. She also depends on her physician's paternalism and knowledge in looking out for her best interests, which in his opinion, may be use of the Axis Woman's Knee. The physician has a fiduciary responsibility to inform the patient that he has a financial interest in the implant system he recommends. A thorough informed consent will respect the patient's autonomy, explain the rationale for the physician's recommendation, and notify the patient that there may be a perceived conflict of interest. The ethical principle of justice has no relevance in this case. The P Re# 27 is 1.

 

 

 

Question 28Figure 28 is the lateral radiograph of a patient who sustained an intra-articular fracture of the calcaneus. The structure (*) depicted by the arrows most likely represents which osseous component of the calcaneus?

1. Middle facet

2. Sustentaculum tali

3. Extruded lateral wall

4. Medial portion of the posterior facet

5. Lateral portion of the posterior facet

 

DISCUSSION: Fractures of the calcaneus occur as a result of shear and compression forces. Foot position at the time of impact, the force of the impact, and bone quality all dictate the degree of comminution and fracture line orientation. Two primary fracture

 

 

lines are consistently observed, one of which divides the calcaneus into medial and lateral portions. An essential feature of this fracture line is that it creates a fragment (sustentaculum tali) that remains attached to the talus by the interosseous ligament. This medial portion (constant fragment) of the posterior facet retains its normal anatomic position beneath the posterior talus. Its corresponding lateral component (labeled with an * in the figure), however, can be found displaced inferiorly within the body of the calcaneus. It is often rotated 90 degrees (as depicted in Figure 28) in relation to the remainder of the subtalar joint. This gives the appearance of what has been described as the "double-density" sign. The middle facet is more anterior and less commonly displaced. The lateral wall is nonarticular. The Preferred Response to Question # 28 is 5.

 

Question 29Figure 29 is the radiograph of a 3-month-old boy who has pain and swelling in his left thigh after his mother fell with him in her arms. There are no other injuries and a skeletal survey is otherwise normal. Treatment should consist of

 

 

1. flexible nail fixation.

2. external fixation.

3. a Pavlik harness.

4. growing rod insertion.

5. a hip spica cast.

 

DISCUSSION: The child has a minimally displaced femur fracture that could be stabilized by any of the methods mentioned; however, a Pavlik harness is the best choice. Flexible nails, growing rods, and external fixation would be marked overtreatment. A hip spica cast could be used in a child this age, but a Pavlik harness treats this fracture easily with no anesthesia and is easier for the parents to manage. The Preferred Response to Question # 29 is 3.

 

Question 30During arthroscopic evaluation of a partial-thickness articular-sided supraspinatus tendon tear, the medial-lateral width of the tear is noted to be 6 mm. This represents what percent partial-thickness tear?

1- 10% 2- 25% 3- 50% 4- 75% 5- 90%

 

DISCUSSION: Partial-thickness rotator cuff tears can be bursal-sided, articular-sided, and/or intratendinous. Management of partial-thickness tears requires an understanding of the native anatomy. Dugas and associates and Ruotolo and associates studied

 

 

cadaveric specimens and reported the medial-lateral width of the supraspinatus tendon averages 12.1 to 12.7 mm. Therefore, a 6- to 7-mm tear represents approximately a 50% tear of the supraspinatus tendon. Most authors agree that tears representing greater than 50% of the medial-lateral width of the supraspinatus tendon should be repaired. The Preferred Response to Question # 30 is 3.

 

Question 31 Fragment excision and triceps reattachment is ideally indicated for which of the following situations?

1. A 30-year-old woman with a closed comminuted fracture involving more than 50% of the joint surface

2. A 30-year-old woman with an open transverse olecranon fracture that is proximal to the trochlear notch

3. A 55-year-old woman with an oblique olecranon fracture through the coronoid process

4. A 75-year-old woman with an oblique fracture through the coronoid process

5. An 85-year-old man with a comminuted fracture involving less than 50% of the proximal joint surface

 

DISCUSSION: Fragment excision and reattachment of the triceps tendon may be indicated in a select group of elderly patients with osteoporotic bone in whom the olecranon fracture fragments involve less than 50% of the joint surface, and are too small or too comminuted for successful internal fixation. The triceps tendon is reattached with nonabsorbable sutures that are passed through the drill holes in the proximal ulna. In a physiologically young patient, internal fixation should be performed. Plate fixation would be appropriate for comminuted fractures, whereas tension band wiring could be used for a simple transverse fracture. Oblique fractures passing through the coronoid process are best treated by plate fixation. The Preferred Response to Question # 31 is 5.

 

Question 32Figures 32a through 32e show the radiographs and T2-weighted MRI scans of a 51-year-old man who has had bilateral leg pain for the past 6 months. The pain radiates down both legs, is worsened by ambulation, and relieved with rest and bending forward. Management consisting of physical therapy and medications has failed to provide any improvement in symptoms. Examination reveals normal strength, sensation, and pulses in the lower extremities. What treatment is most likely to provide the greatest pain relief and improved function?

 

 

 

1. Lumbar epidural injections

2. Oral anti-epileptic medications

3. Posterior lumbar arthrodesis L4-5

4. Posterior lumbar decompression L4-5

5. Posterior lumbar interbody arthrodesis L4-5

 

DISCUSSION: The patient has lumbar spinal stenosis and neurogenic claudication. Posterior decompression (laminectomy and bilateral lateral recess decompression) at the L4-5 level is the treatment for this condition when nonsurgical management has failed to provide relief. Weinstein and associates demonstrated statistically significant improvements among surgically treated patients compared to nonsurgical treatment in a prospective (randomized and observational) study. Use of oral anti-epileptic medications (gabapentin) has been reported in small case series to be effective but has not been validated. Whereas epidural injections can provide some therapeutic improvement, they have not demonstrated a proven clinical effect. Lumbar arthrodesis, whether posterolateral or interbody, without a decompression is not recommended because neither will address the patient's symptoms. Additionally, the adjunct of an arthrodesis is not indicated in this patient and would not be beneficial compared with decompression alone given the lack of significant scoliosis, spondylolisthesis, or instability at the L4-5 segment.

 

The Preferred Response to Question # 32 is 4.

 

 

Question 33Radiographs of a 7-year-old child show mid-diaphyseal fractures of the radius and ulna. Closed reduction with sedation in the emergency department is performed. Postreduction radiographs demonstrate 18 degrees angulation, 30% translation, and what appears to be 20 degrees of rotational malalignment. Based on these findings, what is the next most appropriate step in management?

 

1. Another attempt at closed reduction in the operating room

2. Open reduction with plating of the radius only

3. Open reduction with plating of the ulna only

4. Open reduction with plating of both the radius and ulna

5. Close monitoring with follow-up radiographs in 1 week

 

DISCUSSION: In children younger than 8 years of age, acceptable reduction parameters for fractures of the forearm are less than 20 degrees of angulation, 100% translation, and less than 45 degrees of malrotation. Weekly monitoring for loss of reduction and unstable fractures requiring further intervention is needed. When acceptable alignment can be maintained, good outcomes can be expected in this age group. In patients older than 10 years, angulation of less than 10 degrees, full translation, and malrotation of 30 degrees can be accepted. When surgical treatment is indicated, plating of one or both bones is acceptable. However, in this patient, the reduction is acceptable so a repeat closed reduction attempt and surgical treatment are not needed. P R# 33 is 5.

 

 

 

Question 34A 73-year-old man has had severe knee pain and swelling for the past 5 days. There has been no fever. Radiographs are normal in appearance. A knee aspiration specimen is seen in Figure 34 under polarized light. What is the next best course of action?

 

1. Obtain an MRI scan

2. Obtain serum uric acid level

3. Await culture and sensitivity results to start antibiotics

4. Inject a cortisone product, followed by management with oral nonsteroidal anti-inflammatory drugs (NSAIDs)

5. Start colchicine 0.6 mg three times a day until resolution of symptoms

 

 

DISCUSSION: The aspiration specimen shows crystals that are weakly birefringent and rhomboid in shape, reflecting the strong likelihood of calcium pyrophosphate crystal disease. Given the severe pain, a cortisone injection following aspiration will be most useful. Gout is associated with uric acid crystals that are birefringent yet needle shaped. Serum uric acids are often normal in an acute gout attack. Colchicine is useful in treating gout. The treatment of acute pyrophosphate crystalline disorder includes NSAIDs or intra-articular glucocorticoids. The diagnosis of gout is usually confirmed by the presence of strongly birefringent needle-shaped monosodium urate crystals in aspirates of the involved joint. Because monosodium urate crystals often can be found in the first metatarsophalangeal joint and in knees not acutely involved with gout, arthrocentesis of these joints between attacks is a useful diagnostic tool. The serum level of uric acid has a limited role in the diagnosis of gout because it can be normal or low at the time of an acute attack. The mainstay of treatment during an acute gouty attack is the administration of colchicine or NSAIDs. The Preferred Response to Question # 34 is 4.

 

Question 35Figures 35a and 35b are the radiographs of a 59-year-old man who is seen for follow-up after undergoing primary total knee arthroplasty 7 years ago. He has been doing well but recently began to report some swelling and knee pain. Laboratory studies reveal an erythrocyte sedimentation rate of 19 mm/h (normal up to 20 mm/h) and C-reactive protein of 0.9. What is the most appropriate management?

 

 

1. Follow-up as necessary

2. Revision of both components

3. Observation with serial radiographs

4. Debridement and bone grafting with polyethylene exchange

5. Implant resection and antibiotic-impregnated cement spacer

 

 

DISCUSSION: Polyethylene wear debris from total knee arthroplasty can produce significant periprosthetic osteolysis resulting in bony destruction, undermining of component fixation, and eventual loosening of the components. The management of periprosthetic osteolysis is somewhat controversial and depends on the extent of the lysis, the implant design, the method of polyethylene manufacture and sterilization, and the patient's symptoms. The onset of pain in this patient is concerning for loosening in the setting of extensive lysis. The surgeon should be prepared to revise the components at the time of surgery. There is no evidence of infection in the laboratory results so resection with placement of a spacer would not be necessary. Observation is the mainstay of management initially in patients with osteolysis, but when they become symptomatic or the lytic area is large enough to risk component loosening, intervention should be strongly considered. Patients with known lysis should be monitored and not followed as necessary. Significant bone loss can occur in the setting of asymptomatic components and before components become loose and painful, bone grafting with polyethylene exchange may be an option. The Preferred Response to Question # 35 is 2.

 

Question 36Figures 36a through 36c show repeat radiographs of an otherwise healthy 15-year-old boy with continued foot pain following 6 weeks of treatment in a short-leg cast. Initial radiographs showed a minimally displaced fracture. Treatment should now consist of

 

 

1. use of a hard-sole shoe.

2. continued cast treatment for an additional 6 weeks.

3. percutaneous screw fixation of the fracture.

4. electrical stimulation of the fracture.

5. open reduction and internal fixation of the fracture.

 

 

DISCUSSION: The patient has a delayed union of a proximal metatarsal fracture. With continued pain and a widening of the fracture line, fixation is required. An intramedullary screw can be used percutaneously to stabilize the fracture. Open reduction and internal fixation is not necessary because the fracture can be stabilized and reduced percutaneously. Continued cast treatment or a hard-soled shoe is not likely to provide healing as demonstrated by the previous cast treatment. Electrical stimulation can be used but has not been shown to aid in healing of the fracture when used as the only treatment. The Preferred Response to Question # 36 is 3.

 

Question 37The variability of the DASH (disabilities of the arm, shoulder, and hand questionnaire) score reported by patients after nonsurgical management of a distal radius fracture has been shown to be affected by which of the following?

1. Neuroticism

2. Pain-escaping behavior

3. Depression

4. Occupation

5. Handedness

 

DISCUSSION: Wide variability has been seen by Ring and associates in the DASH scores for patients treated for carpal tunnel syndrome, unilateral de Quervain tendinitis, trigger finger, unilateral lateral elbow pain, or nonsurgical distal radius fractures. The authors hypothesized that the large variation in DASH scores could not be accounted for by physical factors and perhaps could be explained by illness behavior. They found that neuroticism did not correlate with the DASH score but depression and pain anxiety did.

The study found a correlation between depression and all the upper extremity conditions looked at in the study. Neuroticism was found not to correlate with the DASH score, pain-escaping behavior is not measurable, and occupation and handedness have not been found to be associated with variations in the DASH score. The Preferred Respo# 37 is 3.

 

Question 38 Figures 38a and 38b are the MRI scans of a 28-year-old man who reports progressively worsening severe back pain for the past 3 months. He denies fevers, chills, weakness, or neurologic dysfunction. Examination reveals tenderness to palpation over the lumbar spine but normal neurologic findings. Laboratory studies reveal an elevated erythrocyte sedimentation rate and C-reactive protein; blood

 

 

 

 

cultures are positive for methicillin-sensitive Staphylococcus aureus. In addition to intravenous antibiotics, what is the next step in management?

 

1. CT-guided biopsy

2. Application of lumbar orthosis

3. Repeat MRI within 48 hours

4. Anterior lumbar debridement and fusion

5. Posterior lumbar debridement and fusion

 

DISCUSSION: The patient's symptoms and MRI findings are consistent with osteomyelitis and diskitis at L3-4 with a paraspinal fluid collection. Cultures confirm bacterial involvement. Given that finding, a biopsy of the level is unnecessary. Surgical treatment for infection is not indicated given the lack of neurologic deficit. Nonsurgical management is the best option, including both intravenous antibiotics and an external lumbar orthosis. A repeat MRI scan within a short duration would not impact clinical care. More important is close clinical follow-up to confirm response to treatment and identify any potential neurologic deficits that may develop. The Preferred Response # 38 is 2.

 

Question 39Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

1. Comminuted fractures

2. Fractures that involve the coronoid process

3. Fractures associated with Monteggia fracture-dislocations

4. Oblique fractures distal to the midpoint of the trochlear notch

5. Transverse fractures through the midpoint of the trochlear notch

 

DISCUSSION: Tension band wiring may not provide adequate stability to prevent displacement in a comminuted fracture. Plate fixation is most commonly recommended for comminuted fractures of the olecranon. Additionally, plate fixation is used for oblique fractures distal to the midpoint of the trochlear notch, fractures that involve the coronoid process, and those associated with Monteggia fracture-dislocations. Tension band wiring is best indicated for simple transverse fractures through the midpoint of the trochlear notch. The Preferred Response to Question # 39 is 5.

 

 

Question 40A 56-year-old man with multiple skin nodules, seven large cafT-au-lait spots, and significant scoliosis, has severe fatigue and shortness of breath. He should be evaluated urgently for which of the following problems?

1. Aortic stenosis

2. Malignant peripheral nerve sheath tumor

3. Lisch nodules

4. Superior mesenteric syndrome

5. Acute chest syndrome

 

DISCUSSION: The clinical description is of a patient with neurofibromatosis, NF-1. Although most of the answer choices can occur with NF-1 or sequelae of secondary malignancy, the new onset of cardiac symptoms should prompt an urgent cardiology evaluation for aortic stenosis, which occurs in approximately 2% of cases. Superior mesenteric syndrome is a rare complication after scoliosis surgery but could not be a source of lethargy prior to scoliosis surgery. Lisch nodules are neurofibromas of the iris and are not an urgent problem at this time. Acute chest syndrome occurs most commonly in patients with sickle cell anemia and would not be typical of patients with NF-1. The Preferred Response to Question # 40 is 1.

 

Question 41 Decreased risk of shoulder and elbow injury in a throwing athlete has been demonstrated with which of the following?

1. Rotator cuff strengthening

2. Superior labral repair

3. Posterior capsular stretching

4. Periscapular muscle strengthening

5. Repair of partial-thickness rotator cuff tears

 

DISCUSSION: Posterior capsular contracture has been demonstrated to significantly impair the ability of the humeral head to translate anterior and inferiorly during the late cocking and early acceleration phases of the throwing motion. This results in an obligatory posterosuperior translation of the humeral head that may contribute to posterior superior glenohumeral internal impingement with posterosuperior labral and articular-sided rotator cuff pathology. Posterior capsular stretching in throwing athletes has been demonstrated to decrease the likelihood of clinically significant shoulder or elbow injury. Periscapular muscle and rotator cuff strengthening are important for

 

 

optimal scapulothoracic rhythm, stable scapular position for throwing, and rotator cuff function but less directly established to result in a decreased risk of shoulder and elbow injury than posterior capsular stretching. Partial-thickness rotator cuff repair and superior labral repair may be necessary for treatment of symptomatic lesions unresponsive to nonsurgical managemen The Preferred Response to Question # 41 is 3.t, but these do not necessarily correlate with decreased shoulder and elbow injury risk.

 

The Preferred Response to Question # 41 is 3.

 

 

 

Question 42Figure 42 shows the radiograph of a 17-year-old girl who reports a 3-month history of plantar foot pain at the second metatarsal head. Pain occurs with activity and at rest. She has not noticed any swelling. Examination reveals only tenderness of the articular portion of the second metatarsal head. What is the most appropriate management?

 

1. Metatarsal pad

2. Corticosteroid injection

3. Second metatarsophalangeal arthrotomy

4. Second metatarsal shortening osteotomy

5. Second metatarsal neck dorsiflexion osteotomy

 

DISCUSSION: A metatarsal pad to reduce pressure on the second metatarsal head effectively relieves pain caused by Freiberg's infraction. The symptoms are typically self-limiting and do not require surgery unless thorough and appropriate nonsurgical management fails to provide relief. The natural history is articular surface collapse and degenerative arthritis. Both metatarsal neck dorsiflexion osteotomy and arthrotomy with joint debridement have been demonstrated to be effective for symptoms in young patients that persist despite the use of thorough and appropriate nonsurgical management, and for symptoms in adults with degenerative arthritis. Intra-articular corticosteroid injection will increase the intra-articular pressure and potentially exacerbate the presumed osteonecrosis, though it may be helpful in adults with secondary degenerative arthritis.

 

The Preferred Response to Question # 42 is 1.

 

 

Question 43Figures 43a through 43d show the MR arthrograms of a 42-year-old man who has shoulder pain. Initially he reported a sharp pain, but now says it is somewhat better. He describes the pain as aggravating, and has difficulty with overhead activities. He reports pain deep within his shoulder and often notes a popping sensation. The primary care physician sent him to physical therapy, which helped initially, but he still is not able to perform his activities normally. Examination reveals symmetrical rotator cuff strength, no increased anterior or posterior translation, and a positive O'Brien's test. What is the next step in management?

 

 

1. Arthroscopic SLAP repair

2. Arthroscopic rotator cuff repair

3. Arthroscopic anterior-inferior capsulolabral plication

4. Arthroscopic subacromial bursectomy and acromioplasty

5. Open anterior-inferior capsulolabral plication

 

DISCUSSION: The patient has a type II SLAP tear. The MR arthrogram shows extension of gadolinium beneath the biceps anchor; therefore, the most appropriate management is arthroscopic SLAP repair. There is no evidence of an anterior-inferior labral tear or rotator cuff injury, making the other surgical choices incorrect. The Preferred Res# 43 is 1.

 

Question 44When a patient with a grade II open tibia fracture presents to the emergency department, which of the following components of treatment would be considered the most important infection deterrent?

1. The use of bacitracin irrigation

2. Application of negative pressure wound therapy

3. A 6-hour time window to get the patient to the operating room

4. High-pressure pulse lavage as a means of mechanical debridement

5. Surgical wound inspection and debridement of devitalized tissue

 

DISCUSSION: Surgical inspection and debridement of devitalized tissue are the main means of decreasing infection in open fractures. The arbitrary 6-hour window has not

 

 

been confirmed in recent studies. The use of bacitracin in the irrigation fluid has not been shown to decrease infection and may create other wound healing problems. Bulb syringe or low-pressure irrigation has been shown to have lower rates of rebound contamination at 48 hours when compared with high-pressure lavage. Negative-pressure wound therapy, although it has been a major advance in soft-tissue management, is still only an adjuvant to surgical debridement and not a substitute for excision of devitalized tissue.

The Preferred Response to Question # 44 is 5.

 

Question 45Figures 45a and 45b show sagittal T1-weighted MRI scans of a 35-year-old man who has had dominant extremity shoulder pain and weakness for the past 6 months. He denies any history of injury. Examination reveals full range of active and passive motion, negative Hawkins and Neer impingement signs, 5/5 abduction strength, 3+/5 external rotation strength with arm adducted at his side, and negative belly press, Hornblower's sign, Gerber lift-off, and O'Brien's test. Radiographs are unremarkable. An MR arthrogram shows no rotator cuff or labral tears and no paralabral cysts. What is the next most appropriate step in management?

 

 

1. Electromyography (EMG) and nerve conduction velocity (NCV) studies of the extremity

2. MRI scan of the cervical spine

3. Corticosteroid injection of the subacromial space

4. Arthroscopic suprascapular nerve release at the suprascapular notch

5. Laboratory evaluation of C-reactive protein, erythrocyte sedimentation rate, and white blood cell count

 

DISCUSSION: The clinical history and physical examination are suggestive of weakness of the infraspinatus. An EMG/NCV study should be obtained to determine the etiology of the atrophy. In this case, the patient was shown to have suprascapular nerve entrapment at the suprascapular notch with atrophy of the infraspinatus and early signs of denervation of the supraspinatus. An MRI scan of the cervical spine would provide information if the EMG study revealed a cervical nerve compression as the etiology of the

 

 

atrophy. Arthroscopic suprascapular nerve release at the suprascapular notch is the correct treatment for the lesion; however, the EMG needs to be obtained first to determine the location of nerve compression. Laboratory evaluation of C-reactive protein, erythrocyte sedimentation rate, and white blood cell count is unnecessary because there are no signs or symptoms of an infection. Corticosteroid injection of the subacromial space would not help the current problem because there are no signs or symptoms of impingement syndrome. The Preferred Response to Question # 45 is 1.

 

 

 

Question 46Figures 46a and 46b are the radiographs of a 10-year-old boy who has severe pain in the anterior tibial region of his left leg after sustaining an injury 6 hours ago. What is the most likely associated problem?

 

1. Vascular injury

2. Peroneal nerve injury

3. Anterior cruciate injury

4. Medial collateral ligament injury

5. Compartment syndrome

 

DISCUSSION: The patient has a proximal tibial tuberosity injury with disruption of

the quadriceps mechanism. Compartment syndrome is associated with this injury. Bleeding from the fracture enters the anterior compartment of the calf and can cause elevated pressures. Because the injury occurred 6 hours ago and the patient has severe pain, elevated compartment pressure should be suspected. Ligament injuries are not associated with this injury. Peroneal nerve and vascular injuries are associated with proximal tibial physeal fractures, but not with those involving only the tibial tuberosity. The Preferred Response to Question # 46 is 5.

 

Question 47Spindled cells that are surrounded in mature osteoid that connect to other similar cells via canaliculi are best described as which of the following?

1. Osteoblasts

2. Osteoclasts

3. Osteocytes

4. Histiocytes

5. Megakaryocytes

 

 

 

DISCUSSION: Osteocyte cell processes travel through canaliculi to interconnect with other osteocytes and cells on the bone surfaces. Osteoblasts are cells that produce bone matrix and are seen rimming immature bone. Osteoclasts are large multinucleated cells that resorb bone and are found in Howship's lacunae. Megakaryocytes and histiocytes are found in marrow but not mature bone cortex. The Preferred Response # 47 is 3.

 

 

 

Question 48Figure 48 shows the radiograph of a 17-year-old boy who sustained a gunshot wound to his forearm. There is a small entrance wound on the volar surface. The exit wound is dorsal and more than 15 cm in size, with loss of skin and an extensive amount of devitalized muscle hanging out of the wound. Vascular supply to the hand is excellent, the ulnar and median nerves are intact in the hand, but the radial sensory nerve function is absent. After repeated surgical debridements of the wound and bone, definitive treatment for the fracture would most likely be which of the following?

 

1. Spanning external fixation of the radius

2. Open reduction and internal fixation of the radius with free fibular flap interposition 3- Open reduction and internal fixation of the radius with interposed strut allograft

1. Open reduction and internal fixation of the radius with massive cancellous allografting

2. Open reduction and internal fixation of the radius with massive cancellous autografting

 

DISCUSSION: The injury needs a very complex traumatic reconstruction. After repeat debridements, there will be a very long segmental loss of the radius, with a significant loss of skin and muscle covering the bone. Spanning external fixation represents a good temporary fixation tool but will not be a definitive solution. The preferred procedure is a vascularized fibular graft with associated skin flap from the lateral leg. This surgical option brings healthy vascularized bone and soft-tissue coverage into an area with significant bone and soft-tissue loss. Placement of large quantities of allograft material, especially strut allograft, is generally contraindicated in the setting of open fractures with soft-tissue compromise because of the risk of infection. Internal fixation and massive cancellous autografting is usually limited to one defect of less than 5 cm with intact soft-tissue covering. The Preferred Response to Question # 48 is 2.

 

 

Question 49Figure 49 is the radiograph of a 73-year-old woman who underwent a left knee revision 9 months ago. She states that she has been unable to extend her knee since she fell 6 months ago. Treatment should consist of which of the following?

 

 

1. Knee fusion

2. Extensor mechanism allograft

3. Patellectomy with primary repair

4. Open reduction and internal fixation

5. Cast immobilization in full extension

 

DISCUSSION: The patient has a chronic extensor mechanism disruption. Attempts at primary repair or open reduction and

internal fixation have a low probability of clinical success. Similarly, cast immobilization is not advised as the patient already has a large diastasis between the superior and inferior pole of the patella. An extensor mechanism allograft will provide the most predictable outcome in patients with chronic extensor mechanism disruption following total knee arthroplasty. A knee fusion remains as a surgical option but this should be considered a salvage procedure. The Pr Res# 49 is 2.

 

Question 50A 7-year-old child has shoulder pain after falling off a swing. Radiographs reveal a Salter II fracture with displacement of over two thirds the width of the shaft (Neer-Horowitz IV). What is the most appropriate management?

1. Sling, graduated physiotherapy, and close monitoring

2. Closed reduction and pinning

3. Open reduction and internal fixation with plates

4. Open reduction and internal fixation with flexible nails

5. Open reduction and internal fixation and removal of the interposed periosteum followed by pin fixation

 

DISCUSSION: Proximal humeral fractures in children are most often treated nonsurgically, even with displaced patterns. Therefore, treatments that include closed or open reduction are not indicated. There is little controversy in the treatment of proximal humerus fractures in this age group and most patients attain good functional outcomes. The humerus contributes about 80% of the growth of the humerus and has excellent remodeling potential. Some reports indicate higher complication rates when surgically treated. The Preferred Response to Question # 50 is 1.

 

 

Question 51 A 17-year-old girl with a history of Scheuermann's kyphosis has a fixed thoracic deformity of 80 degrees. There was no correction of her deformity on supine hyperextension radiographs. What is the most appropriate treatment?

1. Posterior arthrodesis

2. Anterior interbody arthrodesis

3. Smith-Petersen osteotomy with posterior arthrodesis

4. Vertebral column resection with posterior arthrodesis

5. Pedicle subtraction osteotomy with posterior arthrodesis

 

DISCUSSION: The Smith-Petersen osteotomy is most appropriate for long, sweeping, global kyphosis, such as Scheuermann's kyphosis. It can achieve approximately 10 degrees of correction in the sagittal plane at each spinal level at which it is performed. The pedicle subtraction osteotomy is the preferred osteotomy for patients with ankylosing spondylitis, who have a sagittal plane imbalance. It can achieve approximately 30 degrees to 40 degrees of correction in the sagittal plane at each spinal level at which it is performed. Vertebral column resections are extensive procedures, thus they are most appropriately applied to pathologies with sharp angular kyphosis, anterior fusions, and when maximal visualization and decompression of the spinal cord is required. Sagittal curves were reduced an average of 50 degrees, with a lumbosacral deformity treated via vertebral column resection. Anterior arthrodesis alone will not provide sufficient correction and stabilization of the deformity. Posterior arthrodesis alone, while providing stabilization, will not correct the fixed deformity. The Preferred Response # 51 is 3.

 

Question 52A 21-year-old minor league pitcher reports decreasing velocity and ability to target his pitches over the last 2 months. He notes that his arm will start to feel heavy in the later innings and notes pain in the posterior aspect of his shoulder in the late cocking phase of his motion. He denies any specific event that initiated his symptoms. Examination reveals symmetric rotator cuff strength and no increased anterior or posterior translation of either shoulder. 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. The left shoulder has 95 degrees of external rotation and 60 degrees of internal rotation. He has pain with an O'Brien's maneuver and a negative apprehension sign. What is the next most appropriate step in management?

1. Subacromial corticosteroid injection

2. Use of a sling until the pain resolves

    

    

3. Posterior capsular stretching

4. Arthroscopic SLAP repair

5. Arthroscopic anterior-inferior capsulolabral plication with posterior capsular release

 

DISCUSSION: The patient has glenohumeral internal rotation deficit with posterior capsular tightness; therefore, initial management should be directed at physical therapy and posterior capsular stretching. The total arc of motion (external rotation + internal rotation) should be equal between the shoulders. He has a deficit of 30 degrees in his throwing shoulder. A "sleeper stretch" is a common way for patients to stretch the posterior capsule and involves lying on the involved side with the shoulder abducted 90 degrees, the elbow flexed 90 degrees, and pushing the forearm toward the table.

Subacromial injection is not indicated because the pathology of an internal rotation contracture is located within the glenohumeral joint space and not the subacromial space. A sling might be useful for comfort but will not resolve his symptoms. There is no indication for arthroscopy, SLAP repair, or anterior-inferior capsulolabral plication at this time. The Preferred Response to Question # 52 is 3.

 

Question 53 A 48-year-old woman has an open subtrochanteric femur fracture. No other injuries are reported. After thorough evaluation, it is determined that she will need emergent surgical

fixation. The patient and family indicate that they are practicing Jehovah's witnesses and desire adherence to the religious standards with respect to blood product usage. The patient signs a valid advanced directive confirming these wishes. Which of the following would be considered acceptable treatment?

1. Whole blood

2. Platelets

3. Plasma

4. Starch product (ie, Hetastarch, Hespan)

5. Donor-directed blood from a family member who is a practicing Jehovah's witness

 

DISCUSSION: Jehovah's witnesses beliefs regarding blood products stems from direct interpretation of passages from the bible. The use of crystalloid, starch products such as Hetastarch and colloids are accepted. Typically Jehovah's witnesses will accept most medical treatment but refrain from the use of blood products including whole blood, packed red cells, platelets, white cells, or plasma. Any autologous transfusion, whether

 

 

from the patient themself or donor directed, is forbidden. The use of cell-saver type processes is a matter of individual choice by the patient. The use of hemoglobin-based oxygen carriers are now accepted by many patients but it is important to respect the wishes of each individual patient. It is very important to discuss preoperatively with the patient and family their wishes and thoughts on what is acceptable to use. Many facilities have adopted bloodless-surgery protocols and committees that definitively outline the measures that can be used and take into consideration the many ethical issues involved in taking care of these patients.

The Preferred Response to Question # 53 is 4.

 

Question 54 A patient who underwent intramedullary nailing of a femoral shaft fracture 2 weeks ago now reports groin pain. What is the next most appropriate step in management?

1. Obtain a radiograph of the hip

2. Obtain radiographs of the lumbar spine

3. Obtain an MRI scan of the lumbar spine

4. Review the radiographic report from the time of injury

5. Reassure the patient that the pain will improve and order physical therapy

 

DISCUSSION: Whereas ipsilateral fractures of the femoral neck and shaft are uncommon, it is critical to recognize a femoral neck fracture that may occur in conjunction with a femoral shaft fracture. The combined injury is seen in 2% to 9% of femoral shaft fractures and may initially be missed in as many as one third of the cases. Preoperative examination of a thin cut CT scan and dedicated AP internal rotation views of the femoral neck can help identify this injury. In addition, the intraoperative AP and lateral hip fluoroscopic view should be examined, and a dedicated radiograph of the hip obtained at the conclusion of the surgery. At follow-up, Tornetta and associates has recommended obtaining a dedicated AP radiograph of the hip with the leg internally rotated 15 to 20 degrees. Because the femoral neck is anteverted, 15 to 20 degrees of internal rotation of the hip offers the best view of the femoral neck. Whereas associated lumbar spine pathology may cause groin pain, the presence of a missed femoral neck fracture must first be ruled out prior to investigating other sources of pain.

The Pre Res# 54 is 1.

 

 

 

 

Question 55Figure 55 is the lateral radiograph of a 63-year-old man who underwent knee arthroplasty 8 years ago and is returning for his annual follow-up examination. He now reports the development of pain and can walk short distances only. Infection workup is negative. Management should consist of which of the following?

 

1. Bone scan

2. Knee revision

3. Bisphosphonate therapy

4. Routine follow-up in 1 year

5. Polyethylene liner exchange and bone grafting

 

DISCUSSION: The patient has severe periarticular osteolysis. The tibial and femoral components remain well fixed to the bone.

Consequently, he can be treated by removing the wear generator (polyethylene exchange) along with bone grafting of the osteolytic defect. Observation for 1 year is not advised because the amount of osteolysis is extensive. Similarly, bisphosphonate therapy has not been shown to decrease the amount of osteolysis once generated. A bone scan may be helpful when assessing aseptic loosening. The patient is not very symptomatic and loosening is unlikely. Pre Res# 55 is 2.

 

Question 56The femoral insertion of the lateral collateral ligament maintains what consistent relationship relative to the lateral epicondyle of the femur?

1. Anterior and distal

2. Anterior and proximal

3. Posterior and distal

4. Posterior and proximal

5. The lateral collateral ligament inserts directly on the lateral epicondyle

 

DISCUSSION: The femoral insertion of the lateral collateral ligament maintains a proximal and posterior relationship relative to the lateral femoral epicondyle. In a cadaveric study, LaPrade and associates described the consistent anatomic relationship between the lateral collateral ligament insertion and the lateral epicondyle of the femur. On average, the lateral collateral ligament inserts 1.4 mm proximal and 3.1 mm posterior to the lateral epicondyle. The lateral collateral ligament inserts proximal and posterior to the

 

 

popliteus insertion on the femur. The average distance between the femoral insertions of the lateral collateral ligament and popliteus tendon was 18.5 mm. The Pre Res# 56 is 4.

 

 

 

Question 57Figures 57a and 57b are the MRI scans of a 61-year-old man who is unable to elevate his dominant arm following a golf injury 24 hours ago. He has moderate pain during attempted arm elevation. Examination reveals significant spinati atrophy and he is only able to elevate his arm fully overhead while supine. The neurologic examination is normal. What is the next most appropriate step in management?

 

1. Lidocaine injection test

2. Supraspinatus strengthening

3. Reverse shoulder arthroplasty

4. Conventional total shoulder arthroplasty

5. Arthroscopic rotator cuff repair/subacromial decompression

 

DISCUSSION: The patient unknowingly has a chronic massive rotator cuff tear. Because of excellent compensation, he remained functional and was without symptoms. This is evidenced by the significant muscle atrophy. Following even trivial injury, the compensation process of arm elevation fails and the patient suddenly loses the ability to elevate the arm. At this time in management, it is critical to recognize that the rotator cuff had already been torn and that pain now prevents the patient from actively using the arm. To better ascertain a prognosis of return of function, injecting a local anesthetic (lidocaine) into the joint is important. If, with an anesthetized joint, the patient can now elevate the arm, a supine strengthening program will likely return the patient to his pre-injury state. If there is no improvement in the ability to elevate the arm after the injection, surgical considerations may become relevant. There is no role for arthroscopic repair in this chronic, massive rotator cuff tear and decompression would likely lead to superior escape. A reverse shoulder arthroplasty would be contraindicated in a very active 61-year-old patient who 2 days ago was functioning normally. Based on the MRI scan, there is no supraspinatus muscle remaining to strengthen. Total shoulder arthroplasty is contraindicated in patients with a deficient rotator cuff mechanism.

The Preferred Response to Question # 57 is 1.

 

 

 

 

Question 58The radiographic finding in Figure 58 is indicative of what type of acetabular fracture?

1. Anterior column

2. Posterior column

3. Associated both column

4. Transverse

5. Associated transverse plus posterior wall

 

DISCUSSION: The radiographic image is an obturator oblique view of the left acetabulum and demonstrates a "spur" sign. It represents a spike of bone from the intact hemipelvis and no articular surface remains with the hemipelvis, which defines the associated both column fracture. The weight-bearing surface of the acetabulum is displaced with the femoral head. In all other patterns, at least part of the articular surface remains with the intact hemipelvis.

 

The Preferred Response to Question # 58 is 3.

 

Question 59A 4-year-old child has a 3-cm limb-length discrepancy, hemi-hypertrophy, and a large tongue. Additional tests should include which of the following?

1. Thyroid function studies

2. CT scan of the hip, knee, and ankle to measure torsion

3. Echocardiogram and EKG

4. MRI scan of the spine and CBC with differential

5. Abdominal and pelvic ultrasounds and alpha-fetoprotein levels

 

DISCUSSION: The child likely has Beckwith-Wiedemann syndrome and up to a 10% chance for the development of a tumor, especially a Wilm's tumor. Therefore, studies consisting of surveillance abdominal and pelvic ultrasounds and alpha-fetoprotein levels, three to four times per year until age 8, are recommended. An echocardiogram is not needed in this population nor is thyroid function studies, MRI scan of the spine, or a CT scan to address torsion.

 

The Preferred Response to Question # 59 is 5.

 

 

Question 60 An elderly woman with osteoporosis falls from a standing height, sustaining a low-energy fracture of the acetabulum. What structures are most likely fractured?

1. Posterior column and posterior wall

2. Anterior column and medial wall

3. Anterior column, posterior column, and ischium (T-type fracture)

4. Anterior column and posterior column (transverse fracture)

5. Anterior column, posterior column, and posterior wall (transverse/posterior wall fracture)

 

DISCUSSION: Epidemiologic studies suggest that 4,000 acetabular fractures occur in elderly patients each year in the United States. This accordingly may become the most common age group to present with this fracture. In elderly patients with considerable osteoporosis, a typical fracture pattern may present with intrapelvic dislocation of the femoral head with compromise to the anterior column and "medial wall." The resulting fractures are often complex fracture patterns with extensive comminution and displacement. These may present as atypical fracture patterns not always conforming to classic injury patterns described by Judet and associates. This fracture pattern seen commonly in geriatric patients results from low-energy falls with force directly applied to the greater trochanter. Fractures involving the posterior column and/or wall and transverse fracture patterns involving both the anterior and posterior columns occur infrequently in this age group. They are, however, more commonly encountered in younger age groups as a result of higher energy trauma. The Preferred Resp # 60 is 2.

 

Question 61 The foot orthosis/footwear prescription for correction of a flexible deformity typically seen in Charcot-Marie-Tooth disease includes which of the following components?

1. Lateral heel and forefoot posting

2. Medial heel wedge with lateral forefoot posting

3. Metatarsal pad for global metatarsal head offloading

4. 3/8" heel lift with firm heel counter

5. SACH with medial flare

 

DISCUSSION: The typical Charcot-Marie-Tooth deformity consists of a cavus foot with plantar flexion of the first ray with compensatory heel varus. The corrective foot orthosis

 

 

for this deformity (if flexible on examination) would include a lateral heel posting (ie, wedge) to shift the heel into a more neutral position and lateral forefoot posting to elevate the lateral border of the foot and accommodate and neutralize the varus-producing effects of the fixed plantar flexion of the first ray. None of the other devices listed will produce this result. The medial heel wedge will make the deformity worse. Global metatarsal relief is often added to the Charcot-Marie-Tooth foot orthosis for pain relief, but will not correct cavus deformity, nor will a 3/8" heel lift. A lateral flare might be useful on the shoe to help control the lateral thrust on the shoe caused by a varus heel, but a medial flare will accentuate the deformity. Adding SACH cushioning material to the heel would soften the heel and not correct hindfoot malalignment. The Pr Res# 61 is 1.

 

 

 

Question 62Figure 62 shows the radiograph of a 46-year-old man who has had increasing shoulder pain and diminishing motion over the last 10 years. Because his difficulties are severely impacting his quality of life, he is seeking advice and treatment options. Twenty five years ago, he underwent a shoulder stabilization procedure for recurrent shoulder dislocations. Examination reveals he can only elevate his arm to less than shoulder level and his external rotation is no more than 10 degrees. Management consisting of nonsteroidal anti-inflammatory drugs and intra-articular steroid injections has failed to provide relief. What is the most appropriate treatment recommendation?

 

1. Humeral head arthroplasty

2. Total shoulder arthroplasty

3. Reverse shoulder arthroplasty

4. Arthroscopic debridement/capsular release

5. Corticosteroid injection and physical therapy

 

DISCUSSION: The patient has classic "arthritis of dislocation." Procedures done years ago were designed to enhance shoulder stability by limiting external rotation. However, it is now understood that limiting external rotation results in significant alteration of joint mechanics and kinematics, thus leading to the development of osteoarthritis. The average age of patients who develop `arthritis of dislocation` is 45 years old. Despite the young age of these patients, total shoulder arthroplasty offers the most predictable improvement in pain and function. However, the patient must be made aware of the need to protect the arm from excessive loads to protect the glenoid implant. Because there is complete loss of articular cartilage and incongruent joint surfaces, there is no role

 

 

for arthroscopic debridement and capsular release. Injections offer little, if any, chance of improvement with the prior history of nonresponse. Physical therapy predictably makes patients worse because loading the arthritic joint generates more pain. Reverse shoulder arthroplasty is reserved for elderly patients with severe rotator cuff deficiency. A humeral head arthroplasty, while potentially more ideal than a total shoulder arthroplasty because of glenoid concerns, would likely not offer pain relief in the face of the significant glenoid involvement and incongruity. The Preferred Response to Question # 62 is 2.

 

Question 63A 10-year-old girl is seen in the emergency department after being involved in a motor vehicle accident. She has right hip pain and is unable to bear weight. She has no neurovascular deficits and no other injuries. Radiographs reveal a posterior dislocation of the right hip without apparent fracture. The acetabulum appears to be developing normally. What is the best course of treatment?

1. Open reduction under general anesthesia

2. Closed reduction under general anesthesia with fluoroscopy

3. Closed reduction under general anesthesia without fluoroscopy

4. Conscious sedation in the emergency department and closed reduction with fluoroscopy

5. Conscious sedation in the emergency department and closed reduction without fluoroscopy

 

DISCUSSION: Hip dislocation in the pediatric population is a rare event. However, prompt recognition and rapid care for this injury is imperative to avoid future hip problems including osteonecrosis of the femoral head (a devastating problem for a pediatric patient). Reduction maneuvers can create violent impact between the posterior wall of the (intact) acetabulum and the femoral head, resulting in shearing of the proximal femoral physis and displacement of the epiphysis from the remainder of the femoral head in skeletally immature patients. Therefore, deep sedation with good muscle relaxation, such as that achieved with general anesthetic, is recommended. Reduction is best accomplished with fluoroscopy for a number of reasons, including assessment of concentricity of the hip joint after reduction, and to detect any catastrophic femoral head physeal separation that occurs during the reduction maneuver. Sedation in the emergency department is often insufficient to achieve acceptable muscle relaxation for the patient. Open reduction is only indicated if closed reduction fails completely or if the hip is not concentric after an apparently successful closed reduction. Pre Res# 63 is 2.

 

 

Question 64What is the most effective footwear modification for restoring the gait pattern of the patient who has undergone an ankle arthrodesis?

1. Rocker sole

2. Lateral sole flare

3. Total contact insert

4. Extended steel shank

5. Solid ankle cushion heel (SACH)

 

DISCUSSION: When ankle range of motion is decreased, a rocker sole on the shoe helps to accommodate for the lost motion by creating a more efficient heel-to-toe gait pattern and allows the patient to "roll off" the foot during the late stance phase of gait using the rolling action of the sole. The SACH is a soft material added to the heel of the shoe to reduce the stress of heel strike. Although SACH modification will help to mimic the shock absorbing action of ankle plantar flexion that occurs during heel strike, it is not as beneficial to gait as a rocker sole. An extended steel shank stiffens the shoe and is designed to reduce bending of the sole, but will not accommodate for lost ankle motion (in fact, it will make ambulating more difficult for patients with decreased ankle motion unless coupled with a rocker sole). A total contact insert is designed to cushion the foot and offload certain areas of high stress or correct a flexible foot deformity. A lateral sole flare is an outrigger attached to the sole of shoe and is used to help correct varus deformities or compensate for lateral ankle instability. The Preferred Resp# 64 is 1.

 

Question 66Figures 66a through 66d are the radiographs and CT scans of a 72-year-old woman with osteoporosis who sustained a fall from standing height. She has pain and is unable to bear weight on the right knee. Surgical management is considered. Which of the following best describes the preferred proximal screw fixation construct within a laterally applied buttress plate?

 

 

 

 

1. 3.5-mm locking screws only

2. 3.5-mm nonlocking screws followed by 3.5-mm locking screws

3. 3.5-mm locking screws followed by 3.5-mm nonlocking screws

4. 6.5-mm fully threaded cancellous screws

5. 6.5-mm partially threaded cancellous screws

 

DISCUSSION: Displaced split depression fractures of the lateral tibial plateau require articular surface elevation, restoration of anatomic plateau width, and sustained elevation of the reduced articular components. This is accomplished by introducing nonlocking lag screws first to compress and narrow the lateral rim thus restoring plateau width. The introduction of locking screws first would disallow compression and accordingly prevent reduction of the lateral rim. Locking screws are inserted after the lag screws if the bone is osteoporotic to maintain articular elevation. Several biomechanical studies have demonstrated inferior performance of large implants (6.5-mm screws and 4.5-mm plates) with regard to sustaining joint surface elevation. The Pre Res# 66 is 2.

 

Question 67.The radiograph seen in Figure 67 reveals an ankle fracture in a 65-year-old woman who slipped on the ice. She has a history of diabetes mellitus for the past 7 years and reports that she maintains fair control of her diabetes; her last HgbA1c was 8%. The patient is a community ambulatory who lives independently. Examination reveals she has absent sensation with the 5.07 monofilament. When determining management, the physician must consider which of the following?

 

 

1. Supplemental internal fixation

2. Primary ankle arthrodesis

3. Nonsurgical treatment to avoid infection

4. Early bone grafting because of poor bone quality

5. Early mobilization and weight bearing to minimize stiffness

 

DISCUSSION: Increased immobilization and delayed weight bearing are indicated in the neuropathic population after treating an ankle fracture. Patients with diabetes mellitus and peripheral neuropathy have higher complication rates following

ankle fractures treated surgically or nonsurgically. The elevated HgbA1c and neuropathy both predict a higher complication rate with this fracture. Outcomes after nonsurgical management of this fracture are poorer than after surgical treatment. Early bone grafting

 

 

is not recommended in closed fractures, but the use of supplemental internal fixation is recommended because of the high risk of nonunion. More substantial constructs with supplemental fixation, locking fixation, fixation through the calcaneus and talus into the tibia, or external fixation are necessary. Primary arthrodesis is not recommended in this fracture pattern or in a relatively active patient.

The Preferred Response # 67 is 1.

 

 

 

Question 68 A 17-year-old girl has a 2-year history of progressive, painful hallux valgus deformity that is limiting her activities. Examination reveals no hypermobility. Weight-bearing radiographs are shown in Figures 68a through 68c. Surgical correction of the deformity should include which of the following?

 

1. Lapidus procedure

2. Akin osteotomy

3. Double metatarsal osteotomy

4. Distal metatarsal osteotomy

5. Distal soft-tissue release and/or proximal metatarsal osteotomy

 

DISCUSSION: The patient has a juvenile hallux valgus deformity, with

an increased distal metatarsal articular angle (DMAA), congruent first metatarsophalangeal joint, and high

intermetatarsal angle. This constellation of findings is best managed with a closing wedge or biplanar distal metatarsal osteotomy to correct the increased DMAA, and a proximal metatarsal osteotomy to correct the high intermetatarsal angle. A Lapidus procedure would be indicated for treatment of a hypermobile first ray, often manifested radiographically as a plantar flexion sag through the first tarsometatarsal joint. A distal soft-tissue release is indicated for an incongruent joint, whereas an Akin osteotomy is used to treat hallux valgus interphalangeus. Although a distal metatarsal osteotomy alone would correct the increased DMAA, it has insufficient corrective power to address the high intermetatarsal angle.

The Preferred Response to Question # 68 is 3.

 

 

 

 

Question 69 A patient reports startup pain 3 months after undergoing a primary total hip arthroplasty. Figures 69a and 69b show postoperative radiographs at 6 weeks and 3 months, respectively. Laboratory studies reveal a normal CBC count, C-reactive protein, and erythrocyte sedimentation rate. Which of the following options is most appropriate?

 

1. Continued observation

2. Revision of the femoral component

3. Hip aspiration for cell count and culture

4. Physical therapy for quadriceps strengthening

5. Resection arthroplasty, antibiotic spacer, and intravenous antibiotics

 

DISCUSSION: The patient has a loose femoral component, which has subsided at least 1 cm. The stem is undersized which is a risk factor for subsidence, especially with tapered stems.Continued observation is not indicated. Revision total hip arthroplasty is the best option. With a normal erythrocyte sedimentation rate and C-reactive protein, further workup and treatment for infection is not indicated. The Preferred Response # 69 is 2.

 

 

 

Question 70 A 15-year-old girl sustained the injury shown in Figures 70a and 70b when she jumped from the back of a moving truck. She is seen in the emergency department 2 hours after her injury. She has no other injuries. Her foot is warm and she has a normal motor and sensory examination. Pulses are only evident on Doppler. What is the most appropriate management?

 

1. MRI scan of the knee

2. CT scan of the distal femur

3. Application of a long-leg cast

4. Arteriogram of the extremity

5. Reduction and fixation of the fracture

 

DISCUSSION: The radiographs reveal a distal femoral fracture that is often associated with a neurovascular injury at the level of the fracture. Initial treatment should be to reduce the fracture, stabilize it, and then reevaluate the extremity for neurovascular function. A

 

 

CT scan, arteriogram, or MRI scan would not help and would delay treatment. A cast would not be appropriate because access to the extremity is necessary and it would not provide stabilization for vascular repair if it is required. The Preferred Resp# 70 is 5.

 

Question 71 A 54-year-old woman sustains the injury seen in Figures 71a and 71b. The injury involves her nondominant extremity. What should the patient be told regarding her expected outcome?

 

 

1. She should expect to return to full function and regain full range of elbow motion.

2. Reduction and casting has equivalent outcomes to those of surgical treatment.

3. This type of injury is associated with a high rate of complications.

4. Nerve dysfunction is commonly associated with this injury.

5. Ulnohumeral instability is the major complication seen with this fracture pattern.

 

DISCUSSION: This is a Bado type 2 (posterior) Monteggia lesion, which is associated with higher rates of complications than other types of Monteggia lesions. The injury is associated with indirect high-energy trauma and less often pathologic causes. Of the four types of Monteggia lesions, the type 2 or posterior type is associated with the worst prognosis. These injuries are best treated surgically with dorsal plating of the ulna and reduction with fixation or arthroplasty of the radial head. The major complications seen with this injury pattern are nonunion and plate failure. Almost all patients have some loss of elbow range of motion. Satisfactory results based on functional scores for this injury are not universal. Neurologic injury and ulnohumeral instability are unusual with this type of injury. Full functional recovery is not expected with nonsurgical management. The Preferred Response to Question # 71 is 3.

 

 

Question 72In a diagnostic test, the proportion of individuals who are truly free of a designated disorder identified by the test is known as

1. specificity.

2. sensitivity.

3. accuracy.

4. positive predictive value.

5. negative predictive value.

DISCUSSION: Specificity refers to the proportion of individuals who are truly free of the designated disorder who are so identified by the test. Sensitivity refers to the proportion of individuals who truly have the disorder who are so identified by the test. Positive predictive value refers to the proportion of individuals with a positive test who have the disorder. Negative predictive value refers to the proportion of individuals with a negative test who are free of the disorder. Accuracy is the overall ability to identify patients with the disorder (true positives) and without the disorder (true negatives) in the study population. The Preferred Response to Question # 72 is 1.

 

 

 

Question 73A 21-year-old throwing athlete has persistent shoulder pain. Figures 73a and 73b are arthroscopic photographs taken from a posterior viewing portal and an anterior viewing portal. During which phase of the throwing motion did the injury most likely occur?

1. Wind-up

2. Early cocking

3. Late cocking

4. Acceleration

5. Deceleration

DISCUSSION: Five distinct phases of the throwing motion have been identified, each of which places the static and dynamic stabilizers of the shoulder under different stresses. In the late cocking phase, the throwing arm is abducted and maximally externally rotated.

Rotator cuff tears in throwing athletes may be the result of either tensile or compressive forces. Tensile failure is believed to be the result of repetitive eccentric contractions.

Compressive failure is thought to result from direct contact of the articular side of the rotator cuff between the greater tuberosity and posterior glenoid. Compressive failure results in tearing of the posterior supraspinatus and anterior infraspinatus, in contrast to the more common partial tearing of the anterior supraspinatus seen in the general population. In addition to tearing of the articular side of the rotator cuff, compressive

 

 

forces also contribute to the peel-back mechanism and resultant avulsion of the posterosuperior labrum and biceps anchor. Articular-sided posterior supraspinatus and infraspinatus tears in combination with posterosuperior labral and biceps anchor detachment has been termed internal impingement. It is believed to be the primary result of either posterior capsular contracture (GIRD) or anterior capsular laxity. The Preferred Response to Question # 73 is 3.

Question 74Figures 74a through 74c show the radiograph, bone scan, and MRI scan of a 17-year-old pre-professional ballet student who injured her ankle 9 months ago and continues to report posterior pain, weakness, and instability. Which of the following tendons most commonly can have associated pathology?

 

 

1. Peroneus brevis

2. Peroneus longus

3. Flexor hallucis longus

4. Flexor digitorum longus

5. Posterior tibialis tendon

 

DISCUSSION: Dance, especially ballet, requires frequent plantar flexion to an endpoint greater than that of the average non-dancer. This may result in inflammation of the posterior ankle caused by irritation of an os trigonum. An os trigonum is typically an unfused secondary ossification center of the lateral tubercle of the posterior process of the talus, but can also be a united stress fracture of the lateral tubercle of the posterior process of the talus. The flexor hallucis longus runs directly medial to the lateral tubercle of the posterior process of the talus and can develop coexistent tendinopathy. The remaining tendons are not in as close proximity and are not associated with os trigonum pathology. The Preferred Response to Question # 74 is 3.

 

 

Question 75A 60-year-old woman sustains the injury shown in Figure 75. Prior to her injury, she lived independently and was a community ambulator without need for any assistive devices. What treatment will give her the greatest long-term painless hip function with the lowest reoperation rate?

1. Total hip arthroplasty

2. Hemiarthroplasty

3. In situ percutaneous pinning

4. Open reduction and percutaneous pinning

5. Open reduction and internal fixation with an intramedullary device

 

 

 

DISCUSSION: Cemented hemiarthroplasty is typically used to treat displaced femoral neck fractures in elderly patients. Recently, however, there has been a growing realization that many of these patients would be candidates for total hip arthroplasty had they presented with arthritis rather than fracture. Recent randomized studies have demonstrated improved outcomes up to 4 years following total hip arthroplasty compared with hemiarthroplasty in pain and functional scores. The rate of dislocation is higher following total hip arthroplasty. However, some patients with hemiarthroplasties required later conversion to total hip arthroplasty because of acetabular wear. In situ pinning is not recommended for patients with a displaced fracture. Open reduction and internal fixation of displaced femoral neck fractures in elderly patients is not recommended because of the risk of nonunion and osteonecrosis. The Preferred Response to Question # 75 is 1.

 

Question 76Figures 76a and 76b are the sagittal T1-weighted MRI scans of an active 27-year-old man who has had left dominant extremity shoulder pain and weakness for the past 5 months. He denies any history of a precipitating event but recalls that the pain began around the time he started lifting weights after a year off from lifting.

Examination reveals full range of active and passive motion, negative Hawkins and Neer impingement signs, 5/5 abduction strength, 5/5 external rotation strength with arm adducted at his side, and a negative belly press, Gerber lift-off, and O'Brien's test. He does have weakness with resisted external rotation with the arm abducted to 90 degrees. Radiographs are unremarkable. An MRI arthrogram shows no rotator cuff tear or labral tears. What is the most likely diagnosis?

 

 

1. Scapular dyskenisia

2. Quadrilateral space syndrome

3. Subacromial impingement syndrome

4. Suprascapular nerve compression by a spinoglenoid notch

5. Suprascapular nerve compression at the suprascapular notch

 

DISCUSSION: Examination reveals weakness of the teres minor muscle, and the MRI scan shows moderate isolated atrophy of the teres minor muscle belly. This is consistent with quadrilateral space syndrome, which is compression of the axillary nerve and posterior circumflex humeral artery in the quadrilateral space (bounded by the teres minor, teres

 

 

major, long head of triceps and the humerus). This syndrome has been related to compression of the neurovascular structures by muscle hypertrophy consistent with the patient's history of lifting weights near the onset of symptoms. The next step in confirming the diagnosis is a subclavian arteriogram with the arm in adduction as well as in abduction and external rotation. Suprascapular nerve compression would be manifested by atrophy and weakness of both the supraspinatus and infraspinatus (if occurring at the suprascapular notch) or just infraspinatus (if occurring at the spinoglenoid notch). The patient does not demonstrate signs or symptoms of either impingement syndrome or scapular dyskenisia. The Preferred Response # 76 is 2.

 

 

 

Question 77A 32-year-old woman jammed her ring finger. Figures 77a and 77b show radiographs of the finger after a closed reduction. Which of the following interventions, if done correctly, is likely to result in the best possible final

clinical outcome?

1. Early removal of a splint and application of continuous passive motion

2. Application of dynamic extension bracing after the first week

3. Maintaining reduction of the middle phalanx on the condyles of the proximal phalanx with dynamic external fixation

4. Open reduction and anatomic restoration of the middle phalanx articular surface

5. Surgical advancement of the volar plate into the middle phalanx base

 

DISCUSSION: The most important determinant in the final clinical outcome in proximal interphalangeal (PIP) joint fracture locations is the maintenance of the PIP joint alignment on the lateral view. This can sometimes be done with just extension block splinting, sometimes the fracture requires dynamic external fixation, and sometimes the fracture requires open reduction or volar plate arthroplasty. Good function can be the result in the setting of an incongruent middle phalanx base as long as the PIP joint alignment is maintained. Continuous passive motion has not been shown to be of benefit. Whereas dynamic external fixation in a flexed position is a very good treatment, dynamic extension bracing will just precipitate loss of PIP joint reduction and is therefore not indicated.

 

 

Whereas open reduction of the articular surface is theoretically desirable, it is generally impossible in the setting of the comminution of the volar middle phalanx base.

Furthermore, open reduction and internal fixation by itself does not guarantee that the PIP joint alignment will be maintained, and typically it causes finger stiffness given the extensive surgical approach. Likewise, volar plate arthroplasty is a surgery of last resort and requires careful attention to PIP joint alignment before joint pinning. In this case, with characteristics of comminution, dynamic external fixation is the preferred choice. The Preferred Response to Question # 77 is 3.

 

Question 78Figures 78a and 78b show the CT scans of a 22-year-old man with back pain after falling out of a tree. Examination reveals no palpable spinal step-offs, posterior spinal pain, and normal neurologic function in the lower extremities. Normal perineal sensation and normal rectal tone are present. What is the best management?

 

 

1. Bed rest

2. External orthosis

3. Anterior corpectomy and arthrodesis

4. Posterior instrumented arthrodesis

5. Posterior decompression and instrumented arthrodesis

 

DISCUSSION: The patient has a stable L2 burst

fracture. There is no evidence of neurologic injury or disruption of the posterior ligamentous complex. According to the Thoracolumbar Injury Classification System (TLICS), the severity score for this injury is 2 and therefore nonsurgical management is recommended. The TLICS was developed to define injury based on three clinical characteristics: injury morphology, integrity of the posterior ligamentous complex, and neurologic status of the patient. Point values are assigned to each major category based on injury severity. The sum of these points represents the TLICS severity score, which may be used to guide treatment. The injury scores are totaled to produce a management grade that is, in turn, used to guide treatment. A score of >4 suggests the need for surgical treatment because of significant instability, whereas a score of <4 suggests nonsurgical management. The severity score offers prognostic information and is helpful in medical decision making. An external orthosis provides enough support to obviate the need for bed rest and avoid associated complications (deep venous thrombosis, pulmonary embolism, pneumonia, skin ulceration). Surgical treatment, either through an

 

 

anterior or posterior approach, has been shown by Wood and associates to result in increased pain and

disability and is therefore not indicated in this setting. Additionally, there is no need for decompression in the setting of a neurologically intact patient. The Preferred Res# 78 is 2. Question 79Which of the following conditions routinely requires early surgical intervention in patients with Marfan syndrome?

1. Kyphosis

2. Ankle instability

3. Protrusio acetabula

4. Progressive scoliosis

5. Pseudarthrosis of the tibia

 

DISCUSSION: Marfan syndrome is a challenging disease for the orthopaedic surgeon. Most problems of joint laxity, acetabular protrusio, and minor scoliosis curves are treated nonsurgically. Pseudarthrosis of the tibia is not seen in Marfan syndrome; it is more common in patients with neurofibromatosis (NF-1). Treating kyphosis is risky for vertebral subluxation. Rapidly progressive scoliosis in immature patients is associated with higher surgical complications, but surgery is indicated. Overcorrection is associated with significant cardiovascular complications and should be avoided. The Pre Res# 79 is 4.

 

Question 80A 43-year-old woman has a 2-week history of right shoulder pain. She denies any injury to initiate her symptoms but states that she has shoulder pain with range of motion and lifting objects. Examination reveals mild pain with abduction, empty can testing, and with the Neer and Hawkins impingement tests. Her range of motion with the right shoulder reveals passive forward flexion to 90 degrees, abduction to 90 degrees, external rotation at the side to 15 degrees, and internal rotation to her buttock. The uninvolved left shoulder has forward flexion to 160 degrees, abduction to 150 degrees, external rotation at the side to 60 degrees, and internal rotation to T6.

Radiographs of the shoulder are normal. What is the next most appropriate step in management?

1. Home exercise program

2. Sling at all times until her pain decreases

3. Closed manipulation under anesthesia

4. Arthroscopic rotator cuff repair

5. Arthroscopic anterior and posterior capsular release

 

 

 

DISCUSSION: The patient has the recent onset of adhesive capsulitis, which is characterized by loss of both active and passive range of motion. A home exercise program is as helpful as organized therapy to improve her range of motion. While a sling might be appropriate for comfort, continuous use might increase her shoulder stiffness. Surgical treatments, such as a manipulation under anesthesia or arthroscopic capsular release, might be necessary if her motion cannot be restored with physical therapy and home exercises. However, the natural history of idiopathic adhesive capsulitis is self limited and does not usually require surgery. An arthroscopic rotator cuff repair is not indicated because she does not have a rotator cuff tear. The Preferred Resp# 80 is 1.

 

 

 

Question 81Figures 81a and 81b are the radiographs of a 44-year-old woman who reports the development of significant left hip pain over the past 6 months with symptoms located in the groin and buttock. She notes pain while sleeping and increased pain with walking up stairs or sitting for prolonged periods. Examination reveals full range of motion, and internal rotation impingement is absent. The left lower extremity is shorter than the contralateral leg by 1.5 cm. She denies lumbar spine symptoms and has a normal neurologic examination. Treatment should consist of which of the following?

1. Hip resurfacing

2. Total hip arthroplasty

3. Periacetabular osteotomy

4. Trochanteric varus osteotomy

5. Trochanteric valgus osteotomy

 

DISCUSSION: Periacetabular osteotomy is an excellent reconstructive procedure in middle-aged adult patients with early hip arthritis and symptoms. The best candidates have a very low vertical center edge angle of 0 degrees to 15 degrees, a minimum of 2 mm of cartilage joint space remaining, and a concentric articulation throughout the range of motion. In these cases, rotational repositioning consisting of moving the dome of the acetabular sourcil both laterally and anteriorly for improved surface area and coverage of the femoral head during weight bearing can produce a long-term solution for this condition. Whereas the surgical technique is challenging, complication rates are low with surgical experience and offer a better alternative than a salvage procedure such as a total joint arthroplasty or hip resurfacing arthroplasty. Trochanteric osteotomy has been used

 

 

for this condition, but does not offer the ability to significantly improve the surface area on the acetabular side of the joint. The Preferred Response to Question # 81 is 3.

 

Question 82 A 20-year-old woman sustained a laceration to her volar forearm 4 cm proximal to the wrist flexion crease. She has numbness in the thumb, index, and middle fingers. After microscopic repair of the median nerve, 2 weeks of splinting, and commencement of a hand therapy program, the patient is most likely to require what secondary operation 6 months after the injury?

1. Tenolysis of the profundus tendons at the wrist

2. Nerve transfer of the ulnar motor nerve to the median motor nerve

3. Opponensplasty with the extensor indicis

4. Open carpal tunnel release

5. Transfer of the extensor digiti minimi to the first dorsal interosseous tendon

 

DISCUSSION: The patient sustained a laceration of the median nerve in what would be considered a low median nerve injury. Standard treatment entails exploration and microscopic repair of the median nerve. With a good quality nerve repair in a young adult, return of some sensory function (albeit reduced compared with the normal nerve) is usual. Return of motor function to the thenar muscles is more unpredictable. If the patient begins a therapy program within a few weeks after nerve repair, it is unlikely that tenolysis of the profundus tendons would be required. An open carpal tunnel release would be unlikely to change functional return. The patient would not be expected to have lost first dorsal interosseous function after a median nerve laceration because this muscle is innervated by the ulnar nerve. A neurotization procedure for low median nerve palsy has been described, but it consists of transfer of the distal anterior interosseous nerve into the median nerve motor fascicles, not transfer of the ulnar nerve. Therefore, the most likely secondary procedure required in this scenario is an opponensplasty procedure to improve thumb opposition. The Preferred Response to Question # 82 is 3.

 

Question 83Figure 83a shows an axillary radiograph and Figures 83b and 83c show axial MR arthrograms of a 20-year-old collegiate offensive lineman who has shoulder pain while pass-blocking. He sustained a shoulder injury 3 months earlier when he "jammed it." Prior to this injury, he denies any pain or instability in either shoulder. Despite undergoing rehabilitation with a physical therapist and trainer and abstaining from playing for 6 weeks, he is currently unable to play because of his symptoms.

 

 

Examination reveals full active range of motion, a positive jerk test which reproduces his symptoms, and a grade 2 posterior translation of the humeral head with load and shift testing which also reproduces his symptoms. What is the best management option to allow him to return to his pre-injury function next season?

 

 

1. Arthroscopic posterior capsulolabral repair

2. Thermal capsulorrhaphy

3. Open anterior capsulorrhaphy

4. Intra-articular injection of corticosteroid

5. Immobilization for 6 weeks in external rotation

DISCUSSION: Arthroscopic posterior capsulolabral repair is most likely to return him to competitive athletics. The patient has symptomatic posterior instability that is preventing him from performing high-level athletic activities. Posterior subluxation of the humeral head is seen on the axillary radiograph and a posterior labral tear is seen on the axial MR arthrograms. Because nonsurgical management has failed to provide relief, treatment should consist of posterior capsulolabral repair. This can be performed either arthroscopically or open with similar excellent results. An intra-articular injection may help his pain but will not likely allow him to return to his pre-injury functional level.

Thermal capsulorrhaphy has limited use in the shoulder because of the high rate of complications reported, and anterior capsulorrhaphy will not correct the posterior instability. Whereas a trial of immobilization in external rotation may have benefitted him with the acute injury, it is unlike to help with this recurrent instability. The Pre Re# 83 is 1. Question 84What is the greatest benefit of external fixation for treatment of displaced and unstable pelvic ring injuries with hemodynamic instability?

1. It provides rigid fixation of the pelvis.

2. It helps maintain a stable clot over injured vessels.

3. It stabilizes the visceral injuries.

4. It allows the patient to sit and eat without pain.

5. It is more comfortable than skeletal traction.

 

 

DISCUSSION: External fixation has been shown not to provide rigid fixation of the pelvis because a long moment arm from the fixator clamps to the posterior pelvis. Even with elaborate constructs, the fixator alone is inferior to internal fixation of the posterior ring. The main purpose of acute external fixation is to stabilize the initial clot forming about the injured pelvic plexus. This initial clot contains innate clotting factors, making it more stable, if not dislodged. If this clot is dislodged after hemorrhage and factor poor resuscitation, the ensuing hemorrhage will not have the same ability to form a stable clot around the injured vessels. The fixator does not stabilize any visceral structures. It interferes with the ability to sit depending on its application and is no more or less comfortable than skeletal traction. The Preferred Response to Question # 84 is 2.

 

Question 85 During right knee anterior cruciate ligament (ACL) reconstruction, after drilling an appropriately positioned and referenced tibial tunnel, the surgeon finds that the transtibial guide is placing the femoral tunnel at 11:30 within the intercondylar notch. Which of the following choices will best enable appropriate graft placement in this clinical scenario?

1. Revise the tibial tunnel to be more oblique.

2. Revise the tibial tunnel to be more posterior.

3. Convert to a transtibial double-bundle ACL.

4. Prepare the femoral tunnel via an anteromedial portal or two-incision technique.

5. Hyperflex the knee and place the femoral tunnel with the transtibial guide.

 

DISCUSSION: Anatomic placement of the femoral tunnel is best achieved in this clinical scenario by drilling the femoral tunnel through the anteromedial portal or via a two-incision technique. Several recent studies have demonstrated the difficulty that may be encountered in restoring true ACL anatomy on the femoral side when placing a femoral tunnel through a transtibial technique. While this is not always the case and this technique may be reasonable and sufficient, it is important for orthopaedic surgeons to critically assess tunnel placement intraoperatively and postoperatively to minimize errant tunnel placement, demonstrated in the literature as the most common cause of ACL failure and need for revision. In this not uncommon clinical scenario, simply converting to a two-incision ACL technique or drilling through the anteromedial portal with the knee hyperflexed will permit accurate femoral tunnel placement and increase the likelihood of an optimal clinical outcome. Femoral tunnel accuracy with these techniques is enhanced by a lower starting point in the intercondylar notch. Familiarity with these techniques is

 

 

valuable for surgeons performing ACL reconstruction. Revising the tibial tunnel in this scenario would likely lead to bone compromise of the proximal tibia and may interfere with graft fixation and incorporation. Converting to a double-bundle ACL with a transtibial technique would not correct the vertical femoral tunnel. Hyperflexion of the knee may improve femoral tunnel placement to some extent, but is unlikely to allow anatomic placement of a femoral tunnel when the transtibial guide lies in a clearly excessive vertical position. The Preferred Response to Question # 85 is 4.

 

 

 

Question 86An 11-year-old girl has patellar pain with activity and a knock-knee deformity. A standing radiograph is seen in Figure 86. Physical therapy has provided relief for the knee pain. The genu valgum is best treated by which of the following?

1. Observation

2. Brace treatment

3. Osteotomy of the proximal tibia

4. Osteotomy of the distal femur

5. Temporary bilateral distal femoral medial hemiepiphyseodesis

 

DISCUSSION: The hip-knee-ankle axis falls in the lateral compartment of the knee. Most patients by age 11 have achieved the axis they will have as an adult. Bilateral distal femoral medial hemiepiphyseodesis with staples, plates, or screws that can be placed and then removed after correction of the valgus is the appropriate treatment. Observation is not likely to correct the

valgus at this age and hemiepiphyseodesis should be done while there is sufficient growth remaining. Brace treatment and osteotomies of the tibia or femur are not indicated in this age group. The Preferred Response to Question # 86 is 5.

 

Question 87Based on the current available best-evidence, what postoperative activities should be recommended for patients undergoing first-time lumbar diskectomy for disk herniation?

1. Bed rest

2. Avoid exercise for 6 to 8 weeks

3. Early return to low-intensity exercise

4. Early return to high-intensity exercise

5. Gradual return to low-intensity exercise after 6 weeks

 

 

DISCUSSION: Early return to high-intensity exercise is safe at 4 weeks. An update Cochrane review demonstrated that exercise programs starting 4 to 6 weeks after surgery in patients undergoing first-time lumbar diskectomy for disk herniation lead to a faster decrease in pain and disability than no rehabilitation. Additionally, high-intensity exercise programs seem to lead to a faster decrease in pain and disability than low-intensity programs. In a prospective review of 50 consecutive patients undergoing first-time lumbar diskectomy for disk herniation, Carragee and associates demonstrated that lifting of postoperative activity restrictions after limited diskectomy allowed shortened sick leave without increased complications. He concluded that postoperative precautions in these patients may not be necessary. The Preferred Response to Question # 87 is 4.

 

Question 88 Which of the following factors is least likely to have an impact on fracture healing?

1. Smoking

2. Obesity

3. Vitamin D deficiency

4. Use of bisphosphonates for osteoporosis treatment

5. Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

 

DISCUSSION: Although the effect of obesity on complication rates has been studied and it may increase wound complications, it has not been shown to increase nonunion rates.

The negative impact of smoking on bone healing has been shown in animal and human clinical studies. NSAIDs interfere with the inflammatory phase of bone healing and bisphosphonates interfere with osteoclast function, negatively impacting the remodeling phase. Vitamin D deficiency has been identified in up to 70% of nonunion patients.

The Preferred Response to Question # 88 is 2.

 

Question 89 What is the best indication for prosthetic radial head arthroplasty following fracture?

1. Mason type I fracture with full range of motion

2. Mason type I fracture with decreased supination

3. Mason type I fracture with decreased pronation

4. Mason type III fracture with associated interosseous membrane injury

5. Mason type III fracture without associated interosseous membrane disruption

 

 

DISCUSSION: The Mason classification differentiates the degree of displacement, angulation, and mechanical block to motion. Most nondisplaced radial head fractures (Mason I) in which there is no block to motion can be treated nonsurgically. Mason type III injuries are severely comminuted radial head fractures. Fragment excision can be considered in unreconstructable fractures in which the interosseous membrane is intact. However, if the interosseous membrane has been disrupted, fragment excision can lead to proximal migration of the radius with associated wrist problems. In this case, radial head arthroplasty is indicated. Radial head arthroplasty may also be required when the radial head fracture is associated with other ligamentous injuries as seen following an elbow dislocation, or with an associated unstable coronoid fracture. Pre Resp# 89 is 4.

 

Question 90An orthopaedic surgeon in his first year of practice is negotiating with a private for-profit hospital to be their employed trauma specialist. The state of employment is known to have a high rate of malpractice claims because of a favorable plaintiff legal environment. During the course of negotiations, malpractice insurance is being discussed. The surgeon should ask the hospital to provide which type of malpractice insurance policy?

1. Claims made with "nose" coverage

2. Claims made without tail coverage

3. No policy because of employed status and sovereign immunity

4. Occurrence coverage

5. Occurrence coverage with "nose" coverage

 

DISCUSSION: An occurrence policy provides coverage for all claims made during employment irrespective of when it is filed (during or postemployment) and therefore is the best option. Claims made policy only covers suits for the time employed. A prepurchased "tail" is needed to provide coverage for cases that occurred during employment but filed postemployment. Nose coverage is applicable if the surgeon was previously employed and did not have tail coverage from previous employment, but this surgeon just emerged from training where it is not applicable. Claims made without tail coverage is unwise because the surgeon would be unprotected or have to purchase his own policy postemployment. Only in certain situations does sovereign immunity exist, and generally not in a for-profit system. Occurrence coverage with nose coverage is incorrect because it does not apply to this surgeon with no previous employment or claims policy lacking tail coverage. The Preferred Response to Question # 90 is 4.

 

 

Question 91A 21-year-old man who reports prior left knee pain recently felt a pop in his knee and now is not able to ambulate. Examination reveals a well-developed, well-nourished man with some stiffness around the knee. He has some fullness in the lateral femoral condylar area and tenderness to palpation on the lateral side. There is no adenopathy. Radiographs are seen in Figures 91a and 91b. At the time of surgery, open biopsy specimens are seen in Figures 91c and 91d. What is the most appropriate management?

 

 

 

1. Irradiation

2. Methylmethacrylate injection

3. Chemotherapy followed by wide resection

4. Amputation above the level of the lesion

5. Lateral condylar resection and allograft reconstruction

 

DISCUSSION: The patient has a giant cell tumor of the lateral condyle with a pathologic fracture. The best option would be resection of the lateral condyle and osteoarticular allograft reconstruction. There is collapse of the subchondral bone in the giant cell tumor, making curretting and simple cementation difficult. Methylmethacrylate injection for giant cell tumor is never indicated. Although giant cell tumors can be treated with irradiation, surgery when possible is a better option. Amputation is almost never indicated for giant cell tumor of bone. Chemotherapy is not indicated for giant cell tumor of bone.

The Preferred Response to Question # 91 is 5.

 

 

 

 

Question 92Figures 92a and 92b are the radiographs of an elderly patient who underwent revision total hip arthroplasty and was asymptomatic until falling; the patient is now unable to bear weight. What is the most appropriate management? 1- Revision of the femoral component with a longer

stem

1. Revision of the femoral component with open reduction and internal fixation with a plate, screws, and cables or wires

2. Open reduction and internal fixation of the fracture with a plate, screws, and cables or wires

3. Intramedullary fixation after revision of the stem with a cemented device

4. Repair with cortical strut allograft and cerclage wires

 

DISCUSSION: The patient has a periprosthetic femur fracture below a well-fixed, long stem femoral component. Because the patient was asymptomatic prior to the fall and the radiographs do not indicate loosening of the femoral component, revision of the femoral component is not indicated. The fracture is a Vancouver type b-1 fracture and repair of the fracture with plates and screws is indicated. Repair with cortical allograft and cerclage wires may serve as an augment to plates and screws but if used alone (without a plate and screw construct), it will not provide adequate rotational control. Pre Resp# 92 is 3.

 

Question 93What prosthetic factor has the most impact on decreasing the rate of scapular notching in a Grammont-style reverse total shoulder arthroplasty?

1. Posterior tilt of the glenoid component

2. Inferior tilt of the glenoid component

3. Inferior positioning of the glenoid component

4. Use of a cemented humeral component

5. Use of locking screws in the glenoid component

 

DISCUSSION: A low position of the glenoid base plate has been shown to have the greatest effect on decreasing scapular notching with a Grammont-style prosthesis. Scapular notching is the phenomena seen after reverse total shoulder arthroplasty when bone along the inferior scapular neck is lost. It is thought to be the result of repeated

 

 

contact between the humeral component and the bone. The Grammont-style reverse total shoulder arthroplasty has a medialized center of rotation that decreases strain at the glenoid component but has less space for the humerus to clear the scapula. Scapular notching was seen least in components that are placed low on the glenoid. Posterior and inferior tilt has minimal effect on scapular notching and may even increase notching by bringing the humerus closer to the scapula. The use of locking screws and a cemented humeral stem had no influence on notching.

The Preferred Response # 93 is 3.

 

Question 94A 16-year-old competitive female swimmer has a 1-year history of left shoulder pain. She denies any specific injury to her shoulder. She reports that the pain is worse with swimming but also has pain with daily activities. She also notes similar occasional symptoms in her right shoulder. Examination reveals symmetric range of motion and rotator cuff strength. Examination of the left shoulder reveals 2+ anterior and posterior translation with pain in both directions and a 2-cm sulcus sign. The right shoulder also has 2+ anterior and posterior translation and a 2-cm sulcus sign with no pain. She also has hyperextension of the elbows and the ability to touch the radial border of her thumb to her forearm. What is the next step in management?

1. Open inferior capsular shift

2. Arthroscopic thermal capsulorrhaphy

3. Sling at all times until the pain resolves

4. Arthroscopic anterior and posterior capsular plication

5. Physical therapy for rotator cuff and scapulothoracic strengthening

 

DISCUSSION: The patient has symptomatic multidirectional instability. A comprehensive program involving physical therapy to restore dynamic stability to her shoulder is indicated as a first-line treatment. Periscapular strengthening focusing on the serratus anterior and rhomboids and rotator cuff strengthening should be emphasized. A sling might be used occasionally for comfort but will not provide long-term relief of her symptoms. Thermal capsulorrhaphy, although widely used in the past for shoulder instability, has been abandoned because of a high complication rate. Surgical interventions, such as capsular plications or open capsular shift procedures, might be indicated if rehabilitation fails to relieve her symptoms.

he Preferred Resp # 94 is 5.

 

 

Question 95A 29-year-old man sustained an injury when he was playing basketball, landing on his left knee while jumping for a rebound. He had vague pain in the anterior aspect of the knee for several weeks. The initial radiographs were negative with the exception of a large traumatic effusion. Examination reveals no apparent ligament instability but a significant extension lag of 30 degrees. There was a palpable defect above the superior pole of the patella. What is the most appropriate management?

1. MRI scan

2. Diagnostic arthroscopy

3. Surgical repair of a ruptured quadriceps tendon

4. Knee immobilizer for 6 weeks, followed by a sport brace

5. Limited weight bearing for 3 weeks, followed by physical therapy

 

DISCUSSION: This is the classic presentation of a tendon disruption in an active athlete that may represent chronic strain or weakening of the tendon insertion. The factors that lead to this condition are multitude, including biomechanic and cytologic, but there is little evidence that inflammation is an active factor. Surgical treatment is straightforward and logical. Suture anchors have been compared with simple holes made in the patella for suturing the tendon, with no apparent biomechanic advantage.

The Preferred Response to Question # 95 is 3.

Question 96A 23-year-old woman sustains the injury seen in Figures 96a and 96b. Treatment should consist of which of the following?

 

 

1. Total elbow arthroplasty

2. Closed reduction and casting

3. Open reduction and internal fixation of both the radial head and distal humerus

4. Open reduction and internal fixation of the radial head and excisional arthroplasty of the distal humerus

5. Hinged external fixation with associated ligamentous reconstruction

 

 

DISCUSSION: This injury represents a complex partial articular fracture of the distal end of the humerus with an associated radial head fracture. Given this patient's young age, partial or complete arthroplasty is not an option. Closed reduction will lead to poor elbow function. Ligamentous repair is not indicated and external fixation will not aid in articular reduction. The patient requires open reduction and internal fixation of both components of the intra-articular injury. This is best accomplished through an extensile lateral approach or an olecranon osteotomy. Headless screws are preferred for articular reconstruction in these cases. The Preferred Response to Question # 96 is 3.

 

Question 97A 65-year-old patient who underwent ankle arthrodesis 7 years ago is pain free, but has difficulty walking. Hindfoot and transverse tarsal motion is painless. What is the best treatment option?

1. Medial heel wedge

2. Heel-to-toe rocker sole

3. Morton's extension

4. Conversion to pantalar arthrodesis

5. Short polypropylene articulated-ankle foot orthosis

 

DISCUSSION: The use of a heel-to-toe rocker sole can decrease pressure on heel strike, increase propulsion at toe-off, dissipate the forces across the arthrodesis site, and normalize gait. The patient presents after a successful ankle arthrodesis. Extending the arthrodesis is unnecessary with painless hindfoot and transverse tarsal motion. The use of a medial heel wedge in a well-aligned arthrodesis is not indicated. A Morton's extension is indicated for forefoot pain. A short articulated ankle foot orthosis would not relieve any of the stress on the tibiotalar joint.

The Preferred Response to Question # 97 is 2.

Question 98 A 55-year-old woman has arm pain at rest and at night. Studies include a positive bone scan in the metaphysis of the proximal humerus and a radiograph that shows what appears to be a lytic bone lesion. What is the next step in management?

1. Indium scan

2. Skeletal survey

3. CT needle biopsy

4. Obtain a serum lactate dehydrogenase

5. MRI scan of the lesion and CT scan of the chest, abdomen, and pelvis

 

 

DISCUSSION: In patients older than age 40 years, a lytic lesion of bone is most likely metastatic carcinoma. Local staging is achieved with an MRI scan, which can best identify and localize any soft-tissue extension of the lesion. Identifying the primary site with a CT scan of the chest, abdomen, and pelvis is successful 90% of the time. Although some lesions, such as giant cell tumor of bone, have characteristic appearances on an MRI scan, this modality is primarily used for staging rather than diagnosis. For malignancies, systemic staging is required and usually includes a technetium Tc 99m total body bone scan and noncontrast CT scan of the chest to seek potential sites of metastasis. Biopsies are best performed by a team prepared to provide definitive treatment. For myeloma, specifically, a skeletal survey is the preferred method for screening the skeleton.

However, bone scans are notoriously negative or inconclusive in patients with myeloma. Lactate dehydrogenase is useful only in the setting of possible lymphoma of bone. The primary function of indium scans is determining infection. The Preferred Resp# 98 is 5.

 

Question 99An 82-year-old woman underwent cemented right total hip arthroplasty approximately 15 years ago. She fell and sustained the injury shown in Figure 99. What is the most appropriate management for this injury?

 

 

1. Open reduction and internal fixation of the femur with a plate, screws, and cerclage wires

2. Open reduction and internal fixation of the femur with a plate, screws, cerclage wires, and cortical strut allograft

3. Revision of the acetabular component with open reduction and internal fixation of the femur with a plate, screws, and cortical strut allograft

4. Revision of the acetabular and femoral components

5. Revision of the femoral component with a long cemented stem

 

DISCUSSION: The radiograph demonstrates a Vancouver type b-3 periprosthetic femur fracture with a loose femoral stem and acetabular component. Open reduction and

 

 

internal fixation would not be appropriate in the setting of loose components. The femur has circumferential radiolucent lines in the bone-cement interface and the bone quality of the proximal femur is poor. In addition, the cemented acetabular component is loose and has migrated proximally. Appropriate treatment includes acetabular revision and femoral revision. Options for femoral revision include an allograft-prosthesis complex, extended osteotomy with cables, or a proximal femoral replacement.

Pre Res# 99 is 4.

 

Question 100Figures 100a and 100b are the MRI scans of a 45-year-old man who has had elbow and proximal forearm pain for the past 8 months. He can recall no specific trauma and symptoms have not lessened despite his adopting job modifications that limit lifting. He has discomfort with resisted elbow extension and pronation. The biceps tendon can be easily palpated. Treatment should consist of which of the following?

 

 

 

1. Release of the lacertus and transfer of the biceps to the brachialis tendon

2. Open detachment, debridement, and reattachment of the biceps tendon

3. Anterior exploration and decompression of the posterior interosseous nerve

4. Excision of the anterior intramuscular lipoma

5. Endoscopic debridement of the biceps tendon

 

DISCUSSION: The MRI findings are most consistent with a partial tear of the biceps tendon. In the setting of prolonged symptoms that are resistant to nonsurgical interventions like rest, physical therapy, and modality, surgical treatment is indicated. Exploration, debridement, and reattachment with one of a variety of techniques are the standards of care. No lipomatous mass is seen on the MRI scan. There is no weakness in finger extension to suggest posterior interosseous nerve palsy. Transfer of the biceps would result in loss of supination strength. Endoscopic biceps tendon surgery is reserved for long-head pathology.

The Preferred Response to Question # 100 is 2.

 

 

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?

 

 

1. Coracoid transfer

2. Rotator cuff repair

3. Reverse total shoulder arthroplasty

4. Arthroscopic anteroinferior labral repair

5. Physical therapy for range of motion and 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?

 

 

1. He will have weakness with forearm supination.

2. He will have instability to valgus stress.

3. He will have weakness with elbow flexion.

4. He will have a significant loss of motion.

5. He will develop degenerative arthritis in his elbow.

 

 

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

   102

    

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

   111

    

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

1. Open reduction and transfer of the lesser tuberosity into the defect

2. 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 longterm 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.