FREE Orthopedics MCQS 2022 1751-1850..

1801. (686) Q5-945:

Which of the following statements is true regarding the growth plates around the ankle:

1) The distal fibula grows more than the distal tibia.

3) The anterolateral portion of the tibial physis ceases growing first.

2) The distal tibia grows more than the distal fibula.

5) The two growth plates are part of a common physis.

4) The two physes should be at an even level.

The distal tibia grows more than the distal fibula.

The anterolateral portion of the tibial physis ceases growing last, thus explaining the phenomenon of the Tillaux fracture. The physis of the distal fibula is always located more distally than the distal tibia.

The two physes are not conjoined.

 

■Correct Answer:The distal tibia grows more than the distal fibula.

1802. (687) Q5-946:

Which of the following is the most common final attribution of back pain in children and adolescents after all appropriate diagnostic studies are performed:

1) Spondylolysis

3) Infection

2) Osteoid osteoma

5) No identifiable cause

4) Herniated nucleus pulposus

The majority of children and adolescents do not have an identifiable cause of back pain after all appropriate tests are performed. Of the smaller percent of patients with an actual diagnosis, spondylolysis followed by herniated nucleus pulposus are most common.

 

■Correct Answer:No identifiable cause

1803. (688) Q5-947:

Which of the following is the most definitive means of making a diagnosis of active skeletal tuberculosis:

1) Positive tuberculin tine test

3) Positive culture and histological exam

2) Negative tuberculin tine test

5) Enzyme linked immunosorbent assay (ELISA) test

4) Magnetic resonance imaging

The lower thoracic-upper lumbar spine is most commonly affected by tuberculosis. The most definitive diagnosis is by culture and histologic examination.

 

■Correct Answer:Positive culture and histological exam

1804. (689) Q5-948:

Which of the following descriptions is more characteristic of tuberculosis than of pyogenic spondylitis:

1) Disc space is narrowed before significant bony changes occur.

3) Bony erosions seen on computerized tomography are usually small and focal.

2) Involvement of multiple contiguous levels is uncommon.

5) Magnetic resonance imaging rarely shows significant soft tissue swelling.

4) Vertebral destruction exceeds disc destruction.

Vertebral destruction exceeds disc destruction in tuberculosis.

Bony changes occur earlier in tuberculosis than in pyogenic spondylitis.

Involvement of multiple contiguous levels is more common in tuberculosis than pyogenic spondylitis.

Bony erosions seen on computerized tomography are large in tuberclosis and small in pyogenic spondylitis. Magnetic resonance imaging often shows significant soft tissue involvement in both disorders.

 

■Correct Answer:Vertebral destruction exceeds disc destruction.

1805. (690) Q5-949:

A 5-year-old girl comes into the clinic with back pain. Her family has just moved to the United States from southeastern Asia. A lateral radiograph shows destruction of T11, T12, and L1. Magnetic resonance imaging shows a moderate posterior soft tissue mass. A neurological exam is normal. Biopsy confirms tuberculosis. For treatment of the girlâs spinal problem, recommended treatment includes:

1) A two-drug therapy for at least 6 months

3) A two-drug therapy and posterior spinal fusion to prevent deformity

2) A two-drug therapy for at least 6 months along with a body cast

5) Anterior debridement, strut graft, and posterior fusion with instrumentation

4) Anterior spinal debridement and a rib strut graft

Anterior debridement, strut graft, and posterior fusion with instrumentation provide the patient with the best chance of a positive result. This procedure minimizes graft dislodgement and posterior overgrowth.

A two-drug therapy for at least 6 months leaves the patient at a significant risk of progressive kyphosis and neurologic deficit.

A two-drug therapy for at least 6 months along with a body cast also leaves the patient with significant risk of progressive kyphosis and neurologic deficit.

The lack of anterior support from a two-drug therapy and posterior spinal fusion to prevent deformity leaves the patient with significant risk of kyphosis.

Even with an anterior spinal debridement and a rib strut graft, there is a risk of graft dislodgment over this large defect and of posterior growth into kyphosis.

 

■Correct Answer:Anterior debridement, strut graft, and posterior fusion with instrumentation

1806. (691) Q5-950:

A dorsal approach has which of the following characteristics with regard to a posteromedial approach in the surgical treatment of congenital vertical talus:

1) The dorsal approach requires a more extensive dissection.

3) The dorsal approach requires plication of the talonavicular capsule.

2) The dorsal approach has a lower risk of avascular necrosis of the talus.

5) The dorsal approach requires a longer tourniquet time.

4) The dorsal approach has a higher risk of redislocation.

The dorsal approach has not shown evidence of avascular necrosis, whereas the posteromedial approach has shown such changes at follow-up in as many as 40% of cases.

The dorsal approach requires a less extensive dissection than the posteromedial approach.

The dorsal approach does not require or permit plication of the talonavicular capsule, whereas the posteromedial approach does.

The dorsal approach does not appear to have a higher rate of redislocation of the talonavicular joint than the posteromedial approach.

The dorsal approach requires a shorter tourniquet time than the posteromedial approach. 

■Correct Answer:The dorsal approach has a lower risk of avascular necrosis of the talus.

1807. (692) Q5-951:

Which of the following conditions is not associated with an increased risk of congenital vertical talus?

1) Sacral agenesis

3) Myelomeningocele

2) C erebral palsy

5) Nail patella syndrome

4) ArthrogryposisV

Patients with cerebral palsy do not have an increased risk of congenital vertical talus, but they may develop an acquired neuromuscular vertical talus.

Patients with myelomeningocele have approximately a 5% to 10% risk of vertical talus, far above that of the general population.

Arthrogryposis is associated with an increased risk of vertical talus.

Nail patella syndrome is associated with an increased risk of vertical talus. Sacral agenesis is associated with an increased risk of vertical talus.

 

■Correct Answer:C erebral palsy

1808. (693) Q5-953:

Scoliosis in Marfan syndrome, as compared to idiopathic scoliosis, is characterized by which of the following:

1) Scoliosis curves are more likely to begin in the juvenile period.

3) Brace treatment is more likely to be successful because of the flexibility.

2) There is an increased likelihood of left thoracic curves.

5) C urves are more likely to be stable in adulthood.

4) Patients are less likely to have back pain.

Scoliosis curves are much more likely to begin in the juvenile period than idiopathic scoliosis.

There is no significant difference in the likelihood of left thoracic curves in Marfan syndrome. Brace treatment is less likely to be successful in Marfan syndrome than in idiopathic scoliosis. Marfan patients with scoliosis are more likely to have back pain.

Marfan curves are more likely to progress in adulthood.

 

■Correct Answer:Scoliosis curves are more likely to begin in the juvenile period.

1809. (694) Q5-954:

Which of the following statements is true of demineralized bone matrix:

1) Demineralized bone matrix is weakly osteoinductive.

3) Demineralized bone matrix is not osteoconductive.

2) Demineralized bone matrix is consistent between forms and different sterilization methods.

5) Demineralized bone matrix is strongly osteoinductive.

4) Demineralized bone matrix is osteogenic.

Demineralized bone matrix is weakly osteoinductive.

The term osteogenic refers to direct transmittal of cells capable of making bone. Demineralized bone matrix is not osteogenic.

Demineralized bone matrix varies in efficacy between different forms and different methods of sterilization. The term osteoconduction refers to provision of a favorable scaffold and environment for bone formation. Demineralized bone matrix is osteoconductive.

 

■Correct Answer:Demineralized bone matrix is weakly osteoinductive.

1810. (695) Q5-955:

A 16-year-old boy with type I Ehlers-Danlos syndrome has a spinal curvature that has progressed 18° in the past year. The curve is a double major type with a C obb angle of 60° in each curve. There is no associated kyphosis. The following treatment is recommend:

1) Observation

3) Anterior fusion and instrumentation

2) Bracing

5) Anterior and posterior fusion with instrumentation

4) Posterior fusion and instrumentation

Posterior fusion and instrumentation is the best-documented treatment. Although this form of treatment is followed by an increased incidence of wound healing problems, the problems can be treated.

Observation is not recommended because the curve is highly likely to increase and cause a decrease in pulmonary function.

Bracing has no role in large curves, and it is not known if bracing is successful at all in Ehlers-Danlos syndrome.

Anterior fusion with instrumentation would be difficult with a double curve. Anterior fusion carries an increased risk due to vascular fragility. It is not necessary because there is no increased risk of crankshaft or pseudarthrosis.

There is no particular reason for adding an anterior procedure in this situation in view of the vascular risk. 

■Correct Answer:Posterior fusion and instrumentation

1811. (696) Q5-956:

Scoliosis in osteogenesis imperfecta is characterized by which of the following:

1) Scoliosis which is due primarily to vertebral fractures.

3) Scoliosis is due primarily to associated neurologic problems.

2) Scoliosis is due primarily to ligamentous laxity.

5) Scoliosis rarely impairs quality of life.

4) Scoliosis usually responds to brace treatment.

Scoliosis in osteogenesis imperfecta (OI) is due primarily to ligamentous laxity.

Scoliosis in OI is due primarily to ligamentous laxity, not bony fractures. There is no association between brainstem impression and scoliosis. Scoliosis in OI rarely responds to brace treatment.

Scoliosis, when present in OI, is a major impairment of quality of life. 

■Correct Answer:Scoliosis is due primarily to ligamentous laxity.

1812. (697) Q5-957:

Which of the following is not a specific feature in making the diagnosis of a dystrophic curve in neurofibromatosis 1:

1) Penciling of the ribs

3) Widening of the foramen

2) Scalloping of the vertebrae

5) Vertebral rotation

4) Thinning of the transverse processes

Vertebral rotation is not a specific characteristic of dystrophic curves. Rotation is more pronounced in dystrophic curves than in nondystrophic curves, but it is commonly present in both types of curves.

Penciling of the ribs is one of the features specific for dystrophic curves in neurofibromatosis 1.

Scalloping of the vertebrae anteriorly and posteriorly is characteristic of dystrophic curves in neurofibromatosis 1. Widening of the neural foramen is specific for dystrophic curves in neurofibromatosis 1. Widening of the neural foramen is due to tumorous masses passing through the foramen.

Thinning of the transverse process is a characteristic of dystrophic curves in neurofibromatosis 1. 

■Correct Answer:Vertebral rotation

1813. (698) Q5-958:

The spine in familial dysautonomia is characterized by which of the following:

1) Rare scoliosis

3) Dense bone

2) Flexible scoliosis

5) Spinal stenosis

4) Increased risk of loss of fixation after surgery

There is an increased risk of loss of fixation in familial dysautonomia curves due to decreased bone density and curve rigidity.

Scoliosis is common in patients with familial dysautonomia and affects up to one-half of patients with the disorder. The curves in familial dysautonomia are rigid, leading to limited correction.

The bone density in familial dysautonomia is decreased.

Spinal stenosis is not reported in patients with familial dysautonomia. 

■Correct Answer:Increased risk of loss of fixation after surgery

1814. (699) Q5-959:

Which of the following problems is most common in achondroplasia:

1) Atlantoaxial instability

3) Symptomatic kyphosis

2) Basilar invagination

5) Spondylolisthesis

4) Thoracolumbar stenosis

Symptomatic stenosis of the thoracic and lumbar spine is seen in almost half of all achondroplastic patients, although not all patients require surgery.

Atlantoaxial instability is rare in achondroplasia, although it is not uncommon in other dysplasias. Basilar invagination is not present in achondroplasia.

Kyphosis is often transient in achondroplasia and rarely persists beyond the second year. Kyphosis is rarely symptomatic. Spondylolisthesis is rare in achondroplasia.

 

■Correct Answer:Thoracolumbar stenosis

1815. (700) Q5-960:

A 2-year-old girl with diastrophic dysplasia is brought into the office for an overall examination. A lateral radiograph of the spine shows a kyphosis of 35° from C 3 to C 6. A neurologic exam is normal, although she does have stiff joints. The patient is not yet walking. For management of this kyphosis, recommended treatment includes:

1) Observation

3) Halo traction

2) C ervicothoracic orthosis

5) Anterior and posterior fusion

4) Posterior fusion

Many of these kyphoses will correct spontaneously if the curve does not exceed 50°. In this patient, the inability to walk is most likely due to other skeletal factors.

There is no evidence that orthosis will change the natural history of the disorder.

There is no need for traction given the high chance of spontaneous resolution and the dangers of traction.

Posterior fusion is only indicated if the kyphosis is continually progressive, or if neurologic signs or symptoms develop. Anterior and posterior surgery is only indicated in cases with severe pre-existing neurologic deficit.

 

■Correct Answer:Observation

1816. (701) Q5-962:

A baby born with diastrophic dysplasia today may eventually require all of the following orthopedic procedures during childhood or adulthood except:

1) C orrection of equinus or varus feet

3) Posterior spinal fusion for scoliosis

2) Arthrodesis from the occiput to the atlas or axis

5) Arthroplasty of the knees

4) Arthroplasty of the hips

Patients with diastrophic dysplasia rarely have instability of the upper cervical spine.

Babies with diastrophic dysplasia often have rigid equinovarus feet that require surgery to become plantigrade and wear normal shoes.

A number of patients with diastrophic dysplasia develop progressive scoliosis that requires surgical treatment. Degenerative disease of the hips is common and often requires arthroplasty in early adulthood.

Degenerative disease of the knees is common and often requires arthroplasty in early adulthood. 

■Correct Answer:Arthrodesis from the occiput to the atlas or axis

1817. (702) Q5-963:

A patient with spondyloepiphyseal dysplasia congenita reaches the age of 5 without being able to walk with a walker. She has five beats of clonus in both ankles. Her reflexes are brisk and her toes are upgoing. The most likely problem that accounts for these conditions is:

1) Severe scoliosis of the thoracic spine

3) Lumbar stenosis

2) Foramen magnum stenosis

5) Atlantoaxial instability

4) Thoracolumbar kyphosis

Atlantoaxial instability, sometimes combined with stenosis of the atlas, is a frequent cause of myelopathy in spondyloepiphyseal dysplasia congenita.

Scoliosis does not account for developmental delay or myelopathy.

Foramen magnum stenosis is rare in spondyloepiphyseal dysplasia congenita.

Lumbar stenosis is rare with spondyloepiphyseal dysplasia congenita and would not account for myelopathy. Thoracolumbar kyphosis severe enough to cause myelopathy is rare in spondyloepiphyseal dysplasia congenita condition.

 

■Correct Answer:Atlantoaxial instability

1818. (703) Q5-964:

Scoliosis in cleidocranial dysplasia is frequently associated with which of the following conditions:

1) Syringomyelia

3) Spondylolisthesis

2) Atlantoaxial instability

5) Spinal decompensation

4) Spinal stenosis

Scoliosis with cleidocranial dysplasia (C C D) is frequently associated with syringomyelia.

C ervical instability is rare in C C D. Spondylolisthesis is rare in C C D. Spinal stenosis is rare in C C D.

Spinal decompensation is rare in C C D. 

■Correct Answer:Syringomyelia

1819. (704) Q5-965:

A 3-year-old girl with Larsen syndrome is brought into the office for examination. A spinal radiograph demonstrates a 50°

kyphosis of the cervical spine. Her neurologic examination is normal. Recommended treatment includes:

1) Observation

3) C ervical-thoracic orthosis

2) Halo traction

5) Anterior and posterior fusion

4) Posterior cervical fusion

Posterior cervical fusion has been proven effective in curves of 60°or less, in preventing progression, and allowing correction with anterior growth.

This curve is much more likely to worsen than to spontaneously improve, so preventive surgery is indicated. There is no role for halo traction in this situation.

Bracing has not been proven effective in helping patients with Larsen syndrome.

Addition of anterior fusion is not needed for this degree of curve in a neurologically normal child. 

■Correct Answer:Posterior cervical fusion

1820. (705) Q5-966:

A 10-year-old patient with Hurler syndrome has undergone a bone marrow transplant and is currently medically stable. He has developed a painful thoracolumbar kyphosis that measures 50° with 25% subluxation T12 on L1. Recommended treatment includes which of the following:

1) Exercise program for the trunk extensor muscles

3) Halo traction followed by orthosis

2) Thoracolumbar orthosis

5) Anterior and posterior spinal fusion

4) Posterior spinal fusion

Anterior and posterior fusion will correct the translation, instability, and ensure a solid fusion.

Exercises will not correct the subluxation, which is the cause of the pain. A thoracolumbar orthosis is not corrective or well tolerated.

There is no need for halo traction.

Posterior fusion alone is not enough to control this focal instability if the patient is well enough to tolerate a more involved procedure.

 

■Correct Answer:Anterior and posterior spinal fusion

1821. (706) Q5-967:

Aneurysmal bone cyst of the spine is most common in which of the following regions:

1) C ervical

3) Lower thoracic

2) Upper thoracic

5) Sacral

4) Lumbar

Aneurysmal bone cyst of the spine is most common in the lumbar spine, followed by the cervical spine. Aneurysmal bone cyst of the spine is treated with embolization and/or surgical resection and reconstruction.

 

■Correct Answer:Lumbar

1822. (707) Q5-968:

Aneurysmal bone cyst of the spine is most likely in this age group:

1) First decade

3) Third decade

2) Second decade

5) Fifth decade

4) Fourth decade

The most common age is the second decade; the mean age is 13 years old. 

■Correct Answer:Second decade

1823. (708) Q5-969:

A 14-year-old girl is examined because of a pain in her left flank. The radiographs of the lumbar spine show loss of the pedicle with expansion of the lateral wall of the third lumbar vertebral body. Magnetic resonance imaging shows multiple fluid levels in the vertebral body with no additional areas of involvement. She is neurologically normal. The least invasive, effective treatment is which?

1) Observation

3) Selective arterial embolization

2) Radiation therapy

5) C urettage plus radiation therapy

4) Radical en bloc resection

This patient has an aneurysmal bone cyst of the vertebra. Selective arterial embolization is a minimally invasive treatment that often succeeds in arresting the lesions. Many times it is the only treatment needed. Selective arterial embolization can also be used as part of a strategy to be followed by curettage and reconstruction to decrease operative bleeding.

This lesion will continue to expand and might cause neurologic compromise or mechanical instability. Radiation therapy poses risks of later malignant degeneration. There are other ways of treating this lesion. Radical en bloc resection may unnecessarily injure neurologic structures.

While curettage is often necessary, there is no reason to introduce the risk of radiation therapy. 

■Correct Answer:Selective arterial embolization

1824. (709) Q5-970:

A 15-year-old girl has severe hip pain 3 years after a slipped capital femoral epiphysis that was complicated by avascular necrosis. Recommended treatment is a hip arthrodesis. In response to questions about late effects, after surgery the patient should be told that she is most likely to experience:

1) Low back pain

3) Pain in the contralateral hip

2) Marked limitation of activity

5) Significant continued limp

4) C ontinued severe pain in the ipsilateral hip

Low back pain, followed closely by ipsilateral knee pain, is the most common late effect of hip arthrodesis in young patients. The tolerable pain usually occurs much later but may be treated by conversion to arthroplasty, if needed.

Ipsilateral hip pain should be minimal or absent if the fusion is successful.

Activity following arthrodesis is not significantly limited. Sports and heavy physical activities are feasible. The limp is usually minimal because the loss of hip motion is masked by lumbar motion.

Pain in the contralateral hip is rare and is often minimal after hip arthrodesis. 

■Correct Answer:Low back pain

1825. (710) Q5-971:

Which of the following is an appropriate position for arthrodesis of the hip in a young person:

1) Flexion of 45°

3) Adduction of 0°

2) Abduction of 15° if there is shortening

5) Shortening of at least 3 cm

4) External rotation of 25°

Neutral abduction is important in preventing back pain.

The flexion should be between 25° and 35°.

Any abduction beyond neutral poses increased risk of back pain. External rotation beyond approximately 5° is not needed.

Arthrodesis often produces some shortening; therefore, intentional shortening is not needed. 

■Correct Answer:Adduction of 0°

1826. (711) Q5-972:

A 12-year-old girl is brought into the office for an examination because of hip pain. She is able to bear weight on the involved limb while using crutches for stability. Radiographs reveal a grade III slip of the capital femoral epiphysis. Recommended treatment for this patient is:

1) Skeletal femoral traction in order to improve the position

3) Osteotomy of the femoral neck to improve the alignment

2) Manipulate the hip under anesthesia in order to improve the position of the head

5) In situ fixation

4) Application of a hip spica

In situ fixation provides the best results no matter what the grade of slip. 

■Correct Answer:In situ fixation

1827. (712) Q5-973:

A 9-year-old boy with cerebral palsy has trouble sitting. His mother states that whenever his diapers are changed or his hips are moved, he begins to cry. Radiographs demonstrate high dislocations of both femoral heads. The femoral heads have an ovoid shape and superolateral flattening. Recommended treatment is:

1) Botulinum toxin injected into the adductors

3) Bilateral femoral osteotomies with acetabuloplasty

2) Bilateral open adductor tenotomy

5) Bilateral C olonna arthroplasty

4) Bilateral proximal femoral resection

Bilateral proximal femoral resection is the recommended treatment.

Femoral head dislocations may become painful in cerebral palsy at a much earlier age than in nonspastic individuals. Botulinum toxin or adductor tenotomy will not solve the problem.

Replacing the deformed femoral heads into the acetabulum will not achieve the long-term goal of good hip range of motion.

 

■Correct Answer:Bilateral proximal femoral resection

1828. (713) Q5-974:

A 9-year-old boy is examined due to a closed distal forearm fracture. The radius and ulna are both fractured and translated

100%. After manipulation twice with sedation, the translation cannot be reduced. There is 10-mm shortening of the radius and 5- mm shortening of the ulna. The distal radial angulation on the anteroposterior view is 5° less than normal. The least invasive treatment which would produce acceptable results is:

1) C losed reduction in the operating room under general anesthesia

3) Open reduction and percutaneous pin fixation

2) Open reduction and cast application

5) Acceptance of the reduction and maintenance with a cast

4) Open reduction and plate fixation

The translation and shortening are not problems and the amount of angulation will easily remodel with this fracture. There is nothing to be gained from operative reduction.

 

■Correct Answer:Acceptance of the reduction and maintenance with a cast

1829. (714) Q5-975:

When applying a halo for postoperative immobilization in a skeletally mature teenager, which of the following is the proper torque for the pins:

1) 2 inch-pounds

3) 8 inch-pounds

2) 4 inch-pounds

5) 12 inch-pounds

4) 10 inch-pounds

This patient should be treated like an adult. Eight inch-pounds is the currently recommended torque to provide optimal biomechanical fixation while minimizing pin penetration.

 

■Correct Answer:8 inch-pounds

1830. (715) Q5-976:

A posterior spine fusion with segmental hook fixation from T4-L4 is performed for idiopathic scoliosis in a 15-year-old girl. Somatosensory evoked potential monitoring is normal throughout the procedure. The patient awakens and is unable to move either lower extremity, but she does have some sensation in the lower extremities. Recommended treatment includes:

1) Removal of instrumentation

3) Laminectomy above the conus medullaris

2) Myelogram

5) Full heparinization of the patient

4) Administration of corticosteroids and observation for 6 hours

Spinal cord injury occurs in approximately 1% of patients operated upon for idiopathic scoliosis. In some cases, sensory spinal cord monitoring may be unchanged, especially if the injury preserves the dorsal columns. The instrumentation should be removed as soon as possible in case spinal traction or derotation or implant protrusion is producing effects on the cord or its blood supply.

C orticosteroids should be administered at spinal cord injury doses, but this should not be the only measure. Obtaining a myelogram may delay the removal of instrumentation and should not be the first step. Heparinization has no proven effect.

 

■Correct Answer:Removal of instrumentation

1831. (716) Q5-977:

A 12-year-old boy with achondroplasia has a gradual 40° thoracolumbar kyphosis. He is unable to walk more than two blocks. Magnetic resonance imaging reveals spinal stenosis, and the patient is scheduled to undergo posterior decompression from T12- S1. In addition to this procedure, you recommend:

1) Observation with serial radiographs every 4 months

3) In situ fusion with bone graft

2) Postoperative brace for 6 months

5) Anterior corpectomy and fusion of T12

4) Posterior fusion across the kyphosis with instrumentation

Extensive posterior decompression poses a high risk of postoperative increase in kyphosis because of both the patientâs age and pre-existing kyphosis.

Observation would not be a good idea because the risk is already known to be high.

Neither a brace nor an uninstrumented fusion would prevent the deformity from developing. C orpectomy is not indicated because the kyphosis is not focal.

Posterior instrumented fusion at the time of decompression is indicated.

 

■Correct Answer:Posterior fusion across the kyphosis with instrumentation

1832. (717) Q5-978:

Which of the following is true regarding brace treatment for Scheuermann kyphosis:

1) The Milwaukee brace is not indicated.

3) Bracing is effective in curves over 75°.

2) Permanent improvement is usually obtainable if compliant.

5) The brace should be worn for 1 year after starting brace treatment.

4) Bracing is ineffective in curves having an apex at or above T8.

Brace treatment is effective for Scheuermann kyphosis. Unlike idiopathic scoliosis, permanent improvement of the deformity is the goal.

The Milwaukee brace is often indicated.

Brace treatment is ineffective for curves over 74°. The brace should be worn until skeletal maturity.

 

■Correct Answer:Permanent improvement is usually obtainable if compliant.

1833. (718) Q5-979:

Which of the following statements is true about bone marrow transplantation in mucopolysaccharidoses:

1) Bone marrow transplantation is contraindicated.

3) Bone marrow transplantation reverses the orthopedic manifestations.

2) Bone marrow transplantation does not affect the orthopedic problems.

5) Bone marrow transplantation should be deferred until skeletal maturity.

4) Graft-versus-host disease is rare.

Bone marrow transplantation is effective in minimizing the deposition of mucopolysaccharides in solid organs. Transplantation should be done early to prevent organ damage. Because the lysosomal enzyme does not cross the cell membrane of osteocartilaginous cells, it does not affect the orthopedic aspects. The risk of graft-versus-host disease is high but may be treated in most cases. Survival rate is 61% at 2 years for Hurler disease, which is otherwise fatal before maturity.

 

■Correct Answer:Bone marrow transplantation does not affect the orthopedic problems.

1834. (796) Q5-1057:

A 7-year-old boy is brought in for an examination due to back pain. He has limited forward bending. Neurologic examination is normal. Radiographs reveal a uniform flattening of the third lumbar vertebra to 10% of its normal height. His temperature is

37.1° C and his white blood count is 11,000. The erythrocyte sedimentation rate is 18. The most likely diagnosis is:

1) Osteogenesis imperfecta

3) Tuberculosis

2) Eosinophilic granuloma

5) C ompression fracture

4) Bacterial infection

Eosinophilic granuloma often produces complete flattening of a single vertebral body in the absence of trauma or neurologic deficit.

Osteogenesis imperfecta produces a more uniform flattening of the vertebrae but not by this degree.

Tuberculosis rarely produces this much flattening of a single vertebra. The erythrocyte sedimentation rate is elevated in this condition.

Bacterial infection rarely produces this much flattening of a single vertebral body without associated disk changes. The lab studies should suggest an inflammatory process.

C ompression fracture produces less complete flattening of the vertebral bodies. 

■Correct Answer:Eosinophilic granuloma

1835. (797) Q5-1058:

A 12-year-old patient with osteogenic sarcoma metastatic to the spine is noted to have new onset of weakness of both lower extremities. Magnetic resonance imaging shows a mass expanding posteriorly and encroaching on the spinal cord. The recommended initial step is:

1) Radiation therapy and steroids

3) Surgical resection

2) Increasing the dose of chemotherapy

5) Observation only

4) Steroids and observation alone

Radiation therapy combined with steroids should be tried first to try to halt progression of the tumor. Unfortunately, the prognosis for this child is extremely poor.

Increasing the dose of chemotherapy is not likely to work because the metastasis has already progressed despite initial treatment.

Surgical resection must be tried if radiation does not produce improvement. Steroids are an adjunct to treatment but not sufficient alone.

The patient is likely to have progressive paraparesis and loss of bowel function. In order to improve the quality of life remaining, surgical resection should be offered to the patient.

 

■Correct Answer:Radiation therapy and steroids

1836. (798) Q5-1059:

The primary purpose of osteotomy in the closure of classic exstrophy of the bladder is to:

1) Decrease the tension on the closure of the abdominal wall and bladder

3) Prevent degenerative disease of the hip

2) Decrease the strain on the sacroiliac joints

5) Allow reconstruction of a normal symphysis pubis

4) Normalize the gait

The primary purpose of osteotomy is to improve the chance of a successful urologic reconstruction. This is achieved by decreasing the tension on the closure of the abdominal wall and bladder.

The strain on the sacroiliac joints has not been measured with or without closure; this is not a primary purpose of the osteotomy.

There is no conclusive evidence that the hips are at increased risk of degenerative disease in patients with exstrophy, or that osteotomy will alter the condition.

In patients with exstrophy, the gait progressively normalizes over time. It is not possible to reconstruct a normal symphysis pubis in exstrophy.

 

■Correct Answer:Decrease the tension on the closure of the abdominal wall and bladder

1837. (799) Q5-1060:

Which of the following is not a common finding in cloacal exstrophy:

1) Omphalocele

3) Hydrocephalus

2) Spinal dysrhaphism

5) Dislocation of the hip(s)

4) Dysplasia of the sacroiliac joints

Hydrocephalus is rare because most patients have lipomeningocele, not myelomeningocele.

Omphalocele is common in cloacal exstrophy.

Most patients with cloacal exstrophy have a lipomeningocele that is a form of spinal dysrhaphism. Many patients have malformations of the sacroiliac joints.

Approximately 25% of patients have dislocations of at least one hip. 

■Correct Answer:Hydrocephalus

1838. (800) Q5-1061:

The thickness of a flexible intramedullary nail used in pediatric femur fractures should be which of the following percentages of the diameter of the femoral isthmus:

1) 10%

3) 40%

2) 25%

5) 75%

4) 50%

It is recommended that the intramedullary nail be 40% of the diameter of the femoral isthmus. 

■Correct Answer:40%

1839. (801) Q5-1062:

An infant is born with fibular hemimelia and has 20% shortening of the involved below-knee segment. Four rays are present on the foot, and the ankle is in slight valgus. Limb lengthening is likely to be superior to Syme disarticulation in which of the following parameters:

1) Pain

3) Psychological acceptance

2) Function

5) Prosthetic costs

4) Number of procedures

The cost of prosthetics is greater in the disarticulation group.

Pain is greater in the lengthened group.

Function is equal to or better in the group who had disarticulation. Psychological acceptance is greater in the disarticulation group.

The lengthened group requires more than twice the number of procedures. 

■Correct Answer:Prosthetic costs

1840. (802) Q5-1063:

Which of the following is the best discriminator for risk of nonaccidental (child abuse) injury in young children with femoral shaft fractures:

1) Pattern of the fracture

3) Socioeconomic class

2) Level of the fracture on the femur

5) C oexisting disability in the child

4) Ability to walk

Nonaccidental injury was a factor in 29% of patients who were unable to walk vs 3% for patients who were able to walk.

The fracture pattern and level of fracture do not help determine nonaccidental injury.

Socioeconomic class is not the best discriminator and, generally, should not be factored into the decision process. C oexisting disability is not a significant discriminator.

 

■Correct Answer:Ability to walk

1841. (803) Q5-1064:

A 12-year-old boy with hemophilia A has a painless mass in his thigh. The femur is eroded anterolaterally and there is a large overlying soft tissue mass. Magnetic resonance imaging shows a 5 cm x 7 cm mass arising from the bone. The most likely diagnosis is:

1) Telangiectatic osteosarcoma

3) Infection

2) Aneurysmal bone cyst

5) Lymphangioma

4) Pseudotumor

A pseudotumor is a hemophilic subperiosteal hematoma. The pseudotumor expands by repeated bleeds and increasing osmotic pressure.

There was no periosteal reaction or intralesional calcification.

The bone wall itself is not expanded as in aneurysmal bone cyst.

There is nothing in the physical examination or patient history to point to infection. 

■Correct Answer:Pseudotumor

1842. (804) Q5-1065:

In classic hemophilia, a natural factor-VIII level of less than what percentage will lead to severe bleeding and complications:

1) 50%

3) 15%

2) 25%

5) 5%

4) 10%

A surprisingly small amount of circulating factor-VIII (approximately 5%) is necessary to protect a patient from severe bleeding complications.

 

■Correct Answer:5%

1843. (805) Q5-1066:

A 1-week-old female infant with arthrogryposis multiplex congenital has hips that are stiff in flexion and abduction, and her knees have a range of flexion from 20° to 40°. In addition, her right thigh has become swollen and tender. The most likely cause of this latter problem is:

1) Osteomyelitis of the femur

3) Dislocation of the hip

2) Septic arthritis of the hip

5) Fracture of the femur

4) Deep vein thrombosis

Fracture is common in this condition because of osteopenia and the stress concentration due to joint stiffness.

Osteomyelitis is uncommon in the diaphysis and much less common in this scenario than fracture. Septic arthritis of the hip is uncommon in this disease.

Dislocation of the hip would not cause pain and swelling in this setting. Deep vein thrombosis is uncommon at this age.

 

■Correct Answer:Fracture of the femur

1844. (806) Q5-1067:

Which of the following is a true statement regarding the results of surgery for a contracted joint in arthrogryposis:

1) The joint range of motion can easily be doubled.

3) The beginning and end of the range may change, but the total amount of motion remains about the same.

2) The joint cannot be changed.

5) There is not an indication for such surgery.

4) The joint usually becomes stiffer.

The beginning and end of the range may change, but the total amount of motion remains about the same.

The amount of the range cannot be significantly increased. The endpoint can change, but not the amount of the range. The joint does not usually become stiffer.

There may be an indication for surgery to put the joints in a functional position.

 

■Correct Answer:The beginning and end of the range may change, but the total amount of motion remains about the same.

1845. (807) Q5-1068:

Which of the following statements is true regarding scoliosis in cerebral palsy (C P):

1) Scoliosis is most common in hemiplegic C P because of muscle imbalance.

3) Scoliotic curves over 50° are likely to worsen even if the children are mature.

2) A thoracolumbosacral orthosis is usually successful in halting curve progression.

5) The surgical complication rate is lower in C P than idiopathic scoliosis.

4) Surgery for scoliosis will prolong life expectancy.

C urves greater than 50° usually progress.

Scoliosis is most common in totally involved C P patients. Scoliosis is rare in patients with hemiplegia. Braces rarely halt curves in C P.

Surgery has no proven effect on prolonging life expectancy. The complication rate is higher in C P.

 

■Correct Answer:Scoliotic curves over 50° are likely to worsen even if the children are mature.

1846. (808) Q5-1069:

A 12-year-old girl is referred because of a positive school scoliosis screen. She has a curve of 16° from T5 to T12, convex to the right. She incidentally also complains of mild back pain over the region of the curve several times per month. Neurologic examination is normal. Recommended treatment includes:

1) Magnetic resonance imaging

3) Treatment with a thoracolumbosacral orthosis

2) Technetium bone scintigraphy with SPEC T

5) Home exercises and re-examination in follow-up

4) C omputed tomography of the thoracic spine

Home exercises and re-examination in follow-up is the most appropriate treatment in view of lack of any worrisome features. If this child had severe pain or significant night pain, then further imaging studies would be warranted.

The magnetic resonance imaging is not indicated in this situation. The bone scan has a low likelihood of being positive.

Bracing is not indicated for the curve or the pain.

C omputer tomography is unlikely to demonstrate any pathology. 

■Correct Answer:Home exercises and re-examination in follow-up

1847. (809) Q5-1070:

A 10-year-old boy undergoes biopsy of a spinal cord tumor through a laminectomy of C 7-T2. The most likely complication of this procedure is:

1) Progressive cervicothoracic kyphosis

3) Progressive scoliosis

2) Progressive cervicothoracic lordosis

5) Progressive C 7 radiculopathy

4) Degenerative disk disease

The removal of posterior restraints in the young and growing flexible spine usually leads to cervicothoracic kyphosis. 

■Correct Answer:Progressive cervicothoracic kyphosis

1848. (810) Q5-1071:

A patient with neurofibromatosis and a 55° scoliosis may be treated with a posterior fusion and instrumentation alone in which of the following situations:

1) He has a kyphosis of 75°.

3) He has a prior pseudarthrosis.

2) He is also undergoing multilevel laminectomy for tumor.

5) He has a bone age of 9.

4) He has a kyphosis of 35°.

He has a kyphosis of 35°.

This degree of kyphosis increases the risk of pseudarthrosis with posterior fusion alone. The laminectomy increases the risk of pseudarthrosis.

Anterior fusion should be added when there is a history of pseudarthrosis.

A 9-year-old boy has a high risk of crankshift phenomenon with posterior fusion alone. 

■Correct Answer:He has a kyphosis of 35°.

1849. (811) Q5-1072:

Which of the following statements is true regarding school screening for scoliosis:

1) The American Academy of Orthopaedic Surgeons (AAOS) no longer recommends it.

3) The AAOS recommends screening boys and girls at age 9.

2) The AAOS recommends screening each year.

5) The AAOS recommends screening only boys at age 16.

4) The AAOS recommends screening boys and girls at age 11.

All children should be screened at age 11.

The AAOS still recommends school screening for scoliosis.

The AAOS recognizes that yearly screening is counterproductive. Screening at age 9 is too early..

Screening at age 16 is too late.

 

■Correct Answer:The AAOS recommends screening boys and girls at age 11.

1850. (812) Q5-1073:

Treatment of a patient with lumbar level myelomeningocele who has a vertical talus should consist of:

1) Observation only

3) Achilles tenotomy

2) Talectomy

5) Triple arthrodesis in a reduced position

4) Open reduction of the vertical talus

Open reduction of the vertical talus will most likely prevent problems.

With observation only, the patient is likely to stand or walk and develop pressure problems. Talectomy will not produce the most usable foot.

Achilles tenotomy will not produce significant correction by itself. Triple arthrodesis will concentrate stress and lead to ulcers.

 

■Correct Answer:Open reduction of the vertical talus