ORTHO MCQS 011 FREE BANK 01

 

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

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

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

4. When there is preexisting radiocapitellar arthritis

5. 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 long- term 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

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

5. 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

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

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

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

5. 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.

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