Question #: 1Which of the following structures represents a site of compression of the median nerve atthe elbow?1- Ligament of Struthers2- Intermuscular septum3- Osborne’s ligament4- Fascia of the flexor carpi ulnaris5- Flexor-pronator aponeurosis in the forearmPreferred Response: 1Recommended Reading(s):Elhassan B, Steinmann SP: Entrapment neuropathy of the ulnar nerve. J Am Acad OrthopSurg 2007;15:672-681.Bainbridge C: Cubital tunnel syndrome, in Berger RA, Weiss APC (eds): Hand Surgery.Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 887-896.Question #: 2In infants with congenital muscular torticollis, passive stretching exercises should include1- lateral head tilt with no rotation.2- lateral head tilt and chin rotation toward the affected side.3- lateral head tilt and chin rotation away from the affected side.4- lateral head tilt toward the affected side and chin rotation away from the affected side.5- lateral head tilt away from the affected side and chin rotation toward the affected side.Preferred Response: 5Recommended Reading(s):Coventry MB, Harris LE: Congenital muscular torticollis in infancy: Some observationsregarding treatment. J Bone Joint Surg Am 1959;41:815-822.Loder RT: The cervical spine, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’sPediatric Orthopaedics, ed 6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, pp871-919.
Question #: 3What is the best way to prevent failure due to cut-out after fixation of an unstable four-partintertrochanteric fracture with a compression hip screw device?1- Use of an extra large screw and deep thread design2- Use of a supplemental anti-rotation screw3- A Dimon-Hughston medialization to allow load sharing4- Screw tip placement in the inferior hemisphere of the femoral head5- Screw tip placement with a tip-apex distance of less than 25 mmPreferred Response: 5Recommended Reading(s):Baumgaertner MR, Curtin SL, Lindskog DM, et al: The value of the tip-apex distance inpredicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am1995;77:1058-1064.Kyle RF, Gustilo RB, Premer RF: Analysis of six hundred and twenty-two intertrochanterichip fractures. J Bone Joint Surg Am 1979;61:216-221.Koval KJ, Zuckerman JD: Intertrochanteric fractures, in Bucholz RW, Heckman JD (eds):Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams &Wilkins, 2001, pp 1635-1663.Question #: 4Cuboidal cells that line along layers of immature osteoid to synthesize bone matrix and arenot directly inhibited by bisphosphonates are best described as1- osteoblasts.2- osteocytes.3- osteoclasts.4- histiocytes.5- megakarocytes.Preferred Response: 1Recommended Reading(s):Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 189-196.Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 129-159.
Figure 5a Figure 5bQuestion #: 5Figures 5a and 5b show the radiographs of a 64-year-old man who underwent primary totalhip arthroplasty 3 months ago for degenerative arthritis. He has now had four dislocations.How should his instability be managed?1- Acetabular revision2- Femoral head revision3- Femoral head and stem revision4- Abduction orthosis for 6 weeks5- Placement of a constrained acetabular linerPreferred Response: 1Recommended Reading(s):Dorr LD, Wan Z: Causes of and treatment protocol for instability of total hip replacement.Clin Orthop Relat Res 1998;355:144-151.Morrey BF: Instability after total hip arthroplasty. Orthop Clin North Am 1992;23:237-248.
Figure 6Question #: 6A 44-year-old woman undergoes a CT myelogram for evaluation of persistent low backpain and bilateral lower extremity paresthesias. Axial imaging through the vertebral body ofL4 is shown in Figure 6. Further management should include which of the following?1- Nuclear bone scan2- Serum immunoelectrophoresis3- Biopsy of lytic lesions of the vertebral body4- Continued observation of the patient’s clinical course5- Serum thyroid studiesPreferred Response: 4Recommended Reading(s):Ross JS, Bell GR: Spine imaging, in Herkowitz HN, Garfin SR, Eismont FJ, et al (eds):Rothman-Simeone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, pp 187-217.
Question #: 7Which of the following physical examination findings is most helpful to diagnose a fixedposterior shoulder dislocation?1- Apprehension sign2- Sulcus sign3- Jerk test4- Jobe relocation test5- Lack of external rotationPreferred Response: 5Recommended Reading(s):Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 301-311.Ivkovic A, Boric I, Cicak N: One-stage operation for locked bilateral posterior dislocation ofthe shoulder. J Bone Joint Surg Br 2007;89:825-828.
Figure 8Question #: 8Figure 8 shows the radiograph of a 14-year-old girl with sickle cell disease and mild left hipdiscomfort. What is the radiographic natural history of this disease process?1- Initial loss of sphericity of the femoral head with later restoration of sphericity2- Maintenance of sphericity of the femoral head3- Coxa magna without loss of sphericity of the femoral head4- Progressive loss of sphericity of the femoral head5- Protrusio acetabuliPreferred Response: 4Recommended Reading(s):Hernigou P, Habibi A, Bachir D, et al: The natural history of asymptomatic osteonecrosis ofthe femoral head in adults with sickle cell disease. J Bone Joint Surg Am 2006;88:2565-2572.Aguilar C, Vichinsky E, Neumayr L: Bone and joint disease in sickle cell disease. HematolOncol Clin North Am 2005;19:929-941.
Question #: 9In a reverse shoulder arthroplasty, placement of the glenoid component in a high positionon the native glenoid places the patient at risk of1- an acromial fracture.2- scapular notching.3- postoperative instability.4- restricted external rotation.5- early loss of glenoid fixation.Preferred Response: 2Recommended Reading(s):Simovitch RW, Zumstein MA, Lohri E, et al: Predictors of scapular notching in patientsmanaged with the Delta III reverse total shoulder replacement. J Bone Joint Surg Am2007;89:588-600.Gutiérrez S, Levy JC, Lee WE III, et al: Center of rotation affects abduction range of motionof reverse shoulder arthroplasty. Clin Orthop Relat Res 2007;458:78-82.Question #: 10Achondroplasia is associated with which of the following mutations?1- Insulin-like growth factor-1 receptor2- Insulin-like growth factor-13- Insulin-like growth factor-24- Fibroblast growth factor receptor-35- Fibroblast growth factorPreferred Response: 4Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 3-23.Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 773-783.
Figure 11a Figure 11bQuestion #: 11An otherwise healthy 20-year-old dancer has a 1-year history of foot and ankle pain. Shedescribes her great toe locking with active range of motion. Examination reveals triggeringof the great toe but no tenderness at the level of the first metatarsal head. Palpablecrepitus is present along the medial ankle with active range of motion of the great toe.Radiographs are unremarkable. MRI scans are shown in Figures 11a and 11b. What isthe most likely diagnosis?1- Tarsal tunnel syndrome2- Medial sesamoid stress fracture3- Flexor hallucis longus tendon tear at the metatarsophalangeal joint4- Flexor hallucis longus tendon tear at the posteromedial ankle5- Chronic deep space infection of the posterior anklePreferred Response: 4Recommended Reading(s):Hamilton WG, Hamilton LH: Foot and ankle injuries in dancers, in Coughlin MJ, Mann RA(eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1225-1256.Sammarco GJ, Cooper PS: Flexor hallucis longus tendon injury in dancers andnondancers. Foot Ankle Int 1998;9:356-362.
Question #: 12A 15-year-old boy has diffuse back pain, particularly in the morning. Examination revealsan increased kyphosis in the thoracic spine. Spinal mobility in flexion and extension islimited. He has decreased chest excursion with inspiration. The FABER test is positive.Standing radiographs show absence of the anterior concavity of the vertebral body and akyphosis of 62° from T-3 to T-12. What is the most likely diagnosis?1- Pott disease2- Reiter syndrome3- Scheuermann’s kyphosis4- Ankylosing spondylitis5- Diffuse idiopathic skeletal hyperostosisPreferred Response: 4Recommended Reading(s):Azouz EM, Dufy CM: Juvenile spondyloarthropathies: Clinical manifestations and medicalimaging. Skeletal Radiol 1995;24:399-408.Gensler L, Davis JC Jr: Recognition and treatment of juvenile-onset spondyloarthritis. CurrOpin Rheumatol 2006;18:507-511.Kredich D, Patrone NA: Pediatric spondyloarthropathies. Clin Orthop Relat Res1990;259:18-22.Question #: 13Which of the following represents a contraindication to hyperbaric oxygen therapy?1- Intubation2- Osteomyelitis3- Insulin pump4- Thermal burns5- Thoracostomy tubePreferred Response: 3Recommended Reading(s):Greensmith JE: Hyperbaric oxygen therapy in extremity trauma. J Am Acad Orthop Surg2004;12:376-384.Kindwall EP: Contraindications and side effects to hyperbaric oxygen treatment, in KindwallEP, Whelan HT (eds): Hyperbaric medicine practice, ed 2. Flagstaff, AZ, Best PublishingCompany, 1999, pp 83-98.Buettner MF, Wolkenhauer D: Hyperbaric oxygen therapy in the treatment of open fracturesand crush injuries. Emerg Med Clin North Am 2007;25:177-188.
Question #: 14A 42-year-old woman injured her dominant middle finger in a car door. Examinationreveals a partial nail avulsion with nail bed lacerations. No fractures are seen onradiographs. Without compromising functional and cosmetic results, what is the mostexpeditious treatment?1- Placement of 6-0 chromic suture2- Placement of 6-0 fast-absorbing gut suture3- Application of a saline gauze dressing4- Application of a non-adherent dressing5- Application of 2-octylcyanoacrylatePreferred Response: 5Recommended Reading(s):Strauss EJ, Weil WM, Jordan C, et al: A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am 2008;33:250-253.Richards AM, Chrick A, Cole RP: A novel method of securing the nail following nail bedrepair. Plast Reconstr Surg 1999;103:1983-1985.
Figure 15a Figure 15bQuestion #: 15Figures 15a and 15b show the bone scan and CT scan of a 20-year-old collegiate footballplayer who has persistent low back pain without neurologic symptoms. What physicalexamination maneuver would you expect to be abnormal?1- Babinski test2- Femoral stretch test3- Straight leg raise4- Contralateral straight leg raise5- Single-limb standing lumbar extensionPreferred Response: 5Recommended Reading(s):Hu SS, Tribus CB, Diab M, et al: Spondylolisthesis and spondylolysis. J Bone Joint SurgAm 2008;90:656-671.Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont IL,American Academy of Orthopaedic Surgeons, 2004, pp 19-28.
Question #: 16During surgical reduction of a congenitally dislocated hip through an anteromedialapproach, what structure is most at risk when performing the psoas tenotomy?1- Femoral vein2- Femoral artery3- Lateral circumflex artery4- Medial circumflex artery5- Obturator arteryPreferred Response: 4Recommended Reading(s):Morrissy RT, Weinstein SL: Atlas of Pediatric Orthopaedic Surgery, ed 4. Philadelphia, PA,Lippincott Williams & Wilkins, 2006, pp 271-277.Weinstein SL, Ponseti IV: Congenital dislocation of the hip. J Bone Joint Surg Am1979;61:119-124.
Question #: 17The 20-year-old man sustains the fracture seen in Figures 17a through 17d. Whattechnical aspect of the surgical treatment is most important for the patient’s outcome?1- Restoring fibular length2- Achieving fibular compression3- Reduction of the posterior malleolus4- Reduction of the anteromedial impacted fragments5- Fixing the distal tibiofibular syndesmosisPreferred Response: 4Recommended Reading(s):Marsh JL, Saltzman CL: Ankle fractures, in Rockwood and Green’s Fractures in Adults, ed6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, pp 2147-2247.McConnell T, Tornetta P III: Marginal plafond impaction in association with supination-adduction ankle fractures: A report of eight cases. J Orthop Trauma 2001;15:447-449.Question #: 18A unicompartment knee arthroplasty is contraindicated in which of the following clinicalscenarios?1- Inflammatory arthritis2- Anteromedial osteoarthritis3- Lateral compartment osteoarthritis4- Medial femoral condyle osteonecrosis5- Advanced agePreferred Response: 1Recommended Reading(s):Marmor L: Unicompartment arthroplasty for osteonecrosis of the knee joint. Clin OrthopRelat Res 1993;294:247-253.Parrette S, Argenson JN, Dumas J, et al: Unicompartmental knee arthroplasty for avascularnecrosis. Clin Orthop Relat Res 2007;464:37-42.Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 457-471.
Question #: 19Decreased stature and bone density due to lead poisoning is thought to be caused byinterference in the signaling of which of the following growth factors?1- BMP22- RANKL3- PTHrP/TGF-beta4- Fibroblast growth factor 3 (FGF3)5- Insulin-like growth factor (IGF)Preferred Response: 3Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 115-127.Campbell JR, Rosier RN, Novotny L, et al: The association between environmental leadexposure and bone density in children. Environ Health Perspect 2004;112:1200-1203.Question #: 20Which of the following is considered the strongest predictor of disability in adult patientswith scoliosis?1- Concomitant diagnosis of osteoporosis2- Presence of a vacuum disk sign at two or more lumbar levels3- Sagittal plane imbalance and inability to obtain neutral upright stance4- The number of spinal levels affected by disk degeneration in the lumbar spine5- Coronal plane Cobb angle measurement of greater than 30° in the lumbar spinePreferred Response: 3Recommended Reading(s):Schwab F, Farcy JP, Bridwell K, et al: A clinical impact classification of scoliosis in theadult. Spine 2006;31:2109-2114.Glassman SD, Bridwell K, Dimar JR, et al: The impact of positive sagittal balance in adultspinal deformity. Spine 2005;30:2024-2029.Kim YJ, Bridwell KH, Lenke LG, et al: Sagittal thoracic decompensation following long adultlumbar spinal instrumentation and fusion to L5 or S1: Causes, prevalence, and risk factoranalysis. Spine 2006;31:2359-2366.
Figure 21a Figure 21bQuestion #: 21A 9-year-old boy is seen for bilateral thigh pain. He has a history of precocious puberty.Examination reveals multiple café-au-lait spots. AP pelvis and frog lateral hip radiographsare shown in Figures 21a and 21b. His condition is linked to an abnormality in1- G protein function.2- osteoclastic function.3- vitamin D metabolism.4- sulfate transporter gene.5- type I collagen formation.Preferred Response: 1Recommended Reading(s):DiCaprio MR, Enneking WF: Fibrous dysplasia: Pathophysiology, evaluation, andtreatment. J Bone Joint Surg Am 2005;87:1848-1864.Parekh SG, Donthineni-Rao R, Ricchetti E, et al: Fibrous dysplasia. J Am Acad OrthopSurg 2004;12:305-313.
Question #: 22What is the incidence of full-thickness rotator cuff tears in patients undergoing arthroplastyfor the treatment of primary glenohumeral osteoarthritis?1- 1% to 2%2- 5% to 10%3- 10% to 15%4- 15% to 20%5- 20% to 25%Preferred Response: 2Recommended Reading(s):Edwards TB, Boulahia A, Kempf JF, et al: The influence of rotator cuff disease on theresults of shoulder arthroplasty for primary osteoarthritis: Results of a multicenter study. JBone Joint Surg Am 2002;84:2240-2248.Norris TR, Iannotti JP: Functional outcome after shoulder arthroplasty for primaryosteoarthritis: A multicenter study. J Shoulder Elbow Surg 2002;11:130-135.Question #: 23In children with Morquio syndrome, atlantoaxial instability is most commonly the result of1- hypoplasia of the odontoid.2- failure of fusion of the base of the odontoid.3- incompetence of the transverse ligament.4- generalized joint hypermobility.5- erosion of the odontoid base due to synovial hypertrophy.Preferred Response: 1Recommended Reading(s):Copley LA, Dormans JP: Cervical spine disorders in infants and children. J Am AcadOrthop Surg 1998;6:204-214.Stevens JM, Kendall BE, Crockard HA: The odontoid process in Morquio-Brailsford’sdisease: The effects of occipitocervical fusion. J Bone Joint Surg Br 1991;73:851-858.
Question #: 24A 51-year-old woman has had left hand numbness for the past 2 years. Examinationreveals decreased sensation over the fifth metacarpal region and little finger, both palmarand dorsal. There is no loss of abduction/adduction strength. Brace treatment has failed toprovide relief, and neurodiagnostic studies reveal ulnar nerve compression with increasedlatency. The next step in treatment is ulnar nerve decompression at the1- wrist only.2- wrist and the elbow without transposition.3- wrist and the elbow with anterior submuscular transposition.4- elbow only without transposition.5- elbow only with anterior submuscular transposition.Preferred Response: 4Recommended Reading(s):Zlowodzki M, Chan S, Bhandari M, et al: Anterior transposition compared with simpledecompression for treatment of cubital tunnel syndrome: A meta-analysis of randomized,controlled trials. J Bone Joint Surg Am 2007;89:2591-2598.Bartels RH, Verhagen WI, van der Wilt GJ, et al: Prospective randomized controlled studycomparing simple decompression versus anterior subcutaneous transposition for idiopathicneuropathy of the ulnar nerve at the elbow: Part 1. Neurosurgery 2005;56:522-530.Nabhan A, Ahlhelm F, Kelm J, et al: Simple decompression or subcutaneous anteriortransposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg Br 2005;30:521-524.Question #: 25During the Henry (volar) approach for a junction mid and upper third diaphyseal radial shaftfracture, what nerve is most at risk for injury?1- Ulnar2- Radial3- Median4- Anterior interosseous5- Posterior interosseousPreferred Response: 5Recommended Reading(s):Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics. Philadelphia, PA, LippincottWilliams & Wilkins, 1984, pp 58-63.Martini FH, Timmons MJ, Tallitsch RB: Human Anatomy, ed 5. San Francisco, CA,Pearson/Benjamin Cummings, 2006, pp 197-199.
Question #: 26What is the most common reason for failure of anterior cruciate ligament reconstruction?1- Malposition of the bone tunnels2- Medial meniscus deficiency3- Lateral meniscus deficiency4- Improper graft selection5- Articular surface damagePreferred Response: 1Recommended Reading(s):Battaglia TC, Miller MD: Management of bony deficiency in revision anterior cruciateligament reconstruction using allograft bone dowels: Surgical technique. Arthroscopy2005;21:767.Grossman MG, ElAttrache NS, Shields CL, et al: Revision anterior cruciate ligamentreconstruction: Three- to nine-year follow-up. Arthroscopy 2005;21:418-423.
Figure 27a Figure 27bQuestion #: 27A 75-year-old woman has a slow growing mass in her thigh. She reports difficulty walkingbecause of the increasing size of the mass. Chest imaging shows no evidence ofmetastatic disease. A radiograph and a T1-weighted MRI scan are shown in Figures 27aand 27b. What is the next step in management?1- Biopsy2- Surgical excision3- Preoperative radiation therapy4- Preoperative chemotherapy5- Treatment with pain medication, physical therapy, and follow-up in 12 monthsPreferred Response: 2Recommended Reading(s):Schwartz HS (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont,IL, American Academy of Orthopaedic Surgeons, 2007, pp 277-287.Dalal KM, Antonescu CR, Singer S: Diagnosis and management of lipomatous tumors. JSurg Oncol 2008;97:298-313.
Question #: 28A patient who underwent intramedullary nailing of a femoral shaft fracture 2 weeks ago nowreports hip pain that radiates to the knee. What is the next most appropriate step inmanagement?1- Reassure the patient that the pain will improve and order physical therapy.2- Review the radiographic report from the time of injury.3- Obtain an AP and lateral view of the hip.4- Obtain an MRI of the lumbar spine.5- Obtain lumbar spine radiographs.Preferred Response: 3Recommended Reading(s):Tornetta P III, Kain MS, Creevy WR: Diagnosis of femoral neck fractures in patients with afemoral shaft fracture: Improvement with a standard protocol. J Bone Joint Surg Am2007;89:39-43.Daffner RH, Riemer BL, Butterfield SL: Ipsilateral femoral neck and shaft fractures: Anoverlooked association. Skeletal Radiol 1991;20:251-254.
Question #: 29A 2½-year-old boy is examined for flat feet. Examination reveals bilateral flat feet, with theleft side affected more than the right. The arch on his right foot is restored when he standson his toes or is sitting. The left foot remains flat when standing on his toes or sitting. AP,lateral, and plantar flexion lateral radiographs of the left foot are shown in Figures 29athrough 29c. Treatment of the left foot should consist of1- triple arthrodesis.2- serial casting followed by application of a foot abduction orthosis.3- a supramalleolar orthosis.4- surgical correction of the midfoot and heel cord lengthening.5- talectomy.Preferred Response: 4Recommended Reading(s):Sullivan JA: Pediatric flatfoot: Evaluation and management. J Am Acad Orthop Surg1999;7:44-53.Drennan JC: Congenital vertical talus. Instr Course Lect 1996;45:315-322.
Figure 30Question #: 30What anatomic structure is at the tip of the arrow in Figure 30?1- Anterior sacral artery2- S1 nerve root3- L5 nerve root4- Iliac vein5- Sympathetic chainPreferred Response: 3Recommended Reading(s):Louis R: Fusion of the lumbar and sacral spine by internal fixation with screw plates. ClinOrthop Relat Res 1986;203:18-33.Aylwin A, Saifuddin A, Tucker S: L5 radiculopathy due to sacral stress fracture. SkeletalRadiol 2003;32:590-593.
Question #: 31A 48-year-old woman fell onto her outstretched arm 8 weeks ago. Radiographs at the timeof injury revealed a comminuted radial head fracture and no dislocation. She was initiallytreated with early mobilization. Examination reveals no medial-sided tenderness orbruising and no wrist pain. She has a persistent block to supination and extension. CTscans are shown in Figures 31a through 31c. Treatment at this time should consist of1- radial head arthroplasty.2- resection of the radial head.3- open reduction and internal fixation of the radial head.4- manipulation under anesthesia with an intra-articular steroid injection.5- arthroscopic debridement of the elbow.Preferred Response: 2Recommended Reading(s):Herbertsson P, Josefsson PO, Hasserius R, et al: Uncomplicated Mason type-II and IIIfractures of the radial head and neck in adults: A long-term follow-up study. J Bone JointSurg Am 2004;86:569-574.Jackson JD, Steinmann SP: Radial head fractures. Hand Clin 2007;23:185-193.
Figure 32a Figure 32bQuestion #: 32A 45-year-old man reports a 6-month history of lateral foot pain. Radiographs are shown inFigures 32a and 32b. What is the most appropriate orthotic device for this patient?1- Solid ankle cushioned heel2- Three-quarter length rigid insole with medial hindfoot and forefoot posting3- Full-length rigid insole with medial forefoot posting4- Full-length semi-rigid insole with medial hindfoot and forefoot posting5- Full-length semi-rigid insole with a depression for the first ray and a lateral wedgePreferred Response: 5Recommended Reading(s):Manoli A II, Graham B: The subtle cavus foot, “the underpronator.” Foot Ankle Int2005;26:256-263.Janisse DJ, Janisse E: Shoe modification and the use of orthoses in the treatment of footand ankle pathology. J Am Acad Orthop Surg 2008;16:152-158.
Figure 33Question #: 33Figure 33 shows the radiograph of an 84-year-old woman who is seen in the emergencydepartment with new onset severe right groin pain and inability to bear weight. She doesnot recall a fall but uses a walker and frequently stumbles. Laboratory studies, including aCBC, erythrocyte sedimentation rate, and C-reactive protein, are all normal. What is themost likely diagnosis?1- Septic total hip2- Metastasis to pelvis3- Insufficiency fracture of the ramus4- Primary bony malignancy5- Loose acetabular componentPreferred Response: 3Recommended Reading(s):Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology andBiomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy ofOrthopaedic Surgeons, 2000, pp 289-306.Vanderschot P: Treatment options of pelvic and acetabular fractures in patients withosteoporotic bone. Injury 2007;38:497-508.
Question #: 34Randomized controlled trials are considered to provide the highest level of evidence, andconcealed treatment allocation is essential to prevent bias in this study design.Concealment is best achieved by using1- even-odd days.2- patient birth date.3- randomization by surgeon.4- patient hospital identification number.5- opaque envelopes containing the randomization number.Preferred Response: 5Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 87-101.Poolman RW, Struijs PA, Krips R, et al: Reporting of outcomes in orthopaedic randomizedtrials: Does blinding of outcome assessors matter? J Bone Joint Surg Am 2007;89:550-558.Question #: 35A 25-year-old competitive soccer player has chronic anterior knee pain and reports“sloppiness” since injuring it in a collision with another player 2 months ago. He missedseveral weeks of practice but has since attempted a return to play. Examination reveals noquadriceps atrophy, standing varus alignment of 8°, a posterior sag sign, 3+ posteriordrawer, 2+ varus instability in extension, 3+ varus instability at 30°, and 20° increasedprone external rotation at 30° and 90°. He walks with a varus thrust. What is the besttreatment option?1- High tibial osteotomy2- Reconstruction of the posterior cruciate ligament (PCL) and repair of the posterolateralcorner (PLC)3- Reconstruction of the PCL4- Reconstruction of the PCL and PLC5- High tibial osteotomy and PCL/PLC reconstructionPreferred Response: 5Recommended Reading(s):Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2004, pp 183-197.Giffin JR, Vogrin TM, Zantop T, et al: Effects of increasing tibial slope on the biomechanicsof the knee. Am J Sports Med 2004;32:376-382.
Question #: 36When assessing the location of a guide pin for minimal-open screw fixation of a transversescaphoid waist fracture, which of the following locations provides the best biomechanicalfixation?1- Central axis of the proximal and distal fragments2- Dorsal axis in the distal and proximal fragments3- Volar axis in the distal and proximal fragments4- Dorsal axis distally and volar axis in the proximal fragment5- Volar axis distally and dorsal axis in the proximal fragmentPreferred Response: 1Recommended Reading(s):McCallister WV, Knight J, Kaliappan R, et al: Central placement of the screw in simulatedfractures of the scaphoid waist: A biomechanical study. J Bone Joint Surg Am 2003;85:72-77.Dodds SD, Panjabi MM, Slade JF III: Screw fixation of scaphoid fractures: A biomechanicalassessment of screw length and screw augmentation. J Hand Surg Am 2006;31:405-413.Question #: 37What is the most frequent variant of the relationship between the sciatic nerve and thepiriformis tendon as the nerve exits the sciatic notch?1- Entire nerve courses anterior to the piriformis muscle2- Entire nerve courses posterior to the piriformis muscle3- Entire nerve pierces and divides the piriformis muscle4- Nerve divides and courses around the piriformis muscle5- Nerve divides, with one division dividing the piriformis musclePreferred Response: 1Recommended Reading(s):Pokorny D, Jahoda D, Veigl D, et al: Topographic variations of the relationship of the sciaticnerve and the piriformis muscle and its relevance to palsy after total hip arthroplasty. SurgRadiol Anat 2006;28:88-91.Tornetta P III: Hip dislocations and fractures of the femoral head, in Bucholz RW, HeckmanJD (eds): Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, LippincottWilliams & Wilkins, 2001, p 1556.Beaton LE, Anson BJ: The relation of the sciatic nerve and of its subdivisions to thepiriformis muscle. Anat Rec 1937;70:1-5.
Question #: 38A 36-year-old woman has right knee pain and swelling that first began 4 months ago.Figures 38a through 38d show radiographs, MRI scans, and H & E histology slides at 20Xand 100X. These findings are most consistent with what diagnosis?1- High-grade central osteosarcoma2- Periosteal osteosarcoma3- Juxta-articular chondroma4- Osteochondroma5- Bizarre parosteal osteochondromatous proliferation (Nora’s lesion)Preferred Response: 2Recommended Reading(s):Campanacci M: Periosteal osteosarcoma, in Campanacci M (ed): Bone and soft tissuetumors, ed 2. New York, NY, Springer-Verlag Wien, 1999, pp 517-524.Weis L: Common malignant bone tumors, in Simon M, Springfield D (eds): Osteosarcoma:Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Williams & Wilkins,1998, pp 265-274.
Question #: 39An 18-month-old boy is being evaluated for intoeing gait. Foot progression angles are -10°.Thigh-foot angles are -20° bilaterally. There is no metatarsus adductus. His height is in the60th percentile for his age. What is the most appropriate treatment?1- Observation2- Denis Browne bar3- Referral to physical therapy4- Vitamin D, calcium, and phosphate levels5- Bilateral knee-ankle-foot orthoses with a medial uprightPreferred Response: 1Recommended Reading(s):Lincoln TL, Suen PW: Common rotational variations in children. J Am Acad Orthop Surg2003;11:312-320.Staheli LT: Rotational problems in children. Instr Course Lect 1994;43:199-209.Kling TF Jr, Hensinger RN: Angular and torsional deformities of the lower limbs in children.Clin Orthop Relat Res 1983;176:136-147.Question #: 40Postoperative loss of reduction after iliosacral screw fixation of a posterior pelvic ring injuryhas been attributed to which of the following?1- Use of a partially threaded screw2- Vertical fracture pattern through the sacrum3- Lateral compression fracture pattern4- Open book fracture pattern5- Initial non-anatomic reductionPreferred Response: 2Recommended Reading(s):Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 389-397.Griffin DR, Starr AJ, Reinert CM, et al: Vertically unstable pelvic fractures fixed withpercutaneous iliosacral screws: Does posterior injury pattern predict fixation failure? JOrthop Trauma 2006;20:S30-S36.
Question #: 41A 65-year-old man with a distal femoral low grade exostotic chondrosarcoma reports mildknee pain. Radiologic work-up reveals no metastases. The patient’s leg otherwisefunctions normally. Definitive treatment for this tumor consists of1- wide excision only.2- chemotherapy only.3- chemotherapy followed by wide excision.4- radiation therapy only.5- radiation therapy followed by wide excision.Preferred Response: 1Recommended Reading(s):Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont,IL, American Academy of Orthopaedic Surgeons, 2002, pp 187-202.Lee FY, Mankin HJ, Fondren G, et al: Chondrosarcoma of bone: An assessment ofoutcome. J Bone Joint Surg Am 1999;81:326-338.Question #: 42Shoulder pathology in adult patients with juvenile idiopathic arthritis (formerly juvenilerheumatoid arthritis) is characterized by1- above average bone density.2- large bone size.3- a superiorly migrated humeral head.4- medialization of the humeral head due to glenoid bone loss.5- significant posterior glenoid erosion.Preferred Response: 4Recommended Reading(s):Thomas S, Price AJ, Sankey RA, et al: Shoulder hemiarthroplasty in patients with juvenileidiopathic arthritis. J Bone Joint Surg Br 2005;87:672-676.Jolles BM, Grosso P, Bogoch ER: Shoulder arthroplasty for patients with juvenile idiopathicarthritis. J Arthroplasty 2007;22:876-883.
Question #: 43An acutely injured quadriplegic patient undergoes an anterior diskectomy and fusion withplating at C6-7. Two days postoperatively the patient has sweating, a severe headache,flushing, and a blood pressure of 180/120 mm Hg. What is the most appropriate initialmanagement?1- IV administration of epinephrine2- MRI of the cervical spine3- Removal of the cervical plate4- Irrigation and/or replacement of the indwelling urinary catheter5- Placement of a lumbar subarachnoid drainPreferred Response: 4Recommended Reading(s):Banovac K, Sherman AL: Spinal cord injury rehabilitation, in Herkowitz HN, Garfin SR,Eismont FJ, et al (eds): Rothman-Simeone The Spine, ed 5. Philadelphia, PA, SaundersElsevier, 2006, pp 1220-1231.Furlan JC, Fehlings MG: Cardiovascular complications after acute spinal cord injury:Pathophysiology, diagnosis, and managment. Neurosurg Focus 2008;25:E13.
Figure 44a Figure 44bQuestion #: 44The clinical test shown in Figures 44a and 44b, in which the hip is first flexed, abducted,and externally rotated, and then is extended and allowed to fall into adduction and internalrotation, tests for contractures of what muscle?1- Sartorius2- Pectineus3- Gluteus medius4- Rectus femoris5- Tensor fascia lataPreferred Response: 5Recommended Reading(s):Herring JA: The orthopaedic examination: A comprehensive overview, in Herring JA (ed):Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 27-53.Gross R: Physical examination, in Staheli LT (ed): Pediatric Orthopaedic Secrets, ed 2.Philadelphia, PA, Hanley Belfus, 2003, p 15.
Question #: 45In synovial fluid analysis before revision total knee arthroplasty, what is the minimumthreshold for white blood cell count that is considered strongly indicative of infection?1- 1002- 5003- 2,5004- 10,0005- 25,000Preferred Response: 3Recommended Reading(s):Mason JB, Fehring TK, Odum SM, et al: The value of white blood cell counts beforerevision total knee arthroplasty. J Arthroplasty 2003;18:1038-1043.Parvizi J, Ghanem E, Menashe S, et al: Periprosthetic infection: What are the diagnosticchallenges? J Bone Joint Surg Am 2006;88:138-147.Schinsky MF, Della Valle CJ, Sporer SM, et al: Perioperative testing for joint infection inpatients undergoing revision total hip arthroplasty. J Bone Joint Surg Am 2008;90:1869-1875.Question #: 46A patient has a both bone forearm fracture. After open reduction and internal fixation withmodern plating techniques, addition of a bone graft to the radius is indicated if there iswhich of the following findings?1- Forty percent comminution of the circumference of the radius2- Segmental fracture of the ulna3- Segmental bone loss of the radius4- Open radius and ulna fractures5- Open radius fracturePreferred Response: 3Recommended Reading(s):Wright RR, Schmeling GJ, Schwab JP: The necessity of acute bone grafting in diaphysealforearm fractures: A retrospective review. J Orthop Trauma 1997;11:288-294.Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy ofOrthopaedic Surgeons, 2002, pp 307-316.Moed BR, Kellam JF, Foster RJ, et al: Immediate internal fixation of open fractures of thediaphysis of the forearm. J Bone Joint Surg Am 1986;68:1008-1017.
Question #: 47Which of the following modes better defines corrosion resulting from an electrochemicalpotential created between two metals in contact and immersed in a conductive medium?1- Crevice2- Galvanic3- Fretting4- Degradation5- DelaminationPreferred Response: 2Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 65-85.Mazzocca AD, Caputo AE, Browner BD, et al: Principles of internal fixation, in Browner BD,Jupiter JB, Levine AM (eds): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders,2003, pp 195-249.
Figure 48Question #: 48A 4-year-old boy injures his finger in a lawn mower. A clinical photograph of the palmarside of the little finger is shown in Figure 48. With exam under sedation, the bone is notedto be covered by the subcutaneous tissue. To preserve length, contour, and sensation,treatment after irrigation and debridement should consist of1- a thenar flap.2- a V-Y advancement flap.3- direct closure.4- microvascular reattachment.5- application of antibiotic ointment and a sterile dressing.Preferred Response: 5Recommended Reading(s):Lamon RP, Cicero JJ, Frascone RJ, et al: Open treatment of fingertip amputations. AnnEmerg Med 1983;12:358-360.Söderberg T, Nyström A, Hallmans G, et al: Treatment of fingertip amputations with boneexposure: A comparative study between surgical and conservative treatment methods.Scand J Plast Reconstr Surg 1983;17:147-152.Farrell RG, Disher WA, Nesland RS, et al: Conservative management of fingertipamputations. JACEP 1977;6:243-246.
Figure 49Question #: 49A 2-month-old boy is evaluated for short stature and severe clubfeet. Examination revealsswelling of the pinnae of the ears. The appearance of the hands and feet are shown inFigure 49. What is the most likely diagnosis?1- Achondroplasia2- Apert syndrome3- Congenital syphilis4- Diastrophic dysplasia5- Cleidocranial dysplasiaPreferred Response: 4Recommended Reading(s):Sponseller PD: The skeletal dysplasias, in Morrissy RT, Weinstein SL (eds): Lovell andWinter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins,2001, pp 243-285.Ryoppy S, Poussa M, Morikanto J, et al: Foot deformities in diastrophic dysplasia: Ananalysis of 102 patients. J Bone Joint Surg Br 1992;74:441-444.
Question #: 50A 34-year-old woman reports pain in the tibia. Radiographs, a CT scan, and a biopsyspecimen are shown in Figures 50a through 50d. What is the most appropriate treatmentoption?1- Observation2- External beam radiation3- Radiofrequency ablation4- Curettage with power burr and packing with cement5- Wide resection and osteoarticular allograft reconstructionPreferred Response: 4Recommended Reading(s):Turcotte RE: Giant cell tumor of bone. Orthop Clin North Am 2006;37:35-51.Bini SA, Gill K, Johnston JO, et al: Giant cell tumor of bone: Curettage and cementreconstruction. Clin Orthop Relat Res 1995;321:245-250.Question #: 51A 63-year-old man with a history of renal cell carcinoma has had severe thoracic pain forthe past month. Examination shows mild lower extremity weakness with positive Babinski.Radiographs show a lytic lesion within T9 and a localized gibbus deformity of 40° from T8-T10. What is the most appropriate management prior to surgery?1- Radiation therapy2- Chemotherapy3- Chemotherapy and radiation therapy4- Epidural corticosteroid placement5- Intra-arterial embolizationPreferred Response: 5Recommended Reading(s):Prabhu VC, Bilsky MH, Jambhekar K, et al: Results of preoperative embolization formetastatic spinal neoplasms. J Neurosurg 2003;98:156-164.Heary RF, Bono CM: Metastatic spinal tumors. Neurosurg Focus 2001;11:e1.
Question #: 52In which of the following fracture patterns is the optimal orientation of the screws used torepair the medial malleolar fragment, parallel to the ankle joint?1- Supination external rotation2- Supination internal rotation3- Pronation external rotation4- Supination adduction5- Pronation abductionPreferred Response: 4Recommended Reading(s):Michelson JD: Ankle fractures resulting from rotational injuries. J Am Acad Orthop Surg2003;11:403-412.Hak DJ, Lee MA: Ankle fractures: Open reduction internal fixation, in Wiss DA (ed): MasterTechniques in Orthopaedic Surgery: Fractures, ed 2. Philadelphia, PA, Lippincott Williams& Wilkins, 2006, pp 551-567.Question #: 53A 9-year-old boy with an L-4 level myelomeningocele is scheduled to undergo soft-tissuesurgery for equinocavovarus feet. In addition to shunt clearance, what safety precautionsshould be taken in the perioperative period?1- Latex-free environment2- Avoidance of fiberglass casting material3- Avoidance of intravenous narcotics4- Hyperthermia prophylaxis5- Preoperative echocardiogramPreferred Response: 1Recommended Reading(s):Drennan JC: Current concepts in myelomeningocoele. Instr Course Lect 1999;48:543-550.Herring JA: Disorders of the spinal cord, in Herring JA (ed): Tachdjian’s PediatricOrthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 1405-1482.
Figure 54a Figure 54bQuestion #: 54A 7-month-old infant has the findings shown in Figures 54a and 54b. Which of thefollowing approaches to the surgical reconstruction is most appropriate?1- The intrinsic tendon and collateral ligament insertions from the radial thumb should bepreserved.2- The ulnar thumb should be deleted with transfer of the extensor tendons.3- The radial half of one thumb should be combined with the ulnar half of the other tocreate one thumb (Bilhaut-Cloquet procedure).4- The radial digital nerves should be transferred into the ulnar thumb.5- Brunner incisions across the palmar surfaces should be avoided.Preferred Response: 1Recommended Reading(s):Ogino T, Ishii S, Takahata S, et al: Long-term results of surgical treatment of thumbpolydactyly. J Hand Surg Am 1996;21:478-486.Baek GH, Gong HS, Chung MS, et al: Modified Bilhaut-Cloquet procedure for Wassel type-II and III polydactyly of the thumb. J Bone Joint Surg Am 2007;89:534-541.
Question #: 55Somitization of the axial skeleton has been shown to be highly dependent on whatmechanism?1- Sequential activation of homeobox genes2- Notochord activation of sonic hedgehog3- Formation of collagen 1 matrix in the ribosome4- Dorsal sclerotome activation of MSX1 and MSX25- Alternation of activation of noggin and bone morphogenic proteinsPreferred Response: 1Recommended Reading(s):Iimura T, Pourquie PO: Hox genes in time and space during vertebrate body formation.Dev Growth Differ 2007;49:265-275.Turnpenny PD, Alman B, Cornier AS, et al: Abnormal vertebral segmentation and the notchsignaling pathway in man. Dev Dyn 2007;236:1456-1474.Kappen C: Early and late functions of Hox genes in the development of the axial skeleton,in Buckwalter JA, Ehrlich MG, Sandell LJ, et al (eds): Skeletal growth and development:Clinical issues and basic science advances. Rosemont, IL, American Academy ofOrthopaedic Surgeons, 1997, pp 147-162.Question #: 56A 26-year-old man has a scaphoid waist fracture, and a decision is made for screw fixationthrough the dorsal approach (antegrade screw placement). Which of the following isconsidered the most reliable method to achieve proper screw seating below thesubchondral bone?1- Direct palpation2- Direct visualization3- Guide wire measurement4- Static fluoroscopic imaging5- Dynamic (live) fluoroscopic imagingPreferred Response: 2Recommended Reading(s):Adamany DC, Mikola EA, Fraser BJ: Percutaneous fixation of the scaphoid through adorsal approach: An anatomic study. J Hand Surg Am 2008;33:327-331.Tumilty JA, Squire DS: Unrecognized chondral penetration by a Herbert screw in thescaphoid. J Hand Surg Am 1996;21:66-68.
Question #: 57While trialing a cruciate-retaining total knee arthroplasty, the knee lacks 10° of extension.When flexed beyond 90°, the tibiofemoral contact point translates posterior and there is nolift-off of the tray trial with deep flexion. What is the next most appropriate step?1- Increase the posterior slope of the tibia2- Resect more tibia3- Resect more distal femur4- Recess the posterior cruciate ligament5- Downsize the femoral compartmentPreferred Response: 3Recommended Reading(s):Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 457-471.Question #: 58With the development of glenohumeral internal rotation deficit in a pitcher, the humeralhead is shifted in what direction during the cocking phase of throwing?1- Anteroinferior2- Anterosuperior3- Posterosuperior4- Posteroinferior5- No change in position occursPreferred Response: 3Recommended Reading(s):Grossman MG, Tibone JE, McGarry MH, et al: A cadaveric model of the throwing shoulder:A possible etiology of superior labrum anterior-to-posterior lesions. J Bone Joint Surg Am2005;87:824-831.Lintner D, Mayol M, Uzodinma O, et al: Glenohumeral internal rotation deficits inprofessional pitchers enrolled in an internal rotation stretching program. Am J Sports Med2007;35:617-621.
Question #: 59Paget’s disease of bone is associated with abnormal function of which of the following celltypes?1- Osteoblasts2- Osteoclasts3- Osteocytes4- Histiocytes5- MegakarocytesPreferred Response: 2Recommended Reading(s):Klein GR, Parvizi J: Surgical manifestations of Paget’s disease. J Am Acad Orthop Surg2006;14:577-586.Robey PG, Bianco P: The role of osteogenic cells in the pathophysiology of Paget’sdisease. J Bone Miner Res 1999;14:9-16.
Question #: 60A 55-year-old electrician who is 5’ 10” tall and weighs 250 lbs developed severe medialcompartment degenerative arthritis 6 months ago and underwent a medial unicondylarknee arthroplasty. He did extremely well initially and returned to work after 5 weeks. Hereports new onset pain made worse by prolonged weight bearing and stair climbing. Hehas no fevers, chills, or pain at rest. Radiographs are shown in Figures 60a and 60b. Adelayed image from a bone scan is shown in Figure 60c. What is most likely diagnosis?1- Infection2- Anterior cruciate ligament disruption3- Osteolysis4- Stress fracture5- Dislodgement of polyethylenePreferred Response: 4Recommended Reading(s):Brumby SA, Carrington R, Zayontz S, et al: Tibial plateau stress fracture: A complication ofunicompartmental knee arthroplasty using 4 guide pinholes. J Arthroplasty 2003;18:809-812.Pandit H, Murray DW, Dodd CA, et al: Medial tibial plateau fracture and the Oxfordunicompartmental knee. Orthopedics 2007;30:28-31.Hamilton WG, Collier MB, Tarabee E, et al: Incidence and reasons for reoperation afterminimally invasive unicompartmental knee arthroplasty. J Arthroplasty 2006;21:98-107.
Question #: 61A 46-year-old female runner without foot deformity received a steroid injection into thesecond metatarsophalangeal (MTP) joint for forefoot pain 3 weeks prior to running amarathon. During the race, pain was noted beneath the second MTP joint. A clinicalphotograph and radiographs of her foot following the race are shown in Figures 61athrough 61c. What is the most likely diagnosis?1- Plantar fascia rupture2- Second metatarsal stress fracture3- Hammertoe deformity4- Plantar plate rupture with subluxation of the second MTP joint5- Rheumatoid arthritisPreferred Response: 4Recommended Reading(s):McGarvey WC: Second metatarsophalangeal instability, in Nunley JA, Pfeffer GB, SandersRW, et al (eds): Advanced Reconstruction of the Foot and Ankle. Rosemont, IL, AmericanAcademy of Orthopaedic Surgeons, 2004, pp 69-75.Mizel MS, Yodlowski ML: Disorders of the lesser metatarsophalangeal joints. J Am AcadOrthop Surg 1995;3:166-173.Question #: 62The parents of a 5-year-old boy report that he had a right clubfoot corrected using thePonseti method shortly after birth. They now note that he has been walking on the outsideof his foot. Examination reveals the forefoot and hindfoot are well corrected. The anklecan be dorsiflexed 15°. When he walks, the foot supinates during swing phase and comesdown on the lateral border during stance phase. What is the preferred management of thispatient?1- Reverse last shoes2- Split posterior tibial tendon transfer3- Full-time use of the Denis-Browne bar for 3 months4- Anterior tibial tendon transfer to the lateral cuneiform5- Percutaneous heel cord tenotomy and plantar fasciotomyPreferred Response: 4Recommended Reading(s):Ponseti IV: Relapses, in Congenital Clubfoot: Fundamentals of Treatment. New York, NY,Oxford University Press, 1996, pp 98-106.Morcuende JA, Weinstein SL, Dietz FR, et al: Plaster cast treatment of clubfoot: ThePonseti method of manipulation and casting. J Pediatr Orthop Part B 1994;3:161-167.
Question #: 63The mechanism of action of bisphosphonates is largely dependent on1- metabolites.2- chemical structure.3- route of administration.4- synthetic characteristics.5- bone binding properties.Preferred Response: 2Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 315-330.Morris CD, Einhorn TA: Bisphosphonates in orthopaedic surgery. J Bone Joint Surg Am2005;87:1609-1618.Question #: 64What is the primary biomechanical role of the rotator cuff?1- It provides the major force to move the arm forward.2- It provides the majority of humeral rotation power.3- It initiates arm elevation before the trapezius, serratus anterior, and deltoid areactivated.4- It compresses the humeral head against the glenoid.5- It is the major dynamic stabilizer in the extremes of motion.Preferred Response: 4Recommended Reading(s):Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2004, pp 79-88.Hirashima M, Kadota H, Sakurai S, et al: Sequential muscle activity and its functional rolein the upper extremity and trunk during overarm throwing. J Sports Sci 2002;20:301-310.
Question #: 65Two-flap Z-plasty with 60° limbs provides how much lengthening of scar contracture?1- 10%2- 25%3- 50%4- 75%5- 100%Preferred Response: 4Recommended Reading(s):Hove CR, Williams EF III, Rodgers BJ: Z-plasty: A concise review. Facial Plast Surg2001;17:289-294.Browne EZ, Pederson WC: Skin grafts and skin flaps, in Green DP, Hotchkiss RN,Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA,Elsevier, 2005, pp 1651-1692.
Question #: 66Figures 66a through 66d show the radiographs and MRI scans of a 68-year-old womanwho reports a 1-year history of worsening low back and left leg pain. Currently she isunable to walk more than two blocks without resting. She is able to complete her groceryshopping by leaning on the cart while in the store. She has a normal neurologic exam andno significant medical comorbidities. She has failed to respond to epidural steroids andphysical therapy. Which of the following treatment options offers the most likely chance torelieve her pain symptoms?1- Anterior diskectomy and interbody fusion at L4/52- Left-sided laminotomy and diskectomy at L4/53- Complete laminectomy at L4 with partial facetectomies and foraminotomies at L4/54- A series of three transforaminal epidural steroid injections at L4/55- Laminectomy, partial facetectomy, and foraminotomy at L4/5 with posterior spinalfusionPreferred Response: 5Recommended Reading(s):Weinstein JN, Lurie JD, Tosteson TD, et al: Surgical versus nonsurgical treatment forlumbar degenerative spondylolisthesis. N Engl J Med 2007;356:2257-2270.Knaub MA, Won DS, McGuire R, et al: Lumbar spinal stenosis: Indications for arthrodesisand spinal instrumentation. Instr Course Lect 2005;54:313-319.Herkowitz HN, Kurz LT: Degenerative lumbar spondylolisthesis with spinal stenosis: Aprospective study comparing decompression with decompression and intertransverseprocess arthrodesis. J Bone Joint Surg Am 1991;73:802-808.
Question #: 67A 7-year-old girl has a mass on the volar radial aspect of her wrist. The mass is 1 cm indiameter, firm, and not fixed to the skin. A decision is made for excision. Before doing this,what two clinical tests should be done?1- Adams test and Steinberg sign2- Stagnara and Froment tests3- Transillumination and Allen test4- Diadochokinesia and Phalen tests5- Digital capillary refill and blood pressurePreferred Response: 3Recommended Reading(s):Herring JA: Kyphosis, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 4.Philadelphia, PA, WB Saunders, 2008, pp 413-441.Wang AA, Hutchinson DT: Longitudinal observation of pediatric hand and wrist ganglia. JHand Surg Am 2001;26:599-602.Question #: 68Osteogenesis imperfecta results from a mutation in which of the following genes?1- Type I collagen2- Type II collagen3- Type IV collagen4- Type VI collagen5- Type X collagenPreferred Response: 1Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 25-47.Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 773-783.
Figure 69a Figure 69bQuestion #: 69A 56-year-old man has a thigh mass. He has no significant history of trauma orsubcutaneous ecchymosis and is not taking anticoagulation medication. The MRI scansshown in Figures 69a and 69b confirm that this is a deep blood-filled cyst-like structure withenhancement of the cyst wall. Aspiration is consistent with old hematoma but it recurs afteraspiration. What is the next most appropriate treatment option?1- Ice, compression, and elevation2- Open biopsy3- Percutaneous drain placement, multiple if necessary4- Irrigation, debridement, and placement of several drains5- Resection of the entire mass including the cyst wallPreferred Response: 2Recommended Reading(s):Ward WG Sr, Rougraff B, Quinn R, et al: Tumors masquerading as hematomas. ClinOrthop Relat Res 2007;465:232-240.Schwartz HS (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont,IL, American Academy of Orthopaedic Surgeons, 2007, pp 59-72.
Question #: 70Following open reduction and internal fixation of an ankle fracture, what is the time framefor patients to return to normal automobile breaking time?1- 3 weeks2- 6 weeks3- 9 weeks4- 12 weeks5- 24 weeksPreferred Response: 3Recommended Reading(s):Egol KA, Sheikhazadeh A, Mogatederi S, et al: Lower-extremity function for driving anautomobile after operative treatment of ankle fracture. J Bone Joint Surg Am2003;85:1185-1189.Egol KA, Sheikhazadeh A, Koval KJ: Braking function after complex lower extremitytrauma. J Trauma 2008;65:1435-1438.
Question #: 71A 20-year-old man has had progressive right buttock pain. AP pelvis and lateral hipradiographs, and an MRI scan are shown in Figures 71a through 71c. He reports that hehas had several “bone spurs” removed in the past in his wrist and ankles. Genotypeanalysis demonstrates EXT 1 expression, which implies1- no clinical significance.2- less severe involvement than EXT 2.3- less likelihood of subsequent familial transmission.4- a high likelihood of local recurrence after removal.5- a higher risk for sarcoma development than EXT 2.Preferred Response: 5Recommended Reading(s):Porter DE, Lonie L, Fraser M, et al: Severity of disease and risk of malignant change inhereditary multiple exostoses: A genotype-phenotype study. J Bone Joint Surg Br2004;86:1041-1046.Alvarez C, Tredwell S, De Vera M, et al: The genotype-phenotype correlation of hereditarymultiple exostoses. Clin Genet 2006;70:122-130.Question #: 72A baseball pitcher reports posterolateral shoulder pain and lateral shoulder paresthesiaswhen in the cocking position of throwing. What is the most likely diagnosis?1- SLAP lesion2- Anterior instability3- Internal impingement4- Posterior capsule tightness5- Quadrilateral space syndromePreferred Response: 5Recommended Reading(s):Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 273-285.DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia,PA, WB Saunders, 2002, p 1247.
Figure 73Question #: 73A 35-year-old man is seen in the emergency department with the injury shown in Figure 73.Reduction of this fracture should be performed urgently to prevent which of the followingcomplications?1- Subtalar arthrosis2- Necrosis of the posterior skin3- Malunion4- Nonunion5- Achilles tendon contracturePreferred Response: 2Recommended Reading(s):Fitzgibbons TC, McMullen ST: Fractures and dislocations of the calcaneus in Heckman J,Bucholz RW (eds): Rockwood and Green’s Fractures in Adults, ed 5. New York, NY,Lippincott Williams & Wilkins, 2001, pp 2133-2174.Sanders R: Fractures and fracture-dislocations of the calcaneus, in Coughlin MJ, Mann RA(eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1422-1464.
Question #: 74McCune-Albright syndrome (polyostotic fibrous dysplasia, café-au-lait spots, precociouspuberty) is caused by a mutation in which of the following genes?1- MAP kinase2- Gs G-protein3- Adenylyl cyclase4- c-fos proto-oncogene5- Parathyroid hormone receptorPreferred Response: 2Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 25-47.Weinstein LS: G(s)alpha mutations in fibrous dysplasia and McCune-Albright syndrome. JBone Miner Res 2006;21:P120-P124.Question #: 75The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that patientsadmitted to an emergency room cannot be transferred unless evaluated by a responsiblehealth care provider and1- they are screened for appropriate insurance coverage.2- blood transfusions and other medication infusions are completed.3- all emergent surgery is performed.4- the benefits of transfer outweigh the risks.5- transportation (air or ground) is less than 60 minutes.Preferred Response: 4Recommended Reading(s):Fishgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 3-12.Koval KJ, Tingey CW, Spratt KF: Are patients being transfered to level-1 trauma centers forreasons other than medical necessity? J Bone Joint Surg Am 2006;88:2124-2132.
Question #: 76Which of the following structures blocks successful closed reduction of a lateral subtalardislocation?1- Spring ligament2- Deltoid ligament3- Extensor digitorum brevis4- Posterior tibial tendon5- Extensor hallucis longus tendonPreferred Response: 4Recommended Reading(s):Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 493-509.Bibbo C, Anderson RB, Davis WH: Injury characteristics and the clinical outcome ofsubtalar dislocations: A clinical and radiographic analysis of 25 cases. Foot Ankle Int2003;24:158-163.
Figure 77a Figure 77bQuestion #: 77A 12-year-old boy sustains an injury to his knee while playing football. He has immediateswelling and is unable to walk on the limb. Examination reveals he is unable to do astraight leg raise and has marked swelling anteriorly. A lateral radiograph and MRI scanare seen in Figures 77a and 77b. What is the most appropriate treatment?1- Reconstruction of the patellar tendon2- Surgical reduction and internal fixation3- Immobilization in a straight cast for 6 weeks4- Open biopsy of the mass5- Application of a range-of-motion brace limiting flexion to 45° for 6 weeksPreferred Response: 2Recommended Reading(s):Zionts LE: Fractures around the knee in children. J Am Acad Orthop Surg 2002;10:345-355.Sponseller PD, Stanitski CL: Fractures and dislocations about the knee, in Beaty JH,Kasser JR (eds): Rockwood and Wilkins’ Fractures in Children, ed 5. Philadelphia, PA,Lippincott Williams & Wilkins, 2001, pp 1029-1033.
Question #: 78Most studies of cemented Charnley all-polyethylene acetabular shells showed a less than5% failure rate at 10 years. What is the failure rate (revision rate) of these cups at 20years?1- Less than 10%2- 15% to 20%3- 30% to 40%4- 60% to 70%5- Greater than 90%Preferred Response: 2Recommended Reading(s):Della Valle CJ, Kaplan K, Jazrawi A, et al: Primary total hip arthroplasty with a flangedcemented all-polyethylene acetabular component: Evaluation at a minimum of 20 years. JArthroplasty 2004;19:23-26.Kavanagh BF, Wallrichs S, Dewitz M, et al: Charnley low-friction arthroplasty of the hip:Twenty-year results with cement. J Arthroplasty 1994;9:229-234.Callaghan JJ, Templeton JE, Liu SS, et al: Results of Charnley total hip arthroplasty at aminimum of thirty years: A concise follow-up of a previous report. J Bone Joint Surg Am2004;86:690-695.Question #: 79Which of the following individuals is considered the most ideal patient for total hiparthroplasty following a femoral neck fracture?1- Healthy 31-year-old man with a displaced vertically oriented fracture2- 61-year-old woman with a nondisplaced stress fracture3- 70-year-old avid golfer4- 81-year-old man with Parkinson’s disease5- 93-year-old woman with dementiaPreferred Response: 3Recommended Reading(s):Blomfeldt R, Tornkvist H, Ponzer S, et al: Displaced femoral neck fracture: Comparison ofprimary total hip replacement with secondary replacement after failed internal fixation: A 2-year follow-up of 84 patients. Acta Orthop 2006;77:638-643.Blomfeldt R, Tornkvist H, Eriksson K, et al: A randomized controlled trial comparing bipolarhemiarthroplasty with total hip replacement for displaced intracapsular fractures of thefemoral neck in elderly patients. J Bone Joint Surg Br 2007;89:160-165.
Question #: 80A 25-year-old woman has a Boutonniere deformity of the ring finger. Which of the followingmechanisms is the most likely cause of this deformity?1- Chronic mallet finger2- Old avulsion fracture of the central slip insertion3- Rupture of the flexor digitorum superficialis4- Sagittal band rupture at the metacarpophalangeal joint5- Loss of continuity of the volar plate of the proximal interphalangeal jointPreferred Response: 2Recommended Reading(s):Tuttle HG, Olvey SP, Stern PJ: Tendon avulsion injuries of the distal phalanx. Clin OrthopRelat Res 2006;445:157-168.Lilly SI, Messer TM: Complications after treatment of flexor tendon injuries. J Am AcadOrthop Surg 2006;14:387-396.Imatami J, Hashizume H, Wake H, et al: The central slip attachment fracture. J Hand SurgBr 1997;22:107-109.Burton RI, Melchihor JA: Extensor tendons - late reconstruction, in Green DP, HotchkissRN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, ChurchillLivingstone, 1999, pp 1988-2019.
Figure 81a Figure 81bQuestion #: 81A 5-year-old boy fell in the park and sustained a closed injury to the elbow. He was initiallytreated with closed reduction and casting. Postreduction AP and lateral radiographs areshown in Figures 81a and 81b. At the 1-week follow-up visit, the radial head is noted to bedislocated. What is the next most appropriate step in treatment?1- Closed reduction of the radial head and closed reduction of the ulna, with pin fixation ofthe ulna2- Closed reduction of the ulna with open reduction of the radiocapitellar joint andreconstruction of the annular ligament3- Closed reduction of the ulna and closed reduction of the radial head with pin fixation ofthe radiocapitellar joint4- Open reduction of the ulna and radiocapitellar joint, with reconstruction of the annularligament5- Application of a joint spanning external fixator on the elbow to maintain reductionPreferred Response: 1Recommended Reading(s):Ring D, Jupiter JB, Waters PM: Monteggia fractures in children and adults. J Am AcadOrthop Surg 1998;6:215-224.Wilkins KE: Changes in the management of Monteggia fractures. J Pediatr Orthop2002;22:548-554.
Question #: 82What is the central concept in rehabilitating an athlete during nonsurgical care of anisolated grade II posterior cruciate ligament tear?1- The knee should be splinted in full extension for 6 weeks.2- Early range of motion and quadriceps strengthening should start as soon as painpermits.3- Open chain hamstring strengthening exercises should be initiated early.4- Functional braces have a high rate of success in patients with persistent symptoms.5- Patients should not return to sport until hamstring strength equals the contralateralside.Preferred Response: 2Recommended Reading(s):Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2004, pp 155-168.Margheritini F, Rihn J, Musahl V, et al: Posterior cruciate ligament injuries in the athlete: Ananatomical, biomechanical and clinical review. Sports Med 2002;32:393-408.
Figure 83a Figure 83bQuestion #: 83Figures 83a and 83b show the MRI scans of a 52-year-old man with a history of metastaticlung adenocarcinoma. He reports weakness involving the right leg over the last week tothe extent that he is no longer able to ambulate independently. His oncologist estimatesthat his life expectancy is between 6 months to 1 year. His pulmonary function is stablewithout a need for supplemental oxygen. What treatment option offers the best potential torestore and maintain the patient’s ambulatory status?1- Directed radiation therapy alone2- Surgical laminectomy followed by radiation therapy3- Combined focused radiation therapy and chemotherapy4- Receptor-directed chemotherapy based on an open biopsy5- Circumferential neurologic decompression and surgical stabilization with postoperativeradiation therapyPreferred Response: 5Recommended Reading(s):Schmidt MH, Klimo P Jr, Vrionis FD: Metastatic spinal cord compression. J Natl ComprCanc Netw 2005;3:711-719.Klimo P Jr, Kestle JR, Schmidt MH: Clinical trials and evidence-based medicine formetastatic spine disease. Neurosurg Clin N Am 2004;15:549-564.Patchell RA, Tibbs PA, Regine WF, et al: Direct decompressive surgical resection in thetreatment of spinal cord compression caused by metastatic cancer: A randomized trial.Lancet 2005;366:643-648.
Question #: 84Implantable direct current bone stimulators decrease osteoclast activity and increaseosteoblast activity by which of the following mechanisms?1- Reduces oxygen concentration and increases local tissue pH2- Activates calmodulin3- Activates fibroblast growth factor receptor-34- Activates transmembrane calcium translocation via voltage-gated channels5- Creates nano motion and mechanical stimulation at the fracture sitePreferred Response: 1Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 331-348.Otter MW, McLeod KJ, Rubin CT: Effects of electromagnetic fields in experimental fracturerepair. Clin Orthop Relat Res 1998;355S:S90-S104.Question #: 85A 62-year-old man has advanced osteoarthritis of the shoulder. Examination reveals noatrophy of the infraspinatus and good external rotation strength. A CT scan shows theglenoid version to be -10°, and there is mild posterior subluxation of the humeral head.What is the most appropriate treatment?1- Reverse total shoulder arthroplasty2- Hemiarthroplasty3- Arthroscopic capsular release4- Total shoulder arthroplasty5- Glenoid bone blockPreferred Response: 4Recommended Reading(s):Bryant D, Litchfield R, Sandow M, et al: A comparison of pain, strength, range of motion,and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patientswith osteoarthritis of the shoulder: A systematic review and meta-analysis. J Bone JointSurg Am 2005;87:1947-1956.Gartsman GM, Roddey TS, Hammerman SM: Shoulder arthroplasty with or withoutresurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg Am2000;82:26-34.
Question #: 86Which of the following factors correlates most with a satisfactory clinical outcome whenmanaging an intra-articular fracture of the proximal tibia?1- Age2- Type of graft substitute3- Condylar widening4- Maintenance of mechanical axis5- Degree of residual articular incongruencyPreferred Response: 4Recommended Reading(s):Rademakers MV, Kerkhoffs GM, Sierevelt IN, et al: Operative treatment of 109 tibialplateau fractures: Five- to 27-year follow-up results. J Orthop Trauma 2007;21:5-10.Weigel DP, Marsh JL: High-energy fractures of the tibial plateau: Knee function after longerfollow-up. J Bone Joint Surg Am 2002;84:1541-1551.Stevens DG, Beharry R, McKee MD, et al: The long-term functional outcome of operativelytreated tibial plateau fractures. J Orthop Trauma 2001;15:312-320.Honkonen SE: Degenerative arthritis after tibial plateau fractures. J Orthop Trauma1995;9:273-277.Honkonen SE: Indications for surgical treatment of tibial condyle fractures. Clin OrthopRelat Res 1994;302:199-205.
Figure 87a Figure 87bQuestion #: 87A 5-month-old girl with a dislocated left hip has been treated in a Pavlik harness full-time forthe last 4 weeks. An ultrasound obtained with the patient in the harness is shown inFigures 87a and 87b. Based on these image findings, what is the next step in treatment?1- Arthrogram, closed reduction, and hip spica casting2- MRI arthrogram to further assess obstacles to reduction3- Continued use of the Pavlik harness for 4 more weeks4- Change to an Ilfeld splint for 3 more months of abduction splinting5- Open reduction and innominate osteotomyPreferred Response: 1Recommended Reading(s):Guille JT, Pizzutillo PD, MacEwen GD: Development dysplasia of the hip from birth to sixmonths. J Am Acad Orthop Surg 2000;8:232-242.Mubarak S, Garfin S, Vance R, et al: Pitfalls in the use of the Pavlik harness for treatmentof congenital dysplasia, subluxation, and dislocation of the hip. J Bone Joint Surg Am1981;63:1239-1248.Weinstein SL, Mubarak SJ, Wenger DR: Developmental hip dysplasia and dislocation: PartII. Instr Course Lect 2004;53:531-542.
Question #: 88Resident work hour guidelines should increase patient safety by decreasing residentfatigue. However, there is concern that safety benefits may be offset by the need forchanges in systems of patient care necessitated by these guidelines. Which of thesechanges has caused the most concern for patient safety?1- Night float rotations2- Urgent surgery done the next day instead of on call3- Home call4- Decreased continuity of care5- Use of physician extenders instead of residentsPreferred Response: 4Recommended Reading(s):Friedlander GE: The 80-hour duty week: Rationale, early attitudes, and future questions.Clin Orthop Relat Res 2006;449:138-142.Horwitz LI, Moin T, Krumholz HM, et al: Consequences of inadequate sign-out for patientcare. Arch Intern Med 2008;168:1755-1760.Okie S: An elusive balance: Residents’ work hours and the continuity of care. N Engl JMed 2007;356:2665-2667.Question #: 89Following total knee arthroplasty with resurfacing of the patella, a patient has lateralsubluxation of the patella. What issue with the components is a cause of this complication?1- Lateral placement of the tibial tray2- Reduced composite thickness of the patella3- External rotation of the femoral component4- Internal rotation of the tibial component5- Posterior translation of the femoral componentPreferred Response: 4Recommended Reading(s):Malo M, Vince KG: The unstable patella after total knee arthroplasty: Etiology, prevention,and management. J Am Acad Orthop Surg 2003;11:364-371.
Question #: 90What anatomic structure inserts most anteriorly on the proximal fibula?1- Sartorius2- Iliotibial band3- Biceps femoris4- Popliteofibular ligament5- Lateral collateral ligamentPreferred Response: 5Recommended Reading(s):LaPrade RF, Ly TV, Wentorf FA, et al: The posterolateral attachments of the knee: Aqualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteustendon, popliteofibular ligament, and lateral gastrocnemius tendon. Am J Sports Med2003;31:854-860.Stannard JP, Brown SL, Farris RC, et al: The posterolateral corner of the knee: Repairversus reconstruction. Am J Sports Med 2005;33:881-888.
Figure 91Question #: 91What nerve is most at risk when placing the intramedullary device shown in Figure 91?1- Lateral plantar2- Medial plantar3- Deep peroneal4- Saphenous5- Medial calcanealPreferred Response: 1Recommended Reading(s):Flock TJ, Ishikawa S, Hecht PJ, et al: Heel anatomy for retrograde tibiotalocalcanealroddings: A roentgenographic and anatomic analysis. Foot Ankle Int 1997;8:233-235.Pochatko DJ, Smith JW, Phillips RA, et al: Anatomic structures at risk: Combined subtalarand ankle arthrodesis with a retrograde intramedullary rod. Foot Ankle Int 1995;16:542-547.
Question #: 92A 67-year-old woman reports knee and calf pain after mild exercise, and states that thepain is relieved by rest. She notes that radiographs were obtained 5 years ago and againrecently. Figure 92a is from 5 years prior. Figure 92b is current. Current CT scans of thedistal femur are seen in Figures 92c and 92d. What is the next most appropriate step intreatment?1- Vascular surgery consultation2- Biopsy and radiofrequency ablation3- Biopsy, neoadjuvant chemotherapy, and resection4- Biopsy, curettage, and filling the void with methylmethacrylate5- Distal femoral resection and metal endoprosthetic reconstructionPreferred Response: 1Recommended Reading(s):Skeletal Lesions Interobserver Correlation Among Expert Diagnosticians (SLICED) Studygroup: Reliability of histopathologic and radiologic grading of cartilaginous neoplasms inlong bones. J Bone Joint Surg Am 2007;89:2113-2123.Ryzewicz M, Manaster BJ, Naar E, et al: Low-grade cartilage tumors: Diagnosis andtreatment. Orthopaedics 2007;30:35-46.
Figure 93Question #: 93The injury shown in Figure 93 is associated with which of the following?1- Child abuse2- Folic acid deficiency3- Osteogenesis imperfecta4- Hypophosphatemic rickets5- Generalized joint hypermobilityPreferred Response: 1Recommended Reading(s):DeLee JC, Wilkins KE, Rogers LF, et al: Fracture-separation of the distal humeralepiphysis. J Bone Joint Surg Am 1980;62:46-51.Akbarnia BA, Silberstein MJ, Rende RJ, et al: Arthrography in the diagnosis of fractures ofthe distal end of the humerus in infants. J Bone Joint Surg Am 1986;68:599-602.
Question #: 94What is the most common cause of hematogenous osteomyelitis in sickle cell disease?1- Salmonella2- Propionibacterium3- Enterobacteriaceae4- Bartonella henselae5- Pseudomonas aeruginosaPreferred Response: 1Recommended Reading(s):Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 301-318.Cornwall R, Dormans JP: Diseases of the hematopoietic system, in Morrissy RT, WeinsteinSL (eds): Lovell and Winter’s Pediatric Orthopaedics. Philadelphia, PA, Lippincott Williams& Wilkins, 2006, pp 357-404.Question #: 95Patients with multiple hereditary osteochondromas frequently have loss of forearm rotationand ulnar shortening. What procedure is most likely to improve forearm rotation in thesepatients?1- Tendon transfer2- Ulnar lengthening3- Radial head excision4- Distal ulnar resection5- Simple excision of the osteochondromaPreferred Response: 5Recommended Reading(s):Shin EK, Jones NF, Lawrence JF: Treatment of multiple hereditary osteochondromas of theforearm in children: A study of surgical procedures. J Bone Joint Surg Br 2006;88:255-260.Akita S, Murase T, Yonenobu K, et al: Long-term results of surgery for forearm deformitiesin patients with multiple cartilaginous exostoses. J Bone Joint Surg Am 2007;89:1993-1999.
Question #: 96Partial distal biceps tendon tears occur primarily on which side of the tuberosity footprint?1- Radial2- Ulnar3- Proximal4- Distal5- CentralPreferred Response: 1Recommended Reading(s):Kelly EW, Steinmann S, O’Driscoll SW: Surgical treatment of partial distal biceps tendonruptures through a single posterior incision. J Shoulder Elbow Surg 2003;12:456-461.Davis WM, Yassine Z: An etiological factor in tear of the distal tendon of the biceps brachii:Report of two cases. J Bone Joint Surg Am 1956;39:1365-1368.Question #: 97What is the preferred treatment for a 50% laceration of the flexor tendons with triggering?1- Core 4/0 suture repair2- Core 4/0 suture repair with 6/0 peritendinous suture3- Epitendinous repair with 4/0 suture4- Epitendinous repair with 6/0 suture5- Trimming of frayed edgesPreferred Response: 5Recommended Reading(s):Bishop AT, Cooney WP III, Wood MB: Treatment of partial flexor tendon lacerations: Theeffect of tenorrhaphy and early protected mobilization. J Trauma 1986;26:301-312.McGeorge DD, Stillwell JH: Partial flexor tendon injuries: To repair or not. J Hand Surg Br1992;17:176-177.
Question #: 98A 52-year-old man was involved in a motor vehicle accident and now reports severe lowback pain and left anterior leg and foot paresthesias. Radiographs and CT scans areshown in Figures 98a through 98d. He has no lower extremity weakness. He is otherwisehemodynamically stable and neurologically intact. What is the most appropriatemanagement?1- Thoracolumbosacral orthosis and mobilization2- Anterior vertebrectomy, vertebral body reconstruction, and plating3- Posterior L5 laminectomy4- Posterior L5 laminectomy and L4-S1 posterolateral fusion5- Transpedicular reduction of intracanal fragmentsPreferred Response: 1Recommended Reading(s):Butler JS, Fitzpatrick P, Ni Mhaolain AM, et al: The management and functional outcome ofisolated burst fractures of the fifth lumbar vertebra. Spine 2007;32:443-447.Seybold EA, Sweeney, CA, Fredrickson BE, et al: Functional outcome of low lumbar burstfractures: A multicenter review of operative and nonoperative treatment of L3-L5. Spine1999;24:2154-2161.
Question #: 99Which of the following arteries connect the obturator to the external iliac?1- Corona mortis2- Recurrent obturator3- Circumflex magnus4- Hypogastric branches of the deep internal iliac5- Ascending pudendal communicating branchesPreferred Response: 1Recommended Reading(s):Tornetta P III, Hochwald N, Levine R: Corona mortis: Incidence and location. Clin OrthopRelat Res 1996;329:97-101.Letournel E, Judet R: Fractures of the Acetabulum, ed 2. New York, NY, Springer-Verlag,1993, pp 375-381.Question #: 100The most common cause of a malpractice suit against an orthopaedic surgeon involvestreatment of which of the following conditions?1- Femoral fracture2- Humeral fractures with nerve palsy3- Knee arthroplasty4- Meniscal tear5- Spinal stenosisPreferred Response: 1Recommended Reading(s):Femur fracture care frequent cause of lawsuit. Managing Orthopaedic Malpractice Risk, ed2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001 Bulletin.http://www2.aaos.org/aaos/archives/bulletin/feb01/fline4.htm. Accessed on July 24, 2009.
Question #: 101A 12-year-old boy has had pain in the right knee for the past 6 weeks. He has had twoepisodes of giving way but no locking. He denies any history of injury. Examinationreveals no effusion, ligaments are stable, range of motion is full, and there is no localizedtenderness. An AP radiograph and MRI scans are shown in Figures 101a through 101c.What is the most appropriate management?1- Excision of the lesion2- Retrograde drilling of the lesion3- Antegrade drilling of the lesion4- Arthroscopic reduction and fixation5- Observation and limitation of activitiesPreferred Response: 5Recommended Reading(s):Schenck RC Jr, Goodnight JM: Osteochondritis dissecans. J Bone Joint Surg Am1996;78:439-456.Herring JA: Disorders of the knee, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics,ed 4. Philadelphia, PA, WB Saunders, 2008, pp 919-971.Question #: 102What muscle groups are weakest after antegrade intramedullary nailing of a midshaftfemoral fracture?1- Hamstrings and abductors2- Hamstrings and adductors3- Quadriceps and abductors4- Quadriceps and external rotators5- Abductors and external rotatorsPreferred Response: 3Recommended Reading(s):Kapp W, Lindsey RW, Noble PC, et al: Long-term residual musculoskeletal deficits afterfemoral shaft fractures treated with intramedullary nailing. J Trauma 2000;49:446-449.Archdeacon M, Ford KR, Wyrick J, et al: A prospective functional outcome and motionanalysis evaluation of the hip abductors after femur fracture and antegrade nailing. JOrthop Trauma 2008;22:3-9.
Question #: 103Which of the following surgical approaches to the hip uses an internervous plane?1- Posterolateral2- Posterior lateral (Moore)3- Anterior (Smith-Peterson)4- Anterolateral (Watson-Jones)5- Direct lateral (Hardinge)Preferred Response: 3Recommended Reading(s):Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip andKnee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons,2006, pp 311-321.Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach, ed2. Philadelphia, PA, Lippincott Williams & Wilkins, 1994, pp 325-335.Question #: 104Which of the following methods of antibiotic treatment has been associated with the highestsuccess rate in diabetic patients treated nonsurgically for osteomyelitis of the foot?1- Vancomycin IV antibiotic2- Dual drug oral antibiotics3- IV antibiotics based on a bone biopsy4- IV antibiotics based on a swab of the open wound5- IV antibiotics based on the hospital profile of the most common organismsPreferred Response: 3Recommended Reading(s):Senneville E, Lombart A, Beltrand E, et al: Outcome of diabetic foot osteomyelitis treatednonsurgically: A retrospective cohort study. Diabetes Care 2008;31:637-642.Lipsky BA: Infectious problems of the foot in diabetic patients, in Bowker JH, Pfeifer MA(eds): Levin and O’Neal’s The Diabetic Foot, ed 6. St Louis, MO, Mosby, 2001, pp 467-480.
Question #: 105Which of the following is considered the most important portion of the kinetic chain inprotecting the thrower’s elbow from valgus loads?1- Forearm pronation2- Scapular retraction3- Scapular protraction4- Glenohumeral internal rotation5- Glenohumeral external rotationPreferred Response: 4Recommended Reading(s):Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2002, pp 101-111.Marshall RN, Elliott BC: Long-axis rotation: The missing link in proximal-to-distalsequencing. J Sports Sci 2000;18:247-254.
Figure 106Question #: 106Figure 106 shows the MRI arthrogram of an 18-year-old football player who injured hisshoulder. What physical examination finding is most likely to demonstrate his pathology?1- Jerk test2- Gerber lift-off test3- O’Brien test4- Sulcus sign5- Apprehension signPreferred Response: 1Recommended Reading(s):Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2004, pp 53-77.Millett PJ, Clavert P, Hatch GF III, et al: Recurrent posterior shoulder instability. J Am AcadOrthop Surg 2006;14:464-467.
Question #: 107Which of the following findings on microscopy best characterizes the pathologic features oflateral epicondylitis?1- Giant cell infiltration2- Cystic degeneration with Rice bodies and fatty infiltration3- Localized hemorrhage with proliferation of neutrophils4- Fibroblast hypertrophy, disorganized collagen, and vascular hyperplasia5- Hypertrophic collagen fibers, mature fibroblasts, and frequent macrophagesPreferred Response: 4Recommended Reading(s):Kraushaar BS, Nirschl RP: Tendinosis of the elbow (tennis elbow): Clinical features andfindings of histological, immunohistochemical, and electron microscopy studies. J BoneJoint Surg Am 1999;81:259-278.Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow & Shoulder. Rosemont, IL,American Society for Surgery of the Hand, 2003, pp 271-284.Nirschl RP, Pettrone FA: Tennis elbow: The surgical treatment of lateral epicondylitis. JBone Joint Surg Am 1979;61:832-839.Question #: 108What method of terminal polyethylene sterilization results in the greatest number ofremaining free radicals within the polyethylene?1- Gas plasma2- Ethylene oxide3- Gamma irradiation4- Gamma irradiation and annealing5- Gamma irradiation and remeltingPreferred Response: 3Recommended Reading(s):Gordon AC, D’Lima DD, Colwell CW Jr: Highly cross-linked polyethylene in total hiparthroplasty. J Am Acad Orthop Surg 2006;14:511-523.McKellop H, Shen FW, Lu B, et al: Effect of sterilization method and other modifications onthe wear resistance of acetabular cups made of ultra-high molecular weight polyethylene: Ahip-simulator study. J Bone Joint Surg Am 2000;82:1708-1725.
Question #: 109Which of the following conditions has little or no published data to support the use of lockedplating techniques?1- Proximal intra-articular bicondylar tibia fracture2- Proximal humeral fracture3- Bicondylar distal femur fracture4- A geriatric periprosthetic fracture5- Hypertrophic humeral nonunion in a young malePreferred Response: 5Recommended Reading(s):Haidukewych GJ, Ricci W: Locked plating in orthopaedic trauma: A clinical update. J AmAcad Orthop Surg 2008;16:347-355.Question #: 110The halo vest is least effective at controlling which of the following spinal motions?1- Lateral bend2- Flexion3- Extension4- Axial rotation5- Axial distractionPreferred Response: 5Recommended Reading(s):Ivancic PC, Beauchman NN, Tweardy: Effect of halo-vest components on stabilizing theinjured cervical spine. Spine 2009;34:167-175.Johnson RM, Hart DL, Simmons EF, et al: Cervical orthoses: A study comparing theireffectiveness in restricting cervical motion in normal subjects. J Bone Joint Surg Am1977;59:332-339.
Question #: 111An 11-year-old girl has had neck pain for the past 6 months. She has had no neurologicsymptoms and is neurologically normal on physical examination. Cervical spine range ofmotion is normal. An open-mouth view and flexion and extension radiographs are seen inFigures 111a through 111c. What is the most appropriate treatment?1- Cessation of contact sports2- Decompressive laminectomy3- Anterior cervical spinal fusion4- Posterior cervical spinal fusion5- Anterior and posterior cervical spinal fusionPreferred Response: 4Recommended Reading(s):Reilly CW, Choit RL: Transarticular screws in the management of C1-C2 instability inchildren. J Pediatr Orthop 2006;26:582-588.Sankar WN, Wills BP, Dormans JP, et al: Os odontoideum revisited: The case for amultifactorial etiology. Spine 2006;31:979-984.Question #: 112A review of a patient’s AP pelvis and oblique (Judet) radiographs reveals that theiliopectineal line is intact, the ilioischial line is disrupted, and there is a fracture of theinferior pubic ramus. Based on these findings, what is the most likely acetabular fracturepattern?1- Transverse2- Transverse and posterior wall3- Posterior wall4- Posterior column5- T-typePreferred Response: 4Recommended Reading(s):Letournel E: Acetabulum fractures: Classification and management. Clin Orthop Relat Res1980;151:81-106.Patel V, Day A, Dinah F, et al: The value of specific radiological features in theclassification of acetabular fractures. J Bone Joint Surg Br 2007;89:72-76.
Question #: 113The most effective method for nonsurgical management of a chronic (symptoms lastinggreater than 3 months) flexible acquired adult flatfoot deformity is with which of thefollowing devices?1- UCBL orthosis2- Ankle-foot orthosis3- Patellar tendon-bearing orthosis4- Indepth shoe with total contact foot orthosis5- Indepth shoe with extended medial counter and medial flarePreferred Response: 2Recommended Reading(s):Alvarez, RG, Marini A, Schmitt C, et al: Stage I and II posterior tibial tendon dysfunctiontreated by a structured nonoperative management protocol: An orthosis and exerciseprogram. Foot Ankle Int 2006;27:2-8.Augustin JF, Lin SS, Berberian WS, et al: Nonoperative treatment of the adult acquired flatfoot with the Arizona brace. Foot Ankle Clin 2003;8:491-502.Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendondysfunction. Foot Ankle Int 1996;17:736-741.Question #: 114When performing a lateral column lengthening procedure with a posterior tibial tendonreconstruction for correction of an acquired adult flatfoot deformity, what procedure is alsocommonly required?1- Talar neck osteotomy2- Lengthening of the gastrocsoleus complex3- First metatarsophalangeal joint fusion4- Lateral ankle ligament reconstruction5- Peroneus longus to brevis tendon transferPreferred Response: 2Recommended Reading(s):Myerson MS: Adult acquired flatfoot deformity: Treatment of dysfunction of the posteriortibial tendon. Instr Course Lect 1997;46:393-405.Pinney SJ, Lin SS: Current concepts review: Acquired adult flatfoot deformity. Foot AnkleInt 2006;27:66-75.
Question #: 115The amount of energy per volume that a material can absorb prior to failure defines whichof the following terms?1- Toughness2- Failure point3- Viscoelasticity4- Fatigue strength5- Young’s modulusPreferred Response: 1Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 49-64.Chao EYS, Aro HT: Biomechanics of fracture fixation, in Mow VC, Hayes WC (eds): BasicOrthopaedic Biomechanics. New York, NY, Raven Press, 1991, pp 293-336.Question #: 116Which of the following postoperative modalities to prevent deep venous thrombosis isassociated with the highest risk of hematoma?1- Aspirin2- Dipyridamole3- Compression device4- Clopidogrel bisulfate5- Low-molecular-weight heparinPreferred Response: 5Recommended Reading(s):Dorr LD, Gendelman V, Maheshwari AV, et al: Multimodal thromboprophylaxis for total hipand knee arthroplasty based on risk assessment. J Bone Joint Surg Am 2007;89:2648-2657.Lee MC, Nickisch F, Limbird RS: Massive retroperitoneal hematoma during enoxaperantreatment of pulmonary embolism after primary total hip arthroplasty: Case-reports andreview of the literature. J Arthoroplasty 2006;21:1209-1214.
Figure 117a Figure 117b Figure 117cQuestion #: 117A 4-year-old girl has bowleg deformities. Radiographs of her lower and upper extremitiesare shown in Figures 117a through 117c. She is below the 25th percentile for height.Which of the following laboratory findings are most likely to be present?1- Normal serum Ca; low serum phosphate; elevated alkaline phosphatase2- Low serum Ca; normal serum phosphate; elevated alkaline phosphatase3- Low serum Ca; elevated serum phosphate; low alkaline phosphatase4- Elevated serum Ca; low serum phosphate; low alkaline phosphatase5- Elevated serum Ca; elevated serum phosphate; elevated alkaline phosphatasePreferred Response: 1Recommended Reading(s):Loeffler RD Jr, Sherman FC: The effect of treatment on growth and deformity inhypophosphatemic vitamin D-resistant rickets. Clin Orthop Relat Res 1982;162:4-10.Ferris B, Walker C, Jackson A, et al: The orthopaedic management of hypophosphatemicrickets. J Pediatr Orthop 1991;11:367-373.
Figure 118a Figure 118bQuestion #: 118What plating strategy provides the most optimal fixation for the fracture seen in Figures118a and 118b?1- Lateral locking plate2- Posteromedial plate3- Lateral buttress plate4- Anteromedial plate5- Medial and lateral platesPreferred Response: 2Recommended Reading(s):Georgiadis GM: Combined anterior and posterior approaches for complex tibial plateaufractures. J Bone Joint Surg Br 1994;76:285-289.Bhattacharyya T, McCarty LP III, Harris MB, et al: The posterior shearing tibial plateaufracture: Treatment and results via a posterior approach. J Orthop Trauma 2005;19:305-310.
Question #: 119In lateral epicondylitis, the area of tendinopathy is classically located at the origin of the1- anconeus.2- extensor digitorum.3- extensor carpi ulnaris.4- extensor carpi radialis longus.5- extensor carpi radialis brevis.Preferred Response: 5Recommended Reading(s):Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2002, pp 91-99.Nirschl RP, Pettrone FA: Tennis elbow: The surgical treatment of lateral epicondylitis. JBone Joint Surg Am 1979;61:832-839.Question #: 120Warfarin is commonly used to prevent deep venous thrombosis after total hip arthroplasty.What is its mechanism of action?1- Forms complexes with antithrombin III2- Inactivates active thrombin and active factor Xa3- Prevents conversion of fibrinogen to fibrin4- Prevents gamma carboxylation in factor X and prothrombin5- Prevents thromboxane A2 formation, interfering with platelet aggregationPreferred Response: 4Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 395-413.Lieberman JR, Hsu WK: Prevention of venous thromboembolic disease after total hip andknee arthroplasty. J Bone Joint Surg Am 2005;87:2097-2112.
Figure 121a Figure 121bQuestion #: 121Figures 121a and 121b show the radiographs of an otherwise healthy 42-year-old man whosustained a left ankle injury in a fall on stairs. The ankle is maintained in a position ofexternal rotation and proves irreducible with closed efforts under general anesthesia. Whatanatomic structure is serving as a hindrance to reduction?1- Peroneus longus2- Tibialis posterior3- Tibialis anterior4- Ruptured deltoid ligament5- Posterolateral tibial ridgePreferred Response: 5Recommended Reading(s):Beekman R, Watson JT: Bosworth fracture-dislocation and resultant compartmentsyndrome. J Bone Joint Surg Am 2003;85:2211-2214.Hoblitzell RM, Ebraheim NA, Merritt T, et al: Bosworth fracture-dislocation of the ankle: Acase report and review of the literature. Clin Orthop Relat Res 1990;255:257-262.Mayer PJ, Evarts CM: Fracture-dislocation of the ankle with posterior entrapment of thefibula behind the tibia. J Bone Joint Surg Am 1978;60:320-324.Perry CR, Rice S, Rao A, et al: Posterior fracture-dislocation of the distal part of the fibula:Mechanism and staging of injury. J Bone Joint Surg Am 1983;65:1149-1157.Szalay MD, Roberts JB: Compartment syndrome after Bosworth fracture-dislocation of theankle: A case report. J Orthop Trauma 2001;15:301-303.White SP, Pallister I: Fracture-dislocation of the ankle with fixed displacement of the fibulabehind the tibia-a rare variant. Injury 2002;33:292-294.
Figure 122Question #: 122Figure 122 shows the radiograph of a 66-year-old woman who reports right thumb pain.Examination reveals a positive grind test. The patient requests an injection, and she hasheard of off-label administration of hylan. You advise her that, for the relief of pain andimprovement in function, hylan offers which of the following outcomes?1- Better than placebo and better than corticosteroids2- Better than placebo but worse than corticosteroids3- Worse than placebo but better than corticosteroids4- Worse than placebo and worse than corticosteroids5- No better than placebo and no better than corticosteroidsPreferred Response: 5Recommended Reading(s):Heyworth BE, Lee JH, Kim PD, et al: Hylan versus corticosteroid versus placebo fortreatment of basal joint arthritis: A prospective, randomized, double-blinded clinical trial. JHand Surg Am 2008;33:40-48.Stahl S, Karsh-Zafrir I, Ratzon N, et al: Comparison of intraarticular injection of depotcorticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints.J Clin Rheumatol 2005;11:299-302.Henderson EB, Smith EC, Pegley F, et al: Intra-articular injections of 750 kD hyaluronan inthe treatment of osteoarthritis: A randomized single centre double-blinded placebo-controlled trial of 91 patients demonstrating lack of efficacy. Ann Rheum Dis 1994;53:529-534.
Figure 123a Figure 123bQuestion #: 123Figures 123a and 123b show the radiographs of a 57-year-old man who injured his foot in a5-foot fall into a ditch. The radiographs indicate what type of injury?1- Medial subtalar dislocation2- Lateral subtalar dislocation3- Calcaneocuboid joint dislocation4- Lisfranc subluxation5- Spring ligament rupturePreferred Response: 1Recommended Reading(s):Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 493-509.Bibbo C, Anderson RB, Davis WH: Injury characteristics and the clinical outcome ofsubtalar dislocations: A clinical and radiographic analysis of 25 cases. Foot Ankle Int2003;24:158-163.
Figure 124Question #: 124Figure 124 shows the lateral radiograph of a 24-year-old man who was involved in a motorvehicle accident. He reports axial back pain on arrival in the emergency department. Hehas no neurologic deficit nor complaints of paresthesia or pain in the lower extremities. Heis otherwise healthy and uninjured. His injury is best treated by which of the following?1- Open reduction and internal fixation2- Thoracolumbosacral orthosis with a thigh cuff3- Posterior spinal fusion with instrumentation4- Bed rest for 4 weeks followed by mobilization in a plaster body jacket5- Mobilization as tolerated with further treatment based on symptomsPreferred Response: 5Recommended Reading(s):O’Brien MF: Low-grade isthmic/lytic spondylolisthesis in adults. Instr Course Lect2003;52:511-524.Virta L, Ronnemaa T: The association of mild-moderate isthmic lumbar spondylolisthesisand low back pain in middle-aged patients is weak and it only occurs in women. Spine1993;18:1496-1503.
Question #: 125Type II (beta) errors in clinical studies are minimized by performing which of the following?1- Power analysis2- Bonferroni correction3- Mann-Whitney U test4- Logistical regression analysis5- Increase sample size by 20%Preferred Response: 1Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 87-101.Lochner HV, Bhandari M, Tornetta P III: Type-II error rates (beta errors) of randomizedtrials in orthopaedic trauma. J Bone Joint Surg Am 2001;83:1650-1655.Question #: 126What is the most common complication following a hip revision with isolated polyethyleneexchange for osteolysis?1- Infection2- Recurrent osteolysis3- Dislocation4- Heterotopic ossification5- Loosening of the acetabular componentPreferred Response: 3Recommended Reading(s):Boucher HR, Lynch C, Young AM, et al: Dislocation after polyethylene liner exchange intotal hip arthroplasty. J Arthroplasty 2003;18:654-657.Restrepo C, Ghanem E, Houssock C, et al: Isolated polyethylene exchange versusacetabular revision for polyethylene wear. Clin Orthop Relat Res 2009;467:194-198.
Question #: 127What is the first cell to appear following acute muscle injury?1- Neutrophils2- Monocytes3- Macrophages4- Fibroblasts5- MyoblastsPreferred Response: 1Recommended Reading(s):Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2004, pp 285-290.Tidball JG: Inflammatory cell response to acute muscle injury. Med Sci Sports Exerc1995;27:1022-1032.
Figure 128a Figure 128bQuestion #: 128A 50-year-old man sustains the injury shown in Figures 128a and 128b. The besttreatment of this fracture to prevent articular reduction loss is with a lateral plate, raftingscrews, and1- allograft.2- autograft.3- BMP-2.4- calcium phosphate cement.5- methylmethacrylate.Preferred Response: 4Recommended Reading(s):Baumgartner MR, Tornetta P III (eds): Orthopaedic Knowledge Update: Trauma 3.Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 419-429.Russell TA, Leighton RK: Comparison of autogenous bone graft and endothermic calciumphosphate cement for defect augmentation in tibial plateau fractures: A multicenter,prospective, randomized study. J Bone Joint Surg Am 2008;90:2057-2061.Lobenhoffer P, Gerich T, Witte F, et al: Use of an injectable calcium phosphate bonecement in the treatment of tibial plateau fractures: A prospective study of twenty-six caseswith twenty-month mean follow-up. J Orthop Trauma 2002;16:143-149.
Question #: 129A 12-year-old right-hand dominant boy has medial right elbow pain that is made worse byoverhand throwing. There are no mechanical symptoms. AP and lateral elbowradiographs and a T2-weighted MRI scan are shown in Figures 129a through 129c.Treatment should consist of1- corrective humeral osteotomy.2- screw fixation of the medial epicondyle.3- rest followed by a gradual return to activities.4- elbow arthroscopy and removal of the loose body.5- arthroscopic drilling of the osteochondral lesion.Preferred Response: 3Recommended Reading(s):Chen FS, Diaz VA, Loebenberg M, et al: Shoulder and elbow injuries in the skeletallyimmature athlete. J Am Acad Orthop Surg 2005;13:172-185.Limpisvasti O, ElAttrache NS, Jobe FW: Understanding shoulder and elbow injuries inbaseball. J Am Acad Orthop Surg 2007;15:139-147.
Figure 130Question #: 130Figure 130 shows the radiograph of a 68-year-old woman with type 2 diabetes mellitus whoreports a 2-week history of a plantar midfoot ulcer with exposed subcutaneous tissue.Pedal pulses are palpable, there is no exposed bone or tendon, and her blood glucoselevels have been stable. Which of the following is the most appropriate treatment?1- Wound swab for culture and administration of IV vancomycin2- Plantar midfoot exostectomy3- Application of a small wire multiplanar external fixator4- Application of a total contact cast5- Debridement and application of a vacuum-assisted wound closure devicePreferred Response: 4Recommended Reading(s):Wukich DK, Motko J: Safety of total contact casting in high-risk patients with neuropathicfoot ulcers. Foot Ankle Int 2004;25:556-560.Bowker JH, Pfeifer MA: Total contact casting in the treatment of neuropathic ulcers inBowker JH, Weir J, Pfeifer MA (eds): Levin and O’Neals’s The Diabetic Foot, ed 7. StLouis, MO, Mosby, 2007.
Question #: 131In the case of a mother (who is a carrier for Duchenne’s muscular dystrophy gene) and afather (who does not have the Duchenne’s muscular dystrophy gene), what is the chancethat the son will be affected by Duchenne’s muscular dystrophy?1- 25%2- 50%3- 75%4- 100%5- Unable to determine since the father may be a carrier.Preferred Response: 2Recommended Reading(s):Thomson WH: The biochemical identification of the carrier state in X-linked recessive(Duchenne) muscular dystrophy. Clin Chim Acta 1969;26:207-221.Question #: 132The immune response to metallic orthopaedic implants is typically what type?1- Type I (Ig-E mediated)2- Type II (antibody mediated)3- Type III (immune complex mediated)4- Type IV (delayed-type hypersensitivity reaction)5- Type V (Ig-M mediated)Preferred Response: 4Recommended Reading(s):Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology andBiomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy ofOrthopaedic Surgeons, 2000, pp 401-426.Hallab NJ, Mikecz K, Jacobs JJ: A triple assay technique for the evaluation of metal-induced, delayed-type hypersensitivity responses in patients with or receiving total jointarthroplasty. J Biomed Mater Res 2000;53:480-489.
Question #: 133A 32-year-old man reports shoulder stiffness following hospitalization for 8 weeks followinga polytrauma. Current radiographs show an anterior glenohumeral dislocation. A CT scanreveals 30% attritional bone loss from the anterior inferior glenoid. What is the mostappropriate treatment?1- Closed reduction under general anesthesia2- Closed reduction followed by arthroscopic Bankart repair3- Total shoulder arthroplasty4- Open reduction with Bankart repair5- Open reduction with bone augmentation of the glenoidPreferred Response: 5Recommended Reading(s):Shahajpal DT, Zuckerman JD: Chronic glenohumeral dislocation. J Am Acad Orthop Surg2008;16:385-398.Churchill S, Moskal M, Lippitt S, et al: Extrascapular anatomically contoured anteriorglenoid bone grafting for complex glenohumeral instability. Techniques in Shoulder &Elbow Surgery 2001;2:210-218.
Figure 134Question #: 134Figure 134 shows the radiograph of a 54-year-old man who underwent bilateral hipresurfacing 2 years ago and had been doing well until recently. He now describes rightgroin pain with ambulation and has 4/5 hip flexor strength on this side. What is the nextmost appropriate step in management?1- MRI scan of the lumbar spine2- Revision of the acetabular component3- Non-weight-bearing for 6 weeks with crutches4- Conversion to a conventional total hip arthroplasty5- Physical therapy to improve range of motion and strengthPreferred Response: 4Recommended Reading(s):Anglin C, Masri BA, Tonetti J, et al: Hip resurfacing femoral neck fracture influenced byvalgus placement. Clin Orthop Relat Res 2007;465:71-79.Hing C, Back D, Shimmin A: Hip resurfacing: Indications, results, and conclusions. InstrCourse Lect 2007;56:171-178.
Figure 135Question #: 135A 13-year-old boy was involved in a motor vehicle collision and sustained severe closedhead trauma as well as a minimally displaced pelvic fracture. The latter was treatednonsurgically. Two years later, the patient has improved greatly from his comatosecondition but his hip is fixed in a position of abduction and 40° of flexion, preventing himfrom sitting in a wheelchair. A radiograph is shown in Figure 135. If surgery iscontemplated to restore hip range of motion, what is the best way to prevent recurrentankylosis?1- Perioperative pamidronate2- Radiation of the surgical field immediately following surgery3- Meticulous washing of any bony debris after excision of the bar4- Complete excision of the proximal femur, including femoral head5- Intraoperative and postoperative prophylaxis with ketoralacPreferred Response: 2Recommended Reading(s):Board TN, Karva A, Board RE, et al: The prophylaxis and treatment of heterotopicossification following lower joint arthroplasty. J Bone Joint Surg Br 2007;89:434-440.Ayers DC, Pelegrini VD Jr, Evarts CM: Prevention of heterotopic ossification in high-riskpatients by radiation therapy. Clin Orthop Relat Res 1991;263:87-93.
Figure 136Question #: 136The injury shown in Figure 136 is most likely caused by what mechanism?1- Repetitive overhead throwing2- Forced external rotation with the arm at the side3- Fall onto an abducted, externally rotated shoulder4- Fall onto a forward flexed, internally rotated shoulder5- Impingement of the posterior rotator cuff on the posterosuperior labrumPreferred Response: 3Recommended Reading(s):Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 301-311.Sanders TG, Morrison WB, Miller MD: Imaging techniques for the evaluation ofglenohumeral instability. Am J Sports Med 2000;28:414-434.
Figure 137Question #: 137The structure identified by the arrow in Figure 137 represents the1- spur of the anterior column in its displaced position.2- spur of the posterior column in its displaced position.3- portion of the posterior wall in its displaced position.4- portion of the posterior ilium in its undisplaced position.5- portion of the posterior ilium in its displaced position.Preferred Response: 4Recommended Reading(s):Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Heidelberg, Germany,Springer-Verlag, 1981.Vrahas MS, Tile M: Fractures of the acetabulum, in Bucholz RW, Heckman JD (eds):Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams &Wilkins, 2001, pp 1513-1545.
Question #: 138A two-part olecranon fracture is fixed using Kirschner wires and a tension band.Postoperative radiographs show that the wires have penetrated the anterior cortex of theulna by 7 mm. Postoperative clinical examination reveals an inability to flex the thumbinterphalangeal joint and weak distal interphalangeal flexion of the index finger, but nosensory changes. The preoperative neurovascular examination was normal. The mostlikely cause of the postoperative examination findings is injury to which of the followingnerves?1- Ulnar2- Radial3- Median4- Posterior interosseous5- Anterior interosseousPreferred Response: 5Recommended Reading(s):Mekhail AO, Ebrahaim NA, Jackson WT, et al: Anatomic considerations for the anteriorexposure of the proximal portion of the radius. J Hand Surg Am 1996;21:794-801.Parker JR, Conroy J, Campbell DA: Anterior interosseous nerve injury following tensionband wiring of the olecranon. Injury 2005;36:1252-1253.Question #: 139Which of the following bone morphogenetic proteins (BMP) exhibits no osteogenic activity?1- BMP22- BMP33- BMP44- BMP65- BMP7Preferred Response: 2Recommended Reading(s):Bahamonde ME, Lyons KM: BMP3: To be or not to be a BMP. J Bone Joint Surg Am2001;83:S56-S62.Daluiski A, Engstrand T, Bahamonde ME, et al: Bone morphogenetic protein-3 is anegative regulator of bone density. Nat Genet 2001;27:84-88.Cheng H, Jiang W, Phillips FM, et al: Osteogenic activity of the fourteen types of humanbone morphogenetic proteins (BMPs). J Bone Joint Surg Am 2003;85:1544-1552.
Figure 140Question #: 140Figure 140 shows the radiograph of a 72-year-old woman who fell 4 weeks afterundergoing an elective primary total hip arthroplasty. She was pain free until her fall.Treatment should now consist of1- femoral revision.2- acetabular and femoral revision.3- non-weight-bearing in an abduction orthosis.4- open reduction and internal fixation with a locking plate.5- open reduction and internal fixation with cerclage cables.Preferred Response: 1Recommended Reading(s):O’Shea K, Quinlan JF, Kutty S, et al: The use of uncemented extensively porous-coatedfemoral components in the management of Vancouver B2 and B3 periprosthetic femoralfractures. J Bone Joint Surg Br 2005;87:1617-1621.Sledge JB III, Abiri A: An algorithm for the treatment of Vancouver type B2 periprostheticproximal femoral fractures. J Arthroplasty 2002;17:887-892.
Figure 141Question #: 141A 3-year-old girl is brought to the emergency department because she is unable to walk.Her mother indicates that she may have fallen while playing the day before and has criedand not walked since then. She is hard to examine but there is little visible swelling andshe seems to react more to pressure over the tibia. Knee motion appears normal. Cryingensues with dorsiflexion of the ankle. Radiographs are shown in Figure 141. What is themost appropriate management?1- Immobilization in a long leg cast2- Intramedullary nailing3- MRI of the lower extremity4- Laboratory studies including CBC count, erythrocyte sedimentation rate, CRP, andblood cultures, followed by antibiotic treatment5- Notification of child protective services and initiation of a work-up for suspected childabusePreferred Response: 1Recommended Reading(s):Mashru RP, Herman MJ, Pizzutillo PD: Tibial shaft fractures in children and adolescents. JAm Acad Orthop Surg 2005;13:345-352.Heinreich SD: Fractures of the shaft of the tibia and fibula, in Beaty JH, Kasser JR (eds):Rockwood and Wilkins’ Fractures in Children, ed 5. Philadelphia, PA, Lippincott Williams &Wilkins, 2001, pp 1077-1111.Mellick LB, Reesor K, Demers D, et al: Tibial fractures of young children. Pediatr EmergCare 1988;4:97-101.
Figure 142Question #: 142A 21-year-old collegiate baseball pitcher reports a 6-month history of posterior shoulderpain with ball release. Examination reveals external rotation of 110° and internal rotation of35° with the shoulder at 90° of abduction. The area of pathology is demonstrated in the CTscan shown in Figure 142. What is the most likely cause of his symptoms?1- Glenohumeral osteoarthritis2- Superior labral tear3- Bankart lesion4- Bennett lesion5- Hill-Sachs lesionPreferred Response: 4Recommended Reading(s):Galatz LM (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2008, pp 125-133.Wright RW, Paletta GA Jr: Prevalence of the Bennett lesion of the shoulder in major leaguepitchers. Am J Sports Med 2004;32:121-124.
Figure 143Question #: 143The initial injury responsible for the shoulder pathology shown in Figure 143 is typically bestdiagnosed on what radiographic view?1- Axillary2- Serendipity3- Supraspinatus outlet4- AP of the acromioclavicular joint5- AP of the shoulderPreferred Response: 1Recommended Reading(s):Sanders TG, Morrison WB, Miller MD: Imaging techniques for the evaluation ofglenohumeral instability. Am J Sports Med 2000;28:414-434.Sanders TG, Miller MD: A systematic approach to magnetic resonance imaginginterpretation of sports medicine injuries of the shoulder. Am J Sports Med 2005;33:1088-1105.
Question #: 144Marginal impaction associated with a posterior wall acetabular fracture is best appreciatedon which of the following imaging studies?1- AP pelvis radiograph2- Obturator oblique radiograph3- Iliac oblique radiograph4- CT5- False profile view of the hipPreferred Response: 4Recommended Reading(s):Kellam JF, Messer A: Evaluation of the role of coronal and sagittal axial CT scanreconstructions for the imaging of acetabular fractures. Clin Orthop Relat Res1994;305:152-159.Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Springer-Verlag, 1993, pp29-61.Question #: 145A physician recently completed his/her residency and began practice in a three-membergroup. The physician has been having difficulty attracting new patients and beganadvertising in the local paper and personal web site as a surgeon that can perform “pain-free” minimally invasive knee arthroplasty on all patients. Are these actions appropriate?1- No, physicians should not market or promote their skills.2- No, the Federal Trade Commission prohibits false advertising.3- No, the physician did not receive specific fellowship training in adult reconstruction.4- Yes, these actions are appropriate provided the physician has had a patient that hadminimal pain after surgery.5- Yes, these actions are appropriate because the physician trained at an institution thatperformed minimally invasive knee surgery.Preferred Response: 2Recommended Reading(s):AAOS Opinion Statement: Opinions on Ethics and Professionalism. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2007.http://www.aaos.org/about/papers/ethics/1205eth.asp. Accessed on July 24, 2009.Capozzi JD: Physician advertising: Evaluation of a sample advertisement. J Bone JointSurg Am 2007;89:2089-2091.
Question #: 146Which of the following conditions is most commonly associated with postaxial polydactyly ofthe hand?1- Fanconi’s anemia2- Radial deficiency3- Ulnar deficiency4- Thrombocytopenia5- Positive family history of polydactylyPreferred Response: 5Recommended Reading(s):Kozin SH: Upper-extremity congenital anomalies. J Bone Joint Surg Am 2003;85:1564-1576.
Figure 147Question #: 147Without a history of a significant reinjury, a 22-year-old student reports recurrent instability1 year after undergoing autologous patellar tendon anterior cruciate ligamentreconstruction. A radiograph is seen in Figure 147. What is the most likely cause of theinstability?1- Varus alignment2- Tunnel malposition3- Failure of biological graft ingrowth4- Failure of bone healing in the tunnels5- Unrecognized posterolateral corner injuryPreferred Response: 2Recommended Reading(s):Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2004, pp 169-181.Pinczewski LA, Salmon LJ, Jackson WF, et al: Radiological landmarks for placement oftunnels in single-bundle reconstruction of the anterior cruciate ligament. J Bone Joint SurgBr 2008;90:172-179.
Question #: 148A 76-year-old man reports progressive bilateral lower extremity pain over the past 6 monthsdespite physical therapy. He has a sense of fatigue of the lower extremities withambulation. He has replaced his prior workout regime of treadmill ambulation withstationary bicycling. Examination reveals normal motor strength in both lower extremitieswith 2+ pedal pulses. Radiographs and MRI scans are shown in Figures 148a through148e. What intervention is most likely to reduce his pain level and improve his functionalstatus?1- A daily program of home lumbar traction2- A series of transforaminal epidural steroid injections3- Laminotomy and microdiskectomy at L4/5 bilaterally4- Laminectomy and partial facetectomies with foraminotomies of L4/55- Laminectomy, partial facetectomies, and foraminotomies with posterior spinal fusionfrom L4/L5Preferred Response: 4Recommended Reading(s):Weinstein JN, Tosteson TD, Lurie JD, et al: Surgical versus nonsurgical therapy for lumbarspinal stenosis. New Eng J Med 2008;358:794-810.Malmivaara A, Slatis P, Heliovaara M, et al: Surgical or nonoperative treatment for lumbarspinal stenosis? A randomized controlled trial. Spine 2007;32:1-8.Atlas SJ, Keller RB, Wu YA, et al: Long-term outcomes of surgical and nonsurgicalmanagement of lumbar spinal stenosis: 8 to 10 year results from the main lumbar spinestudy. Spine 2005;30:936-943.
Question #: 149Marfan syndrome demonstrates what type of inheritance pattern?1- Autosomal dominant2- Autosomal recessive3- X-linked dominant4- X-linked recessive5- Germline mutationPreferred Response: 1Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 25-47.McBride A, Gargan M: Marfan syndrome. Current Orthopaedics 2006;20:418-423.Question #: 150A 17-year-old volleyball player has pain and weakness in her dominant shoulder withoverhead use during her most recent season. She has been able to voluntarily subluxatethe shoulder since the age of 10 and has no history of direct trauma to the shoulder.Appropriate management at this time should include1- open capsular shift.2- arthroscopic rotator interval closure.3- thermal capsulorrhaphy.4- shoulder stabilization bracing.5- initiation of a dynamic stabilization therapy program.Preferred Response: 5Recommended Reading(s):Lee SB, Kim KJ, O’Driscoll SW, et al: Dynamic glenohumeral stability provided by therotator cuff muscles in the mid-range and end-range of motion: A study of cadavera. JBone Joint Surg Am 2000;82:849-857.Schenk TJ, Brems JJ: Multidirectional instability of the shoulder: Pathophysiology,diagnosis, and management. J Am Acad Orthop Surg 1998;6:65-72.
Figure 151Question #: 151A 10-month-old boy has been irritable with diaper changes and not been moving his rightlower extremity for the past 3 days. His parents report that he had a fever 3 days ago, forwhich antibiotics were prescribed by his pediatrician. Examination reveals the patient crieson any attempted movement of the right lower extremity. A radiograph of the pelvis isshown in Figure 151. Management of this patient should include1- aspiration of the hip.2- observation.3- application of a Pavlik harness.4- open reduction and proximal femoral osteotomy.5- admission to the hospital for bed rest, traction, and anti-inflammatory medication.Preferred Response: 1Recommended Reading(s):Stans AA: Osteomyelitis and septic arthritis, in Morrissy RT, Weinstein SL (eds): Lovell andWinter’s Pediatric Orthopaedics, ed 6. Philadelphia, PA, Lippincott Williams & Wilkins,2006, pp 39-491.Sucato DJ, Schwend RM, Gillespie R: Septic arthritis of the hip in children. J Am AcadOrthop Surg 1997;5:249-260.
Figure 152Question #: 152A newborn infant is brought to the office with the features shown in Figure 152. Manychildren with this condition have multiple systemic anomalies. Which of the following bodysites is most likely to have associated abnormalities?1- Vertebral complex2- Renal system3- Cardiac system4- Hematopoetic system5- Central nervous systemPreferred Response: 4Recommended Reading(s):Maschke SD, Seitz W, Lawton J: Radial longitudinal deficiency. J Am Acad Orthop Surg2007;15:41-52.Goldfarb CA, Wustrack R, Pratt JA, et al: Thumb function and appearance inthrombocytopenia: Absent radius syndrome. J Hand Surg Am 2007;32:157-161.Goldfarb CA, Wall L, Manske PR: Radial longitudinal deficiency: The incidence ofassociated medical and musculoskeletal conditions. J Hand Surg Am 2006;31:1176-1182.
Question #: 153What surgical technique will improve a flexion-extension mismatch in a revision total kneearthroplasty when the knee is stable in extension and loose in flexion?1- Remove additional tibial bone2- Insert a full block tibial augment3- Use distal femoral augments4- Downsize the femoral component5- Translate the femoral component posteriorlyPreferred Response: 5Recommended Reading(s):Peters CL: Soft-tissue balancing in primary total knee arthroplasty. Instr Course Lect2006;55:413-417.Question #: 154The mechanism of action of functional electrical stimulation in the rehabilitation of patientswith a spinal cord injury is via direct stimulation of the1- spinal cord.2- nerve roots.3- motor cortex.4- cauda equina.5- skeletal muscles.Preferred Response: 5Recommended Reading(s):Mulcahey MJ, Betz RR, Smith BT, et al: Implanted functional electrical stimulation handsystem in adolescents with spinal injuries: An evaluation. Arch Phys Med Rehabil1997;78:597-607.Davis SE, Mulcahey MJ, Smith BT, et al: Self-reported use of an implanted FES handsystem by adolescents with tetraplegia. J Spinal Cord Med 1998;21:220-226.
Figure 155a Figure 155bQuestion #: 155The radiograph of a 46-year-old woman with hip dysplasia is seen in Figure 155a. Sheundergoes total hip arthroplasty and a postoperative radiograph is shown in Figure 155b.On postoperative day two she reports the inability to dorsiflex her foot when she is sitting ina chair after physical therapy. What is the most appropriate management?1- IV methylprednisolone 30 mg/kg2- Remain seated and place the operative leg on a stool3- MRI/CT to evaluate for a hematoma4- Transfer to bed with the head of the bed elevated to at least 60°5- Transfer to bed with the bed level and the knee on the operative side flexedPreferred Response: 5Recommended Reading(s):Eggli S, Hankemayer S, Muller ME: Nerve palsy after leg lengthening in total replacementarthroplasty for developmental dysplasia of the hip. J Bone Joint Surg Br 1999;81:843-845.Farrell CM, Springer BD, Haidukewych GJ, et al: Motor nerve palsy following primary totalhip arthroplasty. J Bone Joint Surg Am 2005;87:2619-2625.
Figure 156Question #: 156A 59-year-old woman reports the insidious onset of left forefoot pain and swelling over thepast 4 weeks. A radiograph is shown in Figure 156. What is the next most appropriatestep in management?1- MRI2- Reassurance that this will resolve with time3- Walker boot application and evaluation for metabolic bone disease4- Walker boot application and administration of calcium and vitamin D supplements5- Noninvasive bone stimulator with pulsed electromagnetic fieldPreferred Response: 3Recommended Reading(s):Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 189-196.Bogoch ER, Elliot-Gibson V, Beaton DE, et al: Effective initiation of osteoporosis diagnosisand treatment for patients with a fragility fracture in an orthopaedic environment. J BoneJoint Surg Am 2006;88:25-34.
Figure 157Question #: 157Figure 157 shows the radiograph of a 30-year-old individual who sustained a noncontactsoccer injury 2 days ago. What physical examination test is most likely to be abnormal?1- McMurray2- Lachman3- Posterior drawer4- Varus laxity at 30°5- Patellar apprehensionPreferred Response: 2Recommended Reading(s):Bathala EA, Bancroft LW, Ortiguera CJ, et al: Radiologic case study: Segond fracture.Orthopedics 2007;30:689, & 797-798.DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia,PA, WB Saunders, 2002, p 1643.
Question #: 158A 13-month-old boy has had right hip irritability for the last 36 hours. He is febrile and haspain with motion of the right hip. He holds the hip flexed, abducted, and externally rotated.Aspiration of the hip reveals a WBC count of 70,000 cells per mL of fluid. What is the nextstep in treatment?1- Arthroscopic debridement2- Emergent arthrotomy3- Arthrotomy after MRI is obtained4- Repeat aspiration in 12 hours while awaiting definitive culture results5- Administration of IV antibiotics with reevaluation in 24 hoursPreferred Response: 2Recommended Reading(s):Sucato DJ, Schwend RM, Gillespie R: Septic arthritis of the hip in children. J Am AcadOrthop Surg 1997;5:249-260.Caird MS, Flynn JM, Leung YL, et al: Factors distinguishing septic arthritis from transientsynovitis of the hip in children: A prospective study. J Bone Joint Surg Am 2006;88:1251-1257.
Question #: 159A patient undergoes surgical fixation of an articular fracture of the distal tibia. A clearlyinappropriate approach and improper implant selection results in an infected nonunion andimplant failure. The patient pursues a second opinion and questions if the standard of carehas been breached. The second physician has what type of obligation when answering thepatient’s question?1- Legal but not ethical2- Ethical but not legal3- Neither legal nor ethical4- Both legal and ethical5- No clear guidelines exist regarding appropriate ethical and legal responsePreferred Response: 2Recommended Reading(s):Bhattacharyya T, Yeon HL: “Doctor, was this surgery done wrong?” Ethical issues inproviding second opinions. J Bone Joint Surg Am 2005;87:223-225.Hébert PC, Levin AV, Robertson G: Bioethics for clinicians: 23: Disclosure of medical error.CMAJ 2001;164:509-513.Riddick FA Jr: American Medical Association Council on Ethical and Judicial Affairs. Codeof medical ethics: Current opinions with annotations. Chicago, IL, American MedicalAssociation, The Ochsner Journal, 2003, Vol 5, Issue 2.Riddick FA Jr: American Medical Association Counsel: Reporting impaired, incompetent, orunethical colleagues. Chicago, IL, The Ochsner Journal, Spring 2003, Vol 5, Issue 2, p247.
Figure 160Question #: 160A patient sustains a fracture of the acetabulum. An axial CT scan is shown in Figure 160.What structure takes origin from the region depicted by the arrow?1- Pectineus2- Sartorius3- Iliopectineal fascia4- Direct (straight) head of the rectus femoris5- Indirect (reflected) head of the rectus femorisPreferred Response: 4Recommended Reading(s):Pan H, Kawanabe K, Akiyama H, et al: Operative treatment of hip impingement caused byhypertrophy of the anterior inferior iliac spine. J Bone Joint Surg Br 2008;90:677-679.Hoppenfeld S, deBoer P: The hip and acetabulum, in Hoppenfeld S, deBoer P (eds):Surgical Exposures in Orthopaedics, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins,2003, pp 365-453.
Question #: 161A 12-year-old boy reports left foot pain for the past 2 months that he attributes to jumpingoff a bunk bed. He denies any penetrating injury to his heel and the skin over the plantarsurface is intact. He has pain with walking and has no fever. Examination reveals swellingof the hindfoot and tenderness to direct palpation of the left heel. Laboratory studies showa WBC of 11,000/mm3 (normal 3,500-10,500/mm3), and an erythrocyte sedimentation rateof 45 mm/h (normal up to 20 mm/h). Radiographs and a MRI are shown in Figures 161athrough 161c. A culture of material obtained following a needle aspiration of the calcaneusis most likely to yield which of the following organisms?1- Kingella kingae2- Staphylococcus aureus3- Streptococcus pyogenes4- Pseudomonas aeruginosa5- Mycobacterium tuberculosisPreferred Response: 2Recommended Reading(s):Blyth MJ, Kincaid R, Craigne MA, et al: The changing epidemiology of acute and subacutehematogenous osteomyelitis in children. J Bone Joint Surg Br 2001;83:99-102.Karwowska A, Davies HD, Jadavji T: Epidemiology and outcome of osteomyelitis in the eraof sequential intravenous-oral therapy. Pediatr Infect Dis J 1998;17:1021-1026.Puffinbarger WR, Gruel CR, Herndon WA, et al: Osteomyelitis of the calcaneus in children.J Pediatr Orthop 1996;16:224-230.
Question #: 162Which of the following tendon ruptures is associated with rheumatoid degeneration of thedistal radioulnar joint?1- Flexor carpi ulnaris2- Flexor digitorum profundus to the little finger3- Flexor digitorum superficialis to the little finger4- Extensor digiti minimi5- Extensor pollicis longusPreferred Response: 4Recommended Reading(s):Vaughn-Jackson OJ: Rupture of extensor tendons by attrition at the inferior radioulnar joint:Report of two cases. J Bone Joint Surg Am 1948;30:528-530.Williamson SC, Feldon P: Extensor tendon ruptures in rheumatoid arthritis. Hand Clin1995;11:449-459.Question #: 163Which of the following best describes an associated both column fracture of theacetabulum?1- A fracture through the acetabular dome involving both columns2- A fracture of the articular surface involving both columns with no articular surfaceremaining attached to the intact posterior ilium3- A separation of the posterior articular surface and attached ilium from the anteriorarticular surface and column4- A central fracture of the articular surface that separates the articular surfaces of theposterior and anterior acetabulum5- An articular fracture across both columns with extension into the obturator fossa andthrough the ischiumPreferred Response: 2Recommended Reading(s):Letournel E, Judet R: Fractures of the Acetabulum. New York, NY, Springer-Verlag, 1993,pp 253-254.Vrahas MS, Tile M: Fractures of the acetabulum, in Bucholz RW, Heckman JD (eds):Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams &Wilkins, 2001, pp 1513-1545.
Question #: 164A 32-year-old man sustains an incomplete spinal cord injury characterized by ipsilateralimpaired motor function and proprioception, and decreased contralateral pain andtemperature sensation. What is the most likely clinical syndrome?1- Anterior cord2- Central cord3- Lateral cord4- Posterior cord5- Brown-SequardPreferred Response: 5Recommended Reading(s):Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 49-65.Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2006, pp 179-187.Question #: 165Polymorphisms in the genes for the calcitonin receptor, estrogen receptor-1, type I collagenalpha-1 chain, or the vitamin D receptor have been shown to be associated with which ofthe following bone diseases?1- Osteopetrosis2- Osteoporosis3- Osteomalacia4- Vitamin D-deficient rickets5- X-linked hypophosphatemic ricketsPreferred Response: 2Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 25-47.Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 415-426.
Question #: 166What aspect of the fracture pattern may not be adequately addressed when using a laterallocking plate for the treatment of the fracture seen in Figures 166a through 166d?1- Posteromedial fragment2- Posterolateral fragment3- Fibular head fracture4- Anteromedial fragment depressed fragment5- Lateral wall comminutionPreferred Response: 1Recommended Reading(s):Barei DP, O’Mara TJ, Taitsman LA, et al: Frequency and fracture morphology of theposteromedial fragment in bicondylar tibial plateau fracture patterns. J Orthop Trauma2008;22:176-182.Higgins TF, Kemper D, Klatt J: Incidence and morphology of the posteromedial fragment inbicondylar tibial plateau fractures. J Orthop Trauma 2009;23:45-51.Higgins TF, Klatt J, Bachus KN: Biomechanical analysis of bicondylar tibial plateau fixation:How does lateral locking plate fixation compare to dual plate fixation? J Orthop Trauma2007;21:301-306.
Question #: 167Inhibition of what family of proteins has become the basis for a new approach to targetedchemotherapy for a wide variety of human cancers?1- Tyrosine kinases2- Tumor necrosis factors (TNFs)3- Bone morphogenetic proteins (BMPs)4- Fibroblast growth factor (FGF) family5- Transforming growth factor (TGF)-beta familyPreferred Response: 1Recommended Reading(s):Shawver LK, Slamon D, Ullrich A: Smart drugs: Tyrosine kinase inhibitors in cancertherapy. Cancer Cell 2002;1:117-123.Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 379-393.Question #: 168Fractures of the anteromedial process of the coronoid can lead to medial elbow instabilityand early arthritis because of injury at the attachment site of the1- anterior capsule.2- annular ligament.3- anterior bundle of the medial collateral ligament.4- posterior bundle of the medial collateral ligament.5- transverse bundle of the medial collateral ligament.Preferred Response: 3Recommended Reading(s):Steinmann SP: Coronoid process fracture. J Am Acad Orthop Surg 2008;16:519-529.Ring D: Fractures of the coronoid process of the ulna. J Hand Surg Am 2006;31:1679-1689.
Question #: 169The greatest difference in strength between unicortical locked screws and bicortical lockedscrews is seen in what loading conditions?1- Torsion2- Axial compression3- 3-point bending4- 4-point bending5- Cantilever bendingPreferred Response: 1Recommended Reading(s):Roberts JW, Grindel SI, Rebholz B, et al: Biomechanical evaluation of locking plate radialshaft fixation: Unicortical locking fixation versus mixed bicortical and unicortical fixation in asawbone model. J Hand Surg Am 2007;32:971-975.Fulkerson E, Egol KA, Kubiak EN, et al: Fixation of diaphyseal fractures with a segmentaldefect: A biomechanical comparison of locked and conventional plating techniques. JTrauma 2006;60:830-835.Question #: 170A complete spinal cord injury after a cervical fracture-dislocation is best characterized bywhich of the following clinical scenarios?1- Inability to elevate both arms to perform feeding and self care2- Absent bowel and bladder control or perirectal sensation3- Absent voluntary motor function but retained proprioceptive and vibratory sensation inthe lower extremities4- Absent distal motor function with flaccid rectal tone and no bulbocavernosus reflex5- Absent distal motor function and sensation with absent rectal tone and an intactbulbocavernosus reflexPreferred Response: 5Recommended Reading(s):Kirshblum S, Campagnolo D, DeLisa J: Spinal Cord Medicine. Philadelphia, PA, LippincottWilliams & Wilkins, 2002.American Spinal Injury Association/International Medical Society of Paraplegia.International standards for neurological and functional classification of spinal cord injurypatients. Chicago, IL, 2000.Neurological assessment: The motor examination in Ditunno JF, Donovan WH, MaynaredFM (eds): Reference Manual for the International Standards for Neurological andFunctional Classification of Spinal Cord Injury. Chicago, IL, American Spinal InjuryAssociation, 1994.
Question #: 171Which of the following preoperative findings in a patient with cerebral palsy best predictsimprovement in function after wrist and hand tendon transfer surgery?1- Good sensation2- Dystonic features3- Improvement in resting tone after botulinum injections4- Full passive range of motion5- Voluntary control of motionPreferred Response: 5Recommended Reading(s):Van Heest AE, House JH, Cariello C: Upper extremity surgical treatment of cerebral palsy.J Hand Surg Am 1999;24:323-330.Van Heest AE. Surgical management of wrist and finger deformity. Hand Clin2003;19:657-665.Question #: 172The lowest hip joint reactive forces are present when the acetabular component is placed inwhat position?1- Superior and medial2- Superior and lateral3- Inferior and medial4- Inferior and lateral5- Acetabular location does not have an effectPreferred Response: 3Recommended Reading(s):Johnston RC, Brand RA, Crowninshield RD: Reconstruction of the hip: A mathematicalapproach to determine optimum geometric relationships. J Bone Joint Surg Am1979;61:639-652.
Question #: 173The mechanism of injury of the fracture seen in Figures 173a through 173c is bestdescribed as1- pronation external rotation.2- pronation abduction.3- supination external rotation.4- supination adduction.5- supination internal rotation.Preferred Response: 2Recommended Reading(s):Marsh JL, Saltzman CL: Ankle fractures, in Rockwood and Green’s Fractures in Adults, ed6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, pp 2147-2247.Siegel J, Tornetta P III: Extraperiosteal plating of pronation-abduction ankle fractures. JBone Joint Surg Am 2007;89:276-281.
Question #: 174At long-term follow-up (more than 25 years after the initial procedure), infants with clubfootwho were treated with extensive soft-tissue release demonstrate1- joint stiffness only at the subtalar joint.2- good long-term function if treated before age 1 year.3- outcomes unrelated to the extent of the soft-tissue release.4- muscle weakness primarily in the peroneal muscles.5- poor long-term foot function, with the degree of impairment related to the extent of thesoft-tissue release.Preferred Response: 5Recommended Reading(s):Dobbs MB, Nunley R, Schoenecker PL: Long-term follow-up of patients with clubfeettreated with extensive soft-tissue release. J Bone Joint Surg Am 2006;88:986-996.Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 741-756.Question #: 175Of the available osteoconductive bone graft substitutes, which is most rapidly resorbed?1- Calcium sulfate2- Calcium phosphate3- Tricalcium phosphate4- Coralline hydroxyapatite5- Collagen-based matricesPreferred Response: 1Recommended Reading(s):Walsh WR, Morberg P, Yu Y, et al: Response of a calcium sulfate bone graft substitute in aconfined cancellous defect. Clin Orthop Relat Res 2003;406:228-236.Watson JT: The use of an injectable bone graft substitute in tibial metaphyseal fractures.Orthopedics 2004;27:S103-S107.Bucholz RW: Nonallograft osteoconductive bone graft substitutes. Clin Orthop Relat Res2002;395:44-52.Kelly CM, Wilkins RM, Gitelis S, et al: The use of a surgical grade calcium sulfate as abone graft substitute: Results of a multicenter trial. Clin Orthop Relat Res 2001;382:42-50.Tay BK, Patel VV, Bradford DS: Calcium sulfate- and calcium phosphate-based bonesubstitutes: Mimicry of the mineral phase of bone. Orthop Clin North Am 1999;30:615-623.
Figure 176Question #: 176When treating the fracture shown in Figure 176 with intramedullary nailing, in what positionwould a blocking screw help prevent an apex anterior deformity?1- Anterior to the nail in the distal fragment2- Anterior to the nail in the proximal fragment3- Anterior to the nail in the proximal fragment and posterior to the nail in the distalfragment4- Posterior to the nail in the proximal fragment5- Posterior to the nail in the distal fragmentPreferred Response: 4Recommended Reading(s):Krettek C, Stephan C, Schandelmaier P, et al: The use of Poller screws as blocking screwsin stabilizing tibial fractures treated with small diameter intramedullary nails. J Bone JointSurg Br 1999;81:963-968.Ricci WM, O’Boyle M, Borrelli J, et al: Fractures of the proximal third of the tibial shafttreated with intramedullary nails and blocking screws. J Orthop Trauma 2001;15:264-270.
Question #: 177When performing open reduction and internal fixation, absolute stability at the fracture siteis best achieved with a1- locking plate in “bridging” mode.2- single interfragmentary lag screw and neutralization plate.3- long standard plate with widely spaced screws placed in a neutral position.4- ring external fixator.5- reamed intramedullary nail with good endosteal contact.Preferred Response: 2Recommended Reading(s):Ito K, Perren SM: Biology and biomechanics in bone healing, in Rüedi TP, Buckley RE,Moran CG (eds): AO Principles of Fracture Management, ed 2. Boston, MA, AOPublishing, 2007, pp 9-31.Claes LE, Heigele CA: Magnitudes of local stress and strain along bone surfaces predictthe course and type of fracture healing. J Biomech 1999;32:255-266.
Figure 178a Figure 178bQuestion #: 178A 15-year-old boy injured his right elbow in a fall. Radiographs are shown in Figures 178aand 178b. Treatment should consist of1- open reduction and internal fixation of the fracture.2- open reduction of the elbow joint and removal of the loose body, followed by earlymotion of the elbow.3- closed reduction and percutaneous pin fixation of the fracture.4- immobilization for 3 weeks, followed by gradual mobilization.5- arthroscopic excision of the loose body, followed by early elbow motion.Preferred Response: 1Recommended Reading(s):Lee HH, Shen HC, Chang JH, et al: Operative treatment of displaced medial epicondylefractures in children and adolescents. J Shoulder Elbow Surg 2005;14:178-185.Farsetti P, Potenza V, Caterini R, et al: Long-term results of treatment of fractures of themedial humeral epicondyle in children. J Bone Joint Surg Am 2001;83:1299-1305.
Question #: 179Rheumatoid factors are antibodies directed against1- multiple immunoglobulins.2- IgA.3- IgE.4- IgM.5- IgG.Preferred Response: 5Recommended Reading(s):Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy ofOrthopaedic Surgeons, 2005, pp 229-244.James D, Young A, Kulinskaya E, et al: Early Rheumatoid Arthritis Study Group (ERAS).Orthopaedic intervention in early rheumatoid arthritis: Occurrence and predictive factors inan inception cohort of 1064 patients followed for 5 years. United Kingdom, Rheumatology(Oxford) 2004;43:369-376.Question #: 180Which of the following is an inhibitor of particle-induced osteolysis?1- Interleukin-1 alpha2- Interleukin-63- Osteoprotegerin4- Tumor necrosis factor (TNF)-alpha5- Receptor-activator of nuclear factor KB(RANK) ligandPreferred Response: 3Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 365-377.Jacobs JJ, Roebuck KA, Archibeck M, et al: Osteolysis: Basic science. Clin Orthop RelatRes 2001;393:71-77.
Question #: 181Which of the following nonsurgical treatment techniques has the strongest supportingevidence as an effective treatment for osteoarthritis of the knee?1- Acupuncture2- Intra-articular injection of hyaluronan3- Unloading knee brace4- Weight loss5- Range of motion and flexibility exercisesPreferred Response: 4Recommended Reading(s):AAOS Clinical Guideline on the Treatment of Osteoarthritis of the Knee (Non-Arthroplasty).Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008.http://www.aaos.org/research/guidelines/GuidelineOAKnee.asp. Accessed on July 24,2009.Question #: 182Which of the following best describes the contour and vertical position of the lateral tibialplateau relative to the medial?1- Symmetric in contour and vertical position2- More concave-shaped and situated more proximal3- More concave-shaped and situated more distal4- More convex-shaped and situated more proximal5- More convex-shaped and situated more distalPreferred Response: 4Recommended Reading(s):Watson T, Schatzker J: Tibial plateau fractures, in Browner BD, Jupiter JB, Levine AM(eds): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 2074-2130.Egol KA, Koval KJ: Fractures of the proximal tibia in, Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults, ed 6. Philadelphia, PA, Lippincott Williams & Wilkins,2001, pp 1999-2029.Hashemi J, Chandrashekar N, Gill B, et al: The geometry of the tibial plateau and itsinfluence on the biomechanics of the tibiofemoral joint. J Bone Joint Surg Am2008;90:2724-2734.
Question #: 183During the posterior approach to the humerus, where is the radial nerve found relative tothe triceps muscle?1- Superficial to all heads2- Medial to the long, lateral, and deep heads3- Medial to the long and lateral heads and proximal to the deep head4- Medial to the long head and superficial to the lateral and deep heads5- Medial to the lateral head, superficial to the long head, and proximal to the deep headPreferred Response: 3Recommended Reading(s):Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics. Philadelphia, PA, LippincottWilliams & Wilkins, 1984, pp 58-63.Martini FH, Timmons MJ, Tallitsch RB: Human Anatomy, ed 5. San Francisco, CA,Pearson/Benjamin Cummings, 2006, pp 300-302.Question #: 184A 56-year-old woman with end-stage arthritis undergoes a primary total knee arthroplastywith a standard posterior stabilized knee implant. Preoperatively she had a 10° flexioncontracture with 120° of flexion. A postoperative radiograph demonstrates well-alignedimplants and full extension on the lateral radiograph. At 4 weeks postoperatively she has a10° flexion contracture. What is the most likely cause of her residual contracture?1- Hamstring tightness and spasm2- Oversized femoral implant3- Overstuffing the patellofemoral space4- Inability to reach terminal extension preoperatively5- Use of standard knee implants instead of gender-specific implantsPreferred Response: 1Recommended Reading(s):Bellemans J, Vandenneucker H, Victor J, et al: Flexion contracture in total kneearthroplasty. Clin Orthop Relat Res 2006;452:78-82.
Figure 185Question #: 185Given the data in Figure 185, the positive predictive value of the new meniscus test isexpressed as which of the following times 100?1- A+B/A+B+C+D2- A/A+B3- D/C+D4- A/A+C5- D/B+DPreferred Response: 4Recommended Reading(s):Wojtys EM, Greenfield ML, Kuhn JE: A statistics primer: Statistical thermology-part 2. Am JSports Med 1996;24:564-565.Kuhn JE, Greenfield ML, Wojtys EM: A statistics primer: Prevalence, incidence, relativerisks, and odds ratios: Some epidemiologic concepts in the sports medicine literature. AmJ Sports Med 1997;25:414-416.
Figure 186Question #: 186In the fracture shown in Figure 186, which of the following radiographic views of the elbowis most likely to accurately show the maximum degree of displacement of the fracturefragment?1- Lateral2- Anteroposterior3- Internal oblique4- External oblique5- PosteroanteriorPreferred Response: 3Recommended Reading(s):Song KS, Kang CH, Min BW, et al: Internal oblique radiographs for diagnosis ofnondisplaced or minimally displaced lateral humeral condylar fractures of the humerus inchildren. J Bone Joint Surg Am 2007;89:58-63.Bast SC, Hoffer MM, Aval S: Nonoperative treatment for minimally and non-displacedlateral humeral condyle fractures in children. J Pediatr Orthop 1998;18:448-450.
Question #: 187A 24-year-old man sustained an open tibia fracture in a motorcycle accident. What patientor injury factor has the highest relative odds for amputation of the limb?1- Fracture classification/pattern2- Associated open foot fracture3- Severity of the muscle injury4- History of alcohol abuse5- Type of medical insurancePreferred Response: 3Recommended Reading(s):MacKenzie EJ, Bosse MJ, Kellam JF, et al: Factors influencing the decision to amputate orreconstruct after high-energy lower extremity trauma. J Trauma 2002;52:641-649.Question #: 188Which of the following nerves serves as an anatomic landmark leading to the radial nerveduring a paratricipital approach for humeral shaft fracture fixation?1- Musculocutaneous2- Lateral antebrachial cutaneous3- Medial antebrachial cutaneous4- Medial brachial cutaneous5- Posterior antebrachial cutaneousPreferred Response: 5Recommended Reading(s):Gerwin M, Hotchkiss RN, Weiland AJ: Alternative operative exposures of the posterioraspect of the humeral diaphysis, with reference to the radial nerve. J Bone Joint Surg Am1996;78:1690-1695.Zlotolow DA, Catalano LW III, Barron OA, et al: Surgical exposures of the humerus. J AmAcad Orthop Surg 2006;14:754-765.
Question #: 189What is the most common deformity seen after intramedullary nailing of a proximal tibiafracture?1- Varus and apex anterior angulation2- Varus and apex posterior angulation3- Valgus and apex anterior angulation4- Valgus and apex posterior angulation5- Valgus and external rotationPreferred Response: 3Recommended Reading(s):Freedman EL, Johnson EE: Radiographic analysis of tibial fracture malalignment followingintramedullary nailing. Clin Orthop Relat Res 1995;315:25-33.Lang GJ, Cohen BE, Bosse MJ, et al: Proximal third tibial shaft fractures: Should they benailed? Clin Orthop Relat Res 1995;315:64-74.
Figure 190a Figure 190bQuestion #: 190The patient whose MRI scans are seen in Figures 190a and 190b has a 4-week history oflower extremity weakness and imbalance with ambulation. Examination showshyperreflexia and clonus in the lower extremities. What is the best treatment option?1- Laminectomy2- Physical therapy3- Epidural injection4- Anterior diskectomy5- Observation and pain medicationsPreferred Response: 4Recommended Reading(s):Bohlman HH, Zdeblick TA: Anterior excision of herniated thoracic discs. J Bone Joint SurgAm 1988;70:1038-1047.Currier BL, Eismont FJ, Green BA: Transthoracic disc excision and fusion for herniatedthoracic discs. Spine 1994;19:323-328.
Figure 191a Figure 191bQuestion #: 191Figures 191a and 191b show the radiographs of a 55-year-old man who elects to undergosurgery for chronically dislocated second and third metatarsophalangeal joints. Followingextensor tenotomies and complete capsular releases, the toes continue to dislocate. Whatis the next most appropriate step in treatment?1- Flexor tenotomies2- Amputation of the second toe3- Metatarsal head resections4- Metatarsal shortening osteotomies5- Osteotomies of the proximal phalanxPreferred Response: 4Recommended Reading(s):Coughlin MJ: Lesser-toe abnormalities. J Bone Joint Surg Am 2002;84:1446-1469.Trinka HJ, Muhlbauer M, Zettl R, et al: Comparison of the results of the Weil and Helalosteotomies for the treatment of metatarsalgia secondary to dislocation of the lessermetatarsophalangeal joints. Foot Ankle Int 1999;20:72-79.
Question #: 192When using a tension band technique for fixation of a simple transverse olecranon fracture,gentle active motion of the elbow produces what type of forces across the fracture at thelevel of the articular surface?1- Tension2- Shear3- Compression4- Bending5- No load - the implants and fixation neutralize the fracture from loadPreferred Response: 3Recommended Reading(s):Jupiter JB: AO Manual of Fracture Management: Hand and Wrist. Boston, MA, AOPublishing, 2006.Chandler RW: Principles of internal fixation, in Bucholz RW, Heckman JD (eds): Rockwoodand Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins,2001, pp 181-229.Question #: 193Osteosarcoma most commonly develops in which of the following locations?1- Pelvis2- Distal humerus3- Proximal tibia4- Proximal femur5- Proximal humerusPreferred Response: 3Recommended Reading(s):Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont,IL, American Academy of Orthopaedic Surgeons, 2002, pp 175-186.Mankin HJ, Hornicek FJ, Rosenberg AE, et al: Survival data for 648 patients withosteosarcoma treated at one institution. Clin Orthop Relat Res 2004;429:286-291.
Figure 194a Figure 194bQuestion #: 194Figures 194a and 194b show the radiographs of a 25-year-old woman who reports that asoftball impacted the tip of her middle finger. Which of the following factors is the mostimportant determinant of final functional outcome?1- Stable internal fixation2- Continuous passive motion in the postoperative period3- Anatomic reduction of the middle phalanx articular surface4- Reattachment of the volar plate to the base of the middle phalanx5- Reduction of the middle phalanx on the condyles of the proximal phalanxPreferred Response: 5Recommended Reading(s):Kiefhaber TR, Stern PJ: Fracture dislocations of the proximal interphalangeal joint. J HandSurg Am 1998;23:368-380.Dias JJ: Intra-articular injuries of the distal and proximal interphalangeal joints, in BergerRA, Weiss APC (eds): Hand Surgery. Philadelphia, PA, Lippincott Williams & Wilkins,2004, pp 153-174.
Question #: 195When comparing a retrograde insertion technique to an antegrade insertion technique fortreatment of femoral shaft fractures, the retrograde technique has a greater incidence of1- union.2- nonunion.3- malunion.4- hip pain.5- knee pain.Preferred Response: 5Recommended Reading(s):Ricci WM, Bellobarba C, Evanoff B, et al: Retrograde versus antegrade nailing of femoralshaft fractures. J Orthop Trauma 2008;22:S31-S38.Winquist RA, Hansen ST Jr, Clawson DK: Closed intramedullary nailing of femoralfractures: A report of five hundred and twenty cases. J Bone Joint Surg Am 1984;66:529-539.Moed BR, Watson JT, Cramer KE, et al: Unreamed retrograde intramedullary nailing offractures of the femoral shaft. J Orthop Trauma 1998;12:334-342.Question #: 196A 16-year-old male soccer player collapses on the field. What is the most likely cause ofsudden cardiac death in this case?1- Aortic stenosis2- Mitral valve prolapse3- Dilated cardiomyopathy4- Hypertrophic cardiomyopathy5- Arrhythmogenic right ventricular dysplasiaPreferred Response: 4Recommended Reading(s):Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2004, pp 311-321.Basillico FC: Cardiovascular disease in athletes. Am J Sports Med 1999;27:108-121.
Figure 197a Figure 197bQuestion #: 197A 19-year-old man has had a 6-month history of progressive left hip pain. He has takenibuprofen continuously for the past 3 months, stating that it provides complete but transientrelief. An AP radiograph and CT scan are shown in Figures 197a and 197b. What is thenext most appropriate step in management?1- Biopsy2- Crutches3- Chest imaging4- En bloc resection5- Percutaneous ablationPreferred Response: 5Recommended Reading(s):Lee EH, Shafi M, Hui JH: Osteoid osteoma: A current review. J Pediatr Orthop2006;26:695-700.Moser T, Giacomelli MC, Clavert JM, et al: Image-guided laser ablation of osteoid osteomain pediatric patients. J Pediatr Orthop 2008;28:265-270.
Question #: 198Early (less than 5 days) rather than late (10-14 days) open reduction and internal fixation ofcomplex acetabular fractures is beneficial because it is most likely to result in which of thefollowing?1- Less blood loss2- Reduced surgical time3- Reduced incidence of deep venous thrombosis4- Reduced risk of neurologic injury5- Improved fracture reductionPreferred Response: 5Recommended Reading(s):Baumgaertner MR, Tornetta P III (eds): Orthopaedic Knowledge Update: Trauma 3.Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 271-280.Plaisier BR, Meldon SW, Super DM, et al: Improved outcome after early fixation ofacetabular fractures. Injury 2000;31:81-84.
Figure 199a Figure 199bQuestion #: 199Figures 199a and 199b show the MRI scans of a man who reports cervical pain with right-sided upper extremity radiating pain. His neurologic examination is most likely to showwhich of the following deficits?1- Weakness in the deltoid with no reflex abnormality and diminished sensation over theupper shoulder2- Weakness in the elbow flexors with a diminished biceps reflex and loss of sensationover the lateral arm3- Weakness in the triceps with decreased triceps reflex and diminished sensationinvolving the middle finger4- Weakness in the elbow flexors with a decreased brachioradialis reflex and diminishedsensation over the thumb and index finger5- Weakness in the interossei with no reflex change and diminished sensation over themedial border of the hand and forearmPreferred Response: 3Recommended Reading(s):Heller JG: The syndromes of degenerative cervical disease. Orthop Clin North Am1992;23:381-394.Zeidman S: Evaluation of patients with cervical spine lesions, in Clark CR, Benzel EZ,Currier BL, et al (eds): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams &Wilkins, 2004, pp 149-165.
Figure 200a Figure 200bQuestion #: 200An obese 60-year-old woman with type 2 diabetes mellitus has a painless swollen foot.Radiographs are shown in Figures 200a and 200b. Which of the following is most likelyassociated with this foot deformity?1- Acute trauma2- Morbid obesity3- Peripheral neuropathy4- Peripheral vascular disease5- Plantar fascial rupturePreferred Response: 3Recommended Reading(s):Brodsky JW: The diabetic foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot andAnkle, ed 7. St Louis, MO, Mosby, 1999, pp 895-969.Guyton GP, Saltzman CL: The diabetic foot: Basic mechanism of disease. J Bone JointSurg Am 2001;83:1083-1096.
Question #: 201When performing a transfemoral amputation, what surgical technique has the greatestimpact on functional outcome?1- Iliotibial band release2- Adductor myodesis3- Primary wound closure4- A posterior-based skin flap5- An anterior-based skin flapPreferred Response: 2Recommended Reading(s):Pinzur MS, Gottschalk F, Pinto MA, et al: Controversies in lower extremity amputation.Instr Course Lect 2008;57:663-672.Pinzur MS, Bowker JH, Smith DG, et al: Amputation surgery in peripheral vascular disease.Instr Course Lect 1999;48:687-691.Question #: 202What clinical scenario is a contraindication for use of a constrained acetabular liner?1- Patient with a cup in 40° of abduction and 25° of anteversion2- Patient with a cup in 60° of abduction and 5° of retroversion3- Neurologic decline4- Absent abductor mechanism5- When used in combination with an acetabular reconstruction cagePreferred Response: 2Recommended Reading(s):Callaghan JJ, O’Rourke MR, Goetz DD, et al: Use of a constrained tripolar acetabular linerto treat intraoperative instability and postoperative dislocation after total hip arthroplasty: Areview of our experience. Clin Orthop Relat Res 2004;429:117-123.Soong M, Rubash HE, Macaulay W: Dislocation after total hip arthroplasty. J Am AcadOrthop Surg 2004;12:314-321.
Question #: 203A 12-year-old girl reports a history of right foot pain and recurrent right ankle sprains. AP,lateral, and oblique foot radiographs are shown in Figures 203a through 203c.Immobilization in a short leg cast for 6 weeks has failed to provide significant pain relief.Treatment should now consist of1- subtalar fusion with internal fixation.2- extra-articular subtalar fusion with allograft.3- triple arthrodesis.4- combined cuboid-cuneiform osteotomy.5- excision of the calcaneal navicular coalition with interposition of extensor digitorumbrevis muscle.Preferred Response: 5Recommended Reading(s):Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.Cowell HR, Elener V: Rigid painful flatfoot secondary to tarsal coalition. Clin Orthop RelatRes 1983;177:54-60.Swiontkowski MF, Scranton PE, Hansen S: Tarsal coalitions: Long-term results of surgicaltreatment. J Pediatr Orthop 1983;3:287-292.
Figure 204Question #: 204What is the best treatment option for the injury to the ankle shown in Figure 204?1- Closed reduction and a total contact cast2- Open reduction and internal fixation of the fibula only3- Open reduction and internal fixation of the fibula and syndesmotic fixation4- Open reduction and internal fixation of the fibula and repair of the deltoid ligament5- Open reduction and internal fixation of the fibula, repair of the deltoid ligament, andsyndesmotic fixationPreferred Response: 3Recommended Reading(s):Zalavras C, Thordarson D: Ankle syndesmotic injury. J Am Acad Orthop Surg2007;15:330-339.Marsh JL, Saltzman CL: Ankle fractures, in Bucholz RW, Heckman JD (eds): Rockwoodand Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins,2001, pp 2001-2090.
Question #: 205When evaluating patients after severe lower extremity injuries, what subscale of theSickness Impact Profile does not improve with time?1- Work2- Recreation3- Psychosocial4- Physical function5- Household managementPreferred Response: 3Recommended Reading(s):Bosse MJ, MacKenzie EJ, Kellam JF, et al: An analysis of outcomes of reconstruction oramputation of leg-threatening injuries. N Engl J Med 2002;347:1924-1931.MacKenzie EJ, Morris JA Jr, Jurkovich GJ, et al: Return to work following injury: The role ofeconomic, social, and job-related factors. Am J Public Health 1998;88:1630-1637.
Figure 206a Figure 206bQuestion #: 206Figures 206a and 206b show the MRI scans of a 39-year-old woman with a 2-month historyof right-sided leg pain radiating down the posterior aspect of the thigh and onto the sole ofthe foot. Her pain has improved only slightly over time despite a caudal epidural steroidinjection and oral anti-inflammatory drugs, as well as physical therapy. What intervention ismost likely to provide the greatest pain relief at this time?1- Spinal manipulation2- Repeat caudal epidural steroid injection3- Laminotomy and diskectomy of the L5/S1 level4- Lumbar diskectomy and interbody fusion at L5-S15- Posterior instrumented lumbar spine fusion across the L5/S1 disk with a right-sidedlaminectomy of L5Preferred Response: 3Recommended Reading(s):Weinstein JN, Lurie JD, Tosteson TD, et al: Surgical vs nonoperative treatment for lumbardisk herniation: The Spine Patient Outcomes Research Trial (SPORT) observationalcohort. JAMA 2006;296:2451-2459.Weinstein JN, Tosteson TD, Lurie JD, et al: Surgical vs nonoperative treatment for lumbardisk herniation: The Spine Patient Outcomes Research Trial (SPORT): A randomized trial.JAMA 2006;296:2441-2450.Weber H: Lumbar disc herniation: A controlled, prospective study with ten years ofobservation. Spine 1983;8:131-140.
Question #: 207Figures 207a through 207c show the radiographs and CT scan of an otherwise healthy 42-year-old man who sustained a displaced right talar neck fracture in a motor vehicleaccident. Reduction and fixation are performed through a medial approach withanteromedial compression screws. What motion is most significantly compromised?1- Ankle dorsiflexion2- Ankle plantar flexion3- Ankle axial rotation4- Foot eversion5- Foot inversionPreferred Response: 4Recommended Reading(s):Daniels TR, Smith JW, Ross TI: Varus malalignment of the talar neck: Its effect on theposition of the foot and on subtalar motion. J Bone Joint Surg Am 1996;78:1559-1567.Herscovici D Jr, Anglen JO, Archdeacon M, et al: Avoiding complications in the treatment ofpronation-external rotation ankle fractures, syndesmotic injuries, and talar neck fractures. JBone Joint Surg Am 2008;90:898-908.Sanders DW, Busam M, Hattwick E, et al: Functional outcomes following displaced talarneck fractures. J Orthop Trauma 2004;18:265-270.
Figure 208Question #: 208A nonambulatory 7-year-old girl with spastic quadriplegia has hip abduction of 30° on theright and 10° on the left. An AP pelvis radiograph is shown in Figure 208. Treatmentshould consist of1- full-time hip abduction bracing.2- observation, with follow-up AP pelvis radiographs in 1 year.3- administration of botulinum toxin to the hip adductors bilaterally, followed by physicaltherapy.4- bilateral hip adductor releases without osteotomy, followed by abduction bracing.5- bilateral varus derotation femoral osteotomies in conjunction with bilateral hip adductorreleases.Preferred Response: 5Recommended Reading(s):Flynn JM, Miller F: Management of hip disorders in patients with cerebral palsy. J Am AcadOrthop Surg 2002;10:198-209.Spiegel DA, Flynn JM: Evaluation and treatment of hip dysplasia in cerebral palsy. OrthopClin North Am 2006;37:185-196.
Question #: 209A patient with an open mid-diaphyseal tibial shaft fracture undergoes debridement,unreamed tibial nailing, and soleus flap coverage. Radiographs obtained 6 monthsfollowing the injury reveal a hypertrophic nonunion. The most appropriate treatment is1- open reduction and plate fixation using iliac crest bone graft.2- open reduction and plate fixation using bone morphogenetic protein.3- exchanged reamed tibial nailing.4- exchanged reamed tibial nailing with iliac crest bone graft.5- exchanged reamed tibial nailing with bone morphogenetic protein.Preferred Response: 3Recommended Reading(s):Brinker MR, O’Connor DP: Exchange nailing of ununited fractures. J Bone Joint Surg Am2007;89:177-188.Zelle BA, Gruen GS, Klatt B, et al: Exchange reamed nailing for aseptic nonunion of thetibia. J Trauma 2004;57:1053-1059.Question #: 210A 45-year-old man sustained a humeral shaft fracture. Examination reveals no wristextension, no thumb extension, and absent sensation in the first dorsal webspace.Interphalangeal finger extension is noted to be present. What extensor function isexpected to be regained first with neurologic recovery?1- Elbow2- Thumb3- Metacarpophalangeal joint4- Wrist in neutral5- Wrist in radial deviationPreferred Response: 5Recommended Reading(s):Abrams RA, Ziets RJ, Lieber RL, et al: Anatomy of the radial nerve motor branches in theforearm. J Hand Surg Am 1997;22:232-237.Branovacki G, Hanson M, Cash R, et al: The innervation pattern of the radial nerve at theelbow and in the forearm. J Hand Surg Br 1998;23:167-169.
Figure 211Question #: 211Which of the following is considered a risk factor for recurrence following surgical correctionof the hallux valgus deformity shown in Figure 211?1- Resection of the lateral sesamoid2- Correction using a proximal osteotomy3- Undercorrection of the widened 1-2 intermetatarsal angle4- Overcorrection of the widened 1-2 intermetatarsal angle5- Overtightening of the medial metatarsophalangeal joint capsulePreferred Response: 3Recommended Reading(s):Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2004, pp 3-15.Mann RA, Coughlin MJ: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of theFoot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 150-269.
Figure 212Question #: 212A 42-year-old man sustained a shoulder injury after falling from a ladder. The MRI scanshown in Figure 212 reveals an injury to the structure marked with a white asterisk (*).Which of the following physical examination findings will most likely reveal weakness in thispatient?1- Shoulder external rotation with the arm at the side2- Shoulder abduction3- Belly-press maneuver4- Forward elevation in the scapular plane5- Elbow flexionPreferred Response: 3Recommended Reading(s):Sanders TG, Miller MD: A systematic approach to magnetic resonance imaginginterpretation of sports medicine injuries of the shoulder. Am J Sports Med 2005;33:1088-1105.Tennent TD, Beach WR, Meyers JF: A review of the special tests associated with shoulderexamination: Part I: The rotator cuff tests. Am J Sports Med 2003;31:154-160.
Question #: 213Eight weeks after undergoing open reduction and internal fixation of a C3 distal humerusfracture, a 55-year-old man has persistent limited range of motion (40° to 90°) despiteparticipating in an outpatient physical therapy program. Radiographs demonstrate partialhealing without other abnormalities. What is the next most appropriate step inmanagement?1- Open capsular release2- Arthroscopic scar releases3- Static turnbuckle splinting4- More active-assisted therapy sessions5- A continuous passive motion devicePreferred Response: 3Recommended Reading(s):Gelinas JJ, Faber KJ, Patterson SD, et al: The effectiveness of turnbuckle splinting forelbow contractures. J Bone Joint Surg Br 2000;82:74-78.Doornberg JN, Ring D, Jupiter JB: Static progressive splinting for posttraumatic elbowstiffness. J Orthop Trauma 2006;20:400-404.Question #: 214Intramedullary pressure and marrow embolization is greatest during what procedure?1- Reaming for a femoral nail2- Placement of an unreamed femoral nail3- Pressurization of cement for a total hip arthroplasty4- Impaction of a cementless total hip arthroplasty5- Broaching for a cementless total hip arthroplastyPreferred Response: 3Recommended Reading(s):Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology andBiomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy ofOrthopaedic Surgeons, 2000, pp 307-316.Dobrjanski D, Saghir Z, Behdinan K, et al: Intramedullary canal pressure distribution: Anexperimental parametric study. J Arthroplasty 2007;22:417-427.
Question #: 215The Heuter-Volkmann Law is summarized best by which of the following statements?1- Bone remodels in response to mechanical stimuli.2- Bone formation is induced in an electronegative zone and resorbed in anelectropositive zone.3- Compression across the growth plate slows longitudinal growth.4- Tensile load across the growth plate increases longitudinal growth.5- The bending strength of diaphyseal bone is determined by its diameter raised to thethird power.Preferred Response: 3Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 115-127.Stokes IA: Mechanical effects on skeletal growth. J Musculoskelet Neuronal Interact2002;2:277-280.Question #: 216Treatment of infectious mononucleosis in young athletes is guided by attempts to preventwhat potential complication of infection?1- Splenic rupture2- Pneumothorax3- Hemorrhagic cystitis4- Dilated cardiomyopathy5- Acute tubular necrosis of the kidneyPreferred Response: 1Recommended Reading(s):Committee on Sports Medicine and Fitness: American Academy of Pediatrics: Medicalconditions affecting sports participation. Pediatrics 2001;107:1205-1209.Farley DR, Zietlow SP, Bannon MP, et al: Spontaneous rupture of the spleen due toinfectious mononucleosis. Mayo Clin Proc 1992;67:846-853.
Question #: 217Figure 217a shows an AP pelvis radiograph of a patient with an acetabular fracture.Figures 217b through 217e are successive axial CT scan cuts through this fracturedacetabulum. The fracture fragment labeled A in Figure 217d represents the1- posterior wall fragment of a transverse/posterior wall acetabular fracture.2- posterior wall fragment of a posterior wall acetabular fracture.3- posterior column fragment of a posterior column acetabular fracture.4- proximal (posterior/superior) fragment of a transverse acetabular fracture.5- distal fragment of a both column acetabular fracture.Preferred Response: 4Recommended Reading(s):Letournel E, Judet R: Associated transverse and posterior wall fractures, in Letournel F,Judet R (eds): Fractures of the Acetabulum, ed 2. Berlin, Heidelberg, Springer-Verlag,1993, pp 201-221.Reilly MC: Fractures of the acetabulum, in Rockwood and Green’s Fractures in Adults, ed6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, pp 1665-1714.
Question #: 218When performing a posterior approach to the hip, what structure protects the anteriorretractor from causing damage to the iliac vessels?1- Psoas2- Piriformis3- Rectus femoris4- Obturator externus5- Obturator internusPreferred Response: 1Recommended Reading(s):Skaggs DL, Kaminsky CK, Eskander-Rickards E, et al: Psoas over the brim lengthenings:Anatomic investigation and surgical technique. Clin Orthop Relat Res 1997;339:174-179.Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach, ed2. Philadelphia, PA, Lippincott Williams & Wilkins, 1994, pp 385-387.Question #: 219After a total shoulder arthroplasty, which of the following activities should be avoided in thefirst 6 weeks to prevent failure of the subscapularis repair?1- Reaching at waist level2- Picking up a cup of coffee3- Passive elevation to shoulder level4- Pushing oneself up from a chair5- Performing pendulum exercisesPreferred Response: 4Recommended Reading(s):Arroyo JS: Surgical technique and results, in Crosby LA (ed): Total Shoulder Arthroplasty.Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 27-37.Wirth MA, Rockwood CA Jr: Complications of total shoulder-replacement arthroplasty. JBone Joint Surg Am 1996;78:603-616.
Figure 220a Figure 220bQuestion #: 220What factor most closely correlates with failure of fixation after reduction and cannulatedscrew fixation of the fracture seen in Figures 220a and 220b?1- Surgery after 24 hours2- Use of three screws3- 7-mm spread of screws on the lateral view4- Varus malreduction5- Early postoperative weight bearingPreferred Response: 4Recommended Reading(s):Swiontkowski MF: Intracapsular fractures of the hip. J Bone Joint Surg Am 1994;76:129-138.Haidukewych GJ, Rothwell WS, Jacofsky DJ, et al: Operative treatment of femoral neckfractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am2004;86:1711-1716.
Question #: 221A 16-year-old girl has a large, painful anterior ankle mass. Radiographs, MRI scans, andbiopsy specimens are shown in Figures 221a through 221f. What is the most likelydiagnosis?1- Blastomycosis2- Synovial sarcoma3- Myositis ossificans4- Parosteal osteosarcoma5- Pigmented villonodular synovitisPreferred Response: 5Recommended Reading(s):Bickels J, Isaakov J, Kollender Y, et al: Unacceptable complications following intra-articularinjection of yttrium-90 in the ankle joint for diffuse pigmented villonodular synovitis. J BoneJoint Surg Am 2008;90:326-328.Sharma H, Jane MJ, Reid R: Pigmented villonodular synovitis of the foot and ankle: Fortyyears of experience from the Scottish bone tumor registry. J Foot Ankle Surg 2006;45:329-336.
Question #: 222Which of the following factors has the greatest effect on the rate of implant cutout followingfixation of an intertrochanteric hip fracture with a sliding hip screw implant?1- Length of the sliding hip screw barrel2- Angle of the sliding hip screw device3- Tip-apex distance4- Accuracy of reduction5- Whether the sliding hip screw device is constrained or nonconstrainedPreferred Response: 3Recommended Reading(s):Baumgaertner MR, Solberg BD: Awareness of tip-apex distance reduces failure of fixationof trochanteric fractures of the hip. J Bone Joint Surg Br 1997;79:969-971.Templeman D, Baumgaertner MR, Leighton RK, et al: Reducing complications in thesurgical treatment of intertrochanteric fractures. Instr Course Lect 2005;54:409-415.Question #: 223In what position should the lower limb be placed during open reduction and internal fixationof the acetabulum to minimize tension on the sciatic nerve?1- Hip flexion and knee flexion2- Hip flexion and internal rotation3- Hip extension and knee extension4- Hip extension and knee flexion5- Hip external rotation and knee flexionPreferred Response: 4Recommended Reading(s):Borrelli J Jr, Kantor J, Ungacta F, et al: Intraneural sciatic nerve pressures relative to theposition of the hip and knee: A human cadaveric study. J Orthop Trauma 2000;14:255-258.
Figure 224a Figure 224bQuestion #: 224Figures 224a and 224b show the clinical photographs of a 15-month-old boy who has anouttoeing gait. Examination reveals an external foot-progression angle of 20° and a neutralthigh-hindfoot angle. What is the most likely cause of his outtoeing?1- Excessive femoral anteversion2- Excessive external tibial torsion3- Slipped capital femoral epiphyses4- External rotation contracture of the hips5- Bilateral developmentally dislocated hipsPreferred Response: 4Recommended Reading(s):Lincoln TL, Suen PW: Common rotational variations in children. J Am Acad Orthop Surg2003;11:312-320.Abel MF: Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2006, pp 3-12.
Question #: 225A 42-year-old woman has an enlarging mass in her foot and she reports that recently it hasbecome painful to stand on. T1- and T2-weighted MRI scans are shown in Figures 225aand 225b. Figure 225c shows a biopsy specimen. What immunohistochemical marker ismost likely positive?1- S1002- CD993- Cytokeratin4- PTH5- Estrogen receptor betaPreferred Response: 5Recommended Reading(s):Deyrup AT, Tretiakova M, Montag AG: Estrogen receptor-beta expression inextraabdominal fibromatoses: An analysis of 40 cases. Cancer 2006;106:208-213.Weiss SW, Goldblum JR: Enzinger and Weiss’ Soft Tissue Tumors, ed 5. Philadelphia,PA, Mosby Elsevier, 2008, pp 237-246.
Figure 226Question #: 226Figure 226 shows the clinical photograph of a 5-month-old girl who has a flexible deformityof her toe. What is the most appropriate management?1- Observation2- Genetics consultation3- Syndactylization to the adjacent toe4- Daily taping and stretching of the toe5- Epiphyseolysis of the bracket epiphysisPreferred Response: 1Recommended Reading(s):Sweetnam R: Congenital curly toes: An investigation into the value of treatment. Lancet1958;2:398-400.Kasser JR: The foot, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s PediatricOrthopaedics, ed 6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, pp 1257-1328.
Question #: 227A 45-year-old patient reports wrist pain and swelling following a fall from a ladder.Radiographs show a perilunate dislocation. Examination reveals an intact motor exam butslightly diminished two-point discrimination in the median nerve distribution. What is thenext most appropriate step in management?1- Closed reduction2- Open reduction because the lunate is usually irreducible due to a button-hole tear inthe capsule3- CT to rule out an occult scaphoid fracture prior to reduction4- MRI to identify specific ligament tears and rule out an occult scaphoid fracture5- ObservationPreferred Response: 1Recommended Reading(s):Melone CP Jr, Murphy MS, Raskin KB: Perilunate injuries: Repair by dual dorsal and volarapproaches. Hand Clin 2000;16:439-448.Kozin SH: Perilunate injuries: Diagnosis and treatment. J Am Acad Orthop Surg1998;6:114-120.Question #: 228The use of BMP-2 has been shown to lead to fewer reoperations in what clinical scenario?1- Acute open tibia fractures treated with intramedullary nails2- Acute open tibia fractures treated with external fixators3- Metaphyseal proximal tibia fractures treated with locking plates4- Tibial nonunions treated with plates5- Tibial nonunions treated with intramedullary nailsPreferred Response: 1Recommended Reading(s):Swiontkowski MF, Aro HT, Donell S, et al: Recombinant human bone morphogeneticprotein-2 in open tibial fractures: A subgroup analysis of data combined from twoprospective randomized studies. J Bone Joint Surg Am 2006;88:1258-1265.Govender S, Csimma C, Genant HK, et al: Recombinant human bone morphogeneticprotein-2 for treatment of open tibial fractures: A prospective, controlled, randomized studyof four hundred and fifty patients. J Bone Joint Surg Am 2002;84:2123-2134.
Question #: 229A 28-year-old man reports a 6-month history of right wrist pain. The symptoms came oninsidiously and he denies any history of trauma. A radiograph and MRI scan are shown inFigures 229a and 229b. Wrist arthroscopy findings in the ulnocarpal joint are shown inFigure 229c. What is the most appropriate treatment at this time?1- Reconstruction of the lunotriquetral ligament tear2- Ulnar shortening osteotomy3- Arthroscopic debridement of the triangular fibrocartilage complex (TFCC)4- Arthroscopic repair of the TFCC5- Matched hemiresection arthroplasty of the distal ulnaPreferred Response: 2Recommended Reading(s):Baek GH, Chung MS, Lee YH, et al: Ulnar shortening osteotomy in idiopathic ulnarimpaction syndrome. J Bone Joint Surg Am 2005;87:2649-2654.Chun S, Palmer AK: The ulnar impaction syndrome: Follow-up of ulnar shorteningosteotomy. J Hand Surg Am 1993;18:46-53.
Figure 230Question #: 230The patient shown in Figure 230 is having difficulty managing stairs after cruciate-retainingtotal knee arthroplasty. What is the most likely explanation?1- Elevation of the joint line2- Patellar tendon rupture3- Posterior cruciate insufficiency4- Anterior cruciate insufficiency5- External rotation of the femoral componentPreferred Response: 3Recommended Reading(s):Pagnano MW, Hanssen AD, Lewallen DG, el al: Flexion instability after primary posteriorcruciate retaining total knee arthroplasty. Clin Orthop Relat Res 1998;356:39-46.Waslewski GL, Marson BM, Benjamin JB: Early incapacitating instability of posteriorcruciate ligament retaining total knee arthroplasty. J Arthroplasty 1998;13:763-767.
Figure 231Question #: 231A 5-year-old girl has shoulder asymmetry as well as restricted range of motion of the leftshoulder. A three-dimensional CT reconstruction is shown in Figure 231. What is the mostlikely cause of the shoulder condition?1- Upper thoracic myelodysplasia2- Intrauterine exposure to cytomegalovirus3- Birth palsy involving the upper cervical nerve roots4- Hypoplasia of the pectoralis major and trapezius muscles5- Failure of the scapula to migrate caudally during fetal developmentPreferred Response: 5Recommended Reading(s):Bellemans M, Lamoureux J: Results of surgical treatment of Sprengel deformity by amodified Green’s procedure. J Pediatr Orthop B 1999;8:194-196.Leibovic SJ, Ehrlich MG, Zaleske DJ: Sprengel deformity. J Bone Joint Surg Am1990;72:192-197.Borges JL, Shah A, Torres BC, et al: Modified Woodward procedure for Sprengel deformityof the shoulder: Long-term results. J Pediatr Orthop 1996;16:508-513.
Figure 232Question #: 232The tumor shown in Figure 232 is located in which of the following muscles?1- Sartorius2- Vastus medialis3- Biceps femoris4- Rectus femoris5- SemimembranosusPreferred Response: 4Recommended Reading(s):Miller M, Gomez B: Anatomy, in Miller MD (ed): Review of Orthopaedics, ed 3.Philadelphia, PA, WB Saunders, 2000, pp 519-585.Hoppenfeld S, deBoer P: Surgical Exposures in Orthpaedics, ed 2. Philadelphia, PA, 1994,pp 330-331.
Question #: 233The changes that have occurred in recent years to practice patterns for treating geriatricintertrochanteric femoral fractures with plates or intramedullary nails are best characterizedby which of the following statements?1- There is little geographic variation in device use.2- There is increased use of intramedullary nails, which have a higher Medicarereimbursement.3- Uncommon use of intramedullary nails continues despite evidence of superiority toplates.4- Intramedullary nails are the most commonly used method based on clear scientificevidence of superior patient outcomes.5- Despite wide geographic variation, overall the two devices are equally used.Preferred Response: 2Recommended Reading(s):Anglen JO, Weinstein JN: American Board of Orthopaedic Surgery Research Committee.Nail or plate fixation of intertrochanteric hip fractures: Changing pattern of practice. Areview of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg Am2008;90:700-707.Forte ML, Virnig BA, Kane RL, et al: Geographic variation in device use for intertrochanterichip fractures. J Bone Joint Surg Am 2008;90:691-699.Question #: 234Wrist injuries often occur after a fall on the outstretched hand. When the wrist is extended,force transmission is shifted to which articulation?1- Radiolunate2- Radioscaphoid3- Distal radioulnar4- Triangular fibrocartilage-lunate5- Triangular fibrocartilage-triquetrumPreferred Response: 2Recommended Reading(s):Majima M, Horii E, Matsuki H, et al: Load transmission through the wrist in the extendedposition. J Hand Surg Am 2008;33:182-188.Weber ER, Chao EY: An experimental approach to the mechanism of scaphoid waistfractures. J Hand Surg Am 1978;3:142-148.
Question #: 235A disk herniation between the vertebral bodies of L3 and L4 that is located lateral to theneuroforamen will most likely cause clinical signs and symptoms involving what nerve root?1- L22- L33- L44- L55- S1Preferred Response: 2Recommended Reading(s):Tamir E, Anekshtein Y, Melamed E, et al: Clinical presentation and anatomic position of L3-L4 disc herniation: A prospective and comparative study. J Spinal Disord Tech2004;17:467-469.Rhee JM, Schaufele M, Abdu WA: Radiculopathy and the herniated lumbar disc:Controversies regarding pathophysiology and management. J Bone Joint Surg Am2006;88:2070-2080.
Question #: 236A 35-year-old woman has increasing shoulder pain. A radiograph, sagittal T2-weightedMRI scan, and CT scan are shown in Figures 236a through 236c. A biopsy specimen isshown in Figure 236d. What is the most likely diagnosis?1- Infection2- Tuberculosis3- Giant cell tumor4- Aneurysmal bone cyst5- Telangiectatic osteosarcomaPreferred Response: 4Recommended Reading(s):Kaila R, Ropars M, Briggs TW, et al: Aneurysmal bone cyst of the pediatric shoulder girdle:A case series and literature review. J Pediatr Orthop B 2007;16:429-436.Schwartz HS (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont,IL, American Academy of Orthopaedic Surgeons, 2007, pp 87-102.
Question #: 237A 22-year-old polytrauma patient sustained bilateral femoral fractures, an open grade IIIBtibial fracture, and a pneumothorax that was treated with a thoracostomy. In the operatingroom, immediately after appropriate debridement and irrigation of the open fracture, thepatient becomes acutely unstable and hypoxic. In addition to resuscitative measures, whatis the next most appropriate step in management?1- Retrograde nailing of both femurs and nailing of the tibia2- Retrograde nailing of both femurs and external fixation of the tibia3- Two-team plating of both femurs and external fixation of the tibia4- External fixation of both femurs and external fixation of the tibia5- External fixation of both femurs and percutaneous tibial platingPreferred Response: 4Recommended Reading(s):Roberts CS, Pape HC, Jones AL, et al: Damage control orthopaedics: Evolving concepts inthe treatment of patients who have sustained orthopaedic trauma. Instr Course Lect2005;54:447-462.Turen CH, Dube MA, LeCroy MC: Approach to the polytraumatized patient withmusculoskeletal injuries. J Am Acad Orthop Surg 1999;7:154-165.Question #: 238A 12-year-old boy is referred for scoliosis treatment. He has moderate pectus excavatum.He is tall and slender, with a ratio of 1.2 of wingspan to height, a high arched palate, and apositive Steinberg thumb sign. On echocardiogram, he has a dilated aortic arch. He has a32° curve measured from T-2 to T-11. What is the most likely long-term outcome of bracetreatment?1- Aggravation of his pectus excavatum2- Stabilization of the curve magnitude3- Decrease in the curve magnitude4- Progression of the curve magnitude5- Exacerbation of thoracic kyphosisPreferred Response: 4Recommended Reading(s):Jones KB, Sponseller PD, Erkula G, et al: Symposium on the musculoskeletal aspects ofMarfan syndrome: Meeting report and state of the science. J Orthop Res 2007;25:413-422.Jones KB, Erkula G, Sponseller PD, et al: Spine deformity correction in Marfan syndrome.Spine 2002;15:2003-2012.
Question #: 239An otherwise healthy 17-year-old wrestler suspects that he has been bitten on the neck bya spider. He has no recent history of hospitalization. Other members of his wrestling teamhave also recently reported skin lesions. Examination reveals superficial abscessformation on the right side of his neck. No other skin lesions are noted. The patient isafebrile. What is the most likely cause of the abscess?1- Highly drug-resistant Pseudomonas aeruginosa2- Extremely drug-resistant Mycobacterium tuberculosis3- Vancomycin-resistant Enterococcus faecium4- Penicillin-resistant Clostridium perfringens5- Methicillin-resistant Staphylococcus aureusPreferred Response: 5Recommended Reading(s):Marcotte AL, Trzeciak MA: Community-acquired methicillin-resistant staphylococcusaureus: An emerging pathogen in orthopaedics. J Am Acad Orthop Surg 2008;16:98-106.Bach HG, Steffin B, Chhadia AM, et al: Community-associated methicillin-resistantstaphylococcus aureus hand infections in an urban setting. J Hand Surg Am 2007;32:380-383.Question #: 240The female athlete triad refers to which of the following?1- Anterior cruciate ligament tears, overuse tendinopathy, and osteoporosis2- Eating disorders, amenorrhea, and osteoporosis3- Knee injuries, amenorrhea, and carpal tunnel syndrome4- Tendinitis, stress fractures, and scoliosis5- Ligament laxity, anemia, and urinary tract infectionsPreferred Response: 2Recommended Reading(s):Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2004, pp 345-352.Nattiv A, Agostini R, Drinkwater B, et al: The female athlete triad: The inter-relatedness ofdisordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994;13:405-418.
Question #: 241A 52-year-old man is injured in a rollover ATV accident. He describes an immediate loss ofstrength in the arms following the accident, which is worse on the right side than on the left.He currently reports severe burning dysesthesias in both arms. His lower extremitystrength is normal to manual examination; however, he demonstrates very brisk reflexes inthe patellar tendons and five to six beats of clonus bilaterally. He has an up-going toe onthe right and has a frontal scalp laceration just above his forehead but is otherwiseuninjured. CT and MRI scans are shown in Figures 241a through 241c. Which of thefollowing most accurately describes this patient’s injury?1- Conversion disorder2- Bilateral brachial plexus injury3- Unstable ligamentous injury4- Complete spinal cord injury5- Central spinal cord injuryPreferred Response: 5Recommended Reading(s):Harrop JS, Sharan A, Ratliff J: Central cord injury: Pathophysiology, management, andoutcomes. Spine J 2006,6:198S-206S.Epstein N, Epstein JA, Benjamin V, et al: Traumatic myelopathy in patients with cervicalspinal stenosis without fracture or dislocation: Methods of diagnosis, management, andprognosis. Spine 1980;5:489-496.
Figure 242Question #: 242Figure 242 shows the preoperative radiograph of a 72-year-old woman who underwentprimary total knee arthroplasty and now describes shifting of the patella during flexion andextension. What is the most likely explanation for these symptoms?1- Medialization of the patella2- Damage to the iliotibial band3- Medial collateral ligament laxity4- Excessive external rotation of the femoral component5- Excessive internal rotation of the femoral componentPreferred Response: 5Recommended Reading(s):Lee GC, Cushner FD, Scuderi GR, et al: Optimizing patellofemoral tracking during totalknee arthroplasty. J Knee Surg 2004;17:144-149.Briard JL, Hungerford DS: Patellofemoral instability in total knee arthroplasty. JArthroplasty 1989;4:S87-S97.
Question #: 243Management of an olecranon fracture through triceps advancement is best indicated in1- a transverse fracture in a young adult.2- a transverse fracture in an elderly patient with osteoporosis.3- an oblique fracture in both young and elderly patients.4- a comminuted fracture involving proximal 40% of the olecranon in a young adult.5- a comminuted fracture involving proximal 40% of the olecranon in an elderly lowdemand patient.Preferred Response: 5Recommended Reading(s):Hak DJ, Golladay G Jr: Olecranon fractures: Treatment options. J Am Acad Orthop Surg2000;8:266-275.Veillette CJ, Steinmann SP: Olecranon fractures. Orthop Clin North Am 2008;39:229-236.Question #: 244Transverse instability of the Lisfranc joint is the result of injury to the interosseous firstcuneiform-second metatarsal ligament (Lisfranc’s ligament) and which of the followingligaments?1- No other ligament injury is necessary2- Spring ligament3- Plantar ligament between the first cuneiform and the second and third metatarsals4- Long plantar ligament5- Bifurcate ligamentPreferred Response: 3Recommended Reading(s):Kaar S, Femino J, Morag Y: Lisfranc joint displacement following sequential ligamentsectioning. J Bone Joint Surg Am 2007;89:2225-2232.Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 485-492.
Figure 245Question #: 245What type of lateral plating technique is most appropriate for the fracture shown in Figure245?1- Locked2- Buttress3- Bridge4- Neutralization5- Dynamic compressionPreferred Response: 2Recommended Reading(s):Baumgaertner MR, Tornetta P III (eds): Orthopaedic Knowledge Update: Trauma 3.Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 419-429.Bucholz RW, Heckman JD, Court-Brown C: Fractures of the proximal tibia, in Bucholz RW,Heckman JD, Court-Brown C (eds): Rockwood and Green’s Fractures in Adults, ed 6.Philadelphia, PA, Lippincott Williams & Wilkins, 2006, pp 1999-2036.
Figure 246Question #: 246What structure is most at risk for injury during percutaneous placement of the plate shownin Figure 246?1- Superficial peroneal nerve2- Deep peroneal nerve3- Posterior tibial artery or nerve4- Posterior tibial tendon5- Flexor digitorum communisPreferred Response: 1Recommended Reading(s):Deangelis JP, Deangelis NA, Anderson R: Anatomy of the superficial peroneal nerve inrelation to fixation of tibia fractures with the less invasive stabilization system. J OrthopTrauma 2004;18:536-539.Roberts CS, King D, Wang M, et al: Should distal interlocking of tibial nails be performedfrom a medial or a lateral direction? Anatomical and biomechanical considerations. JOrthop Trauma 1999;13:27-32.Wolinsky P, Lee M: The distal approach for anterolateral plate fixation of the tibia: Ananatomic study. J Orthop Trauma 2008;22:404-407.
Question #: 247A football player is tackled and sustains a direct blow to his anterolateral thigh.Examination reveals a significant loss of motion and an extensor lag of 30°, and he isunable to return to play. Immediate management should include1- hematoma evacuation.2- thigh compartment releases.3- immediate range of motion and stretching.4- splinting the knee in extension.5- splinting the knee in hyperflexion (120°) overnight.Preferred Response: 5Recommended Reading(s):Ryan JB, Wheeler JH, Hopkinson WJ, et al: Quadriceps contusions: West Point update.Am J Sports Med 1991;19:299-304.Aronen JG, Garrick JG, Chronister RD, et al: Quadriceps contusions: Clinical results ofimmediate immobilization in 120 degrees of knee flexion. Clin J Sport Med 2006;16:383-387.
Question #: 248A 49-year-old woman has medial foot pain, swelling, and progressive loss of arch height.Nonsurgical management has failed to provide symptomatic relief. Examination reveals fullactive and passive range of motion of her ankle and hindfoot and pain with resistedinversion. Radiographs are shown in Figures 248a through 248c. Which of the followingsurgical treatments is most appropriate for this patient?1- Triple arthrodesis2- Isolated flexor hallucis longus transfer to the navicular3- Isolated flexor digitorum longus transfer to the navicular4- Flexor digitorum longus transfer to the navicular with lateral calcaneal displacementosteotomy5- Flexor digitorum longus transfer to the navicular with calcaneal osteotomy for lateralcolumn lengtheningPreferred Response: 5Recommended Reading(s):Myerson MS: Adult acquired flatfoot deformity: Treatment of dysfunction of the posteriortibial tendon. Instr Course Lect 1997;46:393-405.Pinney SJ, Lin SS: Current concepts review: Acquired adult flatfoot deformity. Foot AnkleInt 2006;27:66-75.
Question #: 249A 7-year-old boy is brought to the emergency department by his grandmother, who onlyspeaks Spanish. You speak no Spanish, but the child speaks fluent English. The childindicates that he was born in the United States, but his mother is still in Mexico. He needssurgical reduction and internal fixation for a type III supracondylar humerus fracture. Howshould informed consent for the surgery be obtained?1- Talk to the grandmother using the child as a translator.2- Talk to the grandmother using a Spanish-speaking nurse as a translator.3- Call the mother in Mexico using the child as a translator over the phone.4- Call the mother in Mexico using a Spanish-speaking nurse as a translator.5- Do the surgery and document that this is an emergency and informed consent for thepatient was not obtainable.Preferred Response: 4Recommended Reading(s):Bhatacharyya T, Yeon H, Harris MB: The medical-legal aspects of informed consent inorthopaedic surgery. J Bone Joint Surg Am 2005;87:2395-2400.Wenger NS, Lieberman JR: Achieving informed consent when patients appear to lackcapacity and surrogates. Clin Orthop Relat Res 2000;378:78-82.Lindseth RE: Ethical issues in pediatric orthopaedics. Clin Orthop Relat Res 2000;378:61-65.
Question #: 250An 8-year-old girl has had right elbow pain for the past 2 months. Radiographs, MRI scans,and a biopsy specimen are seen in Figures 250a through 250e. What is the most likelydiagnosis?1- Osteomyelitis2- Chondroblastoma3- Simple bone cyst4- Eosinophilic granuloma5- Aneurysmal bone cystPreferred Response: 5Recommended Reading(s):Basarir K, Piskin A, Guclu B, et al: Aneurysmal bone cyst recurrence in children: A reviewof 56 patients. J Pediatr Orthop 2007;27:938-943.Gibbs CP Jr, Hefele MC, Peabody TD, et al: Aneurysmal bone cyst of the extremities:Factors related to local recurrence after curettage with a high-speed burr. J Bone JointSurg Am 1999;81:1671-1678.
Question #: 251When applying casts, which of the following actions results in a decreased incidence ofthermal injuries?1- Dip water temperatures are set to 68°F to 75.2°F (20°C to 24°C).2- The cast rests on a pillow while setting.3- The number of layers of the cast is increased.4- The curing cast is overwrapped in fiberglass.5- Isopropyl alcohol is applied to the exterior of the cast.Preferred Response: 1Recommended Reading(s):Halanski MA, Halanski AD, Oza A, et al: Thermal injury with contemporary cast-applicationtechniques and methods to circumvent morbidity. J Bone Joint Surg Am 2007;89:2369-2377.Lavalette R, Pope MH, Dickstein H: Setting temperatures of plaster casts: The influence oftechnical variables. J Bone Joint Surg Am 1982;64:907-911.Question #: 252Which of the following best describes the clinical presentation of a patient who hassustained an inferior dislocation of the glenohumeral joint (luxatio erecta)?1- Arm at side, unable to externally rotate past neutral2- Arm at side, internally rotated with hand behind lower back3- Arm at side, externally rotated with limited internal rotation4- Arm abducted between 110° and 160°5- Arm abducted to side about 45°Preferred Response: 4Recommended Reading(s):Sewecke JJ, Varitimidis SE: Bilateral luxatio erecta: A case report and review of theliterature. Am J Orthop 2006;35:578-580.Wirth MA, Rockwood CA Jr: Subluxations and dislocations about the glenohumeral joint, inBucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 5.Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 1109-1207.
Question #: 253Which of the following clinical signs characterize an upper motor neuron disorder?1- Spasticity and fasciculations2- Spasticity and exaggerated deep tendon reflexes3- Fasciculations and decreased deep tendon reflexes4- Flaccid weakness, muscle atrophy, and increased deep tendon reflexes5- Flaccid weakness, muscle atrophy, and decreased deep tendon reflexesPreferred Response: 2Recommended Reading(s):Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations ofClinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007,pp 427-443.Renshaw TS, Deluca PA: Cerebral palsy, in Morrissy RT, Weinstein SL (eds): Lovell andWinter’s Pediatric Orthopaedics. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, pp551-603.Question #: 254Sudden inability to extend the thumb 3 months after a distal radius fracture is mostcommonly associated with what type of injury?1- Open volar Barton’s fracture2- Open dorsally displaced extra-articular fracture3- Closed nondisplaced metaphyseal fracture4- Closed dorsally comminuted metaphyseal fracture5- Closed displaced intra-articular fracture of the distal radiusPreferred Response: 3Recommended Reading(s):Jupiter JB, Fernandez DL: Complications following distal radial fractures. J Bone JointSurg Am 2001;83:1244-1265.Hove LM: Delayed rupture of the thumb extensor tendon: A 5-year study of 18 consecutivecases. Acta Orthop Scand 1994;65:199-203.
Question #: 255A 44-year-old woman has had right hip fullness and severe aching for the past 6 months.She denies any history of trauma. A radiograph, coronal T1- and axial T2-weighted MRIscans, and a biopsy specimen are shown in Figures 255a through 255d. Treatment shouldinclude1- surgery alone.2- surgery and radiation therapy.3- radiation therapy alone.4- physical therapy.5- chemotherapy and surgery.Preferred Response: 1Recommended Reading(s):Prado MA, Miró RL, Leal IM, et al: Intramuscular myxoma: Differential diagnosis and reviewof the literature. Orthopedics 2002;25:1297-1299.Schwartz HS (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont,IL, American Academy of Orthopaedic Surgeons, 2007, pp 257-263.
Question #: 256The superior gluteal nerve is located between what two structures at what level above thetrochanter?1- Capsule and gluteus minimus 4 to 5 cm above the tip2- Capsule and gluteus minimus 8 to 10 cm above the tip3- Gluteus minimus and gluteus medius 4 to 5 cm above the tip4- Gluteus minimus and gluteus medius 8 to 10 cm above the tip5- Gluteus medius and gluteus maximus 8 to 10 cm above the tipPreferred Response: 3Recommended Reading(s):Hoppenfeld S, deBoer P (eds): Surgical Exposures in Orthopaedics: The Hip andAcetabulum, ed 2. Philadelphia, PA, Lippincott Williams & Wilkins, 1994, pp 323-399.Question #: 257A patient is undergoing a cervicothoracic osteotomy for a severe kyphotic deformity fromankylosing spondylitis. Performing this surgery in the seated position compared to theprone position is associated with a greater risk of1- an air embolus.2- a neurologic deficit.3- blood loss.4- pressure necrosis of the skin.5- inadequate reduction of the deformity.Preferred Response: 1Recommended Reading(s):Matjasko J, Petrozza P, Cohen M, et al: Anesthesia and surgery in the seated position:Analysis of 554 cases. Neurosurgery 1985;17:695-702.Engelhardt M, Folkers W, Brenke C, et al: Neurosurgical operations with the patient insitting position: Analysis of risk factors using transcranial Doppler sonography. Br JAnaesth 2006;96:467-472.
Question #: 258Patients with familial adenomatous polyposis have a 10,000 times increased risk ofdeveloping what kind of mesenchymal tumor?1- Neurofibroma2- Enchondroma3- Osteochondroma4- Pleomorphic soft-tissue sarcoma5- Extra-abdominal desmoid tumorPreferred Response: 5Recommended Reading(s):Donthineni R: Orthopaedic clinics: Oncology. Orthop Clin North Am 2006;37:53-63.Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont,IL, American Academy of Orthopaedic Surgeons, 2002, pp 243-253.Question #: 259Which of the following factors is associated with the highest rate of complications fromtreatment of a patient with diabetes mellitus and an ankle fracture?1- Osteopenia2- Renal dialysis3- Presence of peripheral neuropathy4- Open treatment of the ankle fracture5- Closed treatment of the ankle fracturePreferred Response: 3Recommended Reading(s):Chaudhary SB, Liporace FA, Gandhi A, et al: Complications of ankle fracture in patientswith diabetes. J Am Acad Orthop Surg 2008;16:159-170.Costigan W, Thordarson DB, Debnath UK: Operative management of ankle fractures inpatients with diabetes mellitus. Foot Ankle Int 2007;28:32-37.Jones KB, Maiers-Yelden KA, Marsh JL, et al: Ankle fractures in patients with diabetesmellitus. J Bone Joint Surg Br 2005;87:489-495.
Question #: 260A 25-year-old man injured his knee in a motor vehicle collision. Abnormal examinationfindings include 10° increased external tibial rotation at 30° and 90° knee flexion. Whatadditional examination finding is expected?1- Increased opening to valgus stress at 30° of knee flexion2- Increased varus opening at 0° of knee flexion3- Positive apprehension sign with lateral patellar translation4- Positive pivot shift test5- Medial tibial plateau rests 10 mm anterior to the medial femoral condylePreferred Response: 2Recommended Reading(s):LaPrade RF, Terry GC: Injuries to the posterolateral aspect of the knee: Association ofanatomic injury patterns with clinical instability. Am J Sports Med 1997;25:433-438.Gollehon DL, Torzilli PA, Warren RF: The role of posterolateral and cruciate ligaments inthe stability of the human knee: A biomechanical study. J Bone Joint Surg Am1987;69:233-242.Question #: 261With the diagnosis of valgus extension overload of the elbow, radiographs often showosteophyte formation on the1- radial head.2- posteromedial olecranon fossa.3- posterolateral olecranon fossa.4- tip of the olecranon process.5- medial humeral epicondyle.Preferred Response: 2Recommended Reading(s):Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2002, pp 101-111.Wilson FD, Andrews JR, Blackburn TA, et al: Valgus extension overload in the pitchingelbow. Am J Sports Med 1983;11:83-88.
Question #: 262Which of the following conditions is a contraindication to the use of most bisphosphonates?1- Paget’s disease2- Osteomyelitis3- Bone infarct4- Myasthenia gravis5- Severe renal insufficiency/failurePreferred Response: 5Recommended Reading(s):Lin JT, Lane JM: Bisphosphonates. J Am Acad Orthop Surg 2003;11:1-4.Rosier RN: Expanding the role of the orthopaedic surgeon in the treatment of osteoporosis.Clin Orthop Relat Res 2001;385:57-67.
Question #: 263A 38-year-old woman underwent curettage of the lesion shown in Figures 263a through263c at the time of anterior cruciate ligament reconstruction. A biopsy specimen is shownin Figure 263d. What is the next most appropriate step in management?1- CT of the chest2- Wide resection3- Chemotherapy4- Radiation therapy5- ObservationPreferred Response: 5Recommended Reading(s):Weiner SD: Enchondroma and chondrosarcoma of bone: Clinical, radiologic, and histologicdifferentiation. Instr Course Lect 2004;53:645-649.Schwartz HS (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont,IL, American Academy of Orthopaedic Surgeons, 2007, pp 103-120.Question #: 264In a Monteggia fracture-dislocation with an anteriorly dislocated radial head, where is theapex of the ulnar fracture?1- Medial2- Lateral3- Anterior4- Posterior5- PosterolateralPreferred Response: 3Recommended Reading(s):Bado JL: The Monteggia lesion. Clin Orthop Relat Res 1967;50:71-86.Fowles JV, Sliman N, Kassab MT: The Monteggia lesion in children: Fracture of the ulnaand dislocation of the radial head. J Bone Joint Surg Am 1983;65:1276-1282.
Question #: 265What modality recommended in the AAOS Guideline on the Prevention of SymptomaticPulmonary Embolism is recommended across all risk (low to high risk of either bleeding orpulmonary embolism) groups undergoing total hip or total knee arthroplasty?1- Mechanical prophylaxis2- Vena cava filter3- Spinal anesthesia4- Low-molecular-weight heparin5- Synthetic pentasaccharidesPreferred Response: 1Recommended Reading(s):AAOS Clinical Guideline on Prevention of Pulmonary Embolism in Patients UndergoingTotal Hip or Knee Arthroplasty. Rosemont, IL, American Academy of OrthopaedicSurgeons, 2007. http://www.aaos.org/research/guidelines/PE_guideline.pdf. Accessed onJuly 24, 2009.Question #: 266Botulinum toxin A exerts its therapeutic effect via what mechanism of action?1- Blocks presynaptic release of acetylcholine2- Blocks reuptake of acetylcholine3- Blocks acetylcholinesterase release4- Increases production of acetylcholine at the nerve terminus5- Increases acetylcholinesterase releasePreferred Response: 1Recommended Reading(s):Abbruzzese G, Berardelli A: Neurophysiological effects of botulinum toxin type A. NeurotoxRes 2006;9:109-14.Das TK, Park DM. Effect of treatment with botulinum toxin on spasticity. Postgrad Med J1989;65:208-210.
Question #: 267Which of the following prosthetic limb knee joints is most commonly used in childhood, isnot recommended for older or weaker patients, allows only a single speed of walking, andrelies solely on alignment for stance phase stability?1- Polycentric2- Stance-phase control3- Fluid control4- Constant friction5- Variable frictionPreferred Response: 4Recommended Reading(s):Tang PC, Ravji K, Key JJ, et al: Let them walk! Current prosthesis options for leg and footamputees. J Am Coll Surg 2008;206:548-560.Rossbuch PG, Joyce MA, Schaffer E, et al: Principles of amputee prosthetics, in ChapmanMW (ed): Chapman’s Operative Orthopaedics, ed 3. Philadelphia, PA, Lippincott Williams& Wilkins, 2001, pp 3181-3199.Question #: 268For an 8-mm nerve gap in the hand, which of the following has been shown to be asreliable and effective as the gold standard of autogenous nerve grafting?1- Silicone sleeve repair2- Mobilization and primary repair3- Collagen conduit4- Poly-L-lactic acid conduit5- Vein graft interpositionPreferred Response: 3Recommended Reading(s):Bertleff MJ, Meek MF, Nicolai JP: A prospective clinical evaluation of biodegradableneurolac nerve guides for sensory nerve repair in the hand. J Hand Surg Am 2005;30:513-518.Waitayawinyu T, Parisi DM, Miller B, et al: A comparison of polyglycolic acid versus type Icollagen bioabsorbable nerve conduits in a rat model: An alternative to autografting. JHand Surg Am 2007;32:1521-1529.Li ST, Archibald SJ, Krarup C, et al: Peripheral nerve repair with collagen conduits. ClinMater 1992;9:195-200.
Question #: 269A 68-year-old woman underwent total hip arthroplasty 2 years ago for degenerative arthritissecondary to acetabular dysplasia. She now reports an unstable hip that has dislocated sixtimes. She walks with a severe Trendelenburg limp. Examination reveals no activeabduction of the hip. The components appear well positioned. What management offersthe best chance of success?1- Re-education on hip precautions2- Revision to a large femoral head3- Revision to a constrained liner4- Use of a hip abduction brace5- Trochanteric advancementPreferred Response: 3Recommended Reading(s):Shrader MW, Parvizi J, Lewallen DG: The use of a constrained acetabular component totreat instability after total hip arthroplasty. J Bone Joint Surg Am 2003;85:2179-2183.Lieberman JR, Berry DJ (eds): Advanced Reconstruction: Hip. Rosemont, IL, AmericanAcademy of Orthopaedic Surgeons, 2005, pp 223-231.Question #: 270A healthy 64-year-old woman sustains a compression fracture of L3 in a fall. She isneurologically intact. On radiographic examination, the anterior column is compressed25%, and there is 20° of localized kyphosis. Based on these findings, what is the mostappropriate management?1- Bed rest for 2 weeks followed by use of a lumbosacral orthosis2- Application of a thoracolumbosacral orthosis and progressive increasing ambulation3- Anterior column reconstruction and placement of structural autograft and a plate4- Posterior short segment pedicular fixation and placement of autogenous bone graft5- Combined anterior and posterior reconstructionPreferred Response: 2Recommended Reading(s):Wood K, Buttermann G, Mehbod A, et al: Operative compared with nonoperative treatmentof a thoracolumbar burst fracture without neurological deficit: A prospective, randomizedstudy. J Bone Joint Surg Am 2003;85:773-781.Gertzbein SD: Scoliosis Research Society: Multicenter spine fracture study. Spine1992;17:528-540.
Question #: 271What is the most effective shoe modification for reducing plantar pressures in the forefoot?1- SACH heel2- Rocker sole3- Custom indepth shoe4- Extended steel shank5- Closed cell polyethylene foam insolePreferred Response: 2Recommended Reading(s):Janisse DJ, Janisse E: Shoe modification and the use of orthoses in the treatment of footand ankle pathology. J Am Acad Orthop Surg 2008;16:152-158.Brown D, Wertsch JJ, Harris GF, et al: Effects of rocker soles on plantar pressures. ArchPhys Med Rehabil 2004;85:81-86.Question #: 272A 53-year-old woman is seen in the emergency department after sustaining an injury to herleft nondominant shoulder in a fall last week. Radiographs reveal 100% displacement ofthe distal clavicle above the acromion. What is the best treatment option at this time?1- Distal clavicle resection2- Sling and early range-of-motion exercises3- Weaver-Dunn procedure including coracoacromial ligament transfer4- Anatomic coracoclavicular ligament reconstruction with allograft5- Anatomic coracoclavicular ligament reconstruction with autograft semitendinosustendonPreferred Response: 2Recommended Reading(s):Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL,American Academy of Orthopaedic Surgeons, 2004, pp 53-77.Schlegel TF, Burks RT, Marcus RL, et al: A prospective evaluation of untreated acutegrade III acromioclavicular separation. Am J Sports Med 2001;29:699-703.
Question #: 273The rotator cable, seen arthroscopically at the margin of the avascular zone, is anextension of the1- biceps tendon sheath.2- teres minor tendon.3- subscapularis tendon.4- coracohumeral ligament.5- superior labrum.Preferred Response: 4Recommended Reading(s):Clark JM, Harryman DT II: Tendons, ligaments, and capsule of the rotator cuff: Gross andmicroscopic anatomy. J Bone Joint Surg Am 1992;74:713-725.Burkhart SS, Lo IK: Arthroscopic rotator cuff repair. J Am Acad Orthop Surg 2006;14:333-346.Question #: 274Disease modifying antirheumatic drug therapy such as infliximab is primarily targetedagainst1- leukocytes.2- rheumatoid factor.3- antinuclear antibodies.4- C-reactive protein.5- tumor necrosis factor-alpha.Preferred Response: 5Recommended Reading(s):Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy ofOrthopaedic Surgeons, 2005, pp 229-244.Elliot MJ, Maini RN, Feldmann M: Treatment of rheumatoid arthritis with chimericmonoclonal antibodies to tumor necrosis factor alpha. Arthritis Rheum 2008;58:S92-S101.
Question #: 275Osteoclasts are the primary cells involved in bone resorption. What is one of the mostcritical factors for osteoclast differentiation and activation?1- PTH2- BMP23- RANKL4- Calcitonin5- TNF-alphaPreferred Response: 3Recommended Reading(s):Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academyof Orthopaedic Surgeons, 2008, pp 115-164.Alman BA, Howard AW (eds): Metabolic and endocrine abnormalities, in Morrissy RT,Weinstein SL (eds): Philadelphia, PA, Lippincott Williams & Wilkins, 2006, pp 167-200.