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.