2003 OITE Answers

8/10/2019 2003 OITE Answers

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2003 OITE Questions Divided by Content Domain

Foot and Ankle (20 questions)

11, 18, 28, 42, 54, 66, 77, 82, 92, 105, 121, 137, 155, 174, 188, 217, 242, 253, 265, 270

and (!" questions)

10, 21, 32, 49, 61, 73, 81, 91, 95, 107, 118, 126, 143, 163, 208, 238, 250, 262

i# $ %nee &e'onstu'tion (23 questions)

2, 15, 25, 37, 44, 47, 62, 72, 88, 113, 119, 131, 142, 151, 154, 167, 179, 194, 210, 239, 251, 263,

272

edi'ally &elated Issues (* questions)

31, 75, 116, 160, 203, 235, 259

us'uloskeletal Tauma (+2 questions)1, 8, 14, 23, 33, 43, 50, 57, 59, 68, 74, 79, 87, 90, 94, 98, 103, 10o6, 109, 110, 112, 117, 124,

128, 132, 136, 147, 152, 158, 164, 172, 173, 177, 182, 187, 192, 196, 198, 200, 206, 214, 219,221, 225, 228, 230, 233, 237, 241, 249, 260, 271

Ot,o#aedi' Diseases (2- questions)

7, 13, 29, 38, 46, 63, 67, 93, 100, 111, 122, 134, 141, 149, 159, 165, 170, 193, 209, 220, 224,

229, 246

Ot,o#aedi' .'ien'e (2/ questions)

3, 20, 30, 39, 48, 60, 69, 78, 84, 102, 120, 135, 146, 153, 157, 168, 176, 181, 190, 195, 202, 205,

215, 223, 227, 231, 245, 256, 268

ediati' Ot,o#aedi's (3+ questions)

4, 12, 17, 26, 34, 41, 51, 56, 65, 71, 80, 85, 89, 96, 101, 115, 123, 129, 138, 144, 148, 156, 162,

171, 175, 183, 186, 191, 201, 207, 216, 222, 234, 247, 258

&e,abilitation (/ questions)

22, 55, 70, 104, 133, 150, 185, 236, 261

.,oulde and Elbo1 (!- questions)

6, 24, 35, 52, 86, 108, 114, 125, 130, 145, 199, 213, 232, 244, 255, 267

.#ine (!" questions)

5, 16, 27, 40, 53, 64, 76, 99, 139, 161, 169, 178, 189, 212, 240, 252, 264, 273

.#ots edi'ine (!/ questions)

9, 19, 36, 45, 58, 83, 97, 140, 166, 180, 184, 197, 204, 211, 226, 243, 254, 266, 274


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1. What is the most common complication associated with surgical i!ation o a trans"erse

midshat humeral racture using an antegrade staticall# loc$ed medullar# nail%

1. inection2. radial ner"e pals#

3. &rachial arter# in'ur# during distal interloc$ing

4. shoulder pain5. nonunion

(hapman, et al compared clinical and radiographic results or loc$ed )* nails and plates usedin the treatment o humeral diaph#seal ractures. +he most common complication associated

with antegrade )* nails was shoulder pain and decreased -* ollowed s#mptomatic

hardware reuiring remo"al. (omplications "aried in each group, with the highest incidence oshoulder pain and stiness in those patients treated with antegrade )* nails. +his inding ma# &e

due to the surgical trauma o nail insertion and pro!imal loc$ing /in'ur# o the rotator cu,

su&deltoid &ursa, and deltoid muscle. lating was associated with a higher incidence o el&owpain and stiness as well as a slightl# higher incidence o nonunion and inection. +hese

indings ma# &e attri&uted to the greater amount o sot tissue disruption associated with the

plating procedure.

+his stud# concluded that or the su&set o patients reuiring surgical treatment o diaph#sealhumerus ractures, &oth )* nailing and compression plating &oth pro"ide predicta&le means o

achie"ing racture sta&iliation and ultimate healing. either method was shown to &e mar$edl#

superior to the other. ither method, properl# selected and perormed, should lead to successulresults in a large ma'orit# o patients.

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2. 62#earold woman with primar# osteoarthritis is scheduled to undergo cementless total hip

arthroplast#. istor# re"eals that she underwent pel"ic irradiaton or uterine cancer 10 #ears

ago. +he patient should &e considered at highest ris$ or which o the ollowing complications ototal hip arthroplast#%

1. eep "enous throm&osis2. -steol#sis

3. eterotopic ossiication

4. ip insta&ilit#5. septic loosening

+he correct response to this uestion comes out o a paper :aco&s et al.,JBJS,77,

12, ec. 1995, 18291835. )n this paper, the authors descri&e their re"iew o 1319 total hiparthroplast# cases with insertion o a hemispherical porouscoated aceta&ular component without

cement. +he authors identiied 12 hips in ele"en patients that had &een pre"iousl# irradiated

prior to +. +he preoperati"e diagnosis was radiation osteonecrosis in i"e o the hips and

osteoarthritis in our o those patients who sur"i"ed or the completion o the ollowup period/a"erage 37 months.

ll o the aceta&lular components were o hemispherical design and were coated with aningrowth surace o titanium i&ermetal /arris;alante ) or ))< =immer. +he hips were

e"aluated radiographicall# with an initial postop and ollowup radiographs with the method

o *artell et al. einite loosening o the aceta&ular component was deined as a "ertical orhoriontal change in the position o the component o more than two millimeters when the most

recent radiographs were compared to the si!wee$ postop radiographs. component was

deined as >ailed? i it radiographicall# had migrated.

)n two o the three hips with clinical and radiographic ailure, the aceta&ular componenthad migrated more than one centimeter superiorl# and mediall#. +he third component had

migrated more than two millimeters. +wo hips were re"ised at the completion o ollowup

secondar# to this migration. -ne other hip was seen radiographicall# to ha"e progressi"ecircumrential radiolucenc# and progressi"e condensation o &one at the &oneimplant interace

@hence, it was >pro&a&l# loose.? )n total, our o nine hips e"aluated throughout the ollowup

period had aceta&ular components which ailed. +he other i"e components were sta&le.+he stud# was not large enough to statisticall# determine an# signiicance in regards to

the dosage o radiation &etween those hips which ailed and those which do not. imilarl#, no

signiicant conclusions can &e drawn as to actors such as component sie, the inclination angle,

the num&er o transi!ation screws, the use o &one grat, or the t#pe o emoral stem emplo#ed.)t is &elie"ed that the high ailure rate o&ser"ed in these hips with pre"ious irradiation stems rom

in'ur# to the osteo&lasts themsel"es. istiological e"idence shows generalied demineraliation,

empt# lacunae, and coarse disorganiation o tra&aculae.

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3. Which o the ollowing actors contri&utes to inter"erte&ral dis$ degeneration%

1 )ncrease in cell num&ers2 )ncrease in local p

3 )ncrease in aggregating proteogl#cans

4 ecrease in collagen cross lin$ing5 ecrease in nutritional transport

Arom -rthopaedic Basic cienceC > "ariet# o mechanisms including declining nutrient andwaste product transport mechanisms, decreasing concentration o "ia&le cells, cell senescence,

apoptotic de&ris, loss o aggregating proteogl#cans, modiication o matri! proteins, degradati"e

en#me acti"it#, accumulation o degraded matri! macromolecules, and atigue ailure o thematri!, ma# contri&ute to dis$ degeneration. lthough each o these mechanisms ma# alter dis$

composition and microstructure, their relati"e importance and the interactions among them ha"e

not &een esta&lished.?

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4C (ompared with other classiications o Degg(al"eerthes disease, the lateral pillar

classiciation has the ad"antage o

1. e!hi&iting greater intero&ser"er agreement2. remaining unchanged throughout the course o the disease

3. uanti#ing the osteonecrosis "isi&le on the rog lateral hip radiograph

4. predicting pro!imal emoral growth arrest5. descri&ing the degree o metaph#seal osteonecrosis

We e"aluated the intero&ser"er agreement o radiographic methods when e"aluating patients

with erthesE disease. +he radiographs were assessed at the time o diagnosis and at the 1#earollowup local orthopaedic surgeons /- and 2 e!perienced pediatric orthopedic surgeons

/++ and . +he (atterall, alter+hompson, and erring lateral pillar classiications were

compared, and the emoral head co"erage /A(, centeredge angle /(angle, and articulo

trochanteric distance /+ were measured in the aected and normal hips. -n the primar#e"aluation, the lateral pillar and alter+hompson classiications had a higher le"el o agreement

among the o&ser"ers than the (atterall classiication, &ut none o the classiications showed good

agreement /weighted $appa "alues &etween - and 0.56, 0.54, 0.49, respecti"el#. (om&ining(atterall groups 1 and 2 into one group, and groups 3 and 4 into another resulted in &etter

agreement /$appa 0.55 than with the original 4group s#stem. +he agreement was also &etter

/$appa 0.620.70 &etween e!perienced than &etween less e!perienced e!aminers or allclassiications. +he emoral head co"erage was a more relia&le and accurate measure than the

(angle or uanti#ing the aceta&ular co"ering o the emoral head, as indicated higher

intraclass correlation coeicients /)(( and smaller intero&ser"er dierences. +he + showed

good agreement in all comparisons and had low intero&ser"er dierences. We conclude that allclassiications o emoral head in"ol"ement are adeuate in clinical wor$ i the radiographic

assessment is done e!perienced e!aminers. When the# are less e!perienced e!aminers, a 2

group classiication or the lateral pillar classiication is more relia&le. Aor e"aluation ocontainment o the emoral head, A( is more appropriate than the (angle.

Wiig -C )ntero&ser"er relia&ilit# o radiographic classiications and measurements in theassessment o erthes disease. cta -rthop cand, 2002


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5. )n a patient with cer"ical spond#lotic m#elopath# who reuires surgical decompression,

which o the ollowing is a relati"e contraindication to a posterior approach such as laminaplast#

or laminectom#%

1 *ultile"el stenosis and spinal cord compression

2 F Ai!ed (er"ical G#phosis3 F -&esit#

4 F )nsta&ilit# or unwillingness to compl# with postoperati"e &racing

5 F e"ere / canal diameter o less than 12mm stenosis

+he correct answer is 2. ccording to the article >(er"ical pond#litic *#elopath#C iagnosis

and +reatment?, written anord mer#, posterior decompression techniues are ideal or

patients with diuse canal stenosis or dorsal cord compression due to &uc$ling o posteriorligamentum la"um. osterior decompression o the cord or anterior patholog#, most patients

with cer"ical spond#losis and -DD, is an indirect maneu"er which reuires the cord to

su&seuentl# shit posteriorl#, awa# rom the patholog#, within the thecal sac in order to releasethe cause o anterior compression. )n order or this to ta$e place the cur"ature o the cer"ical

spine must &e >setup? within the saggital plane alignment. +he more lordotic the cer"ical spine

is, the more reedom the cord will ha"e to translate within the sac ollowing decompression.

straight or $#photic spine is less li$el# to allow adeuate mo"ement and thereore &e less li$el#to relie"e s#mptoms caused anterior disease. )nsta&ilit# is also a concern with regard to

choice o approach, howe"er, this pree!isting actor onl# necessitates the need or posterior

i!ation ollowing decompression, and it does not e!clude a posterior approach. +hereore, ai!ed cer"ical $#phosis is a relati"e contraindication i the goal is to decompress due to anterior

cer"ical spine patholog#.

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6C mini open approach or a rotator cu repair has what primar# ad"antage o"er a standard

open repair%

1. ecreased inection rate

2. ecreased ris$ o in'ur# to the ma!illar# ner"e

3. ecreased ris$ o deltoid a"ulsion4. ecreased ris$ o in'ur# to the &iceps tendon comple!

5. )ncreased rotator cu healing rate

+here are 4 principles descri&ed eer in rotator cu repair.

1 nterior)nerior acromioplast# or reshaping or reshaping rather than acromiectom#.

2 *eticulous repair o the deltoid origin and a"oidance o those procedures that ma# place

this area at ris$ or in'ur#.3 eleasing, mo&iliing, and repairing the torn rotator cu tendons.

4 arl# restoration o passi"e motion through surgeon directed indi"idualied

reha&ilitation.

!perienced surgeons report .5H incidence o deltoid a"ulsion. )n ormal open repair deltoid

a"ulsion is rare. owe"er, there are 2 disad"antages to ormal open repair. eltoid ta$edownand repair reuires a period o protection in order to a"oid an# inad"ertent a"ulsion. +his ma#

preclude earl# reha&Imo&iliation. 2nd, open repair appears to &e associated with more

postoperati"e pain than miniopen or all arthroscopic methods.

+he mini approach descri&ed in 1994 uses arthroscopic decompression /acromioplast#anterior deltoid detachment is no longer necessar#. +hereore there is less perioperati"e

mor&idit# since the deltoid is not ta$en down.

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8. )nitial management o a h#potensi"e adult trauma patient in the includes insertion o

at least 2 large &ore )J catheters and administration o C

1 1D &olus o h#pertonic saline

2 2D &olus o h#pteronic saline solution

3 1D &olus o D solution4 2D &olus o D solution

5 2 units o uncrossmatched &lood

#po"olemia is the most common cause o shoc$ in a trauma patient. )nitial treatment or

h#po"olemia is to insert two large &ore )J needles /16gauge or larger and administer 2 D oDactated ingers or ormal aline. )J placement should &e in the antecu&ital "ein o each arm

to allow or luid resuscitation i there is a unilateral "essel in'ur#. ) the patient remains unsta&le

ater luid resuscitation, &lood transusion is indicated. +#ped and crossed &lood is preerred &utthis process can ta$e an hour. +#ped &ut not crossed &lood is the ne!t choice &ut t#ping ta$es

around 20 minutes. )n an emergenc#, gi"e - positi"e or - negati"e /especiall# or emales in

their child&earing #ears.

Class IC loss o 15H o &lood "olume /K750ml. *inimal s#mptoms. Bod# reco"ers

on its own within 24 hours.

Class IIC loss o 1530H o &lood "olume /K7501500ml. +ach#cardia, tach#pnea,decrease pulse pressure, mild mental status changes.

Class IIIC 3040H &lood loss /K15002000ml. igniicant tach#cardia, tach#pnea,

mental status changes, and de'ease in blood #essue. Class IC more than 40H &lood loss /L2000ml. e"ere tach#cardia, tach#pnea

decrease pulse pressure, o&tundation, or coma.

esuscitation with 2D o D solution or normal saline is the recommended intial management,ollowed &lood i indicated. +#pe and crossmatched &lood is the product o choice /ta$es a

hour. +#pe speciic &lood is the second choice /ta$es 20min. Mni"ersal donor &lood -N or -

/or emale pts is usuall# well tolerated when gi"en to trauma "ictims in shoc$.

Browner B, :upiter :B, De"ine *, +raton ;C $eletal +rauma, ed 2. hiladelphia, , WB

aunders, 1998 pp141143

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9. 30#earold man who sustained a $nee dislocation in a oot&all game underwent an

arthroscopicall# assisted anterior and posterior cruciate ligament reconstruction 1 wee$ ater

in'ur#. !amination 3 months ater in'ur# re"eals a small eusion, decreased mo&ilit# o thepatella and passi"e range o motion rom 2060 degrees despite ph#sical therap#. What is the

nest most appropriate step in management.

1 ggressi"e ph#sical therap#

2 (orticosteroid in'ection

3 e"ision anterior cruciate ligament reconstruction4 *anipulation

5 rthroscop#

*an# authors ha"e commented on the acute surgical management o (D tears. +hegeneral conclusions are that acute surgical management /O23 wee$s should &e a"oided in order

to a"oid motion pro&lems and arthroi&rosis. )n a stud# out o /*aro et al, rthroscop# 8,1018< 1992, a re"iew o 642 patients who underwent (D repair, 18 de"eloped motion

pro&lems. -ut o these, 9 patients had reconstructions within 2 wee$s. $nee dislocation with a

com&ined (DI(D in'ur# ma# not aord the surgeon the lu!ur# o waiting and ma# reuireacute treatment secondar# to insta&ilit# o the $nee or associated in'uries /especiall# "ascular.

+he irst reerence discusses the arthroscopic management o com&ined (DI(D in'uries. +he

authors discuss timing o surger# and ad"ocate waiting a&out 46 wee$s.

+his patient presents with signiicantl# restricted -* as well as patelloemoralrestriction o motion at 3months. +he second reerence discusses the management o such

patients. +he# state that limitation o e!tensions is usuall# secondar# to patholog# within the

intercond#lar notch region whereas limitation in $nee le!ion are secondar# to scar in themedialIlateral gutters or within the suprapatellar notch. +he# recommend arthroscopic

e"aluation with de&ridement o scar in the notch or at pad as well as an# >(#clops? lesion

/although this patient did not ha"e a clun$.

!planation o wrong answersC 1 +his patient is alread# undergoing therap#. 2 (orticosteroid

in'ections would not help in that the scar has alread# ormed 3 there is no e"idence that the (D

reconstruction has ailed and would reuire re"ision. 4 *anipulation ma# &e helpul &ut doesnot directl# address the patholog# as well as arthroscop#.

eerences

1 Aanelli ;(, ;iannotti BA et al rthroscopicall#assisted com&ined (DI(Dreconstruction. rthroscop# 1996 12C514

2 Bach et alC ele! #mpathetic d#stroph#, atella inera contracture s#ndrome and loss o

motion ollowing (D surger#. )(D 1997 46C25160

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10. cti"e mo&iliation ollowing le!or tendon repair is &est accomplished with the wrist inC

1. le!ion and the *( 'oints in le!ion2. le!ion and the *( 'oints in e!tension

3. neutral and the *( 'oints in e!tension

4. neutral and the *( 'oints in le!ion5. e!tension and the *( 'oints in le!ion

Aollowing le!or tendon repair, 2 postoperati"e mo&iliation techniues are commonl#

emplo#ed. +he irst, ad"ocated Gleinert, acti"e inger e!tension is used with passi"e le!ion

allowed means o a ru&&er &and attached to the ingernail and at the wrist. +he wrist and *('oints are held in le!ion. +he ru&&er &and maintains the ) in 4060 degrees o le!ion,

allowing e!tension o the ) against the ru&&er &and. +his a"oids stretch on the repair, &ut theallowed motion acilitates healing. +he second techniue, ad"ocated uran, in"ol"es a

controlled passi"e motion techniue with dorsal &loc$ing o the ingers.

+#picall#, d#namic e!tension splinting is started at 68 wee$s, with strengthening permitted at 8

10 wee$s.

orii et al in"estigated le!or tendon e!cursions in "arious loading conditions. +he# alsoin"estigated dierent wrist splinting techniues ollowing le!or tendon repair. (omparing o the

Gleinert splint, splint /Gleinert splint with a palmar &ar, and splint /s#nergistic splint was

perormed. +he splint allows or s#nergistic motion o the wrist and ingers. )ncreased tendone!cursion was noted with use o the splint.

+hough the reerences cited do not speciicall# address it, the results presented indicate thattendon e!cursion and ) motion are impro"ed with the wrist in e!tension and the *( 'oints in

le!ion. +his suggests that wrist e!tension and *( le!ion ma# &e the &est position or acti"e

mo&iliation ollowing le!or tendon repair.

eerencesC

orii et alC (omparati"e le!or tendon e!cursions ater passi"e mo&iliationC n in

"itro stud#. : and urg m 1992< 17C55966.

*ans$e /edC and urger# Mpdate. nglewood, (-, , 1994, 4449.

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11. )n planning a surgical approach on a 23 #earold &allet dancer with os trigonum

s#ndrome, it is important to remem&er that the os trigonum is in what position relati"e tothe le!or hallucis longus tendon%

1. nterior2. osterior

3. *edial

4. Dateral

5. Within the tendon

!planationC

elati"el# straight orward answer. )n the article *arotta et. al., the approach to the

accessor# ossicle was as ollowsC 3cm straight incision was made at the posterior lateral an$le,posterior to the peroneal tendons as the# approach the tip o the lateral malleolus. (are is ta$en

to protect the sural ner"e and all o itPs &ranches. eeper dissection is directed toward the

posterior an$le 'oint and the capsule is identiied. +he capsule is opened in line with the s$inincision o"er the os trigonum, which is palpa&le at the posterior lateral margin o the talus.

harp dissection is then used to e!cise the ossicle in its entiret#. +he# point out that care must &e

ta$en to a"oid in'ur# to the le!or hallucis longus tendon, the ti&ial ner"e, the posterior ti&ialarter#, and the posterior ti&ial tendon on the medial side o the ossicle.

+he incidence or radiographicall# detecta&le os trigonum has &een reported &etween 3

13H in general population. )t is a distinct &ut inreuent ossicle, separate rom the posterior

&order o the talus and containing a groo"e or the le!or hallucis longus tendon. ormall# thetalus contains two posterior tu&ercles, a medial and lateral tu&ercle. )t is thought that os

trigonum is a separation o the second ossiication center o the lateral tu&ercle rom the

remainder o the talus.#mptomatic os trigonum impingement presents with recurrent pain, stiness,

tenderness, and swelling &ehind the an$le in the space anterior to the chilles tendon. +his is

especiall# noticea&le during pointe wor$ in dancing /i.e. the demipointe position in &allet with

the dancerPs oot in ma!imum plantar le!ion and e!treme plantar le!ion in sports li$e 'a"elinand soccer.

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Wredmar$, +., (arlstedt, (.., Bauer, ., aarto$, +. -s +rigonum #ndromeC clinical ntit#

in Ballet ancers. Aoot n$le 1991


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12. Which o the ollowing approaches is most appropriate to correct a pro'ected lim&length

discrepanc# o greater than 6 cm at s$eletal maturit#%

1. piph#siodesis /contralateral alone

2. cute shortening alone

3. hoe lit alone4. ;radual distraction lengthening

5. h#seal &ar resection

adiologic assessment o leg length discrepanc# include determination o leg lengths/scanogram, determination o s$eletal age using the ;reulich#le atlas /standard radiographs o

let handIwrist or &o#s and girls at "arious ages, and then determination o remaining growthusing the ;reennderson growth remaining method or the *osele# >straightline? graph.

;eneral guidelines or treatment &ased on predicted DD areC

0 to 2 cmC no treatment

2 to 6 cmC shoe lit, epiph#siodesis, shortening

6 to 20 cmC lengthening, with or without other procedures

L 20 cmC prosthetic itting

hoe lits greater than 5 cm are not well tolerated. piph#siodesis has low mor&idit# and low

complication rate. )t does ma$e the normal leg a&normal and result in a decrease in the patientPsstature, howe"er. hortening has the same indications as epiph#siodesis &ut is generall# oered

to patients who are s$eletall# mature. ;enerall#, the emur can &e shortened up to 5 cm and the

ti&ia 3 cm with little loss o unction. +he ris$ o nuero"ascular complications with ti&iashortening are higher though. h#seal in'ur# can lead to the de"elopment o ph#seal &ars, or

&one &ridge across the ph#sis that lead to growth arrest. h#seal &ar resection ma# &e indicated i

less than 50H o the ph#sis is damages and more than 2 cm o growth remain in the aected

growth plate.

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*osele# (AC ssessment and prediction in leglength discrepanc#. )nstr (ourse Dect 1980< 38C

32530.*orriss# +, Weinstein D /edsC Do"ellPs and WinterPs ediatric -rthopaedics, ed 5.

hioladephia, . Dippincott Williams and Wil$ins, 2001, pp. 110550.


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13. 43 #ear old woman has a pro!imal humerral lesion that was ound incedentall# on the

chest radiograph shown in Aigure 1a. he reports no pain and has ull shoulder range o motion.

n *) scan is shown in Aigure 1&. What is the ne!t most appropriate step in management%

1 o&ser"ation

2 &iops#3 erum protein electrophoresis

4 (t o the chest, a&domen, and pel"is

5 administration o &isphosphonates

W 1 o&ser"ation /an incedentaloma

*arco, et.al. (artilage tumorsC "aluation and treatment. :- 2000, 8, p 292304.


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14. Aormation o heterotopic &one in the hip a&ductor musculature ater antegrade

intramedullar# emoral nailing is most closel# associated with

1. ipsilateral ti&ia racture

2. the age o the patient

3. timing o i!ation4. reaming

5. wound irrigation

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15. patient who recei"ed lowmolecular weight heparin ater under going total hip arthroplast#

1 da# ago had normal neurologic unction and a hematocrit le"el o 30.8. -n the third post

operati"e da#, she reports se"ere hip pain, is una&le to dorsile! her oot, and has a hct o 21.6.adiographs show the implant in good position. +hese de"elopments are most li$el# caused

1. lim& o"erlengthening2. hematoma

3. inection

4. J+5. heparin induced throm&osis s#ndrome

ciatic ner"e pals# induced postop hematoma was reported orenson and (hristensen in

the :ournal o rthroplast# 1992< 7C551.

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16. espirator# (ompromise ollowing anterior cer"ical spine procedures is most closel#

associated with

1. *ultile"el approaches a&o"e (4

2. urgical time less than 3 hours

3. -&esit#4. mo$ing

5. ia&etes *ellitus

eC agi (, Beutler W, (arroll , (onnol# :. irwa# complications associated with surger#

on the anterior cer"ical spine. pine 2002< 27C949953.

etrospecti"e stud#C 311 anterior cer"ical spine procedures. is$s or respirator# distress

include 1 prolonged procedures /L5 hours, 2 more than 3 le"els (2, (3, (4, 3 more than300cc BD. mo$ing was not a ris$ actor, at was not a ris$ actor, the# donPt comment on *,

&ut intuiti"el# it doesnPt seem to ma$e much sense.

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17. Aigures 2a and 2& show the radiographs o a patient who has disproportionatel# short stature.

+here is a deect in the gene coding or

1 i&ro&last growth actor receptor 3

2 i&rillin

3 c#stathionine s#nthase4 adrenocorticotropin

5 parath#roid hormone

A;A 3C chondroplasia is caused a deect in A;A3

- utosomal dominant disorderotheshel? derotational &racing

3. arthroscopic proph#lactic notchplast#

4. pl#ometrics and neuromuscular training or 6 wee$s5. oral contracepti"e use

Wo't#s et al in"estigated the association &etween (D tears and menstrual c#cle phase. 69

emales with (D tears were e"aluated within 24 hours o in'ur#. !am, menstrual c#cle details,

-( use, and urine samples were in"estigated. higher than e!pected H o (D tears occurred

during the midc#cle /o"ulator# phase, while a less than e!pected H occurred during the lutealphase o the c#cle. Mse o oral contracepti"e agents decreased the association &etween (D tears

and the o"ulator# phase.

ewett et al studied the eects o a 'ump training program on landing mechanics and lowere!tremit# strength in emale athletes in"ol"ed in 'umping sports. +he program is designed to

degrease landing orces and increase "ertical height teaching neuromuscular control.Aollowing completion o the program, pea$ landing orces were ound to decrease 22H, while

$nee adductionIa&duction moments which are predicti"e o landing orces were ound to

decrease appro!imatel# 50H. Aemale athletes demonstrated lower landing orces "s. maleathletes ollowing completion o the program. amstringtouadriceps torue ratios and

hamstring power increased with training and "ertical 'ump height increased appro!imatel# 10H.

+hese results suggest that pl#ometric and neuromuscular training ma# &eneiciall# eect $nee

sta&iliation and help to pre"ent $nee in'ur# in emale athletes.

eerencesC

Wo't#s * et alC +he eect o the menstrual c#cle on (D in'uries on women as

determined hormone le"els. m : ports *ed 2002< 30C18288. ewett +A et alC l#ometric training in emale athletesC decreased impact orces and

increased hamstring torues. m : ports *ed 1996< 24C76573.

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37. Aigure 7 shows the clinical photograph o the $nee o a chronic cigarette smo$er 2 wee$s

ater re"ision total $nee arthroplast#. +reatment should now consist o

1 irrigation and de&ridement with a pol#eht#lene insert e!change

2 remo"al o components and insertion o anti&iotic cement spacer

3 de&ridement and a medial gastrocnemius lap.4 de&ridement and a ree lap.

5 $nee arthrodesis.

W 3

ies, $in ecrosis ater total $nee arthroplast#. : rthroplast# 2002C 17, 7447.


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38. 20#earold woman has progressi"e low &ac$ pain. n pel"ic radiograph, (+ scan,

posterior pel"ic &one scan, and &iops# specimen are shown in Aigure 8a through 8d.

)mmunohistochemistr# re"eals (99 reacti"it# &ut no staining or leu$oc#te common antigen.What is the most li$el# diagnosis%

1. wingPs sarcoma2. D#mphoma

3. *ultiple m#eloma

4. Dangerhans cell histioc#tosis5. -steom#elitis

+he pel"is and the (+ pel"is show a large, purel# l#tic geographic lesion in the right iliaccrest. +his is a #oung emale with progressi"e low &ac$ pain. *#eloma is the most common

primar# &one tumor /35H o all &one tumors, 45H o malignant &one tumors. 70H o patients

with multiple m#eloma are men &ut the a"erage age o patients at presentation is 62 #ears.

adiographicall#, the lesions are sharpl# >punchedout? holes or >&u&&l#? in appearance.wingPs sarcoma is a highl# malignant primar# &one sarcoma that usuall# aects children and

#oung adults. n# &one can &e in"ol"ed, &ut it is usuall# in the long &ones /55H, pel"is, andri&s /25H. ermeati"e destruction is a ma'or eature o wingPs sarcoma &ut can range rom

>motheaten? permeati"e to geographic and purel# l#tic. eriosteal reaction is also uite common

/50H with >onion s$inning? appearance. istologicall#, sheets o monotous, malignant >roundcell? are seen. (ompared to l#mphomas, the# stain less intensel#. -steom#elitis t#picall#

presents as an acute, sharp pain.

W 1

*c(arth# A, Arassica A:C rimar# &one tumors, in *c(arth# A, Arassica A: /edsC atholog#

o Bone and :oint isorders with (linical and adiographic (orrelation. hiladephia, , WB

aunders, 1998, pp 25860.Weis DC (ommon malignant &one tumorsC -steosarcoma, in imon *, pringield /edsC

urger# or Bone and ot +issue +umors. hiladelphia, , Dippincotta"en, 1998, pp. 26574.

*irra :*C Bone tumors. (linical, radiographic, and pathologic correlations. hiladelphia, ,Dea and Ae&iger, 1989.


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39. natomic studies o the pro!imal ti&ia ha"e shown that the capsular relection o the $nee

'oint e!tends the arthest distal to su&chondral &one at what location%

1 anterior to the i&ula

2 posterior to the i&ula

3 directl# medial to the ti&ia4 directl# posterior to the ti&ia

5 anteromedial to the ti&ia

W 2 posterior to the ti&ia

eid, et.al. ae placement o pro!imal ti&ia transi!ian wires with respect to the intracapsular

penetration. :-+ 2001C 15C 1017.

-GM 7 pp47988.


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40. Which o the ollowing is considered a normal agerelated change in the inter"erte&ral dis$

in the elderl#%

1 )ncreased proteogl#con concentration

2 increased &ios#nthetic unction

3 increased "ia&le cell concentration in the central region4 decreased water content

5 decreased stiness

W 4 )ncreeased water

Buc$walter :, maintaining and restoring mo&ilit# in the middle and old ageC the importance o

the sot tissues. )(D 1997, 46C 459469.


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41. tall, thin 13 #r old girl with idiopathic scoliosis undergoes instrumented posterior spinal

usion rom +4 to D3. ostop reco"er# is une"entul, and a clear liuid diet is &egun on the third

da#. +he patient responds with "omiting and is una&le to tolerate an# oral inta$e< howe"er,&owel sounds are normal. asograstric suction re"eals large amounts o persistent &ilious luid

drainage. +he patient is ae&rile, with a normal peripheral WB( count and normal serum

am#lase and lipase le"els. What is the ne!t most appropriate step in management%

1. reuest ps#chological consultation and increase the patientPs sedati"e medications

2. aspirate the spinal wound and institute &roadsprectrum anti&iotic therap#3. o&tain a m#elogram and re"ise the implants to lessen the correction

4. o&tain an ultrasound o the $idne#s and perorm an e!plorator# laparotom#

5. o&tain an upper gastrointestinal stud# and institute parenteral eeding

hapiro, et al, gi"e a nice re"iew o medical complications o scoliosis surger# in (urrent

-pinions in ediatrics 2001


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42. *anagement o (harcot euroarthropath# in the oot ma# include the use o

1 spirin

2 Bisphosphonates3 (ephalosporins

4 strogen

5 Jitamin

eC :ude B, el D, Burgess :, Dille#stone , *awer B, age , onohoe *, Aoster J, dmonds *,Boulton :.

Bisphosphonates in the treatment o (harcot neuroarthropath#C a dou&le&lind randomised

controlled trial.ia&etologia. 2001 o"


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43. 23#earold patient sustains an isolated right $nee dislocation in a motor "ehicle accident. closed reduction is perormed and conirmed with radiographs. What is the ne!t appropriatestud#%

1 (+ o the $nee

2 *) o the $nee

3 adiographs o the emur and ti&ia

4 ngiograph# o the leg

5 onin"asi"e assessment o lower e!tremit# perusion

eems prett# intuiti"e. Gnee dislocations are associated with in'ur# to the popliteal arter#. o reduce the $nee andma$e sure that there is good &lood low distall#. onin"asi"e assessment o lower e!tremit# perusion can &e assimple as eeling or pulses or using a doppler. ) neither o these is a&le to appreciate a pulse then mo"e ontoangiograph#.

mechanism o in'ur#C

distinguish &etween high "elocit# in'uries "ersus low "elocit# in'uries /as this relects

incidence o "ascular and ner"e in'uries o tansition> ;onecontains 'olla8en ?ibes

with a larger diameter and less a##aent o8ani;ation, and the chondroc#tes ha"e a more

rounded appearance. +he dee# ;onecontains the highest concentration o proteogl#cans and thelowest water content< the 'olla8en ?ibesha"e a large diameter and are o8ani;ed#e#endi'ula to t,e oint su?a'e. +he chondroc#tes are spherical and oten are arranged in a

columnar ashion. +he deepest la#er, the one o calciied cartilage, separates the h#aline

cartilage rom the su&chondral &one. )t is characteried small cells distri&uted in acartilaginous matri! encrusted with apatitic salts. istologic staining with hemato!#lin and eosin

shows a wa"# &luish line, called the tidemar$, which separates the deep one rom the calciiedone. +he perpendicular collagen i&ers in the deep one cross the tide mar$ and are secured in

the calciied cartilage la#er thus imparting resistance to shear stress at the &onecartilage

interace.

able 1

A4.5E& +

-rthopaedic Basic cience,

- 2nd

dition

Browne :C urgical alternati"esor treatment o articular

cartilage lesions.

:- 2000


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49. patient with neutral ulnar "ariance sustains an e!traarticular racture o the distal

radius that heals with normal palmar tilt &ut with loss o radial height. esultant ulnar

"ariance is measured at N3mm. What percent o load transmission across the wrist willnow &e &orne the ulna%

6 10H

7 25H

8 40H9 75H

10 90H

+he $inematics o the normal wrist /almer and Werner, (- 187C 2635, 1984 as measured

with an e!perimental model show that the radius /through its articulation with the lateral carpuscarries appro!imatel# 82H o the a!ial load o the orearm, and the ulna /through its articulation

with the medial carpus carries appro!imatel# 18H. Aurther studies were done to e"aluate the

change in the load &orne the ulna with NI "ariance /whether surgical or the result o

shorteningIrelati"e lengthening ater racture. (hanges in the ulna length dramaticall# alteredthe amount o orce &orne the distal ulna. hortening o the ulna 2.5 cm resulted in a decrease

rom 18 H to 'ust 4H. Dengthening 2.5 cm resulted in an increase rom 18H to 42H. +hus, )

uote, >When a (ollesP racture settles 2.5 mm, one can e!pect and increase in ulnar a!ial load oappro!imatel# 40H.?

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50. +he greatest increase in compartment pressure during reamed intramedullar# nailing o a ti&ial shat

racture occurs with the use o

1. an awl or entr# portal creation

2. a tourniuet

3. a large intramedullar# nail4. a static loc$ing construct

5. continuous traction

)ntramedullar# nailing is the treatment o choice or most ti&ial shat ractures. nail is eecti"e atcontrolling &ending and lateral displacement. Because the ma'orit# o the ti&ial medullar# canal is relati"el#

straight, a nail restores a!is alignment or ractures in the diaph#sis. +here is immediate loss o medullar#

arterial low with a some &one necrosis around the nail. +o compensate, the periosteal &lood suppl# assumes a

larger role in perusing the corte!. +he medullar# arterial s#stem usuall# regenerates within a ew wee$s.+here is signiicantl# less cortical necrosis with a loosel# itting intramedullar# nail than with a snug nail ater

reaming. ailing pro"ides e!cellent sta&ilit# or most ti&ial shat ractures. (losed nailing ater reamingoers racture control or weight &earing with a low ris$ o inection or other treatment complications.

eamed intramedullar# nails oer &etter sta&ilit# and strength, and thus earlier unsupported weight

&earing. Aor uncontaminated and uninected dela#ed unions and nonunions, reamed nailing usuall# pro"idesan e!cellent and relia&le unctional treatment, i the racture is appropriatel# located and the nail can &e

inserted with a closed techniue or with minimal sot tissue stripping. onreamed intramedullar# nails can

&e used or closed ti&ial ractures and ha"e &een ad"ocated or use in closed ractures with signiicant sot

tissue in'ur# or compartment s#ndrome. owe"er, compared with largerdiameter nails designed or insertionwith reaming, their smallerdiameter shats, proportionatel# larger loc$ing screw holes, and smaller loc$ing

screw diameters t#picall# result in reduced ultimate strength and shorter atigue lie.

Aractures that need immediate surger# or sot tissue considerations ma# &e treated immediatel# withintramedullar# nails. )t is important to &e aware that restoration o length decreases muscular compartment

"olume, which ma# precipitate a compartment s#ndrome, especiall# i ascial compartments remain intact.

+i&ial shat ractures ha"e a $nown incidence o compartment s#ndrome. +he in'ur# itsel is usuall# themain cause. +here is an increase in compartment pressure when the canal is reamed or when an unreamed

nail is inserted. +hese uic$l# return to &aseline le"els. n awl or entr#, tourniuet, large nail or static

loc$ed nail apparentl# do not cause as much increase in compartment pressure as traction. +raction decreases

the compartment "olume which can lead to increased pressure. thigh post has also &een demonstrated toele"ate compartment pressures.

W 5. continuous traction

eerencesCBrowner :upiterC $eletal +rauma, 1998, pp 222638.

assi, ect o cute eamed "s Mnreamed )ntramedullar# ailing on (ompartment pressure

when +reating (losed +i&ial hat AracturesC andom rospecti"e tud#< :-+ 14, 2000C 554

8.


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51. Which o the ollowing are $nown predicti"e actors or cur"e progression in idiopathic

scoliosis%

1. ea$ height "elocit#, emale gender, open triradiate cartilage, premenarchal status

2. ea$ height "elocit#, male gender, open triradiate cartilage, preadrenarchal status

3. ea$ height "elocit#, emale gender, closed triradiate cartilage, premenarchal status4. ea$ height "elocit#, emale gender, open triradiate cartilage, postmenarchal status

5. Aamil# histor#, emale gender, open triradiate cartilage, premenarchal status

either paper reall# addresses the uestion, &ut we $now that &eing emale is predicti"e. arlierage o diagnosis /open growth plates means that there is more time or the disease to progress,

as it slows down signiicantl# ater the growth plates use. remenarchal status ollows the

a&o"e two. nd pea$ height "elocit# is the period where the greatest progression is e!pected.*enarche occurs appro!imatel# 7 months ater J. ;rowth is complete appro!imatel# 2 #ears

ater menarche.

Dittle ;, ong G*, Gat , erring :C elationship o pea$ height "elocit# to other maturit#indicators in idiopathic scoliosis in girls. :B: 82/C 685693

Dowe +;, dgar *, *argulies :V, et al.C tiolog# o idiopathic scoliosisC (urrent trends in

research. :B: 82/C 11571168

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55/278

53. Within the unctional spinal unit, the nucleus pulposus unctionsC

1. to resist compressi"e loads

2. to resist tension loads3. to resist shear loads

4. independent o the annulus i&rosis

5. independent o the acet 'oints

*otion segments in the spine are comprised o two "erte&ral &odies and an inter"erte&ral dis$.

+he our regions o the dis$ includeC the cartilaginous end plate, the outer annulus i&rosus, the

inner annulus i&rosus, and the nucleus pulposus. +he dense collagenous crosspl#,circumerential lamellae o the outer annulus i&rosus resist large tensile stresses, minimie disc

&ulging, and reduce the strains that are de"eloped during a!ial compressi"e and torsional

loading, sagittal and trans"erse &ending, or a!ial torsional loading o the spine. +his includesshear loads on the spine.

+he nucleus pulposus pro"ides a h#drostatic &arrier that limits the deormation o the disc. +he

high degree o h#dration /70 to 80H allows the nucleus pulposus to resist compressi"e loads

while &eing contained the outer annulus. isc mechanical unction depends not onl# on the annulus i&rosus and nucleus pulposus, &ut

also on the cartilage end plate. *otion segment studies suggest that the cartilage end plate

undergoes signiicant compressi"e deormation. lthough morphologicall# distinct rom theannulus and nucleus, the cartilaginous end plate unctions in con'unction with the two structures

to maintain uniorm stress distru&ution across the &oundar# &etween the "erte&ral &od# and the

dis$.

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54. 52 #earold man sustains a displaced &imalleolar /We&er B an$le racture in a all. istor#

re"eals that he has had t#pe ) dia&etes mellitus or the past 30 #ears. !amination re"eals a

closed in'ur# with mild swelling, palpa&le pulses, and decreased sensation to the midcal le"el.*anagement should consist o

1. closed treatment with a short leg cast

2. percutaneous pininplaster techniue3. e!ternal i!ation spanning the an$le

4. amputation

5. open reduction and internal i!ation o the medial and lateral malleoli

+he treatment o an$le ractures in dia&etics can &e raught with complications including

dela#ed wound healing, surgical inection, and (harcot arthropath#. Aor this reason, and the

somewhat sparse literature comparing the clinical outcomes o nonoperati"e "ersus operati"einter"ention in displaced an$le ractures, there has &een some de&ate as to the &est wa# to handle

these ractures in dia&etics.

)n the article >(omplications o n$le Aractures in ia&etic atients? Orthopedic Clinics

o !orth A"erica. 32 /1 :an. 2001, the authors admit the lac$ o consensus in treating theseractures, &ut recommend the ollowingC

. #reat"ent o !ondisplaced An$le ractures in dia%etics@the nondisplaced racture inthe dia&etic t#picall# heals une"entull# with cast immo&liation ollowed &racing.

+he authors suggest a protocol o cast immo&iliation or a minimum o 8 wee$s non

weight &earing. ter this, the patients ollow a protocol o &race immo&iliation in* short leg wal$er or molded, lined, and &i"al"ed A- or another 816 wee$s with

progressi"e weight &earing. +he# uther recommend an increase o 25l& at 2 to 4

wee$ inter"als until 75H o the patientPs weight is achie"ed.

B. #reat"ent o &isplaced An$le Fractures in dia%etics'chon et al. /ClinOrthop349C116131, 1998 descri&ed a series o 13 pre(harcot displaced an$le ractures.

Aour an$les where treated nonoperati"el# and nine underwent -)A. ter a

minimum o 3 months in cast or &race, the nonoperati"e treatment resulted insigniicant "arus deormit#, non union, or &oth in all cases, reuiring arthodesis or

-)A. (on"ersel#, those undergoing -)A were managed with WB and

immo&iliation or 812 wee$s. +hese an$les showed onl# 1 in 7 progressi"edisplacement. While this series is small, the authors similarl# recommend operati"e

inter"ention o displaced an$le ractures in dia&etics. +he# contend that despite the

potential or possi&le dela#ed wound healing, inection and loss o i!ation secondar#

to osteopenia, articular alignment is more important to help minimie residualdeormit# and the possi&ilit# o de"eloping (harcot arthropath#. urgical i!ation

in"ol"es -)A using 1I3 tu&ular plate lateral and 3.5I4.0I4.5 screw mediall#.

dditional sta&iliation consists o s#ndesmotic screws. ter surger#, WB and castimmo&liation are recommended or 8 wee$s, with cast changes e"er# 2 to 4 wee$s.

remo"a&le * (* wal$er or molded plastiote lined and &i"al"ed A- is used

with weight &earing increased 25 l&.at 2 to 4 wee$ inter"als or another 8 to 12 wee$suntil 75H o the patientPs weight is reached. +hen ull weight &earing allowed.

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55. +reatment o comple! regional pain s#ndrome o the $nee includes

1 Gnee manipulation

2 assi"e range o motion e!ercises

3 Beta&loc$ing agents

4 lpha&loc$ing agents

5 aras#mpathetic &loc$ade

+he treatment o rele! s#mpathetic d#stroph# can include s#mpathetic &loc$ade /not

paras#mpathetic, ph#sical therap# /acti"e and acti"eassisted -* e!ercises andpharmacologic agents. rugs that ha"e shown some eecti"eness in treating s#mpatheticall#

maintained pain include alpha&loc$ers, antidepressants, and anticon"ulsants. arcotics and

&enodiaepines are not recommended, as the# can lead to dependence, depression, andincreased pain.

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56C Based on the radiographic indings shown in Aigures 12a and 12&, the patient is most li$el#

to ha"e deects in what other organ s#stems%

1. Jisual2. ndocrine

3. enal

4. ematologic5. igesti"e

GlippelAeil s#ndrome is a congenital usion o the cer"ical "erte&rae that ma# in"ol"e twosegments, a congenital &loc$ "erte&ra, or the entire cer"ical spine. (ongenital cer"ical usion is a

result o ailure o normal segmentation o the cer"ical somites during the third to eighth wee$ o

lie. +he s$eletal s#stem ma# not &e the onl# s#stem aected during this time, andcardiorespirator#, genitourinar#, and auditor# s#stems reuentl# are in"ol"ed. )n most patients

the e!act cause is not $nown. -ne proposed cause is a primar# "ascular disruption during

em&r#onic de"elopment that results in usion o the cer"ical "erte&rae and other associatedanomalies. Beals and ole suggested that a glo&al insult with "aria&le eects on dierent

tissues or multiple separate insults could e!plain the usions o the cer"ical "erte&rae and other

associated anomalies. ;underson et al. showed that in a ew patients this is an inherited

condition. is stud# suggests that usion o (2(3 ma# &e an autosomal dominant inheritance,&ut the inheritance pattern o other cer"ical "erte&ral usion patterns could not &e determined.

*aternal alcoholism also has &een suggested as a causati"e actor. +redwell et al. ound a 50H

incidence o cer"ical "erte&ral usions in roentgenograms o patients with etal alcohols#ndrome. &out one third o patients with GlippelAeil s#ndrome ha"e urogenital anomalies.

Because the cer"ical "erte&rae and genitourinar# tract dierentiate at the same time and location

in the em&r#o, etal malde"elopment &etween the ourth and eighth wee$s o de"elopment ma#produce &oth genitourinar# anomalies and GlippelAeil s#ndrome. +hese renal anomalies usuall#

are as#mptomatic, and children with GlippelAeil s#ndrome should &e e"aluated with an

ultrasound or intra"enous p#elogram &ecause the renal pro&lems can &e lie threatening. +hemost common renal anomal# is unilateral a&sence o the $idne#. -ther anomalies include

malrotation o $idne#s, ectopic $idne#, horseshoe $idne#, and h#dronephrosis rom ureteral

pel"ic o&struction.

Canale: Campbell's Operative Orthopaedics, 10th ed., Copyright 2003 Mosby, Inc. 1737-1738.

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60/278

58. Wrestler with swelling Q redness o"er the anterior $nee ater a&rasion 2 wee$s ago. o

$nee eusion and acti"e -* 0100 degrees. adiographs show some sot tissue

swelling anterior to the patella. *anagement should consist oC

1. )

2. ph#sical therap#3. *)

4. corticosteroid in'ection

5. aspiration

uni"ersit# o )owa stud# showed prepatellar &ursitis is easil# diagnosed. +here is usuall#histor# o trauma &ut the e!act incident is oten un$nown. welling is supericial to the

patella and the posterior $nee can &e normal. +)( ( -A+

V*+-*+)( owe"er, there ma# &e local e"idence o inection. )n the )owa stud#o 136 wrestlers, 13 de"eloped initial prepatellar &ursitis. 5 had no recurrences &ut the other

8 had 20 recurrences. al o 6 cases in 4 wrestlers with septic prepatellar &ursitis had no

clinical signs o inection at presentation. +hereore it is necessar# to aspirate and get a gramstain o the luid. ll &ut one inection had penicillin resistant staph aureus. +reatment

consists o rest, immo&iliation, padding, aspiration, compressi"e dressings, steroid in'ection,

and surger# /nti&iotics or inected cases o course. teroid in'ection appeared ineecti"e.

+his in'ur# is more reuent in lighter weight classes and during the o season.spirate them all, start anti&iotics i clinicall# inected or positi"e culturesIstains.

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59. 28#earold man underwent surgical i!ation or an intraarticular distal humeral

racture 8 wee$s ago now reports progressi"el# restricted el&ow motion. adiographs at

the time o union are shown in Aigures 13a and 13&. *anagement should now consist o

1 oral indomethacin.

2 irradiation with a single dose o 700 c;#.3 ph#sical therap# with d#namic splinting.

4 ph#sical therap# and dela#ed ectopic &one e!cision at 12 months.

5 immediate el&ow release and ectopic &one e!cision.

+he radiographs demonstrate an and lateral o the el&ow sIp -)A distal humerus racturewith signiicant heterotopic &one o"er the anterior aspect o the distal humerus. egan and

eill# ha"e descri&ed three actors that contri&ute to posttraumatic el&ow stinessC

1. high degree o articular congruit# and conormit# o the el&ow

2. predisposition o periarticular ossiication o the &rachialis3. diicult# in achie"ing rigid internal i!ation reuiring length# postop mo&iliation

+he options or posttraumatic el&ow arthritis are splinting, arthroplast#, interposition

arthroplast#, distraction arthroplast# el&ow arthrodesis, and >simple? el&ow contracture release.

)ndomethacin and radiation therap#, although helpul in pre"enting heterotopic &one ormationwould not &e useul in this patient who alread# has signiicant &one ormed with restricted

motion.

+he recommendations on the timing o e!cision o the ectopic &one ha"e changed within the lastten #ears. -riginall# surgeons ad"ocated dela#ing contracture release one to 2 #ears to allow

&one maturation. urgeons ad"ocated waiting until &one scans and serum al$aline phosphatase

were normal &eore heterotopic &one was remo"ed. )n 1999 Jiola et al. pu&lished a prospecti"estud# o earl# simple el&ow contracture release ollowed a short course or )s and

ph#sical therap# with good results. arl# el&ow release pre"ented prolonged sot tissue

contracture with the potential or articular cartilage degeneration and is now the standard o care.

W 5.

eerencesCJiola W, anel C arl# >simple release o prostraumatic el&ow contracture associated with

heterotopic ossiication. : and urg * 1999


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60. What is the most signiicant mechanism which a cell controls its phenot#pe%

1 rotein degradation2 * degradation

3 +ranslation eicienc#

4 +ranscription5 osttranscriptional m processing

There are 6 potential control points for gene regulation:1. initiation of transcription2. posttranscriptional processing of the mRNA (i.e. splicing)3. mRNA degradation4. ecienc! of translation". posttranslation processing6. protein degradation.

The most signi#cant among these control mechanisms is initiation of transcription.This isthe most sensi$le of the control points $ecause the cell does not %aste energ!s!nthesi&ing a useless RNA. Also' multiple genes ma! $e reuired simultaneousl!'and a common control mechanism allo%s for coordinate epression at theappropriate time and place. Although initiation of transcription is the ma*or controlpoint for the epression of man! genes' this form of control does not eclude othersfrom pro+iding a cell %ith the a$ilit! to #ne,tune the epression of a particular gene.

lthough e!amples o regulation at each o these steps in gene e!pression ha"e &een ound in,

control o transcription initiation the irst step is the most important mechanism or determining

whether or not most genes are e!pressed and how much o the encoded ms, andconseuentl# proteins, are produced.

Buc$walter :, et alC -rthopaedic Basic cience ed 2. osemont )D -, 2000, pp 1976

W 4


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61 patient with (*( 'oint arthritis o the thum& undergoes trapeium e!cision and

interposition arthroplast#. -ne #ear ater treatment, radiographs re"eal that there has&een 25H su&sidence o the thum& metacarpal compared with preoperati"e height. +his

degree o su&sidence will ha"e what eect on surgical outcome%

1 Will not aect unctional outcome

2 Will result in diminished thum& motion

3 Will result in diminished pinch strength4 Will result in diminished grip strength

5 Will result in moderate acti"it#related pain

nswerC 1 will not aect unctional outcome

!cisional arthroplast# has &een used eecti"el# in relie"ing pain associated with &asal

'oint arthritis and preser"ing thum& motion. -ne complication o the procedure has &een loss o

thum& strength and sta&ilit#. )n an eort to impro"e thum& unction and pre"ent pro!imalmigration, operati"e methods ha"e &een de"eloped to reconstruct the ligaments &Iw the &ase o

the thum& *( and the inde! *( /the palmar o&liue ligament. +endon interposition wasde"eloped or that purpose using the A( ligament.

+he surger# in"ol"es a posterior approach &etween the D and B with incision o the

capsule and e!cision o the trapeium. 12 cm o the A( is then o&tained and pulled throughdrill holes in the &ase o the thum& *( and tied onto itsel while the thum& *( is maintained in

the a&ducted ist position with a Gwire. +he remainder o the A( is then &alled up and placed

in the now empt# trapeium ossa as a spacer. +he patient is then immo&ilied in a thum& spica

or 4 wee$s.+wo studies /listed &elow loo$ed at the results o this procedure. +he indings were that

the main trapeial space ratio decreased a&out 33H. When anal#sis was perormed as to the

eect this had on grip strength, pinch strength, pain and thum& motion, there was ound to &e nocorrelation &etween this loss o height and those our actors.

+he conclusion is that tendon interposition is helpul in restoring thum& motion, pain

relie and strength. owe"er, the secondar# goal o reconstructing the palmar o&liue ligamentis not achie"ed this procedure although this has no aect on clinical outcome.

W 1

1 Vang , Weiland :C 1st*( su&sidence during pinch ater ligament reconstruction and

tendon interposition &asal 'oint arthroplast# o the thum&. : and urg m 1998< 23C879883.

2 +omiano **, elligrini J, Burton )C rthroplast# o the &asal 'oint o the thum&C

Dong term ollowup ater ligament reconstruction and tendon interposition arthroplast#.: and urg m 1996< 21C2029.


64/278

62. arl# ailure o a unicompartmental $nee arthroplast# that is the result o pol#eth#lene wear

is primaril# caused C

1. malalignment2. insta&ilit#

3. metal &ac$ing o the ti&ial component

4. gamma irradiation steriliation and shel storage in air5. o&esit#

*c;o"ern et al reported that the mechanical toughness o pol#eth#lene sterilied gamma

irradiation in air decreases ater a long shel lie. 75 unicond#lar $nee replacements were

ollowed clinicall# and radiographicall#. 30 $nees were re"ised at a mean o 18 months.

(omponents retrie"ed at time o re"ision were e!amined or presence o o!idation. +he rate opol#eth#lene wear increased as the shel lie increased. n in"erse correlation was noted &etween

the shel lie o the pol#eth#lene and the time o re"ision. 7 components ractures and 10 had

ractured and ragmented. +he stud# shows the earl# and se"ere wear o ti&ial pol#eth#lene

gammasterilied components stored or O 4.4 #ears.

eerencesC

*c;o"ern +A et alC apid pol#eth#lene ailure o unicond#lar ti&ial components

sterilied with gamma irradiation in air and implanted ater a long shel lie. :B: m

2002< 84C90106.

WC 4


65/278

63. Aigures 14a and 14& show the *) scans o a 38#earold man who has an enlarging,

painless mass in the let distal thigh. &iops# specimen is shown in Aigure 14c. What is

the most li$el# diagnosis.

1. Dipoma

2. esmoid tumor3. Ai&rosarcoma

4. ngiosarcoma

5. Diposarcoma

*ost liposarcomas appear well deined on *)s, mostl# with lo&ulated margins. Welldierentiated liposarcomas are mainl# composed o at with septations or nodules and are

h#perintense on +2weighted images. ter the administration o contrast material, welldierentiated liposarcomas ma# enhance minimall# or not at all.

Doo$ing at the +1 and +2 images we see a lo&ulated mass, that is heterogeneous,

'u!tacortical, and "er# large. )t is mostl# dar$ on +1 /which helps rule out lipoma. )t ish#perintense /enhances on +2 weighted images due to its high cellularit# /which we can see on

the histologic section. Vou can also see some >adiposeli$e? cells on the histologic section /the

larger "acuolated cells. ue to the *) and histologic picture liposarcoma is the one &est

answer to this uestion. Aurthermore, although no real histor# is gi"en, the act that the mass ispainless is also a $e# since most liposarcomas are painless.

FBIC Diposarcoma is second in reuenc# onl# to malignant i&rous histioc#toma /*A

among the sottissue sarcomas. )t occurs almost e!clusi"el# in adults and is ound most oten inthe thigh or retroperitoneum. )t rarel# arises rom a lipoma and does not occur in the

su&cutaneous tissues. Diposarcomas are di"ided into histologic su&t#pes with dierent

microscopic appearances and slightl# dierent &eha"ior characteristics. urgical resection witha wide surgical margin is the treatment o choice. When amputation is reuired to o&tain an

adeuate surgical margin, local irradiation can &e used as an ad'u"ant and a lim&sparing

operation can &e done. (urrentl#, no e"idence e!ists that ad'u"ant chemotherap# is indicated or

patients with liposarcoma, although numerous studies are &eing done to in"estigate its use. s isthe case or all sarcomas, the lung is the most common site o metastasis< howe"er, liposarcoma

has an unusual propensit# to metastasie to the retroperitoneum, mediastinum, and &one.

W C 5

;rainger Q llisonEs iagnostic adiolog#C +e!t&oo$ o *edical )maging, 4th d

Springfield, D.: Liposarcoma. Clin-Orthop Related Research. 1993 Apr.

!"9#. $ %&-'.


66/278

64. Which o the ollowing indings is one o the diagnostic criteria or diuse idiopathic s$eletal

h#perostosis%

1. Alowing osiciation along the anterolateral aspect o at least our contiguous "erte&rae

2. is$ space collapse in the in"ol"ed "erte&ral segments

3. *arginal s#ndesmoph#tes o"er our contiguous "erte&rae4. acroiliac erosion or sclerosis

5. Aacet 'oint an$#losis

iuse idiopathic s$eletal h#perostosis /) is a common disorder characteried &ac$ pain

and spinal stiness. )n older indi"iduals, the pre"alence has &een shown to &e as high as 1525H.+he usual presentation is a middleaged or older patient with chronic mild pain in middle to

lower &ac$, spinal stiness, and t#pical radiographic indings in the thoracic spine. +endinitis

ma# &e present and d#sphagia is an occasional complication. +he diagnostic criteria or )

areC

1. Alowing ossiication along the anterolateral aspect o at least our contiguous

"erte&rae.2. reser"ation o dis$ height in the in"ol"ed "erte&ral segment< the relati"e a&sence o

signiicant degenerati"e changes, such as marginal sclerosis in "erte&ral &odies or

"acuum phenomenon3. &sence o acet'oint an$#losis< a&sence o sacroiliac erosion, sclerosis, or intra

articular osseous usion.

+he irst criteria is the essence o ) while the other two criteria ser"e to eliminate thedierential diagnosis o spond#losis o degenerati"e spinal disorders and an$#losis spond#litis

/ as alternati"e diagnoses.

WC 1

Belanger +, owe C iuse idiopathic s$eletal h#perostosisC *usculos$eletal

maniestations. : m cad -rthop urg 2001< 9C 25867.


67/278

65. n 18month old child has &ilateral >corner ractures? o the distal emoral metph#ses o

un$nown origin. Aollowing a s$eletal sur"e#, the irst step in management should consist o

1 otiication o child protecti"e ser"ices

2 &ilateral long leg casts and discharge3 &ilateral percutaneous pinning, long leg casts, and sicharge

4 hospital admission and Br#antPs traction

5 hosptial admission and modiied Br#antPs traction

W 1 notiiactioan o protecti"e ser"ices

Doder +, et.al. Aracture patterns in &attered children. :-+ 1991< 5< 428433.


68/278

66. What is the most common location or longitudinal peroneus &re"is tendon tears%

1 musculotendinous 'unction2 pro!imal to the i&ular groo"e

3 at the i&ular groo"e

4 t tand &elow the peroneal tu&ercle o the calcaneus5 t the point o insertion on the ith metatarsal

W 3 at the i&ular groo"e

Xanmarco ;:, et.al. (hronic peroneus &re"is tendon lesions. Aoot n$le 1989< 9< 16370.


69/278

67. Aigures 15a through 15c show the plain radiograph, (+ scan, and &iops# specimen o a 23

#o man with acute onset hip pain. istor# re"eals that he underwent a trochanteric ad"ancement

at age 6 #r. What is the most li$el# diagnosis%

1. osteom#elitis2. l#mphoma

3. eosinoph#lic granuloma

4. tu&erculosis5. wingPs sarcoma

+he !ra# shows a geographic l#tic lesion in the pro!imal emur. +he (+ shows serpiginous

tracts and irregular areas o &one destruction and reacti"e ormation along with a walled o area.

+he path slide shows mi!ed cells with a predominance o pol#morphonuclear cells. +he !ra# isnonspeciic. +he (+ is consistent with chronic osteom#elitis the walled o area is a

seuestrum. +he path supports the (+, as does the remote histor# o surger# in the region.

W 1

+he reerence gi"en is :* 1997


70/278

68. 54 #ear old man sustains a patellar racture in a all. !amination re"eals that the patient

can perorm a straight leg r3aise on the in'ured side. Yra#s re"eal a trans"erse racture with 2

mm o displacement o the articular surace and no comminution. *anagement should consist o

1 )mmo&iliation in a long leg cast and no weight &earing

2 )mmo&iliation with $nee straight and ull weight &earing3 o immo&iliation and ull weight &earing

4 +ension &and wire construct

5 Dag screw i!ation

e oc$wood and ;reen

atient with a closed patella racture &ut with no e!tensor lag. o e!tensor lag, no need orsurger#. nswer 3 is not desira&le the racture will not heal optimall# with no immo&iliation.

o the answer is 1 or 2. +he &est answer is 2. With the $nee immo&ilied straight, weight

&earing is ine. lthough technicall#, answer 1 would suice, the gu# would still heal. But

answer 2 is &etter &ecause / in m# opinion &ecause the it speciicall# sa#s immo&iliation ine!tension.

W 2


71/278

69. )nwhich o the ollowing t#pes o studies can an incidence rate &e determined%

1 (rosssectional2 rospecti"e cohort3 (ase control4 andomied trial5 etrospecti"e re"iew

In'iden'eC +he num&er o new cases o the disease or condition that arise during a speciic timeinter"al.

In'iden'e ate6 +he num&er o new cases di"ided the population at ris$ &ut without thedisease. )t gi"es a ar &etter estimation o the signiicance o e!posure

Coss@se'tional study6 "aluates a group at one point in time. -ten descri&ed as a >snapshot?o a population or sample. (ausal lin$s &etween diagnosis and "aria&les are ound, &ut noconclusions are drawn

os#e'tive Co,ot .tudy6 group o disease ree su&'ects is ollowed o"er time to identi#onset o disease or in'ur#. T,is ty#e o? study identi?ies in'iden'e. (ohort studies are useul oresta&lishing relati"e ris$.

Case Contol6 u&'ects in the stud# group are chosen &ased on the presence o an in'ur# or thepresence o disease. +he group is then anal#ed to identi# associated, clinicall# rele"ant

inormation. (asecontrol studies deinition &egin with a population and its disease andcannot &e e"aluated prospecti"el# to determine e!posure.

&andomi;ed tial6 n e!periment arranged to produce a chance distri&ution o su&'ects intodierent treatment or control arms. andomiation is done to cancel out the inluence o actorsthat are not under stud#. With successul randomiation, the chance o one indi"idual &eingplaced in a gi"en stud# arm is independent o the placement o others, and the onl# dierences&etween the groups are those intended the e!perimenter /e.g., dierent drugs ta$en.

&etos#e'tive evie16 +his t#pe o re"iew is conducted ater treatment is rendered and assessesthe ser"ices pro"ided on a casecase or aggregate &asis.

W 2C

Buc$walter :, inhorn +, imon /edsC -rthopaedic Basic cienceC Biolog# andBiomechanics o the *usculos$eletal #stem, ed 2. osemont, )D, merican cadem# o-rthopaedic urgeons, 2000, pp 217.:anssen AC !perimental design and data e"aluation in orthopaedic research. : -rthop es1986


72/278

70. Which o the ollowing actors is considered predicti"e o poor wound healing potential

ollowing lower e!tremit# amputation%

1 serum al&umin le"el o 4.0 gIdD

2 a&solute l#mphoc#te count o 1,750Imm3

3 +cp-2 o 15mmg4 n$le&rachial inde! o 0.7

5 +oe pressures o 40mm g

W 3

Buc$walter :, et.al. -rthopaedic Basic cience< 2000, p217.


73/278

71. patient has numerous light &rown s$in macules, with rec$ling in the a!illae and groin.

+i&ial radiographs are shown in Aig 16a and &. e has a deect in the gene coding or

1. *erlin2. -steoclast acti"ating actor

3. rostaglandin 2

4. euroi&rillin5. #strophin

Do"ell Q WinterPs eds -rtho. euroi&romatosis

(linical indings /1 (aZ au lait spots F +an, macular, and melanotic in origin and islocated in and around the &asal la#er o the epidermis. Desions ma# "ar# in shape, sie, num&er,

and location. +he# are reuentl# ound in areas not e!posed to the sun. +he presence o caZ au

lait spots ma# MD+ to neuroi&romatosis. /2 odules are ound onl# in postpu&escnet

children. ermal neuroi&romas . . . these sot tumors ma# grow under, &e lush with, or raiseda&o"e the le"el o the s$in. /3 e"us. #perpigmentation in up to 6H . . . dar$&rown

pigmented areas o s$in. /4 le!iorm neuroi&roma. Bag o worms eeling, rope# .. tender. . .

lesions o s$in, /5 Jerrucous h#perplasia, /6 !illar# and )nguinal rec$ling. -ther indingsC/1 G#phoscoliosis, /2 scoliosis, /3 araplegia, /4 pond#lolisthesis, /5isorders o &one

growth, /6 (-;)+D B-W); and pseudoarthrosis o the ti&ia. . . +he single &one most

commonl# aected neuroi&romatosis is the ti&ia. Bowing o the ti&ia is mostcharacteristicall# anterolateral and usuall# e"ident within the irst 2 #ears o lie.?

Go"al, -GM 7, pp 209218

:- 1999< 7C 217230 >euroi&romatosis in childremC ole o orthopaedist.?

iagnosis when 2 o 7 criteria met. /1 *ore than 6 caZaulait spots at least 15 mm in

adults or 5 mm in children, /2 two or more neuroi&romas o an# t#pe or one ple!iormneuroi&roma, /3 rec$ling in a!illae or inguinal regions /(rowe sign, /4 -ptic glioma, /5

+wo or more Disch nodules /iris hamartomas, /6 distincti"e &one lesion such as sphenoid

d#splasia, thinning o corte! o a long &one, with or without pseudoarthrosis, /71 stdegreerelati"e with A1 a&o"e criteria.

W C 4


74/278

72. What is the most common site o racture &ecause o osteol#sis ollowing cementless total

hip arthroplast# with an e!tensi"el# porouscoated emoral component%

1 (entral aceta&ulum2 )schial ramus

3 ;reater trochanter

4 Between the lesser trochanter and the stem tip5 Aemoral stem tip

-ne listed reerence states that i"e percent o emur ractures in"ol"e 'ust the greater trochanterand these can usuall# treated nonoperati"el#. )t doesnPt speciicall# state that greater trochanter

ractures are most common. owe"er, gi"en that pro!imal osteol#sis and pro!imal stress

shielding are more common with an e!tensi"el# porouscoated emoral component and thatdistal i!ation ingrowth is generall# sta&le, greater trochanter ractures is the &est answer.

W 3

ritchett )WC Aracture o the greater trochanter ater hip replacement. (lin -rthop 2001 +he most common

inection in the toddler and preschoolerPs hand is herpetic whitlow, a "iral inection caused herpes simple! "irus.? )t is characteried painul "esicles on the distal phalan! o a single

digit without s#stemic in"ol"ement. )t is sellimited and surgical treatment is not indicated.

(hildren are also suscepti&le to &ite wounds, which should &e treated the same as or adults with

de&ridement and anti&iotics.

-&"iousl# a&scesses such as a thenar space a&scess and septic le!or tenos#snoti"itis would &eless common than either a paron#chia or elon, so the# can &e ruled out. +he incidence o elon

and paron#chia is airl# similar.

WC 4 herpetic whitlow

Go"al G:/edC -rthopaedic Gnowledge Mpdate 7. 2002, pp. 329337.


76/278

74. 35 #ear old man who sustained a comminuted radial head racture in a all undergoes

surger# the night o the in'ur#. ostoperati"e radiographs are shown in Aigures 17a and 17&. +he

anticipated success o this treatment would most li$el# &e compromised i the

1 F patient is emplo#ed as a computer operator

2 F patient recei"es no proph#la!is or heterotopic ossiication3 F patient has tenderness at the distal radioulnar 'oint

4 F annular ligament is disrupted

5 F el&ow is splinted or 4 da#s &eore &eginning range o motion e!ercises

Comminuted &adial ead Fa'tues

*ore commonl# associated with higher energ# trauma, comminuted racture patterns are

rarel# amena&le to sta&le internal i!ation. ot tissue swelling and ecch#mosis suggest the

li$elihood o capsular, &rachialis, or ligamentous in'ur#, including a dislocation that has

undergone spontaneous reduction. (apitellar ractures, *onteggia racturedislocations, andwrist and orearm in'uries ma# also accompan# the comminuted radial head racture. )n "iew o

the possi&ilit# o signiicant sot tissue trauma, the timing o surger# in this setting ma# &e omore signiicance. lthough this is uncommon, some patients ha"e had satisactor# outcomes

ater earl# postin'ur# mo&iliation and dela#ed /&e#ond 6 wee$s radial head e!cision.

Alt,ou8, adial ,ead ese'tion e#esents t,e most 'ommonly #e?omed #o'edue

?o 'omminuted ?a'tues> it ,as been obseved to be asso'iated 1it, instability and late

#osttaumati' at,itis 1,en #e?omed in t,e settin8 o? medial 'ollateal li8ament o

inteosseous membane disu#tion7 !cision alone is contraindicated when either o these two

sot tissue in'uries is diagnosed. ither replacement or reconstruction is indicated in these cases.

Teatment &e'ommendation

)n the setting o a lowenerg# in'ur#, an elderl# patient, or a lac$ o ph#sical indings

suggesti"e o associated sot tissue disruption, resection o the radial head alone is a

straightorward approach that in most instances is not associated with longterm seuelae. I?>

,o1eve> medial 'ollateal li8ament instability o disu#tion o? t,e D& is obseved (t,e

Esse@ teatment s,ould 'onsist o? eit,e intenal ?iation o? t,e adial

,ead o sili'one e#la'ement. ter radial head reconstruction or replacement, the el&ow

should &e tested or "algus sta&ilit#, and manual testing o the sta&ilit# o the M: should &ecarried out. hould "algus insta&ilit# &e o&ser"ed, e!ploration and repair o the medial collateral

ligament comple! are recommended. uture anchors placed in the medial column o the distal

humerus can &e used to reattach the a"ulsed medial collateral ligament. imilarl#, i distal ulnarinsta&ilit# is present, it is &est to pin the ulna to the radius with the orearm in supination. l&ow

le!ion and e!tension can then &e started, with the Gwire let in place or 4 to 6 wee$s.

W 3

$eletal +rauma 1161134

-GM 2 trauma 3951


77/278

75. 92#earold man who li"es alone and is a communit# am&ulator sustains a displaced

emoral nec$ racture. Aollowing a detailed inormed consent discussion thatrecommends surger#, he reuses treatment. What is the ne!t most appropriate step%

11 ;o ahead with surger# ater o&taining administrati"e consent.

12 -&tain a second orthopaedic opinion.

13 -&tain consent rom his ne!t o $in.14 ssess the patientPs glo&al mental capacit#, including orientation to person, time

and place.

15 "aluate the patientPs speciic decisional capacit# gauging his understanding o

his condition, treatment alternati"es, and conseuences.

>atients who ha"e decisional capacit# ma# reuse an# treatment, e"en liepreser"ing treament.

h#sicians are o&liged law and ethics to respect the treatment reusals o competent

patients e"en i the ph#sician disagrees with those choices or does not share the patientPs "alues."en when the conseuences will &e dire, a patientPs choices must &e respectedR..

ociet#, howe"er recognies that rom time to time people who are in the grip o ear,

depression, ps#chosis, or who are o"erwhelmed diicult circumstances ma# e!presspreerences that do not relect the "alues, commitments, or goals the# usuall# endorse. ociet#

also recognies that patients ma# sometimes reuse urgent or important medical treatment

&ecause their decisional capacit# is seriousl# impaired. ociet# has, thereore, speciicall#entrusted ph#sicians with the power to assess the decisional capacit# o a patient and, in certain

circumstances, to ta$e measures to o"erride patient reusalR

+he decision to respect o o"erride a patientPs reusal depends on whether the reusal

relects and autonomous choice. )t in"ol"esC 1 the a&ilit# to adopt "alues< principals and goals !0t, ed7> (op#right T 2003 *os, )nc. 796797.

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138/278

135. Which o the ollowing cell t#pes is the $e# initiator o the e"ents associated withperiprosthetic cells%

1 F -steo&last

2 F -steoc#te3 F -steoclast

4 F eutrophil

5 F *acrophage

+he correct answer is 5. eriprosthetic cells are acti"ated a s#stemic inlammator# responsemediated a num&er o hematologicall# signiicant messengers. - the choices listed a&o"e,

macrophages are the onl# component which is increased during an inlammator# response that is

not onl# an eecti"e producer o a cascade o chemical messengers which initiate the acti"itieso periprosthetic cells, &ut also are a"aila&le to carr# out man# o the a&o"e listed tas$s. .

-steo&lasts and -steoclasts are in"ol"ed in &rea$down and production o -steoc#tes, while

neutrophils are generalied inlammator# cells which in turn recruit macrophages to the site oirritationI inlammation.

W 5


139/278

136. Aigs 41 and 41B show the radiograph o a 28 #ear old man who sustained a twisting in'ur#

to his lower e!tremit# while pla#ing soccer. (losed reduction under anesthesia is unsuccessul.

What structure is most li$el# &loc$ing reduction%

1. -s trigonum

2. nterior +i&ial +endon3. osterior +i&ial +endon

4. !tensor igitorum Dongus

5. !tensor igitorum Bre"is

nswerC su&talar dislocation is deined as the simultaneous dislocation o the su&talar and

talona"icular 'oints without associated dislocation o the calcaneocu&oid or ti&iotalar 'oints, and

without talar nec$ racture. *edial dislocations are 4 times as common. rompt reduction isessential to minimie s$in necrosis and circulator# compromise. (losed reductions cannot &e

achie"ed in appro!imatel# 5 to 10H o medial dislocations and 1520H o lateral dislocations.

Bloc$s to closed reduction include e!tensor digitorum &re"is /*)D )D-(+)- andosterior ti&ial tendon /D+D )D-(+)-. ) unsta&le reduction occurs, the presence

o a large intraarticular racture must &e ruled. eduction and i!ation o the o the ragment will

oten sta&ilie the 'oint. (+ scan is recommended ater reduction. !cision or i!ation oragments is recommended.

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140/278


141/278

138. !amination o an 11 #o &o# re"eals a gait the includes &ilateral trendelen&urg lurch and a

right short leg pattern. e has accentuated lum&ar lordosis and a protu&erant a&domen. e hasno pain. adiographs are shown in 42a and 42&, +reatment should consist o

1 open reduction &oth hips2 open reduction o the let hip and arthrodesis o the right hip3 &ilateral greater troch ad"ancement

4 &ilateral +

5 epiph#seodesis at an appropriate time to achie"e lim& length eualit# at completion ogrowth

+he diagnosis is untreated with &ilateral hip dislocations. t this stage in the patientPs

disease and gi"en the a&o"e choices the onl# option is 5. ) cannot ind a speciic reason or the

answer other than to achie"e lim& length eualit#.

ter a certain age, e"en the most s$illul reduction o a dislocated hip is unli$el# to produce a

mo&ile, painree hip o"er the long term. (on"ersel#, man# high dislocations ma# remain mo&ileand pain ree or decades, despite an ineicient gait. Bilateral painree dislocations disco"ered

ater age 6 or 7 #ears pro&a&l# should not &e reduced. +his rules out answer 1. Mnilateraldislocations usuall# create additional diiculties with lim&length discrepanc# and spinal

malalignment. Mnilateral dislocation thereore should &e strongl# considered or reduction whendisco"ered at an# age up to adolescence. ter s$eletal maturit#, arthroplastic reconstruction is

usuall# the primar# treatment o choice or the s#mptomatic dislocation. +hus answer 4 is not

correct &ecause the patient is not s$eletall# mature.

+he uestion states that the child has a lim&length discrepanc#. ince he has &ilateral

dislocations &ut no pain he could tolerate his d#sunction until he reaches s$eletal maturit#.+hereore, correction o the lim&length deormit# is the higher priorit# so that he does not

de"elop a spinal deormit#. +hereore answer 5 is correct.

W 5

Do"ell and WinterPs ediatric -rthopaedics ed 5. hiladelphia , Dippincott Williams and

Wil$ins, 2000 905956

-GM 7. osemont )D, - , 2002 pp 387394


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141. Aigrues 44a and 44& show the radiograph and &one scan o a 70 #ear old man who has right

sided pel"ic pain. What is the most li$el# diagnosis%

1 hemangioma

2 senile osteoporosis

3 multiple m#eloma4 metastatic prostate cancer

5 pagetPs disease

W 5

Gaplan A< agets disease o &oneC pathoph#isiolog# diagnosis and management. :- 1995great ualit#? o the radiographs we are usuall# gi"en. o clear

racture can &e seen other than possi&le pu&ic rami ractures. +he reerence gi"en is a stud# on

>+he conseuences o anterior emoral notching in total $nee arthroplast#?. +he pre"alence o

ipsilateral supracond#lar emoral racture in patients with total $nee replacement has &een citedto &e 0.3 to 4.2H. +he most commonl# suggested predisposing actors are osteopenia, re"ision

arthroplast#, rheumatoid arthritis, use o steroids, neurologic disorder, malalignment o thecomponents, and notching o the anterior emoral corte!. +he pre"alence o notching o the

anterior emoral corte! has &een &etween 3.5 to 26.9H in "arious series. Arom the paper Desh

et al., o the periprosthetic emoral ractures reported in the literature, 50 /30.5H o 164 o themwere associated with intraoperati"e notching. owe"er, the ma'orit# o these patients had other

ris$ actors. 3 mm deep notch leads to a 29.2H reduction in torsional strength. Doo$ing at

periprosthetic emur ractures ater +G, howe"er, numerous authors ha"e shown that there are

more $nees without notching than there are $nees with notching. uthors ha"e postulated thatthis reduction in strength is onl# in the immediate postoperati"e period and osseous remodeling

does occur, leading to strengthening o the distal emur.

W 3

Desh *D, chneider :, eol ;, a"is B, :aco&s (, ellegrini J :C +he conseuences o

anterior emoral notching in total $nee arthroplast#C &iomechanical stud#. : Bone :oint urg

m 2000< 82C 10961101.


146/278

143. 24 #ear old hoc$e# pla#er has persistent deep h#pothenar palm pain ater alling with his

arm e!tended &ehind him. lain radiographs and special radiographic "iews ail to show an#

a&normalities. What stud# will pro"ide the most cost eecti"e anal#sis%

1 &one scan

2 ultrasound3 (+

4 electrodiagnostic studies o the median and ulnar ner"es

5 *) o the wrist

W 3

loi"# G, et.al., Aractures o the hoo$ o the hamateC ailure o clinical diagnosis. : and

urg 1985< 10C101104.


147/278

144. 3 #ear old girl has a let thoracolum&ar scoliosis measuring 40 degrees that has

progressed 12 degreees in the past #ear. eurologic e!amination is intact. adiographs show a

hemi"erte&ra at +12., with a contralateral &ar rom +11 to D1. Based on these indings, what isthe &

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