157 (A & B) Daily Mastery Plan

Front 1

Which of the following best describes the radiographic measurement labeled #1 on Figure A.
1. Tonnis line
2. Galeazzi's line
3. Hilgenreiner's line
4. Shenton's line
5. Perkin's line

Back 1

Radiographic line #1 on Figure A is consistent with Shenton's line.Developmental dysplasia of the hip (DDH) refers to the the continuum of abnormalities involving the growing hip, (ranging from subluxation to dislocation of the hip joint). Shenton’s line is a projected arc from the inferior border of the femoral neck. Displacement of the femoral head or severe external rotation of the hip will result in a break in the continuity of Shenton’s line.Ans 4

Front 2

A 15-year-old soccer player complains of bilateral hip pain. The pain is worse with activity and she notices that she has fatigue and pain that extends to the thighs and knees following a soccer match. She is nontender at the pubis symphysis and has no pain with resisted abdominal crunches. She has no pain with adduction of the hip. Hip flexion and rotation is normal. A radiograph of the right hip is shown in Figure A. Which of the following surgical interventions is best indicated?
1. Single innominate osteotomy (Salter)
2. Double innominate osteotomy
3. Peri-acetabular osteotomy (Ganz)
4. Triple innominate osteotomy (Steele)
5. Medial displacement osteotomy (Chiari)

Back 2

The clinical presentation is consistent with DDH in a patient with a closed triradiate cartilage. A peri-acetabular osteotomy (Ganz) is the most appropriate treatment.

The peri-acetabular osteotomy (Ganz) is a reconstructive osteotomy for DDH patients with a closed triradiate cartilage. It allows for a large degree of three-dimensional correction because the cuts are close to the acetabulum, it preserves the abductor muscles and allows for inspection of the joint. A single innominate osteotomy (Salter) or Pemberton procedure is generally appropriate for a child between the ages of 2 and 10. A triple innominate osteotomy (Steel) is applicable for the older child or adolescent where the triradiate cartilage remains open. After triradiate is closed the Ganz periacetabular osteotomy is an option for DDH reconstruction.Ans3

Front 3

In patients with a symptomatic lumbar disc herniation who have failed nonoperative management, which of the following patient characteristics are associated with improved treatment effects with surgery?
1. Duration of symptoms > 6 mos, improving symptoms at baseline, Mental Component Score (MCS) > 35
2. Duration of symptoms < 6 mos, worsening symptoms at baseline, Mental Component Score (MCS) > 35
3. Age > 41 years, divorced, presence of worker compensation claim
4. Age < 31 years, absence of joint problems, no workers compensation
5. Age > 41 years, absence of joint problems, married status

Back 3

Age > 41 years, absence of joint problems, and married status are associated with improved treatment effects in patients having surgery for lumbar disc herniation.

Lumbar disc herniations are a common cause of low back and leg pain. In the vast majority (>90%) the symptoms improve with nonoperative treatment within 3 months. However, a subset of patients have persistent pain and require surgery. Variables have been associated with outcomes with surgical treatment. The most frequently described is that workers compensation patients have worse surgical outcomes.
Incorrect Answers:
Answer 1: Worsening symptoms at baseline and Mental Component Score (MCS) < 35 are associated with improved treatment effects.
Answer 2: Duration of symptoms > 6 mos and Mental Component Score (MCS) < 35 are associated with improved treatment effects.
Answer 3: Married and absence of worker compensation claim are associated with improved treatment effects.
Answer 4: Age > 41 years are associated wi
Ans5

Front 4

A 38-year-old male presents with a three month history of low back pain and right leg pain that has failed to improve with nonoperative modalities including selective nerve root corticosteroid injections. He localizes her leg pain and paresthesias to her buttock, lateral and posterior calf, and the dorsal aspect of her foot. On strength testing, she is graded a 4/5 for plantar-flexion and 4+/5 to ankle dorsiflexion. On flexion and extension radiographs there is no evidence of spondylolisthesis. Sagittal and axial T2-weighted MRI images are shown in Figure A and B. Which of the following treatment modalities will allow the greatest improvement of physical functioning?
1. Observation alone
2. Physical therapy
3. Medical management with GABA analogs
4. Discectomy
5. Disectomy and instrumented fusion

Back 4

The clinical presentation is consistent for a lumbar disc herniation with symptoms of a combined L5 and S1 radiculopathy that has failed to improve with extensive nonoperative treatment. At this time a discectomy would lead to the greatest improvement in physical functioning. Figures A and B show the axial and sagittal sequences of a T2-weighted MRI of the lower lumbar spine. A large L5/S1 para-central disc herniation is seen that has migrated cephalad. Therefore, it is irritating both the exiting L5 nerve root and descending S1 nerve root.
Incorrect answers
Answers 1, 2, 3: Many (> 90%) disc herniations have a self-limited natural history; the symptoms may be alleviated by bedrest and activites as tolerated, administration of anti-inflammatories or GABA analogs and completion of physical therapy. For symptoms that persist greater than 6 weeks and are disabling, surgery is indicated. Recent data from the SPORT trial suggests that functional outcomes may be improved by completion. As4

Front 5

A 33-year-old woman reports pain down her right leg and numbness across the dorsum of her right foot which started 3 months ago during a bowel movement. Prior to this she had had 1 month of low back pain. She had a lumbar microdiscectomy at L4/5 3 years ago which was successful. On physical exam she has weakness to ankle dorsiflexion and great toe extension on the right. Her new MRI images are shown in Figure A. After a failure of nonoperative treatment, which of the following is the most appropriate surgical treatment?
1. L4/5 microdiskectomy through midline approach
2. L4/5 microdiskectomy with far lateral Wiltse approach
3. L4/5 Decompression, TLIF, and instrumented fusion
4. L4/5 Decompression, PLIF, and instrumented fusion
5. L4/5 Anterior Lumbar Interbody Fusion

Back 5

The clinical presentation is consistent with a recurrent lumbar disc herniation. If conservative measures fail, the most appropriate treatment is revision microdiskectomy.
Incorrect Answers:
Answer 2: A L4/5 microdiskectomy with far lateral Wiltse approach is indicated in a far lateral or foraminal disc herniation. An example of a far lateral disc herniation is shown in Illustration A.
Answer 3,4,5: A fusion would not be indicated at this time, as there is no sign of instability or spondylolisthesis.
Ans1

Front 6

A 35-year-male presents with pain radiating down the left leg, worse in the anterior leg distal to the knee. On physical exam, he is unable to go from a sitting position to a standing position with a single leg on the left, whereas he has no difficulty on the right. His patellar reflex is absent on the left, and 2+ on the right. Which of the following clinical scenarios would best produce this pattern of symptoms?
1. Left L2-3 foraminal herniated nucleus pulposis
2. Left L4-5 central herniated nucleus pulposis
3. Left L4-5 paracentral herniated nucleus pulposis
4. Left L4-5 foraminal herniated nucleus pulposis
5. Left L5-S1 paracentral herniated nucleus pulposis

Back 6

This clinical scenario describes a patient presenting with an L4 radiculopathy. This is supported by his decreased patellar reflex and quadriceps weakness. A L4-5 foraminal (far lateral) herniated nucleus pulposis would most likely cause symptoms in the L4 distribution as foraminal herniations most commonly affect the exiting upper nerve root at a given lumbar level.Ans4

Front 7

A 34-year-old male has 7 months of right-sided radicular pain to his anteromedial shin and medial ankle which has failed non-operative treatment. Physical exam shows a foot drop and decreased patellar reflexes on the affected side. A MRI is shown in figures A & B. Operative treatment should include:
1. anterior retroperitoneal approach with anterior lumbar interbody fusion (ALIF)
2. anterior transperitoneal approach with discectomy only
3. posterior midline lumbar laminectomy, decompression and fusion with pedicle screw fixation
4. posterior midline hemilaminectomy with discectomy
5. paraspinal muscle-splitting approach to the intertransverse space and discectomy

Back 7

the Wiltse paraspinal approach is ideal, which preserves segment stability by avoiding injury to the lamina and facet joints. The clinical presentation and MRI images demonstrate a right-sided far lateral disc herniation at L4/5. As opposed to a paracentral disc which would affect the L5 nerve root, a far lateral disc herniation will affect the L4 N root as it exits the L4/5 foramen. That means that the standard midline approach will not easily allow access laterally.The potential complication to know from the Wiltse approach is potential dorsal root ganglia injury resulting in dysesthesias.
Ans5

Front 8

What is the most common radiographic finding in reflex sympathetic dystrophy (RSD) or complex regional pain syndrome of the knee?
1. patella baja
2. patella alta
3. patella osteopenia
4. generalized osteopenia
5. supracondylar stress fracture

Back 8

Reflex Sympathetic Dystrophy (RSD) of the knee is different than that of the upper extremity. Pain out of proportion to the initial injury is the hallmark symptom. Other features include vasomotor disturbances, delayed functional recovery and various associated trophic changes. The JAAOS article by Cooper et al states that patellar osteopenia "is the most common radiographic finding". However, they go on to state that the most reliable diagnostic test is symptom relief after sympathetic blockade. The JBJS article by Cooper et al treated 14 patients with RSD of the knee with epidural blocks for 4 days. Eleven patients had complete resolution of their symptoms, and pain that was out of proportion to the severity of the injury was the most consistent finding. Katz et al reviewed 36 patients with RSD primarily affecting the knee. They found that injuries or operation about the patellofemoral joint triggered its onset in 64% of patients.
Ans3

Front 9

A 38-year-old patient presents 6 months after intramedullary nailing of a distal third tibia fracture with symptoms consistent with complex regional pain syndrome. During the early stage of the disease he was treated with intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Despite these modalities, he continues to have severe and debilitating symptoms. Which of the following treatment options is indicated as a second line of treatment?
1. Long leg cast immobilization for 3 months
2. Walking boot with non weight bearing for three months
3. Exchange nailing to stimulate healing response to the limb
4. Epidural spinal cord stimulator
5. Surgical sympathectomy of the affected limb

Back 9

Complex regional pain syndrome is a chronic progressive disease of unknown etiology characterized by pain, swelling and skin changes. If nonoperative modalities fail, a surgical sympathectomy of the affected limb is indicated.

The first line of treatment is physical therapy including intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Aggressive passive range-of-motion exercises should be avoided. If nonoperative modalites fail and symptoms remain severe, a surgical sympathectomy of the affected limb is indicated. Keys to successful treatment include early clinical suspicion and treatment. Late CRPS is highly refractory to treatment and often results in permanent disability.Ans5

Front 10

Figure A displays a schematic of the zones of articular hyaline cartilage. Which of the following zones has been shown to contain articular cartilage progenitor cells?
1. A
2. B
3. C
4. D
5. E

Back 10

Articular cartilage progenitor cells (chondrocyte stem cell population) have been identified in the surface zone (superficial tangential zone) of cartilage. Articular cartilage can be divided into different layers, or zones, at various depths that are based on collagen orientation, chondrocyte organization, and proteoglycan distribution. The superficial tangential zone has collagen fibers and disk-shaped chondrocytes paralleling the articular surface and they have a low proteoglycan concentration, high collagen, and high water concentrations.
Incorrect Answers:
2: Middle zone
3: Deep zone
4: Lamina splendens
5: Tidemark
Ans1

Front 11

A 28-year-old marathon runner has a knee MRI done to evaluate medial sided knee pain. No meniscus tear is identified, but the articular cartilage of the femoral condyles is noted to be twice as thick as normal values. What is the most likely cause of this finding?
1. Osteoarthritis
2. Undiagnosed osteopetrosis
3. Synovial cytokine sensitization due to excess running
4. Extra-articular hydrostatic pressure changes
5. Chondrocyte modulation via mechanotransduction

Back 11

Chondrocyte modulation via mechanotransduction secondary to excess load is a known cause for alterations in the cellular structure of articular cartilage. Specifically, chondrocyte metab responds to both mechanical (mechanical load, hydrostatic pressure change) and chemical stimuli (growth factors, cytokines). It is known that articular cartilage remodels quickly following alterations of mechanical stimuli to the tissue in vivo, and can change its metabolic activities in vitro. As such, generalized thickening of articular cartilage in a marathon runner is most likely secondary to the increased mechanotransduction from repeated load.
Incorrect
1) OA - associated with jnt space narrowing, osteophytic changes, increased subchondral sclerosis, and subchondral cysts.
2) Osteopetrosis - a osteoclast disease, not related to chondrocytes
3) Cytokine sensitization - would occur on the chondrocytes, not the synovium
4) Intra-articular, not ext-Ans5

Front 12

Which of the following biochemical changes are common to both aging cartilage and osteoarthritic (OA) cartilage?
1. Increased water content
2. Decreased collagen content and decreased modulus of elasticity
3. Decreased proteoglycan content
4. Increased chondroitin sulfate concentration
5. Decreased keratin sulfate concentration

Back 12

Both aging cartilage and osteoarthritic cartilage share the common change of decreased proteoglycan content as shown in A. states that OA is not an inevitable consequence of aging but rather, aging increases the risk of OA because of a decrease in the ability of chondrocytes to maintain and repair the tissue. Increased water content and chondroitin sulfate concentration are seen with OA but not aging. Decreased collagen content, modulus of elasticity, and keratin sulfate concentration are also seen with osteoarthritis but not aging.Ans3

Front 13

A 27-year-old male presents with an acute onset of low back and right leg pain following a water skiing accident two weeks ago. His physical exam shows no neurological deficits. Lumbar spine radiographs are normal. An axial and coronal CT scan are shown in Figure A and B. What is the first line of treatment?
1. Magnetic Resonance Imaging (MRI)
2. CT guided percutaneous biopsy
3. CT guided radiofrequency ablation
4. Open surgical curettage with chemical cauterization and cementing
5. Continued clinical observation

Back 13

xray findings are consistent with an osteoid osteoma. This lesion is likely an incidental finding, and not likely to be causing the patients symptoms. Continued clinical observation is the most appropriate treatment. Considering the patient has a recent history of a water skiing accident with acute onset of back and leg pain, his symptoms possibly represent an acute muscle sprain and radiculopathy. Of note, the lesion is on the left while his radicular symptoms are on the right. Therefore, the first line of treatment should be clinical observation.
Incorrect
1: An MRI is not yet indicated for his radicular symptoms as they have only been present for two weeks and he had no neurologic deficits.
2,3 &4: The ostoid osteoma is not likely causing the pts sx, so treating it would not be appropriate. Ans5

Front 14

A 24-year-old female has moderate arthrosis of the medial facet of the patella and the medial femoral condyle. Which of the following procedures is contraindicated?
1. Anterior (Maquet) tibial tubercle osteotomy
2. Anteromedial (Fulkerson) tibial tubercle osteotomy
3. Anterolateral tibial tubercle osteotomy
4. Medial opening wedge high tibial osteotomy
5. Lateral closing wedge high tibial osteotomy

Back 14

Anteromedial (Fulkerson) tibial tubercle osteotomy is contraindicated in patients with significant arthrosis of the medial facet of the patella and the med fem condyle. Anteromedial tibial tubercle osteotomy (Fulkerson procedure) involves the transfer of the tubercle to a more ant &med location. Changing the vector of the extensor mechanism can help reduce lateral patellar subluxation/dislocation & concomitantly unload areas of arthrosis on the distal and lat aspects of the patella. When performing a tibial tubercle transfer, the surgeon should beware of proximal lesions or medial facet or condylar lesions. Thus, intact proximal and medial cartilage is required to obtain the max benefit from this procedure.Ans2

Front 15

A 32-year-old female is referred to you for definitive treatment of a symptomatic focal chondral defect on her medial femoral condyle. A photograph from a recent diagnostic arthroscopy shows the defect (Figure A), which measured 20 x 25mm after debridement. What surgical treatment would you recommend?
1. Osteochondral autograft
2. Osteochondral allograft
3. Microfracture
4. Chondroplasty
5. Abrasion arthroplasty

Back 15

Based on the age of this patient and the size of this lesion (2 x 2.5 = approx 5cm square) an osteochondral allograft plug is the best choice. The results of microfracture are better for contained defects less than 2cm square. Autografts are generally reserved for smaller defects as well because harvesting enough plugs to fill this defect may lead to significant donor site morbidity. Chondroplasty &abrasion arthroplasty are not good solutions to this chondral defect in a young symptomatic patient. Autologous chondrocyte implantation (ACI) would also be a correct response, but it was not listed.Ans1

Front 16

All of the following are acceptable scenarios for the use of autologous chondrocyte implantation (ACI) in the patellofemoral joint EXCEPT:
1. Grade 4 lesion of the medial femoral condyle
2. Grade 4 lesion of the trochlea
3. Joint space narrowing on Merchant view
4. Varus mechanical axis on standing full length radiograph
5. Concomitant anteromedial tibial tubercle transfer osteotomy (Fulkerson's)

Back 16

Joint space narrowing on a merchant view is a CI for autologous chondrocyte implantation for patellofemoral arthritis.
ACI relies on intact, full-thickness cartilage margins to maintain the joint space so that the growing cartilage repair tissue may fill the defect. Cartilage loss seen with diffuse arthritis is not amenable to ACI. It is critical that there is a preserved PF joint space as seen on a Merchant/skyline view. ACI can be used for grade 3 or 4 defects on the patella or trochlea. Concomitant realigment procedures of the PF joint (such as lateral release, medial tubercle transfer, or anteromedial tubercle transfer) and the tibiofemoral joint (high tibial osteotomy) are indicated in the presence of mech malalignment. NOTICE: ACI is not FDA approved for use on the patella and the use of ACI "off-label" should be discussed with pts preop.Ans3

Front 17

A competitive marathoner reports 6 months of pain over the lateral distal leg and dysesthesia over the dorsum of the foot. There is a tender fullness over the distal lateral fibula with a positive Tinel's sign. There is normal motor strength, but pain with passive plantar flexion and inversion of the ankle. The most appropriate surgical treatment is:
1. Repair muscle herniation and closure of the fascial defect
2. Fascial release and superficial peroneal neurolysis
3. Fascial release of all four compartments
4. Superficial peroneal neurectomy
5. Lumbar discectomy

Back 17

This is a case of superficial peroneal nerve entrapment by the fascial opening in the distal leg. It is classically exacerbated by plantar flexion and inversion of the foot. Treatment involves release of the fascial opening to reduce this traction phenomenon. Ans2

Front 18

Figure A is a dissection of the medial aspect of the left ankle and foot. Which of the following nerves indicated in Figure A is most commonly implicated in nerve entrapments in the running athlete?
1. A
2. B
3. C
4. D
5. E

Back 18

Point A = first branch of the lateral plantar nerve (Baxter's nerve). Baxter's nerve innervates the abductor digiti quinti, flexor digitorum brevis, quadratus plantae. It traverses just superior to the insertion of the plantar fascia on the med calcaneal tuberosity. Compression of this nerve causes max pain over the plantar medial aspect of the foot, can be difficult to distinguish from plantar fasciitis. Baxter's nerve compression is a common pattern of entrapment found in the running athlete. Illustration A depicts the sensory distribution of the tibial nerve. Illustration B shows the dissection with the other responses labeled; Point B are the medial calcaneal nerve branches, Point C is the tibial nerve, Point D is the lateral plantar nerve and Point E is the medial plantar nerve. Ans4

Front 19

An 28-year-old male presents for evaluation of leg pain. He denies trauma, and is otherwise healthy. A lateral radiograph of the affected leg is shown in Figure A. A biopsy is taken, and the low and high power histology specimens are shown in Figures B and C. The pathology report states the presence of islands and cords of basaloid epithelial cells in a fibrous stroma with nuclear atypias and mitotic figures. Which of the following should be offered as definitive treatment of this lesion?
1. Continued observation
2. Radiation and chemotherapy
3. Bracing to prevent tibial deformity and pathologic fracture
4. Immediate above the knee amputation
5. En bloc resection with wide margins followed by appropriate reconstruction

Back 19

dx of adamantinoma treated by en bloc resection w/wide margins followed by appropriate reconstruction to prev local recurrence /metastasis. AD low-grade malig primary bone tumor that occurs tibia and/or fibula of adolescent persons & young adults; Microscopically, OFD is characterized by a loose, often storiform fibrous background containing spicules of woven bony trabeculae lined by osteoblst.
1-Define & tx B/M
2-5 (SAP 4-GO DDx5-t
3-lytic bone lesion
F-Fibrous dysplasia, Fibrous cortical defect, Focal Fibrocartilaginous Dysplasia of tibia
O-Osteoblastoma, osteosarc; G-Giant Cell Tumor
M-Myeloma (plasmacytoma), Mets _> kidney, thyroid, breast;A-ABC / Angioma; C-Chondromyxoid fibroma, Chondroblastoma;H-Hyperparathyroid brown tumor, Hemangioma, Hemophilia, Histiocytosis X;I-Infection (Brodie abscess, Echinococcus, coccidioidomycosis); N-NOF; E-EG, Enchondroma, Epithelial inclusion cyst
S-Solitary Bn cyst

Front 20

A 21-year-old female presents with 7 years of leg pain and deformity. Radiographs from when she first noticed the lesion at age 14 are shown in Figures A and B. Current radiographs are shown in Figures C and D. Current MRI and histology section are shown in Figures E & F. What is the most likely diagnosis?
1. Osteofibrous dysplasia
2. Adamantinoma
3. Chronic osteomyelitis
4. Periosteal osteosarcoma
5. Fibrous dysplasia

Back 20

The hx, location,xray, and histology slide are all consistent with a diagnosis of adamantinoma - a low grade malignant bone tumor, most commonly found in the tibia after a very indolent course. The association of adamantinoma with osteofibrous dysplasia is a controversial one. Many believe they are a continuum of the same disease process, while others believe they are two separate diagnoses.
Incorrect
Answer 1: Osteofibrous dysplasia - this is the most difficult differentiator for this question. However, given the progression of disease, erosion of the tibial cortex, and malignant features of the histology section, the diagnosis of osteofibrous dysplasia isn't correct.
Answer 2: Chronic osteo - While the xray may be suggestive of osteomyelitis, the histology slide and advanced imaging showing erosion of the cortex aren't consistent with osteo
Answer 4: Neither the xray nor the histology slide show any osteoid - a DX-OSTEOsacr.Ans3

Front 21

The primary function of which of the following structures is to resist internal tibial rotation with the knee in full extension?
1. Anterior cruciate ligament
2. Iliotibial band
3. Popliteus tendon
4. Popliteofibular ligament
5. Posterior oblique ligament

Back 21

The primary function of the posterior oblique ligament is to resist internal tibial rotation with the knee in full extension. The posterior oblique ligament is a structure within the posteromedial corner of the knee, with attachments proximally to the add tubercle of the femur and distally to the tibia/posterior knee capsule. The posterior oblique ligament & posteromedial capsule play a significant role in the prevention of additional posterior tibial translation in the knee in the setting of posterior cruciate ligament injury. They also act to resist internal tibial rotation with the knee in full extension.Ans5

Front 22

Isolated transection of the posterolateral(PL) bundle of the ACL has what effect on anterior tibial translation and rotatory stability of the knee?
1. Increased tibial translation and rotation at 30 degrees of flexion
2. Increased tibial translation and rotation at 90 degrees of flexion
3. Increased tibial translation at 30 degrees of flexion and increased rotation at 90 degrees of flexion
4. Increased tibial translation at 90 degrees and negligible effect on rotatory stability
5. Increased tibial translation at 30 degrees and negligible effect on rotatory stability

Back 22

isolated deficiency of the AM or PL bundle of the ACL on the resulting knee kinematics. transection of the anteromedial bundle leads to increased anterior tibial translation at 90 degrees of knee flexion, whereas transection of the posterolateral bundle shows an increased anterior tibial translation as well as a combined rotatory instability at 30 degrees. This rotatory stability provided by the PL bundle prevents the pivot shift phenomenon found in ACL deficient knees. determine the distances from the tibial and femoral center of the native AM and PL bundle to the articular cartilage and meniscus. They concluded that the center of the femoral PL bundle is shallow and inferior to the AM bundle, and on the tibia the AM bundle lies anterior when compared with the typical single-bundle ACL tunnel. ACL bundle anatomy.Ans1mn PAL

Front 23

A 27-year-old recreational soccer player injures his knee after colliding with an opposing player during a game. On physical exam, his Lachman is graded as 1A. He has laxity to varus stress with the knee flexed to 30 degrees. Dial test of the tibia shows increased external rotation at 30 degrees, but not at 90 degrees in comparison to the contralateral leg. Which of the following structure(s) are torn?
1. Anterior cruciate ligament (ACL)
2. Lateral collateral ligament (LCL)
3. Anterior cruciate ligament (ACL) and lateral collateral ligament (LCL)
4. Lateral collateral ligament (LCL) and posterolateral corner (PLC)
5. Posterior cruciate ligament (PCL) and posterolateral corner (PLC)

Back 23

(LCL) and (PLC). The LCL is part of the posterolateral corner, but can be injured in isolation or along with the rest of the An isolated LCL tested by flexing the knee at 30 & applying varus stress. PLC can be tested by the dial test, which is done by ER he affected tibia. A PLC injury shows increased ER @ 30 while a combined PLC/PCL injury would show increasedER at 30 and 90
Incorrect
1: Isolated ACL injury would have a positive Lachman's test with increased anterior knee translation at 30 degrees of knee flexion. In the given scenario, Grade 1A indicates less than 5mm of translation and a firm endpoint indicating that the ACL is intact.
2: Isolated LCL injury would have increased laxity to varus force at 30 deg of knee flexion, but would not have a positive dial test.
3: Would have both ACL and LCL findings as above.
5: Would have increased external rotation of tibia at both 30 & 90 of knee flex.Ans4

Front 24

In relation to the femoral insertion of the popliteus, the femoral attachment of the lateral collateral ligament is
1. posterior and proximal
2. posterior and distal
3. anterior and proximal
4. anterior and distal
5. directly superficial

Back 24

lateral (or fibular) collateral ligament (LCL) had an average femoral attachment 1.4mm proximal and 3.1mm posterior to the lateral epicondyle. The popliteus has a broad-based femoral attachment at the most proximal and anterior fifth of the popliteal sulcus and always attaches anterior to the fibular collateral ligament. Thus, the LCL's femoral attachment is posterior and proximal compared to the popliteus femoral insertion with the average distance between their femoral attachments being 18.5 mm. (FCL=LCL, popliteus=PLT) Ans1

Front 25

In the radiographic evaluation of femoral-acetabular impingment (FAI), which of the following views is obtained with a standing radiograph at an angle of 65 degrees from anterior between the pelvis and the film?
1. AP pelvis
2. Inlet
3. Outlet
4. Frog lateral
5. False profile

Back 25

The False profile view (also known as Faux profil) is performed with the patient standing with the affected hip on the cassette, the ipsilateral foot parallel to the cassette and the pelvis rotated 65° from the plane of the cassette. It can be used to assess anterior coverage fo the femoral head for patients with hip dysplasia (DDH) and FAI.Ans5

Front 26

what is the most common orthopedic disorder newborns

Back 26

DDH

Front 27

1. DDH was the most common locationof DDH to affect the hips
2. With risk factors for DDH

Back 27

1. LEFT hip female
2. Firstborn, female, reach, family history, oligohydramnios

Front 28

1. with DDH of the hip that the patient has spastic cerebral palsy what direction is acetabular deficiency in
2. indications with DDH of the hip was a typical direction of acetabular deficiency in

Back 28

1. posterior superior
2. anterior or anterolateral

Front 29

what 3 conditions occur commonly with DDH of the hip

Back 29

1. congenital muscular torticollis
2. Metatarsus adductus
3. Congenital knee dislocation

Front 30

with DDH which type of collagen is most commonly affected

Back 30

type III collagen

Front 31

 when doing the physical examon a child for dislocated hip was the maximum age that one can perform the physical exam

Back 31

child must be <3 months

Front 32

 describe the BARLOW test

Back 32

BARLOW =hips by adduction and depression of a flexed femur –dislocates a dislocatable hip

Front 33

describe the ORTOLANI test

Back 33

ORTOLANI=

Elevation and abduction of the flex femur – reduces a dislocated hip

Front 34

describe the GALEAZZI test

Back 34

an apparent leg length discrepancy due to unilateral dislocated hip with the hip and knee flexed to 90° = femur.  Shortening on the dislocated side

Front 35

if the child is >3 months what are the physical exam findings is most sensitive for dislocatable hip

Back 35

1. limitations in abduction
2. Decrease symmetry and bilateral dislocations
3. Leg length discrepancies

Front 36

DAVID child is >1 year or to the physical exam findings of a dislocated hip

Back 36

1. pelvic obliquity
2. Lumbar lordosis
3. TRENDELENBURG gait
4. Toe walking

Front 37

1. at what age and x-rays be taken and information about the hips be obtained if there is concern about dislocation
2. what imaging modality should be used to evaluate the hips to the child is <4-6 months

Back 37

1. >4-6 months after the femoral heads are ossifying
2. Ultrasound

Front 38

what sign on the x-ray AP the hips is a good prognostic sign of hip function after reduction of the hips seen in normal children>18 monthsof age

 

Back 38

acetabular teardrop 

Front 39

 what is  Hilgenreiner's line where in the normal femoral head ossification

Back 39

• this is a horizontal line through the RIGHT and LEFT triradiate cartilage
• Femoral head ossification should be inferior to this line

Front 40

what is PERKINS line and what is its significance for normal

Back 40

• perpendicular line to Hilgenreiner's line through a point at the lateral margin of the acetabulum
• femoral head should be medial to this linehat is Shenton's line

Front 41

what is Shenton's line and one is its clinical significance to normal

Back 41

• an arc along the inferior border of the femoral neck and the superior margin of the obturator foramen
• R KLEIN should be continuous

 

Front 42

what the normal value of the acetabular index in the center edge angle of wiBERG

Back 42

• acetabular index normal = <25° and patient's older than 6 months
• CEA normal= >20° only reliable patient's older than 5 years

Front 43

what is a useful tool to confirm reduction after closed reduction under anesthesia of a hip pediatric

Back 43

arthrogram

Front 44

what the most common block to reduction and a pediatric hip

Back 44

inverted labrum 

Front 45

what is the study of choice to evaluate hip reduction after closed reduction and spica casting

Back 45

CT scani n spica cast

Front 46

1. what is the treatment of DDH patient <6 months and hip is reducible
2. at what time point should the brace be abandoned

Back 46

1. PAVLIK harness 90% success rate
2. abandon if not successful after 3-4 weeks

Front 47

1. was a treatment of a child with DDH 6-18 months of age
2. what test is best to confirm reduction
3. what the 2nd best test to confirm reduction

Back 47

1. closed reduction and spica casting
2. arthrogram
3. CT scan in spica cast

Front 48

1. what is the treatment of a child with DDH >a year and a half of age – 18 months
2. what approach to the hip is used
3. why is this approach used

Back 48

1. open reduction and spica casting
2. anterior approach – SMITH PETERSON
3. Decrease risks of the medial femoral circumflex artery

Front 49

1. what is the treatment of a child with DDH who is > 2 years
2. what approaches is used and why
3. what is the  neurovascular interval  and the innervation

Back 49

1. open reduction and femoral osteotomy
2. The sartorius – femoral nerve and tensor fascia lata – superior gluteal nerve and rectus femoris – femoral nerve and gluteus medius – superior gluteal nerve

Front 50

what is treatment of a child with DDH and dysplasia who is 4 years an older

Back 50

open reduction pelvic osteotomy

Front 51

most common complication with PAVLIK harness

Back 51

AVN

Front 52

1. name this osteotomy can be used to younger patient with open triradiate cartilage
2. what is the technique  to perform

Back 52

1. salter
2. Single cut above the acetabulum through the tissue him into the sciatic notch
3. the acetabulum changes through the pubic symphysis and is every directional osteotomy to provide additional lateral anterior coverage main lengthening leg up to 1 cm

Front 53

1. name this osteotomy that can be used an older children that still have a triradiate cartilage  open 
2. what is the technique To perform

Back 53

1. triple – steel
2. = Salter osteotomy + additional cuts through the superior and inferior pubic rami.  AKA AKAacetabular reorientation procedure (SALTER +2 = triple – steel )

Front 54

1. name this osteotomy used for moderate to severe DDH and the triradiate cartilage is open
2. what is the technique to perform
3. what is the affect acetabular and why don't you need fixation with

Back 54

1. PEMBERTON
2. osteotomy that starts approximately 10-15 mm above the AIIS  procedures posteriorly and hands at the level of the ilioischial limb of the triradiate cartilage that is halfway between the sciatic notch and the posterior acetabular rim.  This osteotomy hinge is the triradiate cartilage posteriorly  and the pubic symphysis anteriorly
3. It reduces the acetabular volume because this osteotomy does not enter the sciatic notch is therefore stable

 

Front 55

1. name this osteotomy activity used an older children and triradiate cartilage is closed
2. what is the technique to perform
3. what is at about this techniquethat allows weightbearing

Back 55

1. PAO (Ganz)
2. (=steel in an older child) = osteotomy through the pubis,  ilium, and ischium near the acetabulum. technically challenging
3. Posterior column and pelvic ring must remain intact to allow weightbearing

Front 56

1. name this osteotomy that is used in patients with neuromuscular dislocations and triradiate cartilage is open
2. What is the technique to perform
3. What is the effect on the acetabulum 
4. Comment I stability

Back 56

1. dega osteotomy
2. osteotomy from the acetabular roof to hinge the triradiate cartilage
3. it reduces acetabular volume
4. stable and does not need fixation

Front 57

1. name this osteotomy

Back 57

• dial leaves the medial wall or teardrop in its original position

Front 58

1. name the osteotomy that is considered a salvage procedure patient's older than 8 years of age
2. Described the technique
3. In order for it to be successful what must occur

Back 58

1. shelf osteotomy
2. Bone to the lateral weightbearing aspect of the acetabulum by placing an extra-articular ruptures of bone over the subluxed femoral head
3. Depends on the fibrocartilage metaplasia with success

Front 59

1. name this osteotomy that is used in salvage situations.  Inadequate femoral head coverage and a concentric reduction cannot be obtained
2. Described the technique to perform
3. order for this to be successful what most of occur and why is used

Back 59

1. Chiari osteotomy
2. Make cut above the sciatic notch and shift the ilium lateral beyond the edge of the acetabulum
3. depends on fibrocartilage metaplasia for successful result and also medialize his acetabulum for a concentric reduction via the iliac  osteotomy.

Front 60

Which of the following is true regarding the structure outlined in Figure A?

1.  It is comprised of the iliopectineal eminence and quadrilateral surface

2.  In normal hips, all children usually have this radiographic figure by 18 months of age

3.  This figure is usually present in children with developmental dysplasia of the hip prior to reduction

4.  The structure is a result of the radiographic superimposition of the ilioischial and Iliopectineal lines

5.  It is comprised of the cotyloid fossa and iliopectineal eminence

 

Back 60

the acetabular teardrop and it is comprised of the quadrilateral surface and cotyloid fossa. In normal hips, all children have a teardrop figure by age 18 months of age.

Albicana et al retrospectively reviewed the radiographs of the pelvis and hips of 45 patients who had unilateral congenital dislocation of the hip treated with closed reduction and casting. The width, shape, and type of the teardrop were measured in the dislocated and contralateral, normal hips. They found that the hips with residual acetabular dysplasia had a v-shaped teardrop, widening of the superior width of the teardrop, and thickening of the acetabular floor which correlated with poorer prognosis in adult life.

Bowerman et al identified the structures responsible for teardrop figure by removing sections from the hemipelvis of an anatomic specimen with an electric saw. The normal and abnormal appearances of the teardrop shadow of the acetabulum of three patients were then demonstrated on both plain radiographs and CT scans.ans2
 

Front 61

Figure A depicts an ultrasound of a newborn infant's hip. Which of the following structures (1 through 5) represents the labrum?

1.  1

2.  2

3.  3

4.  4

5.  5

 

Back 61

which is routinely used in the screening and monitoring for hip dysplasia. The structure labeled by the number 4 is the labrum. Incorrect Answers:
Answer 1. Ilium is labeled is by the number 1
Answer 2. Femoral head is labeled is by the number 2
Answer 3. Triradiate cartilage is labeled by the number 3
Answer 5. Ischium is labeled by the number 5

ans4

Front 62

was most common level for disc herniation

Back 62

L5/S1

Front 63

what helps in the reabsorption of herniated disc

Back 63

macrophage phagocytosis

Front 64

what type of collagen is found in the annulus fibrosis and the nucleus pulposus

Back 64

• annulus fibrosus = type I collagen, I collagen/proteoglycans ratio
• Nucleus pulposus = type II collagen, compressibility low collagen / high proteoglycan ratio

Front 65

patient presents with bilateral leg pain,lower extremity weakness, saddle anesthesia, bowel bladder symptoms

1. with the diagnosis
2. With the treatment

Back 65

1. diagnosis cauda equina syndrome treatment
2. laminotomy and discectomy 

Front 66

1. what is an indication for getting an MRI for lower back pain
2. what a red flags to get an MRI
3. was the best kind of MRI to obtain after surgery

 

Back 66

1. pain lasting >1 month and not responding to nonoperative treatment

• infection – history of fever and chills
• Tumor – history of cancer
• Trauma – history of car accident fall
• Cauda equina – bowel bladder changes

1. MRI with gadolinium – gadolinium enhances postsurgical fibrosis and infection versus recurrent disc herniation which does not enhance

Front 67

patient comes to the office with week EHL and hip abduction

1. what the diagnosis
2. what the treatment
3. Patient on the table and suddenly becomes hypotensive what the most common complication

Back 67

1. disc herniation L4/L5
2. Laminotomy and discectomy
3. Vascular catastrophe – injury to the inferior vena cava or aorta

Front 68

Following surgical treatment of a lumbar disc herniations with radiculopathy, patients with worker's compensation claims have which of the following when compared to patients who do not have worker's compensation claims at 5 years?

1.  Equivalent relief from symptoms and equivalent improvement in quality of life

2.  Less relief from symptoms and less improvement in quality of life

3.  Improved relief from symptoms and greater improvement in quality of life

4.  Significantly decreased return to work status

5.  Significantly improved return to work status

Back 68

Patients with worker's compensation claims have less relief from symptoms and less improvement in quality of life following surgical treatment of lumbar disc herniations. Despite this, they have near equivalent return to work status at 4 years. However, workers' compensation patients had worse symptoms, functional status, and satisfaction outcomes. 
ans2

Front 69

 A 45-year-old male comes into your clinic complaining of right leg radicular pain that extends to the dorsal aspect of his right foot. On physical exam he has slight decreased sensation on the top of his right foot as well as 3/5 strength in his right EHL. He has 5/5 strength in the all other muscle groups in his lower extremities and symmetric 1+ patellar and achilles reflexes bilaterally. Which axial MRI would be consistent with the patients symptoms

1.  far lateral disc herniation at L4/5.

2.  facet cyst at L4/5

3.  paracentral disc herniation at L3/4

4.  paracentral disc herniation at L5/S1

5.  far lateral L5/S1 disc herniation

 

Back 69

The patient presents with a right sided L5 radiculopathy. The only axial MRI image that would cause a right L5 radiculopathy is Figure E, a far lateral L5/S1 disc herniation. 

Radiculopathy secondary to a herniated lumbar disc can affect either the traversing nerve root or the exiting nerve root. Paracentral disc herniations are most common, and they affect the traversing nerve root, i.e. an L5/S1 paracentral disc herniation will cause S1 symptoms. Occasionally disc herniations are far lateral. In these cases, the disc herniation affects the exiting nerve root, i.e. an L5/S1 far lateral disc herniation will cause L5 symptoms. Incorrect Answers: 
Answer 1: This is a far lateral disc herniation at L4/5. This would present with right L4 symptoms 
Answer 2: This is a facet cyst at L4/5. It would present with left L5 symptoms 
Answer 3: This is a paracentral disc herniation at L3/4. This would present with right L4 symptoms
Answer 4: This is a paracentral disc herniation at L5/S1. This would present with right S1 symptoms

ans5

Front 70

 A 32-year-old male presents with left leg pain and weakness. An axial image from his MRI is shown in Figure A. Which of the following physical exam findings would be most consistent with this MRI finding.

1.  Numbness over dorsal aspect of the foot, weakness to gluteus medius

2.  Numbness over plantar foot, weakness to his gastrocsoleus complex

3.  Numbness over medial malleolus, and weakness to quadriceps

4.  Numbness over medial calf, weakness in his EHL

5.  Numbness over lateral malleolus, weakness to hip adduction

Back 70

The MRI demonstrates is a paracentral L4/5 disc protrusion which leads to compression of the traversing left L5 nerve root. Numbness over the dorsal aspect of the foot and weakness to gluteus medius is consistent with a L5 radiculopathy.

While nerve root innervation shows some variability by patient, L5 is "characteristically" responsible for the sensation to the dorsal aspect of the foot, ankle dorsiflexion (tibialis anterior - along with L4), great toe extension (EHL), and hip abduction (gluteus medius). Incorrect Answers:
Answer 2: Numbness over plantar foot, weakness to his gastrocsoleus complex would be consistent with an S1 radiculopathy.
Answer 3: Numbness over medial malleolus and weakness to quadriceps would be consistent with an L4 radiculopathy.
Answer 4 and 5: Neither would be consistent with "characteristic" nerve root innervation.

 

Front 71

A far lateral disc herniation at the L4/5 level would likely present with what neurologic symptoms and physical finding.

1.  Weakness to hip flexion, numbness on the inner thigh, a decreased patellar reflex

2.  Weakness to knee extension, numbness on the anterior shin, a decreased patellar reflex

3.  Weakness to ankle dorsal flexion, numbness on the dorsal foot, a decreased Achilles reflex

4.  Weakness to extensor hallicus longus, numbness in the first web space, a decreased Achilles reflex

5.  Weakness to ankle plantar flexion, numbness on the lateral foot, normal reflexes

Back 71

A far lateral disc herniation affects the exiting nerve root. At the L4/5 level this would be the L4 nerve root. The L4 nerve root innervates knee extension, the patellar reflex, and a sensory distribution that travels over the knee into the anterior shin. (see illustration A). Illustration B demonstrates the ASIA Classification of Spinal Injury diagram which also depicts ankle dorsiflexion as a test for L4.ans2