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70 Cards in this Set
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adolescent injuries knee c/o local tenderness |
knee-lat r/o diagnosis may be missed because the distal bony fragment is not readily discernible on radiographs-->Dx=Patella Sleeve Fracture
-patella alta for distal fractures or patella baja for proximal fractures may be evident 1.1-MRI-may be useful for diagnosing a sleeve fx when the dx is not clear from the clinical and plain xray findings 2.1 cylinder cast=ND fx 2.2 ORIF=>2 mm, modified tension band wiring around two longitudinally placed Kirschner wires |
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A 10-year-old female presents to the emergency department complaining of anterior knee pain after a fall from her bicycle. Exam reveals ecchymosis and swelling over the patella and an extensor lag. Radiographs are shown in Figures A and B. What is the most appropriate next step in treatment?
1. Open reduction and internal fixation with modified tension band technique 2. Open reduction and internal fixation with plating and wire cerclage technique 3. Cylinder cast 4. Partial patellectomy and advancement of patellar tendon 5. Patellar tendon midsubstance rupture repair with nonabsorbable suture |
Patella sleeve fractures occur most commonly in children aged 8-12. This injury involves an avulsion of cartilage (and sometimes a small piece of bone) from the inferior pole of the patella. Sleeve fractures should be accurately reduced and stabilized using modified tension band wiring around two longitudinally placed Kirschner wires.
These fractures may be missed on plain radiographs if there is no obvious bony injury. Radiographs will typically show an effusion, patella alta, and possibly a bony avulsion. In uncertain cases, an MRI is useful to define the extent of injury. Ans1 |
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1-Definition (main characteristics common to both osteopenia and osteoporosis)? most accurate to Dx OP, how is it done, mn?
2-MC #1,#2, #3 osteoporotic fractures occur each year, age of occurrence? why type of disorder of bone mineralization is it? 3-men or female higher prevalence of secondary osteoporosis? ***type THA s risk for fragility fx. 4-MCC of 2^ O-porosis in men, ***what is strongest predictor of a future fx from low energy trauma in PMFemale? if hip fx then mortality is ___? why is xray poor to asses OP fx, ie low sensitivity and specificity 5-MC age group of postmenopausal osteoporosis, senile osteoporosis, secondary osteoporosis **6-(3)MC risk factor for O-porsis 3 in each category: lifestyle, medications, genetic polymorphisms,Dz 7 define FRAX score, **when bone is affected in OP T2 how is affected? what lab is low w/OP fx? 8 factors of FRAX score? |
1-o-porosis=dec bone mass 2^ uncoupling of osteoclast-osteoblast; most accurate=Dexa Scan (Dual Energy Xray Absorptiometry)-lumb spine3: meas BMD from L2->L4 & hip3:meas fem neck, troch, IT
2-Mc O-porosis fx #1-vertebral 60-70 yo #2-hip 70-80 #3-wrist 50-60; dis miner type=quantitative (quantity or amount), not qualitative (kind) 3-higher 2^ Oporsis=men, ***THA w/ constraind compnts 4-MCC-hypogonadism, glucocorticoid excess, alcoholism; ***strongest predictor=hx of 2 vertebral fx =strongest; hip fx=20%mortality 10 fold inc risk of 2nd hip fx;xray poor=>30% bone loss 5-MC-age sentile=>70; postmeno=50-70 **6-LS-age, sex, hx of fx dz-low BMI, 2^ O-porosis, smoke status, meds-oral steroids, alcohol intake, (dilantin) gen=parent hx hip fx,(estrogen receptor-1, COL1A1-OI in adult) 7-WHO fx risk assess tool calculates 10-yr risk HIP fx & 10-yr risk of WRIST & VERTEBRAL; **trabecular> cortical, low lab=low 25 hydroxy cholecalciferol levels (25 hydroxy vit D) FRAX=4 & 2 above |
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1-define osteopenia, osteoporosis on DEXA?***
2-when to Bx, r/o? what is seen on histo (3) ? 3-Osteomalacia define, (etiology, sx, labs-S CA, PO4, ALP, urine CA? 4-abn lab in alcoholic w/hip fx, fagility fx ? 5-MC fragility fx in: 50-60 yo; 60-70 yo; 70-80 yo (3) MC location of fragility fx? 6-define fragility fx? 7-MCC of pathologic fx? 3 names of lab value for serum vit D |
1-**1-O-penia=L2-4 lumb density < 2.5 standard of deviations or (T score bt/ -1 -> -2.5)OP=L2-4 lum density > 2.5 stand of deviatns or (T-score <-2.5 )
2-bx p/ tetracycline label r/o osteomalacia hist=thinned trabeculae, dec osteon size, enlarged haversian & marrow spaces 4-o-malicia=Bone mass variable, reduced mineralization 3-S CA, PO4, urine CA-low nl, ALP=elevated 4-low 25-hydroxy vit D (calcidiol) blood test is used to determine how much vit D is in the body. blood concentn of calcidiol is considered the best indicator of vit D status 5-50-60=wrist fx; 60-70=vertebral fx 70-80=hip fx MC loc=vertebral, hip, wrist 6-a type of pathologic fx-> as result of nl activities, such as a fall from standg height or less. There are 3 fx typical of fragility fx: vertebral fx, fx neck of the femur, Colles fx wrist. 7patholgc fx= OPS, but may also due CA, infecn, inherited bone Dz, bone cyst; 25 hydroxy vit D=25 hydroxy cholecalciferol=1,25-OH vitamin D, ergoc |
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1-MC location of parosteal osteosarcoma?
2-MC presenting Sx of Parosteal Osteosarcoma? 3-MC additional study that must be ordered when doing eval for pt w/ parosteal sarcoma? 4-only osteosarcoma that does not require chemo to treat? why? |
1-MC paroOS-surface of metaphysis of long bones
posterior distal femur 2-painless mas w/ dec ROM of knee 3-CT chest r/o mets, mandatory for staging eval since high propensity for invasion of medullary canal 4-parosteal osteosarcoma, bc low grade and can be treated w/ wide resection alone if not high grade |
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A 24-year-old male presents with increasing knee pain over the last 6 months. He reports that he sustained a non-contact twisting injury to the knee 7 months ago while playing softball. His knee range of motion is full and his knee is stable to varus and valgus at 0 and 30 degrees of knee flexion. There is a grade 1 Lachman examination. His dial test reveals 30 degrees of external rotation at 30 degrees of knee flexion. A radiograph is shown in Figure A. A biopsy is performed and is shown in Figure B. What is the most appropriate definitive management?
1. Reassurance and observation in 6 months with repeat knee radiographs 2. Neoadjuvant external beam radiation, wide surgical resection, and adjuvant chemotherapy 3. Wide surgical resection 4. Neoadjuvant chemotherapy, wide surgical resection, adjuvant chemotherapy 5. Neoadjuvant chemotherapy, marginal surgical resection, adjuvant chemotherapy |
parosteal osteosarcoma. Wide resection alone is sufficient for this form of osteosarcoma. Intramedullary osteosarcoma treatment is different and is most often treated with preoperative chemotherapy given for 8-12 weeks followed by maintenance chemotherapy for 6-12 months after surgical resection. Parosteal osteosarcoma occurs 80% of the time in the posterior aspect of the distal femur followed by the proximal tibia and proximal humerus. There is 95% long term survival when local control has been achieved with wide surgical excision.
Incorrect Answer 1: Reassurance and observation in 6 months with repeat knee radiographs is not indicated for parosteal osteosarcoma. Answer 2: Neoadjuvant external beam radiation, wide surgical resection, and adjuvant chemotherapy is not indicated for parosteal osteosarcoma. Answer 4: Neoadjuvant chemotherapy, wide surgical resection, adjuvant chemo is indicated for intramedullary osteosarcoma. Answer 5: Neoadjuvant chemotherapy, marginal.ans3 |
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35 yo F c/o painless mass in posterior knee that limits her ROM of knee. PE in otherwise nl. histo |
1.0` |
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A 21-year-old male presents with increasing shoulder pain for the past 6 months. Radiograph, CT scan, bone scan, MRI, and histology slide are shown in Figures A through E. What is the most appropriate diagnosis?
1. Ewing's sarcoma 2. Periosteal osteosarcoma 3. Parosteal osteosarcoma 4. Osteochondroma 5. Myositis ossificans |
The radiograph, CT scan, bone scan, MRI, and histologic slide are consistent with a diagnosis of a parosteal osteosarcoma. The radiograph and MRI show a dense bone forming lesion which is "stuck-on" the proximal humerus. These radiographs actually show a multi-focal presentation of this lesion with distinct lesions stuck on the bone. Bone scan shows the lesion to be metabolically active. MRI shows the very dark signal characteristic of heavy matrix calcification. The characteristic histology section shows mature appearing bone with surrounding fibroblastic stroma lacking cytologic pleomorphism. Illustration A shows the pathological specimen and demonstrates that this is a surface lesion which appears to be "stuck-on" the cortex of the bone. Ans3
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1-def osteomalacia?
2-CC of O-malcia (4) 3-criteria for tx of OP? (4) 4-pelvic insufficiency fracture(6) 5-lab w/u for fragility fx of spine? tx? |
1-O-malcia=< nl mineralization, bone mass vaiable
2-CC OM=abn vit D, hypo-phosphatemia & phosphatasia, renal tubular acidosis 3-tx=(1)postmenopausal F & Men> 50 + hip/vertbral fx (2)postmenopausal F & Men> 50 + T score b/t -1-> -2.5 10-yr risk of hip fx >= 3% by FRAX calculation (3)postmenopausal F & Men> 50 + T score b/t -1-> -2.5 mjr related fx >=20% by FRAX calculation (4)postmenopausal F & Men> 50 + T score -2.5 <= @ fem neck/spine 4-sacrum - medial iliac -supracetabular region - iliac wing - pubic rami - parasymphyseal 5-CBC, BMP--r/o mets, ESR r/o infection Urine & serum protein electrophoresis r/o multiple myeloma::tx-bisphosphonates,observation, bracing |
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You are seeing a 13-year-old girl for asymptomatic flat feet and recommend observation. In educating this patient/family about general bone health, you recommend what amount of daily dietary calcium for your patient?
1. 250mg - 500mg 2. 500mg - 750mg 3. 750mg - 1000mg 4. 1000mg - 1500mg 5. over 1500mg per day |
A 13-year-old would require a daily dietary calciuim intake of 1000 to 1500mg/d. According to the National Osteoporosis foundation daily calcium requirements for children are as follows: Age 1-3yrs - 500mg/d, Age 4-8yrs - 800mg/d, Age 9-18yrs - 1000 to 1500mg/d. The level 5 review by Tortolani et al. states that adults aged >50 yrs require 1200 to 1500 mg/d of calcium and lactating women require more daily calcium (2000mg per day). Ans4
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Genetic polymorphisms in all of the following genes are associated with osteoporosis EXCEPT?
1. Calcitonin receptor 2. Estrogen receptor-1 3. Vitamin D receptor 4. Type I collagen alpha-1 chain 5. Cartilage oligomeric matrix protein (COMP) |
Polymorphisms in the genes for the calcitonin receptor, estrogen receptor-1, vitamin D receptor, and the type I collagen alpha-1 chain (along with over 45 other genes) have been shown to be associated with osteoporosis. Answer 5, Cartilage oligomeric matrix protein, shows no current association with osteoporosis, but is the known genetic mutation associated with multiple epiphyseal dysplasia (a frequently tested fact). No single cause for osteoporosis has been shown at this point in time. Jin et al conducted a meta-analysis regarding polymorphisms in the 5' flank of COL1A1 gene and the conflicting results relating to osteoporosis. They found that the COL1A1 Sp1 polymorphism is associated with a modest reduction in BMD and an increased risk of fracture. The attached review by Huang and Kung discusses the multiple genetic and environmental determinants of osteoporosis and illustration A (from a different review by these same authors) lists the known genes currently assoc w/ OP.Ans5
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All of the following medications have been associated with an increased risk of osteoporosis EXCEPT:
1. selective serotonin reuptake inhibitors (SSRI) 2. glucocorticoids 3. non-steroidal anti-inflammatories (NSAIDs) 4. phenytoin 5. protease inhibitors |
oral corticosteroids, androgen-deprivation therapy, aromatase inhibitors, protease inhibitors, selective serotonin reuptake inhibitors, prolactin-raising antiepileptic agents and many cytotoxic agents. Additionally, a number of disease states are associated with osteoporosis, including endocrinopathies such as hyperparathyroidism, thyrotoxicosis and type I diabetes, hypogonadism, chronic glucocorticoid therapy, malnutrition, malabsorption states, chronic immobilization, rheumatoid arthritis, alcoholism, vitamin D deficiency, and multiple myeloma. NSAIDs have not been shown to increase risk of osteoporosis. Ans3
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Continuous infusion of parathyroid hormone has been shown to cause bone resorption. What effect does intermittent parathyroid hormone have on bone?
1. anabolic 2. catabolic 3. no effect 4. decreased quantity 5. decreased quality |
Treatment of osteoporosis centers on increasing bone mass by direct anabolic effect and/or inhibiting osteoclastic absorption. Bisphosphonates, selective estrogen receptor modulators, and calcitonin act to decrease bone resorption by inhibiting osteoclasts. Parathyroid hormone causes both bone formation and resorption, depending on frequency of dosing. Osteoblasts are primary targets for PTH. Once activated, they secrete RANKL and IL-6, which causes osteoclast proliferation/maturation, leading to increased bone resorption. Because of this coupled remodeling process, several observations have been made: 1)intermittent PTH injections increase bone mass, 2) continous infusion lead to bone resorption, and 3) dosing should not continue past 2 yrs. Thus, intermittent parathyroid hormone is anabolic to bone and is used as a treatment of osteoporosis (forteo).
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1-MC loc of pedi spine fx in child<8, & >8?
2-MCC of c spine fx, which have the highest mortality? 3-spinal cord injury is more common/lethal in patients ___ age? 4-pediatric spinal column can stretch up to ___cm without rupture? 5-transporting patients less than 8 years of age requires a spine board with ___? |
1@ or above C3, 87% of injuries at C3 or above in children < 8 years:::>8=below C3
2-MVC, higher mortality rate at C3 or above, C1 lead to a mortality rate of 17% 3-pts > 8 yo 4-5cm (2inches) 5-occipital depression or enough thoracic elevation to align the cervical and thoracic segments of the spine , external auditory meatus in-line with the shoulders |
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An 8-year-old child falls from a 15-foot retaining wall and is found unconscious by emergency personnel. Which of the following is the most appropriate form of cervical stabilization in the acute setting?
1. Utilize adult spine board with modification of a one inch sandbag under the patient's head 2. Maintaining in-line cervical stabilization with the external auditory meatus posterior to the shoulders 3. Maintaining in-line cervical stabilization with the external auditory meatus anterior to the shoulders 4. Halo immobilization with 8 to 12 low insertion torque pins 5. Maintaining in-line cervical stabilization with the external auditory meatus in-line with the shoulders |
Cervical spine injuries should be immobilized in a postion of relative extension in both children and adults. Applying cervical traction with the external auditory meatus in-line with the shoulders can serve as a guideline.
Herzenberg et al. found that because of relatively large head size in children, an adult backboard can force a childs' cervical spine into a position of flexion. This might have catastrophic results and lead to spinal cord injury. Therefore, they recommend that pediatric backboards, or modified adult backboards, should be used in pediatric cervical injuries. Ans5 |
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79yo F s/p low energy fall and is hospitalized for low back pain that prevents her from ambulating. She denies any symptoms of buttock or leg pain. On physical exam she has point tenderness over the T12 vertebral body. Examination of her lower extremities is normal. Radiographs are shown in Fig A &B. An MRI is performed which shows signal intensity within the T12 vertebral body on T2-weighted images and no evidence of retropulsion or spinal cord compression. Which of the following statements is true regarding this injury pattern?
1. There is no association between this fracture and future osteoporotic fragility fractures. 2. Prospective, randomized, double blinded studies have recently showed improvement with vertebroplasty. 3. 2-year mortality rates are greater than those associated with hip fractures. 4. This fracture results in chronic back pain in the majority of patients regardless of tx 5. Neurologic deterioration is a common complication with this injury pattern |
The clinical presentation and radiographs are consistent with an acute osteoporotic vertebral compression fracture. The mortality rate of patients with vertebral fractures exceeds that of patients with hip fractures when they are followed beyond 6 months.
Osteoporotic compression fractures are the most common fragility fracture. Due to the high prevalence of this injury there is a large socioeconomic burden associated with the disease and there has been significant controversy regarding optimal treatment. Several recent prospective, randomized, double blinded studies failed to show any significant improvement with vertebroplasty. Studies looking at the treatment effects of kyphoplasty, as opposed to vertebroplasty, remain controversial.Ans3 |
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In the treatment of acute osteoporotic compression fractures, vertebroplasty has been shown to have which of the following benefits in randomized, double-blind, placebo-controlled trials compared to nonoperative treatment.
1. Improvement in pain at 3 months, but not difference at 1 year 2. Improvement in function at 3 months, but not difference at 1 year 3. Improvement in pain at 2 week and at 1 year, but no difference in function 4. Improvement in pain and function at all time points 5. No benefit at any time point |
Randomized, double-blind, placebo-controlled trials have shown no beneficial effect of vertebroplasty as compared with a sham procedure in patients with painful osteoporotic vertebral fractures.
Vertebral compression fractures (VCF) are the most common fragility fracture with 700,000 VCF per year in US leading to 70,000 hospitalizations annually and 15 billion in annual costs. The presence of a VCF is considered a risk factor for osteoporosis, and all patients with a VCF should be referred for evaluation and possible medical management of osteoporosis.Ans5 |
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A 36-year-old female sustains a knee injury after falling from a ladder onto her flexed knee. A radiograph is shown in Figure A. Which of the following treatment options has been shown to have the best outcomes with this injury?
1. Long leg cast 2. Open reduction and internal fixation of patella 3. Distal patellar resection and patellar tendon advancement 4. Distal patellar resection and allograft reconstruction 5. Placement of a cerclage wire from patella to proximal tibia |
The clinical presentation is consistent with and inferior pole patella fracture. Open reduction and internal fixation is the most appropriate treatment of this injury pattern.
Whenever possible, salvage of the inferior pole through open reduction internal fixation is favored over simple excision and patellar tendon advancement, as this has been shown to be associated with improved outcomes. This is not always possible, however, and pole resection can be performed if the inferior comminution precludes fixation. Inferior outcomes of the partial distal patellectomy and patellar tendon advancement are (aside from the possible resulting patella baja) probably not directly related to the patellofemoral articulation. On the undersurface, the proximal 75% of the patella is covered with articular cartilage; however, the distal 25% is not, and does not articulate with the femoral trochlea. Ans2 |
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Partial patellectomy is the recommended treatment for which of the following injuries?
1. Vertical patella fractures 2. Bipartite patella 3. Severely comminuted inferior pole fracture 4. Stellate patella fracture 5. Chronic quadriceps tendon rupture |
Partial patellectomy is a recommended treatment for a comminuted superior or inferior pole fracture measuring <50% of the patella's height that are not amenable to ORIF. Comminuted patellar fractures are challenging to manage. Older studies show that in severely comminuted fractures, partial patellectomy is the recommended treatment. Newer studies are showing improved outcomes with ORIF. Therefore, if possible, proceed with ORIF. Unfortunately, when the comminution is severe, ORIF is often not possible and partial patellectomy is required. The area can be excised and a technique of quadriceps tendon (superior pole) or patellar tendon (inferior pole) repair can then be undertaken.
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1-pagets dz define
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1-A condition of abnormal bone remodeling, increased osteoclastic bone resorption is the primary cellular abnormality, original osseous tissue is reconstructed through active interplay between excessive bone resorption and abnormal new bone formation
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Paget's disease may predispose a patient to the development of which of the following malignant neoplasms?
1. Chondrosarcoma 2. Osteosarcoma 3. Spindle cell sarcoma of bone 4. All of the above 5. None of the above |
Patients with Paget's disease are predisposed to secondary osteosarcoma, chondrosarcoma, and spindle cell sarcoma of bone (e.g. fibrosarcoma) all which can occur through Pagetoid lesions. Ans4
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A 65-year-old man complains of deformity of the right leg. He denies pain at rest but does complain of ankle and lower leg pain when walking more than a half mile. A radiograph is shown in Figure A. Following 6 months of orthotic and brace treatment, he continues to struggle with pain. Which of the following is the best treatment option?
1. Continued orthotic and brace treatment 2. Corrective osteotomy and plate fixation 3. Corrective osteotomy and intramedullary fixation 4. Amputation 5. Corrective osteotomy, knee arthrodesis, and plate fixation |
Radiograph demonstrates tibial bowing in a Pagetoid tibia. Paget's is a metabolic bone disease disrupting the physiologic cycle of bone remodeling. Illustrations provided demonstrate further examples of pagetoid changes within long bones. Given failure to relieve symptoms with conservative measures, surgical management is recommended.
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A 65-year-old male presents with increasing shoulder pain over the past 9 months. He is otherwise healthy and has no other complaints. Radiograph of his shoulder is shown in Figure A. Whole body bone scan and biopsy photograph are shown in Figures B and C. What is the most appropriate treatment for this patient?
1. Referral to endocrinology 2. Radiation therapy and chemotherapy 3. Wide resection and reconstruction 4. Radiation therapy, wide resection, and reconstruction 5. Chemotherapy, wide resection, and reconstruction |
The radiograph, bone scan, and histology slide are consistent with Paget's sarcoma of the proximal humerus, correctly treated with chemotherapy, wide resection, and reconstruction. The bone scan shows this as a polyostotic disease where the proximal humerus sarcoma has developed from pagetoid bone. Pagetoid bone shows up very "hot" on bone scan, even without sarcomatous change. The histology slide shows a pleomorphic spindle cell sarcoma with many giant cells, large amount of cellular atypia, and high nuclear to cytoplasmic ratio, typical of Paget's sarcoma.
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Which of the following structures attaches between the medial epicondyle and adductor tubercle of the femur?
1. Medial head of gastrocnemius 2. Medial collateral ligament 3. Semimembranosis 4. Adductor magnus 5. Medial patellofemoral ligament |
The femoral attachment of the medial patellofemoral ligament (MPFL) is located between the femoral medial epicondyle and the adductor tubercle. During lateral patellar dislocation, the femoral attachment of the MPFL is a common site of injury and avulsion. Traumatic injury or laxity to the MPFL can cause future patellar instability, as the MPFL is the primary restraint to lateral patellar translation in the first 20 degrees of knee flexion. Surgery for reconstruction of the MPFL requires an understanding of the anatomic landmarks for drilling the femoral socket. answers:
Answer 1- Medial head of gastrocnemius originates off posterior aspect of medial femoral condyle. Answer 2- MCL attaches approximately 3.2 mm proximal and 4.8 mm posterior from the medial femoral epicondyle. Answer 3- Semimembranosis inserts onto posterior surface of the medial tibial condyle. Answer 4- Adductor magnus inserts onto adductor tubercle.Ans5 |
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Which of the following best describes the radiographic landmarks on a lateral radiograph for locating the femoral attachment of the medial patellofemoral ligament (MPFL) during reconstruction?
1. The intersection of a line extended from the middle of the shaft and Blumensaat's line 2. Anterior to a line extended from the middle of the shaft and Blumensaat's line 3. Posterior to a line extended from the posterior cortex of the shaft and distal to Blumensaat's line 4. Anterior to a line extended from the posterior cortex of the shaft and distal to Blumensaat's line 5. Anterior to a line extended from the posterior cortex of the shaft and proximal to Blumensaat's line |
Correct positioning of a graft for MPFL reconstruction requires accurate placement of the femoral attachment site which is anterior to a line extended from the posterior cortex and just proximal to the posterior extension of Blumensaat's line. Intra-operative fluoroscopy can be used to accurately identify this position. Schottle et al have described the radiographic landmark to be 1 mm anterior to the posterior cortex extension line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the level of the posterior point of the Blumensaat line
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A 27-year-old football player sustains an acute lateral patellar dislocation. Which of the following is the most likely site of injury seen on MRI?
1. Soft-tissue patellar-sided avulsion of medial patellofemoral ligament 2. Soft-tissue femoral-sided avulsion of medial patellofemoral ligament 3. Midsubstance medial patellofemoral ligament rupture 4. Bony femoral avulsion of medial patellofemoral ligament 5. Bony patellar avulsion of medial patellofemoral ligament |
The most common site of medial patellofemoral ligament (MPFL) injury is a soft-tissue avulsion injury of the ligament off the femur. Both midsubtance and patellar-sided soft tissue avulsions are more common than bony avulsions. Bony avulsion off the patella can occur as well, and according to the referenced study by Torisuka et al, the MPFL remains attached to the medial patellar fragment and excellent clinical and radiographic results can occur with open reduction and fixation with suture anchors. The reported study by Nomura et al reported that MRI is >80% sensitive and >80% specific (regarding location) for detecting MPFL injuries as well as their location. In addition, they noted a 96% MPFL injury rate with patellar dislocation. Ans2
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A high school softball player has chronic activity-related anterior knee pain without a history of instability. Which radiographic measurement is used to indicate when a lateral retinacular release may be helpful?
1. Congruence angle 2. Q angle 3. Sulcus angle 4. Lateral patello-femoral angle 5. Patellar height index |
The lateral patello-femoral angle is the angle formed by lateral patellar facet and a line drawn across most prominent aspects of anterior portion of the trochlea on a CT scan or Sunrise view radiograph. If there is a negative patellar tilt on this measurement, the patient may benefit from a lateral release for pain relief. Lateral release is not used for instability. The sulcus angle refers to the depth of the trochlea; the congruence angle measures the relationship of the center of the patella to the center of the trochlea. These are used to assess malalignment and instability.
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Which of the following rehabilitation exercises provides for restoration of range of motion while limiting stress on the repair of a ruptured patellar tendon?
1. Active open chain flexion, active closed chain extension 2. Passive flexion, active closed chain extension 3. Active open chain flexion, passive extension 4. Active closed chain flexion, passive extension 5. Active open chain flexion, active open chain extension |
To avoid stress on the repair, no form of active extension should be used for at least 4-6 weeks. Closed versus open chain refers to strengthening exercises, not just range of motion. Closed kinetic chain exercise occurs when the terminal or distal segment of an appendage is fixed (squat, leg press, pull-up). Open kinetic chain exercise occurs when the terminal or distal segment is free to move (leg extension / hamstring curl) – this type of exercise tends to produce greater shear stress and is therefore avoided in many standardized rehab protocols. In the case of patellar or quad tendon repair, active closed chain flexion may be allowed with passive extension. Many of the rehab studies have looked at the effects of various exercises with respect to ACL graft strain. Stuart et al. showed that for common closed chain exercises like squats and lunges the shear force is predominantly posterior and therefore may not stress an ACL graft. Ans4
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A 40-year-old recreational basketball player injured his knee while jumping for a rebound. He felt a pop and developed immediate swelling. His radiographs are shown in Figures A and B. What is the recommended management?
1. Obtain an MRI 2. Ice, rest, and observation 3. Physical therapy to regain motion 4. Knee arthroscopy and repair 5. Open surgical repair |
The mechanism of injury and radiographs are consistent with a complete patellar tendon rupture. The radiographs reveal a patella alta, which in this case is indicative of complete patellar tendon rupture. This can be quantified by using the Insall-Salvati ratio (patellar tendon length / patellar bone length): PTL/PBL normal =1, >1.2 is patella alta, <0.8 is patella baja) with the knee flexed to 30 degrees. A complete patellar tendon rupture requires open surgical repair. A partial tear with an intact extension mechanism may be treated conservatively. An MRI is not needed for diagnosis. Ans5
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A weightlifter feels a pop in his anterior left shoulder while doing a bench press exercise. Which nerve innervates the muscle that is disrupted as seen on the MRI shown in Figure A?
1. Axillary 2. Musculocutaneous 3. Upper and lower subscapularis 4. Suprascapular nerve 5. Lateral and medial pectoral nerves |
The clinical history would be consisted with either a biceps or pectoralis major tendon tear. The MRI shows a normal biceps tendon and a retracted pectoralis muscle. The innervation of the pectoralis major is the lateral and medial pectoral nerves.
Illustration A demonstrates the injury MRI with a blue box indicating the level of pectorialis retraction. Illustration B demonstrates a preinjury, right sided pectoralis tear with ecchymosis, and right sided post injury retracted muscle. Illustration C is a drawing demonstrating the site for pectoralis repair at the footprint lateral to the biceps tendon. Ans5 |
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During a bench press, when is the pectoralis major insertion at greatest risk of rupture?
1. Initiation of upward motion 2. Point of maximum elevation 3. During downward deceleration 4. When bar is touching chest 5. No difference in rupture rate is seen |
Pectoralis major (PM) injuries are most commonly seen in young males, usually athletes involved with heavy lifting or weight training. Injury most commonly occurs when the weight is taken down, and eccentric contraction of the PM during the braking motion prevents the weight from falling down. Diagnosis is often made clinically, but MRI is the imaging modality of choice to accurately assess the site and extent of the rupture. The most common types of injuries of the pectoralis major muscle are the tendon avulsions at the site of insertion followed by myotendinous junction tears. Surgical repair provides the best outcomes in patient satisfaction, strength, cosmesis and return to competitive sports. Any complete tear of the tendon or myotendinous junction should be surgically repaired. Non-surgical treatment is only recommended for elderly, sedentary patients. The referenced article by Petilon et al reviews these injuries and their treatment. Ans3
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A 70-year-old female has persistent anterior knee pain and stiffness 10 months status-post total knee arthroplasty with associated lateral patellar release. Radiographs before and after surgery are shown in Figures A and B respectively. Pre-operatively, her Insall-Savati ratio is 0.95, compared to 0.76 post-operatively. Which of the following is the most likely cause of her radiographic abnormality and pain?
1. Notching of the femur 2. Excessive resection of the distal femur and lateral release of the patella 3. Preoperative patella baja 4. Excessive release of the patellar ligament from the tibial tubercle 5. Excessive resection of the proximal tibia |
Figure B represents iatrogenic patella baja and an elevated joint line caused by excessive resection of the distal femur and contracture of the patellar tendon likely as a result of lateral patellar release. Figure A does not demonstrate pre-operative patellar baja, and answer choices 4 and 5 would lead to patella alta. The Insall-Savati ratio, shown in Illustration A, is the ratio of the patella tendon length to the length of the patella. A value <0.8 is cosistent with patella baja, and a value >1.2 is consistent with patella alta. Weale et al reviewed serial radiographs of 84 patients who had had either TKR or UKR to determine the change in patellar tendon length up to 5 years post-operatively. They found that tendon shortening was greatest in those knees which underwent TKA and had required a lateral release.Ans2
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A patient who has previously undergone a high tibial osteotomy 10 years prior is scheduled for a total knee arthroplasty (TKA). Which of the following factors is most likely to be present and may complicate the arthroplasty?
1. Collateral ligament instability 2. Patella alta 3. Patella baja 4. Patellar tendon insufficiency 5. Severe varus deformity |
TKA after a high tibial osteotomy (HTO) can be more difficult to perform than a primary knee replacement because of a shift of the proximal tibial articular surface in relation to the medullary canal, retained hardware, previous skin incisions, scar tissue, and altered patellofemoral mechanics caused by patella baja and contraction of the patella tendon. The frequency of valgus deformity is greater following HTO.
Ans3 |
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what definition of osteoporosis |
age-related decrease in bone graft secondary to uncoupling of the osteoclastic osteoblastic activity |
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which fracture secondary to osteoporosis is most common on an annual basis |
vertebral fractures > 2:1 hip fractures >3:1 wrist fractures |
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what is the strongest predictor of future fracture from low energy trauma |
prior fragility fracture |
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the patient has a vertebral fracture what is her 5 year mortality rate |
15% increase |
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the patient has a history of 2 vertebral fractures what is the suggest |
2 fractures is strongest indicator of future compression fractures post Apollo ligament |
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if the patient has a hip fracture what is their mortality rate-3 |
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refracts score defined bilateral World Health Organization is an assessment to the calculated ten-year risk of hip fracture and hip risk of major osteoporosis-related fracture would practice visit include 9 |
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if the patient is 80 years oldand has osteoporosis
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what is the definition of osteopenia |
DEXA scan positive = 1–2.5 T score equal negative 1 – negative 2.5 temperature 25-year-old for lumbar bone density |
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Y is x-ray not a good test to diagnose osteoporosis |
>30% bone loss must occur |
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according to the national osteoporosis Foundation guidelines for pharmacologic treatment of osteoporosis treatment should begin when |
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what effect does IV zolendronic acid have on reducing the rate of spine fractures at 3 years and hip fractures over 3 years |
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what is the drug of choice for treat osteoporosis that is subcutaneous injected and as a monoclonal antibody to the RANKL |
Denosumab(Prolia) |
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which treatment for osteoporosis is given daily by subcutaneous injection however if given by infusion what is the effect |
Teriparatide(Forteo) bone resorption |
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name 2 flattening of the osteoclastic ruffled border |
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with the most common complication with IV BISPHOSPHONATES |
osteonecrosis of the jaw |
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what is the best diagnostic study to confirm the effectiveness of BISPHOSPHONATES over time |
assessment of the urine collagen type I cross-linked N-telopeptide, NTx)which will be reduced indicating reduced markers of bone resorption |
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what does the histology show at a patient with osteoporosis |
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which pharmacologic treatment for osteoporosis as a increased risks of osteosarcoma |
Teriparatide(Forteo) Recombinant parathyroid hormone (1-34) contraindicated in Paget's disease due to potential risk of osteosarcoma |
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Which medications would place at increased risk for a non-traumatic hip fracture? |
Phenytoin |
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Which of the following pharmacologic treatments for osteoporosis has been associated with the potential risk for osteosarcoma development? 1. Ergocalciferol 2. Non-nitrogen containing bisphosphonate 3. Monoclonal Ig2 against RANKL 4. Nitrogen containing bisphosphonates 5. Recombinant parathyroid hormone (1-34) |
Recombinant parathyroid hormone (1-34) (Forteo) has been demonstrated to cause osteosarcoma in animal models but has not been to shown to cause the same effect in humans. The FDA's Black Box warning states the following: "In male and female rats, teriparatide caused an increase in the incidence of osteosarcoma (a malignant bone tumor) that was dependent on dose and treatment duration. The effect was observed in rats at systemic exposures to teriparatide ranging from 3 to 60 times the exposure in humans given a 20-mcg dose. Because of the uncertain relevance of the rat osteosarcoma finding to humans, teriparatide should be prescribed only to patients for whom the potential benefits are considered to outweigh the potential risk. Teriparatide should not be prescribed for patients who are at increased baseline risk for osteosarcoma (including those with Paget's disease of bone or unexplained elevations of alkaline phosphatase, open epiphyses, or prior external beam or implant radiation therapy involving the skeleton)"ans5 |
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A 52-year old woman who is not on any hormone replacement therapy (HRT) falls from standing height and sustains the injury seen in Figure A. Review of her medical history reveals that she carries a diagnosis of osteoporosis, and that her latest T-score was -3.0. How much calcium should she have been consuming on a daily basis prior to sustaining her injury? 1. 200-400mg 2. 600-800mg 3. 800-1000mg 4. 1000-1500mg 5. >1500mg |
The clinical presentation and radiographs are consistent with a distal radius fragility fracture. Based on her medical history of osteoporosis, which is confirmed by a T-score <-2.5, she should be taking 1000-1500mg of calcium per day at baseline. ans4 |
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Risk factors for insufficiency fractures of the pelvic ring include all of the following EXCEPT: 1. Osteoporosis 2. Corticosteroid treatment 3. Total hip replacement with constrained liner 4. Rheumatoid arthritis 5. Total hip replacement with ceramic bearings |
Ceramic bearings have not been documented to be an etiology for pelvic insufficiency fractures. constrained liners used with total hip arthroplasty create a mechanical constraint that redistributes more force to the pelvic ring. Pelvic ring insufficiency fractures are increasing in incidence. ans5 |
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Genetic polymorphisms in all of the following genes are associated with osteoporosis EXCEPT? 1. Calcitonin receptor 2. Estrogen receptor-1 3. Vitamin D receptor 4. Type I collagen alpha-1 chain 5. Cartilage oligomeric matrix protein (COMP)
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Polymorphisms in the genes for the calcitonin receptor, estrogen receptor-1, vitamin D receptor, and the type I collagen alpha-1 chain (along with over 45 other genes) have been shown to be associated with osteoporosis. Answer 5, Cartilage oligomeric matrix protein, shows no current association with osteoporosis, but is the known genetic mutation associated with multiple epiphyseal dysplasia (a frequently tested fact). No single cause for osteoporosis has been shown at this point in time. a meta-analysis regarding polymorphisms in the 5' flank of COL1A1 gene and the conflicting results relating to osteoporosis. They found that the COL1A1 Sp1 polymorphism is associated with a modest reduction in BMD and an increased risk of fracture. ans5 |
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5th decade of life (age 40 to 49) white female comes in the office for routine evaluation who previously had been very healthy however recently after returning from the cardiologist she was diagnosed with new onset cardiac symptoms- high-output cardiac failure and recently complains of intense pain and swelling in the pelvic region
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A 67-year-old male patient is scheduled for left total hip arthroplasty. A pre-operative examination reveals elevated serum alkaline phosphatase and urine hydroxyproline. A radiograph of his hip/pelvis is seen in Figure A. Taking into context the clinical and radiographic presentation, what would you expect to be the most common complication with this procedure? 1. Implant malalignment 2. Increased blood loss 3. Peri-prosthetic fracture 4. Sciatic nerve palsy 5. Deep vein thrombosis
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Figure A shows an anteroposterior radiograph of the pelvis in a patient with Paget's bone disease. There is significant left hip arthritis with coxa varus with disease involvement within the femoral shaft and hemipelvis. Increased blood loss is the most common complication associated with total hip arthroplasty in patients with Paget's bone disease. Paget's bone has a rich blood supply and active disease can cause significant blood loss from bone. The activity of disease can be assessed before surgery by measuring serum alkaline phosphatase and urine hydroxyproline. Elevated levels may reflect active disease. The use of pre-operative bisphosphonates may help to dampen the disease process and control blood loss during surgery. ans2 |
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Paget's disease may predispose a patient to the development of which of the following malignant neoplasms? 1. Chondrosarcoma 2. Osteosarcoma 3. Spindle cell sarcoma of bone 4. All of the above 5. None of the above |
Patients with Paget's disease are predisposed to secondary osteosarcoma, chondrosarcoma, and spindle cell sarcoma of bone (e.g. fibrosarcoma) all which can occur through Pagetoid lesions. |
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was the treatment of a fracture through a pathologic bowing of the long bone |
metaphyseal osteotomy and plate fixation |
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what is the definition Paget's disease |
a condition characterize was by excessive bone resorption and disordered bone formation |
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All of the following statements regarding Paget's sarcoma are correct EXCEPT? 1. The 5-year survival for non-metastatic Paget's sarcoma is less than 5% 2. Less than 1% of patients with Paget's disease develop secondary Paget's sarcoma 3. While osteosarcoma is the most common histologic sub-type of Paget's sarcoma, fibrosarcoma and chondrosarcoma sub-types also occur 4. Paget's sarcoma typically occurs in patients over 50 years of age 5. Treatment of Paget's sarcoma is via surgery alone |
Paget's sarcoma is a rare secondary sarcoma which occurs in patients with Paget's disease (Illustration A). Less than 1% of patients with Paget's disease ever develop Paget's sarcoma. It typically presents with progressive pain, soft tissue swelling, or pathological fracture. Typically patients with Paget's sarcoma are older at diagnosis (average 55-80 years). Paget's sarcoma is a very aggressive secondary sarcoma which is histologically similar to osteosarcoma, however fibrosarcoma and chondrosarcoma variants do exist. Treatment consists of surgery with chemotherapy vs. palliative radiotherapy in patients too infirm to withstand surgery or chemotherapy. The 5-year survival for non-metastatic Paget's sarcoma is less than 5%. Mankin and Hornicek review the Mass General experience and report on 43 patients with Paget's sarcoma. Their results are a compilation of two cohorts, the first treated from 1942 to 1967, and the second from 1972 to 2001. As such, they conclude that despite multiple different treatment protocols, the overall survival of Paget's sarcoma is poor.ans5 |
