178/189

Front 1

what is the most common cause of cervical myelopathy?

Back 1

the most common causes degenerative cervical spondylosis

Front 2

patient presents to the office complaining of clumsiness in the hands and gait imbalance what is the diagnosis

What is the next most appropriate step in management.

Back 2

cervical myelopathy

MRI  or CT myelogram for patient with a pacemaker to  R/O Most common associated lumbar spinal stenosis

Front 3

based on gait and ambulatory function if one is having difficulty with gait but is fully employed what grade myelopathy does the patient have?

Back 3

grade 2

Front 4

if one is unable to walk without assistance what grade myelopathy does does the patient have?

Back 4

grade 4

Front 5

if the patient holds fingers extended and adducted the small finger spontaneously abducts what is the diagnosis

Back 5

finger escape sign =cervical myelopathy

Front 6

lateral x-ray of the cervical spine pavlo  ratio less than ____is suggestive congenital narrow cervical spine?

Back 6

0.8.  predisposing to stenosis and spinal cord compression

Front 7

patient's with improved with nonoperative outcomes associated with larger transverse area of the spinal cord_____?

Back 7

greater than 70 mm

Front 8

what is the treatment in a patient with  kyphosis greater than 10° that involves 1 or 2 levels of compression?

Back 8

ACDF anterior corpectomy hybrid

Front 9

what is the treatmen 4 patient  with kyphosis less than 10° that involves 1 or 2 levels of compression?

Back 9

ACDF anterior corpectomy hybrid

Front 10

what is the treatment for patient with kyphosis greater than 10° and involves 3 or more levels of compression?

Back 10

anterior corpectomy to correct the kyphosis and posterior decompression

Front 11

what is the treatment for patient with less than 10° rigid kyphosis that involves 3 or more levels of compression

Back 11

posterior alone laminoplasty versus laminectomy plus fusion

Front 12

the patient with cervical kyphosis  Which  variables has the strongest association with poor clinical outcomes in patients who undergo expansive laminoplasty for cervical spondylotic myelopathy?

Back 12

Local kyphosis angle >13° is contraindicated

Front 13

what is the most common complication with an anterior approach to the cervical spine?

Back 13

RIGHT recurrent laryngeal nerve injury if not improved at 6 weeks consult ENT

Front 14

A 47-year old female with Type-2 diabetes and a pacemaker presents with bilateral buttock and leg pain that is worse with prolonged walking and improves with sitting. Her lower extremity symptoms are severe enough that she reports she feels "unstable" on her feet. Physical exam shows 5/5 strength in all muscles groups in the lower extremity. clonus is present with forced ankle dorsiflexion on physical exam. A lumbar myelogram is performed . What is the most appropriate next step in treatment. 

1.  Lumbar decompression

2.  Lumbar decompression with arthrodesis

3.  A trial of physical therapy and NSAIDS

4.  Lumbar epidural steroid injections

5.  CT myelogram of cervical spine

Back 14

The clinical presentation and imaging studies are consistent with concurrent symptoms of myelopathy and neurogenic claudication in a patient with lumbar degenerative spondylolisthesis. An CT myelogram of the cervical spine would be the most appropriate next step in management as the patient is unable to obtain an MRI due to the pacemaker.ans5

Front 15

A 68-year-old female presents with progressive loss of ability to ambulate and dexterity problems with her hands. Six months ago she was able to walk with a cane, but now has difficulty with ambulating with a walker. She also reports difficulty with her hands and needs assistance with eating. Physical exam shows limited neck extension. Radiographs, tomography, and magnetic-resonance-imaging are shown in Figure A, B, and C respectively. What is the most appropriate treatment?

1.  NSAIDS, physical therapy, and clinical observation

2.  C3 to C6 cervical laminectomy

3.  C3 to C6 laminoplasty using an open-door technique

4.  C3 to C6 decompressive laminectomy with instrumented fusion

5.  Multilevel anterior cervical decompression with strut grafting and anterior plate fixation, followed by posterior decompression and fusion

Back 15

The patients symptoms are consistent with progressive cervical myelopathy. Her symptoms are progressive and severe, and therefore surgical decompression is indicated. She has cervical kyphosis as demonstrated on physical exam and imaging, with compression at three levels (C3/4, C4/5, C5/6). An anterior procedure is mandatory to correct her kyphosis and remove the anterior compressive lesions. Of the options listed, only answer 5 involves an anterior procedure, and therefore, it is the most appropriate treatment.ans5

Front 16

Which of the following variables has the strongest association with poor clinical outcomes in patients who undergo expansive laminoplasty for cervical spondylotic myelopathy?

1.  Multi-level stenosis

2.  Duration of symptoms

3.  Local kyphosis angle > 13 degrees

4.  Osteoporosis

5.  MRI finding of CSF effacement

 

Back 16

Fixed cervical kyphosis is associated with poor functional outcomes when performing an expansive laminoplasty for cervical spondylotic myelopathy.

Front 17

 All of the following clinical signs are characteristic of an upper motor neuron disorder EXCEPT

1.  Fasciculations

2.  Spasticity

3.  Muscle weakness

4.  Exaggerated deep tendon reflexes

5.  Sustained clonus

 

Back 17

Fasciculations are a clinical sign of a lower motor neuron disorders. The lower motor neuron is defined as the nerve fibers traveling from the anterior horn of the spinal cord to the peripheral muscle. Lesions to the lower motor neuron are characterized by fasciculations and flaccid paralysis. The upper motor neuron is defined as the nerve fibers traveling from the motor cortex of the brain to the anterior horn of the spinal cord. Upper motor neuron disorders are characterized by spastic paralysis, exaggerated deep tendon reflexes, sustained clonus, and an up-going Babinski sign. Muscle weakness is a clinical sign of both upper and lower motor neuron disorders. ans1

Front 18

what is the most common neurologic complication after a laminoplasty and a myelopathic patient with cervical stenosis?

clinical presentation?

Back 18

C5 palsy weakness deltoid and biceps

Front 19

Following a C3-C7 laminoplasty in a myelopathic patient with cervical stenosis, the most common neurologic complication would manifest with which of the following new postoperative exam findings  

1.  Change in voice and difficulty swallowing

2.  Triceps weakness

3.  Deviation of the tongue

4.  Ptosis, miosis, anhydrosis

5.  Biceps weakness

 

Back 19

C5 palsy (deltoid and biceps weakness) is the most likely neurologic complication following cervical laminoplasty, with an incidence of ~5%. Its pathogenesis and the options for prevention and treatment remain unidentified and many controversies exist. Two theories to account for the pathogenesis of C5 palsy exist: 1) nerve root injury 2) segmental spinal cord disorder. Neither of these hypotheses has been consistently supported and evidence to refute each hypothesis can be found in the literature. Although patients with C5 palsy generally have a good prognosis for neurologic and functional recovery, those with severe paralysis require significantly longer recovery times when compared to more mild cases.ans5

Front 20

Which classification system for cervical myelopathy focuses exclusively on lower extremity function?

1.  Nurick

2.  Japanese Orthopaedic Association

3.  Modified Japanese Orthopaedic Association

4.  Ranawat

5.  Oswestry

Back 20

The Nurick Classification system is a classification system for cervical myelopathy that focuses on the ambulatory status of the patient.

Incorrect Answers:
Answer 2: The Japanese Orthopaedic Association Classification system includes chopstick function.
Answer 3: The Modified Japanese Orthopaedic Association Classification system includes upper extremity dexterity tasks such as buttoning of a shirt.
Answer 4: The Ranawat Classiciation takes into account upper extremity, and well as lower extremity, symptoms.
Answer 5: The Oswestry Disability Index is a classification for back pain, not cervical myelopathy.ans1

Front 21

A 45-year-old man presents with increasing difficulty ambulating normally and clumsiness when he is either combing his hair or buttoning his shirt. A sagittal cut of his MRI is shown in Figure A. What is the next most appropriate step in management?

1.  Observation

2.  Epidural injection

3.  Physical therapy and anti-inflammatory medication

4.  Anterior cervical diskectomy and fusion

5.  Posterior cervical laminectomy and fusion

Back 21

The MRI scans demonstrate a midline soft cervical disc herniation. Controversy had existed as to whether this entity is best managed by an anterior approach or a posterior cervical laminotomy-foraminotomy. The Herkowitz Spine article from 1990 prospectively compared 28 patients treated with anterior discectomy and fusion to 16 treated with posterior laminotomy-foraminotomy. 26 of 28 patients in the anterior group had excellent or good results and 12 of 16 in the posterior group had excellent or good results, measured by relief of pain and weakness at mean 4.2 year follow-up. This study agreed with other previous ones that demonstrated the anterior approach for cervical central soft disc herniations is superior to the posterior approach.ans4

Front 22

what is the most important prognostic variable relating to neurologic recovery and incomplete spinal cord injury

Back 22

severity of neurologic deficitits completeness

Front 23

was most common incomplete spinal cord injury?

clinical presentation & what is  hyperpathia?

Back 23

central cord syndrome

Weakness and hand dexterity  upper extremity is affected worse than the lower extremities 

hyperpathia burning in the distal upper extremity

Front 24

physical exam findings of upper motor neuron involvement?

name  8 physical exam findings and test  to diagnose upper motor neuron involvement

 

Back 24

upper motor neuron equals  spasticity think of cervical myelopathy the finger with upper motor neuron

1. hyperreflexia
2. Inverted radial reflex
3. HOFFMANN sign
4. Sustained clonus greater than 3 beats
5. BABINSKI test
6. failes heel-to-toe walk
7. ROMBERG test
8. LHERMITTE sign

Front 25

physical exam finding of lower motor neuron signs

Back 25

flaccid paralysis fibrillations fasciculations hypotonia areflexia weakness and strength

everything goes down with lower motor neuron deficits

 

Front 26

which incomplete spinal cord injury has a worse prognosis for recovery?

clinical presentation?

Back 26

anterior cord syndrome lower extremity is affected more than upper extremities loss of motor and loss of pain and temperature

Front 27

which incomplete spinal cord injury has the excellent prognosis for recovery?

Back 27

Brown Sequard syndrome

Front 28

described the clinical presentation of a Brown Sequard syndrome?

Back 28

step on the LEFT loss of motor function on the LEFT ipsilateral and contralateral loss pain and temperature classically 2 levels below

Front 29

A 79-year old man falls sustaining a hyperextension injury to his neck. A lateral radiograph, CT scan and MRI are seen in Figures A through C. On motor examination, he has 3/5 strength in his deltoids, elbow and wrist flexors and extensors. He has 4/5 strength in his hip flexors, knee flexors, extensors, ankle dorsiflexors and plantarflexors. Sensation is preserved in both his upper and lower extremities as well as his sacral segments. Injury to which of the following tracts contributes greatest to his motor function deficits?

1.  Fasciculus gracilis

2.  Fasciculus cuneatus

3.  Anterior corticospinal

4.  Lateral corticospinal

5.  Lateral spinothalamic

 

Back 29

The clinical scenario describes a patient with central cord syndrome, resulting in an injury to his lateral corticospinal tract. Figures A through C show a spondylotic spine with central narrowing and CSF effacement that is worse at the C4-5 level. The lateral corticospinal tract is the main descending motor tract (Illustration A). Its anatomic position places the upper extermity motor tracts at greater risk than the lower extremity tracts. As such, injury to the lateral corticospinal tract is characterized by upper greater than lower extremity involvement and motor deficits being more pronounced than sensory deficits.
ans4

Front 30

A 73-year-old man falls forward from standing height and sustaining a hyperextension injury to his neck. Physical exam of his lower extremities shows he has 4+ of 5 strength to hip flexion, knee extension, and ankle plantar flexion. Physical exam of his upper extremities shows 4 of 5 deltoid and triceps strength, with 3 of 5 wrist flexion and finger flexion strength. A CT scan and MRI are shown in Figures A and B. Which of the following neurologic pathways was most likely affected?

1.  Posterior funiculi

2.  Lateral corticospinal tract

3.  Central Gray matter

4.  Lateral spinothalamic tract

5.  Ventral spinothalamic tract

 

Back 30

The clinical presentation is most consistent with a central cord syndrome, which is believe to be caused by involvement of the lateral corticospinal tract.

Central cord syndrome is characterized by motor deficits more pronounced in the upper extremities than lower extremities. In addition, finger and wrist motor function is more affected than shoulder and biceps function. Sensory deficits are usually minimal.ans2

Front 31

Which of the following clinical scenarios would be an indication for surgical intervention of the spine?

1.  18-year-old male with T12 burst fracture, stable alignment, and no neuro deficit.

2.  25-year-old male with trans-colonic gun shot wound and cord hemi-transection without retained bullet fragment.

3.  80-year-old female with global upper extremity weakness but preserved lower extremity function after fall.

4.  37-year-old male with type III odontoid fracture.

5.  18-year-old male with incomplete sensory and motor deficits after gun shot wound with retained bullet fragment in the lumbar spinal canal.

Back 31

Removal of retained bullet fragments within the spinal canal in a patient with incomplete sensory/motor deficits may improve patient function and therefore is recommended. ans5

Front 32

what are the 6th indication for an anterior approach to the cervical spine?

Back 32

1. cervical radiculopathy– anterior cervical discectomy and fusion
2. Myelopathy – anterior corpectomy and fusion
3. odontoid fracture – C2 anterior screw OsteoSYNthesis
4. tumor–anterior corpectomy and fusion
5. Infection -anterior cervical discectomy and fusion
6. Epidural abscess– anterior cervical discectomy and fusion

Front 33

what is the name of the anterior tubercle of the transverse process of C6?

Back 33

carotid tubercle

Front 34

1. what structure is at risk during the deep dissection an anterior approach to the spine that lies on the longus colli
2. what is the most common taken to prevent this complication  Horner's syndrome complication be avoided
3. where as it relates to the lateral to the vertebral body?
4. I would you know if this structure has been injuredOn physical exam

Back 34

1. the sympathetic chain 
2. Subperiosteal dissection of the longus colli muscle
3. Lateral to the vertebral body
4. HORNER syndrome = ptosis– drooping of the eyelid, anhidrosis miosis-pupil constriction enophthalmos loss of ciliospinal reflex on the same side of the face

Front 35

1.  most common cause of a post surgical edema after anterior after anterior approaches cervical spine
2. what is the treatment of this condition
3. what is the physical exam findings

Back 35

1. postop retropharyngeal hematoma
2. Emergent decompression can cause respiratory compromise
3. tenths mass under the incision patient has difficulty breathing, patient has stridor with inspiration

Front 36

A myelopathic patient undergoes anterior cervical diskectomy and fusion through a left sided approach. Facial asymmetry is noticed postoperatively in the recovery room. A clinical photo is shown in Figure A. What additional finding would likely be found on physical exam?

1.  Pupillary dilation and hyperhidrosis on the patient's right side

2.  Pupillary dilation and hyperhidrosis on the patient's left side

3.  Pupillary constriction and hyperhidrosis on the patient's right side

4.  Pupillary constriction and anhidrosis on the patient's left side

5.  Pupillary constriction and anhidrosis on the patient's right side

Back 36

Horner's syndrome is a rare but known complication of anterior approaches to the cervical spine. Horner’s Syndrome classically presents with 1. ipsilateral ptosis (drooping eyelid caused by injury to nerve to Muller’s muscle) 2. ipsilateral miosis (pupillary constriction caused by injury to long ciliary nerve to pupil dilator) and 3. usually (but not always) ipsilateral anhidrosis. Horner's Syndrome is caused by an injury to the cervical sympathetic ganglia/trunk, which are located anterolaterally to the longus colli and longus capitis muscles. These muscles lie anterolaterally to the cervical vertebral bodies.ans4

Front 37

what is the joint reaction force of the ankle joint

Back 37

5 times body weight with walking on level surfaces

Front 38

defined articulations of the subtalar jointN what motion takes place at the subtalar joint?

Back 38

this joint = talus plus calcaneous, the motion is only inversion/eversion there is no plantar flexion or dorsiflexion

Front 39

defined the articulations of the transverse tarsal joint AKA underlying underlying?

Back 39

transverse tarsal joint = talonavicular  ( medially)+calcaneal cuboid (laterally )

Front 40

what adjustment to the joints in the foot make in order to have stable hindfoot and midfoot for toe off?

Back 40

there is inversion of the subtalar of the subtalar joints which locks the transverse tarsal joints AKA talonavicular and calcaneal cuboid

Front 41

what anatomic structure is the primary structure in the foot for load forced transfer between the hindfoot in the forefoot during stance?

Back 41

the plantar aponeuroses

Front 42

what is a MNeumonic for stance phase as it relates to gait cycle?

Back 42

 

I Like My Tea Pre-Sweetened, I Like My Teapot

I – initial contact heel strike

Like – Loading response

My – M mid stance

Tea – T terminal stance

Pre- Previous swing

Sweeten- Swing phase

 swing phase(In My Teapot )

I – initial swing or toe off

M – mid swing

T – terminal swing

Front 43

where is the bodies Center gravity?

allergies a Center gravity affected during an adult male step?

Back 43

1. 5 cm anterior to the S2 vertebral body
2. 5 cm horizontal and 5 cm vertical

Front 44

Which of the following best describes the relationship of the subtalar and transverse tarsal joints during the phases of gait?

1.  Eversion of the subtalar joint locks the transverse tarsal joint

2.  Transverse tarsal (Chopart) joint axes are parallel during heel strike

3.  The calcaneus is in inversion throughout stance phase

4.  Tibialis anterior concentrically contracts during stance phase

5.  During push-off the foot becomes flexible due to eversion of the calcaneus

Back 44

The transverse tarsal (Chopart) joints consist of the talonavicular and calcaneocuboid joints. The transverse tarsal axes are parallel during most of the heel strike phase when the subtalar joint is everted.Incorrect Answers:
Answer 1: Eversion of the subtalar joint unlocks the transverse tarsal joint.
Answer 3: During heel strike the calcaneus is mostly in eversion.
Answer 4: Tibialis anterior eccentrically contracts during stance phase.
Answer 5: During push-off the foot becomes inflexible with inversion of the calcaneus.ans2

Front 45

Which phase of gait is affected most in a patient with quadriceps atrophy?

1.  Terminal swing

2.  Preswing

3.  Initial swing

4.  Midstance

5.  Midswing

 

Back 45

Quadriceps weakness is most likely to affect the stance phase of the gait cycle, making midstance the correct answer. During the normal stance phase of gait, the quadriceps contracts to prevent buckling of the knee. In a patient with quadriceps atrophy, the patient leans forward at the hip causing the center of gravity to fall anterior to the knee. This causes the knee to go into hyperextension. In contrast, weakness of the hamstrings or the hip flexors are most likely to affect the swing phase of gait by limiting limb advancement.ans4

Front 46

Which of the following descriptions of muscle activity during normal gait is correct?

1.  Gastrocnemius-soleus contracts eccentrically during heel strike

2.  Gastrocnemius-soleus contracts concentrically during heel strike

3.  Gastrocnemius-soleus contracts concentrically during swing phase

4.  Tibialis anterior contracts concentrically during toe-off

5.  Tibialis anterior contracts eccentrically after heel strike

Back 46

One stride (heel strike to heel strike of one leg) of normal gait has been divided into the stance (62%) and swing (38%) phases. The stance phase is further divided into heel strike, foot flat, and toe off. Proper gait requires coordinated contraction of the leg muscles. The tibialis anterior (TA) muscle fires eccentrically at heel strike to lower the foot to the ground, while the gasto-soleus (GS) complex is dormant. The TA then relaxes, while the GS eccentrically contracts as the body’s weight is transferred forward over the foot during foot-flat. As the foot propels the body forward during toe-off, the GS contracts concentrically, while the TA remains dormant. As swing commences, the TA then fires concentrically producing dorsiflexion to clear the foot over the ground while the GS relaxes. Certain conditions like cerebral palsy result in improper firing of the muscles during the gait cycle, resulting in altered gait mechanics.ans5

Front 47

1. at heel strike=tibialis anterior (TA) muscle fires___(1)_ __to lower the foot to the ground, while the gasto-soleus (GS) complex is _____.
2. during foot-flat=The tibialis anterior TA then _____ while the GS ______(2) contracts as the body’s weight is transferred forward over the foot 
3. As the foot propels the body forward during toe-off, the TA remains ______(3)& the GS contracts _______  
4. As swing commences, the TA then fires _____(4) producing dorsiflexion to clear the foot over the ground while the GS ____(4) 

Back 47

1. TA-eccentrically &GS-dormant
2. TA-relaxes & GA-eccentrically
3. TA-dormant & GA-concentrically
4. TA-concentrically & GA-relaxes.

Front 48

The primary antagonist of the anterior tibial tendon is innervated by which of the following nerves? nerve roots

1.  Superficial peroneal nerve

2.  Deep peroneal nerve

3.  Tibial nerve

4.  Posterior tibial nerve

5.  Sural nerve

Back 48

primary antagonist of the anterior tibial tendon is the peroneus longus, which is innervated by the -superficial peroneal nerve L5-S1. ans1 

Front 49

The primary antagonist of the posterior tibialis (PT) is innervated by which of the following nerves? nerve roots

Back 49

The peroneus brevis (PB) -superficial peroneal nerve L5-S1and posterior tibialis (PT) are antagonists to each other. 

Front 50

The primary antagonist of the peroneus longus (PL) is innervated by which of the following nerves? nerve roots

Back 50

peroneus longus (PL) and tibialis anterior (TA)--deep peroneal nerve L4/L5 are antagonists to each other as the PL plantarflexes and everts, while the TA dorsiflexes and inverts the foot. 

Front 51

The primary antagonist of the peroneus brevis (PB)  is innervated by which of the following nerves? nerve roots

Back 51

The peroneus brevis (PB) and posterior tibialis (PT) tibial nerve L4/L5 are antagonists to each other.  

Front 52

what type of collagen is found in the annulus fibrosis and the nucleus pulposus?characterize in terms of collagen amount glycan amount and physiologic function

Back 52

the annulus– type I collagen as obliquely oriented, high collagen low proteoglycan ratio

high tensile strength to prevent intravertebral distraction

the nucleus has type II collagenlow collagen high protein glycan ratio high compressibility

"step 1 tense step 2 bounce"

Front 53

describe the blood supply that the intravertebral disc receive

Back 53

 

The disc is avascular nutrition reaches the nucleus pulposus.  Diffusion from the endplates.

Front 54

at the intervertebral disc AGES is what happens pathologically

1. what decreases
2. what increases
3. What has no change

Back 54

decreased (water  & proteoglycan & pH)  

increase KaratIn suLfATE to CHONDROITIN sulfate ratio, lactate increase conversion to fibrocartilage, increase and degraded enzyme activity

no change in the quantity of collagen

Front 55

A 37-year-old male feels a "pop" in his low back while lifting a heavy object. Four weeks later he continues to have significant low back pain, with no complaints of symptoms in his leg. A T2-weighted MRI is shown in Figure A with a red arrow identifying an abnormal finding in an anatomic structure. What type of collagen is primarily responsible for the biological properties of this anatomic structure? 

1.  Type I

2.  Type II

3.  Type V

4.  Type IX

5.  Type XI

Back 55

The clinical presentation is consistent with an annular tear. The annulus fibrosis is composed of primarily type I collagen.

The intervertebral disk is made up of two major components. The outer structure is referred to as the annulus fibrosis. It is made up of water, proteoglycans and predominantly type I collagen. There is a high collagen/low proteoglycan ratio. The nucleus pulposus is the central portion of the disk. It is composed of water, proteoglycans, and predominantly type II collagen. It has a high compressive strength secondary to its low collagen/high proteoglycan ratio. ans1

Front 56

Recent studies have shown that cells of the intervertebral discs are biologically responsive and increase their production of matrix metalloproteinases, nitric oxide, interleukin-6, and prostaglandin E2 when stimulated by what molecule 

1.  osteoprotegerin (OPG)

2.  interleukin-1 beta

3.  transforming growth factor-beta

4.  receptor activator of nuclear factor-kB ligand (RANKL)

5.  parathyroid hormone (PTH)

Back 56

"cells of the intervertebral discs are biologically responsive and increase their production of matrix metalloproteinases, nitric oxide, interleukin-6, and prostaglandin E2 when stimulated by interleukin-1 beta. The effect is more dramatic in normal, nondegenerated discs where spontaneous synthesis of these mediators is low. Nevertheless, cells of the herniated degenerated discs where spontaneous production was high were still capable of further increasing their synthesis of several of these biochemical agents in response to interleukin-1 beta.Ans2

Front 57

intervertebral discs are biologically responsive and increase their production of matrix metalloproteinases, nitric oxide, interleukin-6, and prostaglandin E2 when stimulated by what molecule?

Back 57

 interleukin-1 beta

Front 58

Which of the following are progressive changes seen with aging of the intervertebral disc? 

1.  Increase in water content

2.  Increase in large aggregated proteoglycans

3.  An increased keratin sulfate to chondroitin sulfate ratio

4.  A decrease in degradative enzyme activity

5.  An increase in nutritional transport

Back 58

As aging occurs, increased degradative enzyme activity is seen in the intervertebral disk. 

The aging process leads to a loss of water and fibrocartilage development within the intervertebral disk. There is an increase in enzymatic degradation activity, lactate levels and the keratin sulfate to chondroitin sulfate ratio. There is a decrease in water content, pH, absolute number of viable cells, and nutritional transportation. Incorrect Answers:
Answers 1, 2: As aging occurs, there are a decreased number of cells in the nucleus pulposus and decreased matrix synthesis. 
Answer 3: There is decreased neovascularization with aging
Answer 5: As the disk ages, there is a decrease in the amount of chondroitin sulfate and an increase in the amount of keratin sulfateans4

Front 59

with internal impingement what causes the BENNETT lesion

 

Back 59

1. anterior micro-instability
2. tightness of the posterior band of the IGHL
3. peelback phenomena of the posterior superior labral

Front 60

was the physical exam finding and the pitcher wrist pain and posterior shoulder is worse with throwing especially during the late cocking and early acceleration phase

1. with the diagnosis
2. With the treatment

Back 60

decrease in internal rotation loss greater than 20°

1. internal impingement pathology on the undersurface of the rotator cuff like a tear
2. Posterior capsule stretching physical therapy ×6 months if he fails then arthroscopic rotator cuff repair and labral repair possible posterior capsule release

Front 61

The term internal impingement is used in throwers to describe a condition where the posterior-superior glenoid labrum impinges on which structure?

1.  The anterior rotator cuff

2.  The posterior rotator cuff

3.  The anterior glenohumeral ligaments

4.  The posterior glenohumeral ligaments

5.  The biceps tendon

Back 61

Internal impingement is seen in throwers with the arm in a cocked position of abduction and external rotation. Often due to posterior soft tissue tightness, the posterior cuff impinges on the posterior superior labrum and is felt to contribute to SLAP tears and articular sided cuff tears. ans2

Front 62

 Internal impingement commonly occurs in overhead athletes and is very common amongst elite baseball pitchers. In which phase of throwing does this pathologic process occur? 

1.  Wind-up

2.  Early cocking

3.  Late cocking

4.  Deceleration

5.  Follow-through

 

Back 62

Internal impingement refers to the impingement within the glenohumeral joint which occurs as the posterosuperior glenoid labrum makes contact with the greater tuberosity, causing impingement on the posterior rotator cuff. This occurs commonly among baseball pitchers during late cocking and early acceleration as the shoulder joint reaches it's maximum external rotation. 
ans3

Front 63

the wound incapability of a bullet directly relates to  what?_____

Back 63

the amount Kinetic energy processes

Front 64

patient is a Vietnam veteran with a purple heart metal presents with anemia neurotoxicity emesis and abdominal colic what is the diagnosis?

Back 64

plumbism – lead intoxication

Front 65

what bullet velocity is considered low velocity causing Gustillo and ANDERSON type 1-2 wounds

Back 65

velocity < 2000 ft./s

Front 66

what bullet velocity is considered high velocity causing  GUstillo and ANDERSON type III wounds

most commonly associated injury with this kind bullet wound

Back 66

velocity > 2000 ft./s

high risk for infection an compartment syndrome Because the high zone of injury and devitalized tissue

Front 67

what is the treatment for a low energy gunshot wound?

Back 67

low energy gunshot wound treatment – local wound care – tetanus – short course of antibiotics primary closure of the wound is contraindicated

Front 68

what his treatment for high energy gunshot wound?

Back 68

high-energy – ORIF versus ex-fix tetanus and short course of antibiotics

Front 69

what is the treatment of a gunshot wound that is intra-articular?

Back 69

arthrotomy with removal of the missile because it can lead to plumbism arthritis and local inflammation

Front 70

what is the treatment of a gunshot wound to the femur low energy?

Back 70

low energy femur and gunshot wound – IM nailing

Front 71

what is the treatment gunshot wound to the femur high-energy?

Back 71

high-energy femur gunshot wound – ex-fixator

Front 72

with the treatment gunshot wound to the spine with associated perforated viscus?

Back 72

bullets the spine and viscus – do not remove the bullet broad-spectrum IV antibiotics for 7-14 days

Front 73

gunshot wound to the spine with an incomplete motor deficit that is a brown Séquardsyndrome what is the treatment

Back 73

bullet causing Brown-Séquard syndrome treatment is surgical decompression and bullet fragment removal if the bullet fragments are Near the neurologic level that is being affected

Front 74

 A 21-year-old male presents to the emergency department after sustaining a gun shot wound to his abdomen. Subsequent radiographs reveal a bullet in the L2 vertebral body. Physical exam shows no neurologic deficits. He undergoes emergent laparotomy and is found to have a small bowel laceration. What would be the preferred treatment following his exploratory laparotomy and small bowel repair?

1.  Intravenous antibiotic coverage for Gram negative bacteria for 7 days

2.  Surgical decompression and bullet fragment removal

3.  Observation

4.  Broad-spectrum oral antibiotic coverage for 7 days

5.  Broad-spectrum intravenous antibiotic coverage for 7 days

 

Back 74

The clinical presentation is consistent with a GSW with bowel perforation and a retained bullet in the vertebral body. Because the patient is neurologically intact broad-spectrum intravenous antibiotic coverage for 7 days is the most appropriate treatment. ans5

Front 75

A 24-year-old man who sustained a gunshot wound to the abdomen ten hours earlier was brought to the emergency department. On physical examination he was found to have 4 of 5 weakness in his bilateral lower extremities. Radiographs are shown in Figure A. Computed tomography of the lumbar spine showed retained missile in the vertebral body and paraspinal soft tissues, but not within the spinal canal. His FAST was positive and he underwent an emergent exploratory laparotomy where an injury to the cecum was identified and treated. Management should now include which of the following? 

1.  Bullet fragment removal from a transabdominal approach

2.  Bullet fragment removal from a retroperitoneal approach

3.  Broad-spectrum oral antibiotics for 3-5 days

4.  Broad-spectrum intravenous antibiotics for 7-14 days

5.  IV methylprednisolone at 5.4mg/kg/h for 48 hours

 

Back 75

The patient in the scenario has a GSW to the lumbar spine with neurologic deficits but without a retained missile in the spinal canal. In patients with visceral injury, the treatment is broad-spectrum antibiotic coverage for 7 days.
Incorrect Answers:
Answer 1 & 2: Indications for surgery with a GSW to the lumbar spine include 1) spinal instability 2) a neurologic deficit is present that correlates with radiographic findings of neurologic compression by the missile. 3) Lead missile is in contact with the cerebrospinal fluid (CSF). This patient does not have any of these criteria.
Answer 5: GSWs are a contraindication for spinal dose steroids. ans4

Front 76

what type of immunologic response is type I anaphylactic reaction

Back 76

type I his IgE mediated by mask cells and basal cells associated with an  allergy

Front 77

what type of immunologic response is a type II anybody dependent hypersensitivity reaction mediated by?

Back 77

type 2 antibody dependent  hypersensitivity mediated by IgG and IgM antibodies

Front 78

what type of immunologic responses type III immune complex deposition hypersensitivity reaction

Back 78

mediated by IgG and IgM antibodies

Front 79

what type of immunologic response is metallic orthopedic implants and mediated by what types of cells?

Back 79

type 4 delayed type hypersensitivity reaction similar to tuberculosis skin test

Front 80

which antibody is the most comment immunoglobulin in the body

Back 80

 most common IgG

Front 81

which immunoglobulin is the 1st type of antibiotic to appearafter exposure to an antigen

Back 81

IgM

Front 82

which class of any body is found and external secretions

Back 82

IgA IgA IgA

Front 83

which class of antibody confers protection against parasites and allergic reactions

Back 83

IgE

Front 84

What is the first class of antibody to appear in serum after exposure to a foreign antigen?

1.  IgA

2.  IgD

3.  IgE

4.  IgG

5.  IgM

 

Back 84

IgM is the first class of antibody to appear in our serum after exposure to an antigen. IgG is the most abundant immunoglobulin in our body. IgA is the major class of antibody in external secretions such as intestinal mucus, bronchial mucus, saliva, and tears. IgE is important in conferring protection against parasites and is also increased in allergic reactions.ans5

Front 85

The acquired immune response mediated by the interaction between the T cell receptor and major histocompatibility complex requires which of the following first steps? 

1.  Antigen phagocytosis by T cells

2.  Antigen processing and presentation to T cells

3.  Antigen recognition by natural killer T cells

4.  Antigen proliferation by polymerase chain reaction

5.  T cell disulfide bond cleavage and enzymatic processing

 

Back 85

The process of antigen processing and presentation is the first step of the acquired immune response. This is performed by the so called antigen presentation cells (APC) of which B cells and dentritic cells are two examples. The APC breaks down the protein antigen in a multitude of enzymatic reactions and presents key peptide sequences via the major histocompatibility complex (MHC) receptors. Once presented on the surface of the APC, the T-cell receptor recognizes the MHC/antigen complex leading to T-cell activation. At no point in this process are antigens phagocytosed by T cells.ans2

Front 86

A type IV (delayed-type hypersensitivity reaction) can be seen in which of the following scenarios?

1.  Packed red blood cell transfusion

2.  Platelet transfusion

3.  Immune inert scaffold placement

4.  Metal plate and screw placement for fracture

5.  Red man syndrome from vancomycin administration

Back 86

A type IV, or delayed-type hypersensitivity reaction, can be seen with placement of orthopedic hardware. Type IV hypersensitivity is often called delayed type hypersensitivity as the reaction takes two to three days to develop. Unlike the other types, it is not antibody mediated but rather is a type of cell-mediated response.ans4

Front 87

pediatric patient less than 3 presents with intoeing what to other 2 conditions must be ruled out

Back 87

DDH and metatarsus adductus

Front 88

  what 3 physical exam test can be used to assess tibial torsion as a child,

 what is considered normal

Back 88

1. foot thigh angle normal = between the 2nd and 3rd toes
2. transmalleolus angle=normal areas 5° of internal rotation
3. Foot progression angle normal is negative 5°

Front 89

A 2-year-old boy is brought to your clinic by his mother for being "pigeon-toed". Each of the following measurements found on physical examination are a routine part of defining the child's lower extremity rotational profile EXCEPT.

1.  thigh-foot axis 

2.  transmalleolar axis

3.  measurement of the Q angle

4.  heel-bisector angle

5.  foot progression angle

Back 89

 "active treatment of childhood rotational disorders is unnecessary in most cases. Prudent care consists of reassurance and education about the natural history of the condition". The correct answer is Figure C which demonstrates the measurement of the Q angle. The Q angle can be affected by femoral anteversion and tibial torsion, but typically is not a part of the rotational profile. The 5 components of Staheli's rotational profile include internal and external hip rotation (shown in Illustration A), thigh-foot axis (Figure A), transmalleolar axis (Figure B), heel-bisector angle (Figure D), and foot progression angle (Figure E). Normal values for clinical measurements are: foot progression angle -5 to 20 degrees, IR and ER up to 70 degrees, thigh-foot axis between -10 to 20 degrees, transmalleolar axis -4 at birth to 23 degrees at maturity, and the heel-bisector line normally passes through the second web space.ans3

Front 90

1. most common infection with  to turf burns
2. what the treatment

Back 90

 

MRSA

MUPIROCIN

Front 91

what the diagnosis with the treatment

Back 91

1. herpes simplex 1
2. ACYCLOVIR, and wrestling

Front 92

what the diagnosis was a treatment

Back 92

fungal infection tinia pedis

topical antifungals topical antifungals

Front 93

what the diagnosis with the treatment

Back 93

acne mechanic, AKA folliculitis, name athlete to wear protective padding

observe for keratolytics

 

Front 94

what is the diagnosis what is the treatment what is the cause

Back 94

impetigo, topical BACTROBAN or ERYTHROMYCIN patient sports most common organism include Streptococcus pyogenes staph aureus

Front 95

patient has splenomegaly malaise nausea headache pharyngitis

What is the diagnosis what is the cause what is the treatment

wwith the most common complication

Back 95

the diagnosis is mononucleosis it causes Epstein-Barr virus the treatment is no contact sports for 3-5 weeks until splenomegaly completely resolves

Splenic rupture within the 1st 3 weeks.equal DEATH

Front 96

A 75-year-old man is brought to the ER after a fall. He complains of right leg pain, and a radiograph is shown in Figure A. Prior to operative fixation of the fracture, biopsy and staging procedures reveal that this is a metastatic lesion. Which of the following primary cancer diagnoses is associated with the shortest life expectancy following pathologic fracture?

1.  Lung

2.  Thyroid

3.  Prostate

4.  Breast

5.  Renal

 

Back 96

This patient is presenting with a pathologic fracture of the proximal tibia. Prior to definitive fixation, the nature of the tumor needs to be determined through biopsy and staging to assist with operative planning. In terms of life expectency, lung cancer and melanoma have the worst median survival (<6 months) and 5 year survival (<5%) when bone metastases are present. ans1

Front 97

An elderly female has just been diagnosed with lung cancer. If her cancer metastasizes to bone, what is the most common site of subsequent pathologic fracture? 

1.  Proximal femur

2.  Distal femur

3.  Proximal humerus

4.  Humeral shaft

5.  Thoracic spine

 

Back 97

While the spine is the most common site for all boney metastasis, the proximal femur is the most common site for pathologic fracture secondary to metastasis to bone. ans1