Quiz of the Month – November 2022

This quiz does not earn users CME credits. The questions must be answered within Clinical Classroom to earn CME credits

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Quiz of the Month - November 2022

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Trauma

A 24-year-old male patient presents to the emergency department after being involved in a high-speed motor-vehicle collision and is diagnosed with a femoral shaft fracture. Which of the following is considered the "gold standard" of fixation for this type of fracture?

Remediation:
A. The "gold standard" for fixation of a midshaft femoral fracture is a reamed, locked antegrade femoral nail.
B. External fixation of a femoral shaft fracture can be used for damage control however, it is not a definitive treatment modality.
C. Plate and screw fixation may be considered in distal femoral fractures or when in combination with a femoral neck fracture.
D. Reaming has been shown to improve union rates and time to union.

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Sports Medicine

A 20-year-old male patient who is a college football player is seen on the sideline after sustaining a direct blow to the front of his left hip. He has a small hematoma and swelling adjacent to his anterior superior iliac spine. No crepitus is noted on palpation. His examination demonstrates limitations in hip strength and range of motion. Which of the following is the best next step in management?

Remediation:
A. The patient has a contusion to the iliac crest (hip pointer) and can be allowed to return to play as tolerated after treatment with ice and the use of protective padding.
B. The patient has a contusion to the iliac crest (hip pointer) and should be treated with ice, but there is no contraindication for play if he is able to play.
C. Radiographs are not needed for a contusion and are not necessary for return to play.
D. A computed tomography scan is not necessary for return to play.

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Spine

A 79-year-old female patient presents to the emergency department with acute-onset back pain that started while carrying her vacuum cleaner up a flight of stairs. The patient lives in her own home, has well-managed hypertension, and uses no assistive ambulatory devices. Physical examination shows middle to low back pain that worsens with standing upright. She is neurologically intact and can walk down the hallway with a wheeled walker. Radiographs demonstrate a vertebral compression fracture of T12. Which of the following is the best initial treatment for this patient?

Remediation:
A. Osteoporotic compression fractures without neurological deficit are stable injuries that do not require acute operative stabilization.
B. The initial treatment of osteoporotic compression fractures should be analgesia and reevaluation. Current American Academy of Orthopaedic Surgeons (AAOS) guidelines do not support acute vertebroplasty in a patient with a newly diagnosed acute vertebral body compression fracture.
C. Bracing and outpatient physical therapy, although likely not harmful, carry inconclusive recommendations and have not demonstrated specific efficacy.
D. In an otherwise healthy community ambulator, osteoporotic vertebral compression fractures should be treated initially with a course of nonoperative management. Patients should resume normal activities, as tolerated, and be evaluated by a spine surgeon to assess for resolution or progression of symptoms in about 2 weeks.

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Shoulder & Elbow

A 34-year-old male patient sustained a segmental humeral shaft fracture in addition to multiple lower extremity fractures following a motor vehicle collision. The patient's body mass index (BMI) is 42 kg/m2. Which of the following is the most appropriate treatment option for this patient's humeral fracture?

Remediation:
A. The patient has a high BMI and a segmental fracture. This patient is best treated with surgery, and an intramedullary nail is the best option.
B. Intramedullary nail fixation is indicated for segmental humeral fractures.
C. Surgery is recommended for patients with multiple lower extremity fractures.  Intramedullary nail fixation is recommended for segmental fractures and patients with a high BMI.
D. Surgery is recommended in patients with multiple lower extremity fractures.  However, intramedullary nail fixation is indicated for segmental fractures.

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Pediatrics

A 14-year-old male patient with no significant medical history presents with progressive left foot and leg swelling and redness. The redness started at the foot and ascended to the calf. He does not recall any injury but was walking with bare feet several days ago while cleaning his garage. He has no fevers or chills. The calf is not tender, and there are no draining or purulent wounds. He has full, preserved passive range of motion of the ankle and foot. Radiographs of the leg and foot are negative. Which of the following treatment approaches are appropriate?

Remediation:
A. Oral antibiotics could be tried initially with intravenous antibiotics and admission if oral antibiotics are not effective.
B. The clinical scenario suggests cellulitis, which can be managed with empiric antibiotics.  Magnetic resonance imaging would be indicated if there is no clinical improvement or if signs of osteomyelitis develop.
C. Redness and swelling in the setting of negative radiographs are more indicative of infection than injury requiring immobilization.
D. Redness and swelling suggest infection.  Therefore, empiric oral antibiotics should begin with a first-generation cephalosporin unless the patient is immunocompromised, in which case broader-spectrum antibiotics should be employed.  Intravenous antibiotics are not indicated at present given the benign clinical presentation.

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Basic Science and Pathology

Which of the following best describes a cell and its phenotypic characteristics?

Remediation:
A. Osteocytes are highly active cells that are interconnected through cytoplasmatic extensions in canaliculi.
B. Articular chondrocytes have a low metabolism, which may be an important contributor to the poor regenerative potential of articular cartilage.
C. Osteocytes comprise 90% to 95% of bone cells, while osteoblasts account for only 4% to 6%.
D. Osteoclasts are large multinucleated cells.

7 / 10

Hand & Wrist

A 40-year-old male patient who is an automobile mechanic presents 1 week after slipping and striking the dorsum of his hand on a fan blade in an engine. He was seen in the emergency department, and the wound was closed primarily. On examination, he presents with a closed wound 3 cm proximal to the long finger metacarpophalangeal joint, with no signs of infection. He can extend all of his digits to neutral; however, retropulsion of the long finger off of a table is not possible. He is scheduled for surgery, and on exploration, the long finger extensor is completely transected. Which of the following most likely explains his ability to extend the digit?

Remediation:
A. A brevis manus is more likely to cause pain and a mass effect.
B. The interconnection distal to the laceration allows pull from the adjacent digit(s).
C. An accessory extensor is an unlikely variant and not the cause of the patient's ability to extend.
D. The intrinsics flex, not extend, at the metacarpophalangeal joint

8 / 10

Foot & Ankle

A 56-year-old male patient presents with several years of pain at the right 5th metatarsophalangeal joint. His pain persists despite extensive nonsurgical treatments. You diagnose him with a Type III bunionette deformity. Which of the following treatment options is most appropriate?

Remediation:
A. A proximal 5th metatarsal osteotomy allows for correction of the underlying deformity, characterized by an increased 4-5 intermetatarsal angle.
B. A 5th metatarsal head lateral condylectomy will likely prove inadequate and should be reserved for pathology involving Type I abnormality (enlarged metatarsal head).
C. Lateral tarsometatarsal joint arthrodesis is poorly tolerated.  The sagittal plane motion at the 4-5 metatarsal base articulation with the cuboid allows the lateral aspect of the forefoot to accommodate the ground.
D. Lesser metatarsophalangeal joint arthrodesis is poorly tolerated.  If the joint cannot be salvaged, resection arthroplasty is preferable.

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Knee

According to the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines on Surgical Management of Osteoarthritis of the Knee, which of the following fixation types in total knee arthroplasty (TKA) are supported by strong evidence supporting their use?

Remediation:
A. Limited evidence supports the use of either all cementless components or hybrid fixation (i.e., cementless femoral component) in TKA.
B. Moderate evidence supports the use of either cementing all of the components or hybrid fixation (i.e., cementless femoral component) in TKA
C. Moderate evidence supports the use of either cemented femoral and tibial components or cementless femoral and tibial components.
D. Strong evidence supports the use of cemented or cementless tibial component fixation

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Hip

According to recent registry data, which of the following is the most common reason for revision total hip arthroplasty (THA) in the United States?

Remediation:
A. According to the 2020 American Joint Replacement Registry (AJRR) report, the top three causes of revision THA overall were infection (19%), instability (17%), and aseptic loosening (16%).
B. According to the 2020 American Joint Replacement Registry (AJRR) report, the top three causes of revision THA overall were infection (19%), instability (17%), and aseptic loosening (16%).
C. According to the 2020 American Joint Replacement Registry (AJRR) report, the top three causes of revision THA overall were infection (19%), instability (17%), and aseptic loosening (16%).
D. According to the 2020 American Joint Replacement Registry (AJRR) report, the top three causes of revision THA overall were infection (19%), instability (17%), and aseptic loosening (16%).

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