Quiz of the Month – October 2022

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Quiz of the Month - October 2022

1 / 10

Trauma

A 23-year-old male patient presents following a motor vehicle collision with new-onset chest pain that is worse with arm movement. The preliminary result of his chest radiograph is negative for acute cardiopulmonary injury, but upon interview, the patient's voice is hoarse, and he reports a choking sensation. Physical examination reveals swelling over the anterior aspect of his chest. Which of the following is the most appropriate treatment option?

Remediation:
A. A compromised airway from the posterior sternoclavicular (SC) dislocation would warrant emergency intervention, and his chest pain is more likely from his SC dislocation.
B. The priority is to get the joint reduced, and pinning in situ would delay this.
C. The patient has symptoms concerning for a posterior sternoclavicular (SC) joint dislocation after a high-energy collision. The medial aspect of the clavicle is likely pressing against vital organs, including his airway and esophagus, causing a choking sensation and hoarseness, and emergency intervention is indicated.
D. A compromised airway from the posterior sternoclavicular (SC) dislocation would warrant emergency intervention, and the chest pain in more likely from his SC dislocation.

2 / 10

Sports Medicine

A 31-year-old male patient who is a professional baseball pitcher complains of medial-sided elbow pain in his throwing arm. He has tenderness over the medial epicondyle. The pain is worse with resisted forearm pronation and wrist flexion. Pulling on the patient's thumb with the forearm supinated and the elbow flexed at 90° does not reproduce any symptoms. A rehabilitation program consisting of initial rest and a progressive strengthening program do not relieve his symptoms. A magnetic resonance imaging arthrogram confirms the diagnosis. Which of the following is the next step in treatment?

Remediation:
A. The patient has medial epicondylitis. He has failed nonoperative treatment and since he is an elite athlete, operative treatment is appropriate. There is no ulnar collateral ligament injury (per imaging and the milking maneuver examination).
B. The patient has medial epicondylitis. He has failed nonoperative treatment and since he is an elite athlete, operative treatment is appropriate.
C. The patient has medial epicondylitis. He has failed nonoperative treatment and since he is an elite athlete, operative treatment is appropriate. There is no ulnar collateral ligament injury (per imaging and the milking maneuver examination).
D. The patient has medial epicondylitis. He has failed nonoperative treatment and since he is an elite athlete, operative treatment is appropriate. There are no ulnar nerve symptoms indicating a cubital tunnel problem.

3 / 10

Spine

A 57-year-old male patient presents with isthmic spondylolisthesis at L5-S1, causing lower-extremity radiculopathy. His pain is primarily on his right side and radiates down his right leg. He has failed nonoperative treatment and undergoes an L5-S1 anterior lumbar interbody fusion (ALIF) with a titanium cage via a retroperitoneal approach, followed by posterior pedicle screw fixation bilaterally at L5 and S1 and posterolateral intertransverse process arthrodesis. Postoperatively, he has left lower-extremity pain that radiates down the posterior aspect of his leg and into the plantar-lateral aspect of his foot. A computed tomography scan shows appropriately placed pedicle screws and that the ALIF cage is positioned posteriorly on the left and is impinging on the traversing S1 nerve root. Which of the following is the appropriate treatment option for him?

Remediation:
A. With symptomatic malpositioned hardware, observation with or without corticosteroids is not recommended. Revision surgery is indicated.
B. The titanium ALIF cage, rather than the pedicle screws, is malpositioned and should be revised.
C. The ALIF cage is impinging on the S1 nerve root and is symptomatic. It should be revised to correct the positioning and relieve the radiculopathy.
D. Epidural corticosteroids would not correct the structural problem leading to the radiculopathy. Revision surgery is indicated.

4 / 10

Shoulder & Elbow

A 28-year-old male patient who is a professional baseball player presents to discuss treatment options for an ulnar collateral ligament tear. When determining whether to address the tear with traditional reconstruction techniques or internal bracing, which of the following should you consider?

Remediation:
A. Ulnar collateral ligament repair with internal bracing is a newer technique that has shown promising early results with regard to gap formation and quicker return to play. It is thought to be indicated with proximal or distal tears.
B. Long-term data are currently lacking on ulnar collateral ligament repair with internal bracing, which has shown small gap formation in biomechanical studies and quicker return to play.
C. Recent biomechanical studies have shown decreased gap formation with ulnar collateral ligament repair with internal bracing as compared with traditional ulnar collateral ligament reconstruction
D. Recent studies looking at ulnar collateral ligament repair with internal bracing have shown early promising results with early return to play and less gap formation in biomechanical studies.

5 / 10

Pediatrics

A 10-year-old girl presents for evaluation of painless left hip popping that has been present for 8 to 9 months. Her parents note that the popping occurs when the girl  is standing or when crossing her legs. The parents report no history of leg trauma and preserved ambulatory function despite the popping. The child is verbal and interactive, but demonstrates a flattened facies, downgoing palpebral fissures, a large tongue, a horizontal palmar crease, and hypotonia. Although the left hip exhibits a full and painless range of motion without gross instability, the child reproduces the popping by standing and rotating the left hip and pelvis. Which of the following is the most appropriate next step in management?

Remediation:
A. The first step in evaluation after history and physical examination should be plain radiographs to evaluate for bony abnormalities as well as radiographic evidence of hip instability/dysplasia.
B. The first step in evaluation after history and physical examination should be plain radiographs to evaluate for bony abnormalities as well as radiographic evidence of hip instability/dysplasia
C. An iliotibial band release may be an appropriate ultimate treatment for external snapping hip syndrome, but a diagnosis must be confirmed first.
D. Nonoperative treatment may be indicated; however, a diagnosis needs to be established first.

6 / 10

Basic Science and Pathology

Loss of function of both copies of the sclerostin gene (SOST) will result in which of the following?

Remediation:
A. The SOST gene provides instructions for making the protein sclerostin. The main function of sclerostin is to stop (inhibit) bone formation; therefore, loss of this function results in a dramatic increase in bone formation (sclerosteosis and van Buchem disease).
B. The SOST gene provides instructions for making the protein sclerostin. The main function of sclerostin is to stop (inhibit) bone formation; therefore, loss of this function results in a dramatic increase in bone formation with no alteration in bone resorption.
C. Loss of SOST gene function results only in an anabolic bone response and does not lead to exogenous bone tissue at abnormal anatomic sites.
D. These are characteristics of Marfan syndrome. It is caused by a defect in fibrillin-1 (FBN1) that encodes the structure of fibrillin and the elastic fibers.

7 / 10

Hand & Wrist

A 55-year-old male patient who is right-hand dominant presents with hand numbness. His symptoms started several years ago primarily at night, but over the last several months he has noted that his fingers are numb all the time and he has difficulty buttoning his shirt. On examination, he has profound atrophy of the thenar muscles and is unable to palmarly abduct his thumb. He reports markedly decreased sensation when touching his thumb, index, middle, and radial half of his ring fingers. Phalen's test and a carpal tunnel compression test are both negative, and a nerve conduction study is unable to demonstrate conduction within the median nerve across the wrist.  Which of the following is the most appropriate treatment for this patient?

Remediation:
A. Nocturnal splinting is a treatment option in mild carpal tunnel syndrome, and this patient is exhibiting symptoms of severe carpal tunnel syndrome. Oral nonsteroidal anti-inflammatory drugs do not have a role in the treatment of carpal tunnel syndrome.
B. Nocturnal splinting is a treatment option in mild carpal tunnel syndrome. This patient is exhibiting symptoms of severe carpal tunnel syndrome.
C. The patient's presentation and clinical examination suggest severe carpal tunnel syndrome. Operative carpal tunnel release is appropriate.
D. A corticosteroid injection into the carpal tunnel has diagnostic and therapeutic value, although its therapeutic effects are usually temporary. Carpal tunnel release is the best treatment for severe carpal tunnel syndrome.

8 / 10

Foot & Ankle

A 22-year-old male patient has increased pain over his 2nd toe with intermittent superficial skin breakdown at the proximal interphalangeal (PIP) joint of the toe. The distal interphalangeal (DIP) joint is in neutral. With the foot in neutral position at the ankle, the toe can be straightened out easily. Radiographs demonstrate no arthritis of the 2nd toe and no subluxation at the metatarsophalangeal (MTP) joint. Operative treatment of this problem should involve which of the following?

Remediation:
A. This patient has a flexible hammertoe deformity.  Transferring the flexor tendon addresses the flexion at the PIP joint, which is considered the apex of the deformity.
B. An extensor-to-flexor tendon transfer would actually exacerbate the deformity.
C. A plantar plate repair is considered for the treatment of 2nd MTP synovitis and instability. In this case, the plantar plate is not torn because there is no subluxation on examination.
D. The DIP joint would be fused in a rigid mallet toe deformity. This patient has a hammertoe and the DIP joint is in neutral.

9 / 10

Adult Knee

A 71-year-old male patient presents with right knee pain. He has a correctable 7° varus deformity and minimal flexion contracture. His body mass index is 28 kg/m2, and he reports being only minimally active. His medications include a daily aspirin and metoprolol. Radiographs show isolated medial compartment arthritis with complete loss of joint space and "bone-on-bone" arthritis. Nonoperative measures to control his pain have been unsuccessful. Which of the following is the best operative option?

Remediation:
A. The patient has "bone-on-bone" arthritis. Arthroscopy is not indicated in the setting of advanced arthritis.
B. The patient is 71 years old with advanced medial compartment arthritis. A tibial osteotomy is not the treatment of choice. The patient is a candidate for arthroplasty.
C. The patient is an excellent unicompartmental arthroplasty candidate. He has a correctable deformity and advanced arthritis confined to the medial compartment.
D. A knee arthrodesis is not indicated here. The patient meets the criteria for arthroplasty. Arthrodesis is a salvage procedure.

10 / 10

Adult Hip

A patient undergoes total hip arthroplasty using a direct lateral (modified Hardinge) approach. Postoperatively, the patient notes a persistent limp and ambulates with a Trendelenburg gait.  This outcome may have been caused by which of the following?

Remediation:
A. Dissection through the iliotibial band would not affect postoperative function of the hip abductors.
B. The inferior division of the superior gluteal nerve (SGN) is the main nerve supply to the abductor muscles of the hip and may be damaged with dissection 3 to 5 cm proximal to the greater trochanter.
C. Release of the indirect head of the rectus would not directly weaken the hip abductors but may affect postoperative hip flexion.
D. A quadriceps avoidance gait pattern is typically seen with a femoral nerve palsy, not a Trendelenburg gait.

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