This quiz does not earn users CME credits. The questions must be answered within Clinical Classroom to earn CME credits
Quiz of the Month - April 2023
1 / 10
A 65-year-old female patient presents with persistent right groin pain 6 months after open reduction and internal fixation of a right peritrochanteric femoral fracture. Imaging shows a cephalomedullary nail fixation with instability. She has no history of delayed wound healing. Evaluation for an infection is negative. Which of the following is the best option for revision for this patient?
Remediation:A. A revision cephalomedullary nail fixation could potentially result in appropriate alignment, but the loss of alignment makes cephalomedullary nail revision technically challenging.B. Locking proximal femoral plates are associated with substantial failure rates and should be used only when other implant options are not viable.C. A sliding hip screw may provide a fixed-angle construct, but is unable to provide compression or precise control of many peritrochanteric femoral fractures.D. Angled blade plates provide the best balance between stable fixation and the ability to create the appropriate conditions for fracture healing.
2 / 10
A 70-year-old female patient presents with chronic posterior left buttock pain of approximately 2 years duration. The pain occasionally radiates to the posterior aspect of the thigh and is exacerbated by walking, sitting, and climbing stairs. Prior magnetic resonance imaging of her lumbar spine shows no significant stenosis. On examination, she has tenderness to palpation in the posterior buttock, which reproduces her radicular pain. She also has pain with resisted flexion and external rotation of the hip. Which of the following is the best next step in the management of this patient?
Remediation:A. An injection into the muscle that relieves symptoms can be diagnostic for the condition.B. The history and physical examination are more consistent with piriformis syndrome than a lumbar radiculopathy.C. A diagnostic injection should be performed to confirm the diagnosis before treatment is initiated. Once treatment is initiated, nonoperative management should be tried first.D. The history and physical examination are more consistent with piriformis syndrome than a lumbar radiculopathy.
3 / 10
A 68-year-old male patient with a history of prostate cancer presents with a several day history of progressive back pain, difficulty walking, and left lower-extremity weakness. On examination, he has difficulty with a tandem gait, left hip flexion and knee extension weakness, and hyperreflexic quadriceps. He has left lower-extremity sensory dysesthesia. Cervical, thoracic, and lumbar magnetic resonance imaging show an isolated metastatic lesion involving the T10 vertebral body with moderate compression of the spinal cord. Which of the following is the best next step in management?
Remediation:A. Radiation therapy should follow surgical decompression and stabilization. Decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with spinal cord compression caused by metastatic cancer.B. Isolated metastatic lesion causing thoracic myelopathy should be managed with surgical decompression and stabilization. followed by adjuvant radiation therapy.C. An isolated metastatic lesion causing thoracic myelopathy should be managed with operative decompression and stabilization, followed by adjuvant radiation therapy (RT). Patchell, et al. (2005) demonstrated that surgery and then RT, if indicated, results in better neurological outcome (walking ability/improvement) compared with RT alone or first.D. Thoracic laminectomy alone will yield inadequate decompression since the metastatic lesion is anterior (T10 vertebral body). Additionally, metastatic bone lacks structural integrity and, therefore, stabilization is typically required, especially when radiation therapy is to follow.
4 / 10
A 50-year-old male patient has isolated posttraumatic osteoarthritis of the radiocapitellar joint. His symptoms are interfering with his daily activities and ability to work. He has failed nonoperative treatment, including physical and occupational therapy, corticosteroid injections, and arthroscopic debridement. Which of the following is the best reconstructive option for this patient?
Remediation:A. Repeat debridement is a temporary solution that has already failed once, so it is not the best option.B. Radial head resection is a possible option, but it is not ideal.C. Radial head arthroplasty will not address both sides of the joint.D. Radiocapitellar arthroplasty is the best reconstructive option to address both sides of the joint
5 / 10
A 4-year-old girl presents with a spontaneous right knee effusion of 6 weeks' duration. During this time, she has been walking with a slight limp and reports no other pain. The girl's mother says she has had no fevers, chills, rashes, or other joint pain. Physical examination confirms a large knee effusion with mild discomfort and a limited range of motion. Her serum erythrocyte sedimentation rate and C-reactive protein level are normal. A synovial fluid sample shows 30,500 nucleated cells. Radiographs of the right knee show a joint effusion but no other bony abnormalities. Which of the following is the most likely diagnosis?
Remediation:A. The case scenario is consistent with oligoarticular juvenile idiopathic arthritis, which has a peak prevalence in patients <6 years old. Ankylosing spondylitis most often occurs in male patients >16 years old with symptoms concentrated in the pelvis and the spine.B. The case scenario is consistent with oligoarticular juvenile idiopathic arthritis, which has a peak prevalence in patients <6 years old. Affected patients have a course of prolonged arthritis that is usually successfully treated with nonsteroidal anti-inflammatory drugs. Patients are monitored long-term for uveitis and late-onset erosive arthropathy.C. The case scenario is consistent with oligoarticular juvenile idiopathic arthritis, which has a peak prevalence in patients <6 years old. Transient synovitis is typically self-limited, with a symptom duration of 1 to 2 weeks.D. The case scenario is consistent with oligoarticular juvenile idiopathic arthritis, which has a peak prevalence in patients <6 years old. Septic arthritis usually involves a more precipitous clinical course with fevers, substantial discomfort, and limitation in the motion of the knee. In addition, 6 weeks of septic arthritis will typically yield radiographic changes in the knee.
6 / 10
During embryogenesis, the vertebral bodies for most of the human spine are derived from which of the following?
Remediation:A. Both the resegmentation model and shift model have been proposed to describe the derivation of the bony vertebrae during development. The resegmentation model states that each vertebral body is derived from a combination of the cranial and caudal sclerotome.B. The cranial sclerotome contributes to forming the cranial portion of the vertebral body only.C. The caudal sclerotome contributes to forming the caudal portion of the vertebral body only.D. The notochord contributes to the nucleus pulposis of the intervertebral disc—it does not contribute to the bony vertebral body.
7 / 10
A 78-year-old male patient with Dupuytren’s disease has palpable cords causing a 60° metacarpophalangeal (MCP) contracture at the small and ring finger. This is interfering with his function, but he wishes to avoid a recovery period and chance of wound complications. He notes that he had a 'severe reaction' during injection treatment for his Peyronie's disease. Which of the following would be the best intervention to offer?
Remediation:A. Corticosteroid injection is not a treatment option for Dupuytren’s diseaseB. Collagenase injection is a treatment option for Dupuytren’s disease. A contraindication to collagenase treatment is a previous allergic reaction.C. Needle aponeurotomy is a treatment option for Dupuytren’s disease. It is less invasive and has a quicker recovery period.D. Limited fasciectomy is a treatment option for Dupuytren’s disease; however, it is more invasive than percutaneous aponeurotomy and has a lengthier recovery period.
8 / 10
A 54-year-old male patient who is a manual laborer and otherwise healthy presents 3 months following an Achilles tendon rupture that was missed on initial presentation to the emergency department. He reports weakness, increased dorsiflexion, and an inability to climb ladders for his job. Magnetic resonance imaging (shown) demonstrates a 4-cm gap in the tendon. Which of the following is the most appropriate treatment?
Remediation:A. This is an option for a primary rupture, but in the chronic setting there is shortening, contracture, and scarring, which prevents restoration of tendon length and tension.B. This is a classic reconstructive option for a chronic Achilles tendon rupture.C. Functional rehabilitation is an acceptable treatment for an acute Achilles rupture. It will not restore length and tension or close the gap, which is filled with intervening scar, in a chronic rupture.D. This is an acceptable option for a lower demand individual, but will likely not allow the patient to return to an active manual labor job.
9 / 10
A 56-year-old female patient presents with bilateral knee pain along with bilateral hand pain. She reports greater pain and stiffness in the morning. Her radiographs show symmetrical joint-space narrowing with periarticular erosions with diffuse osteopenia. Which of the following should be included in operative planning?
Remediation:A. Patients with rheumatoid arthritis do have an increased rate of infection when compared with those undergoing a total knee arthroplasty for osteoarthritis; however, there are no data to support the alteration of perioperative antibiotics.B. The perioperative management of rheumatology medications is an ever-evolving concept. Several medications are now continued throughout the perioperative period.C. Several studies have shown successful long-term results with cruciate-retaining implants in patients with rheumatoid arthritis.D. The history and radiographs are consistent with an inflammatory process, such as rheumatoid arthritis. Patients with rheumatoid arthritis are at increased risk of cervical subaxial instability and basal invagination. A screening cervical spine radiograph is important prior to intubation or positioning during surgery.
10 / 10
A 42-year-old male patient presents with a history of left-sided groin pain for approximately 3 months, which started following a prolonged hike. He denies any previous trauma or hospitalizations for the hip. He had a viral illness approximately 4 months ago with an uneventful resolution. He walks without a limp. He has pain with abduction and internal rotation but painless resisted hip flexion and no tenderness around the hip. He received a greater trochanteric bursitis injection by his primary care doctor without symptom resolution. Imaging is shown. Which of the following is the most likely etiology of this patient's symptoms?
Remediation:A. This patient has characteristic imaging findings of femoroacetabular impingement caused by combined cam and pincer deformities.B. Chronic septic arthritis would likely have radiographic findings with erosive changes around the proximal aspect of the femur and/or deformity. Also, the patient would likely have a history of previous hospitalizations not related to a viral illness.C. Iliopsoas tendinitis presents as pain with resisted hip flexion, which this patient does not have.D. Greater trochanteric bursitis usually manifests as tenderness to palpation at the lateral aspect of the hip over the area of the greater trochanteric bursa. This patient does not have tenderness about the hip on examination, nor did his symptoms improve after greater trochanteric bursa injection.