Quiz of the Month – August 2022

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1 / 10

HIP - Deep dissection to the hip using the direct anterior approach utilizes which of the following internervous intervals?

Remediation:

a-d. The superior gluteal and femoral nerves comprise the correct internervous plane for deep dissection using the anterior approach.

2 / 10

Trauma - A 70-year-old female patient presents to the emergency department with an isolated, displaced femoral neck fracture. She has hip osteoarthritis but is an active community ambulator. Which of the following is the best management option for this patient?

Remediation:
a. Open reduction and internal fixation is not a treatment option for a displaced femoral neck fracture in an elderly patient.
b. Since the patient has arthritis, total hip arthroplasty is preferred over hemiarthroplasty
c. Sliding hip compression screws can be used for patients with nondisplaced or valgus impacted femoral neck fractures, but is preferred for younger patients with a basicervical femoral neck fracture.
d. Total hip arthroplasty is the best option for a patient with a displaced femoral neck fracture who is a community ambulator and has preexisting hip osteoarthritis.

3 / 10

Sports Medicine - A 20-year-old female patient presents with lower leg pain for the past 2 to 3 months. She reports that the pain is worse with any activity and improves at rest. She is currently training for a marathon. Her body mass index is 19 kg/m2 and she reports amenorrhea for the past 6 months. Examination shows focal tenderness of the tibia, and radiographs demonstrate a defect of the anterior cortex of the tibia. Which of the following treatment options are appropriate?

Remediation:
a. If a fracture line seen in the posterior cortex, a tibial stress fracture can be treated nonoperatively with non-weightbearing. If a fracture line is seen in the anterior cortex, there is a high risk of nonunion and fracture, and it is typically treated with operative fixation (although the patient should be made not weight bearing in a cast or boot until surgery is performed).
b. If a fracture line is seen in the posterior cortex, a tibial stress fracture can be treated nonoperatively with non-weightbearing. If a fracture line is seen in the anterior cortex, there is a high risk of nonunion and fracture, and it is typically treated with operative fixation.
c.  A tibial stress fracture in the anterior cortex carries an increased risk of nonunion and fracture and is typically treated with operative fixation. The patient should be made non-weight bearing until surgery with the ankle immobilized in a splint, cast or boot.
d. If a fracture line seen in the posterior cortex, a tibial stress fracture can be treated nonoperatively with non-weightbearing. If a fracture line is seen in the anterior cortex, there is a high risk of nonunion and fracture, and it is typically treated with operative fixation.

4 / 10

Spine - A 55-year-old male patient presents with a new onset of bilateral symmetrical diffuse hand numbness with neck pain. He denies weakness or balance problems. Physical examination reveals symmetrical 3+ upper and lower-extremity reflexes, 5 of 5 upper and lower-extremity motor strength, normal gait without balance disturbance, downgoing Babinski, and no clonus. He has a negative Lhermitte phenomenon. Electromyography with nerve conduction velocity (EMG/NCV) testing shows no evidence of peripheral nerve entrapment or neuropathy. Magnetic resonance imaging (MRI) shows spinal cord compression at C5-C6 from disc-osteophyte complex. There is no cord signal change or myelomalacia on the MRI. Which of the following is the appropriate next step for this patient?

Remediation:
a. This patient has bilateral symmetrical diffuse hand numbness without any other sign or symptom of radiculomyelopathy. Despite having a normal electromyography with nerve conduction velocity (EMG/NCV) study for peripheral nerve entrapment or neuropathy, the next best step is to perform a physical examination and further evaluate for peripheral nerve disease since EMG/NCV can, at times, yield false-negative results.
b. This patient has bilateral symmetrical diffuse hand numbness without any other sign or symptom of radiculomyelopathy. Although the MRI shows cord compression at the C5-C6 level from disc-osteophyte complex, his symptoms are not consistent with his MRI findings. Thus, he needs further workup, not an anterior cervical discectomy and fusion.
c.  This patient has bilateral symmetrical diffuse hand numbness without any other sign or symptom of radiculomyelopathy. Although the MRI shows cord compression at the C5-C6 level from disc-osteophyte complex, his symptoms are not consistent with his MRI findings. Thus, he needs further workup, not a corpectomy.
d. This patient has bilateral symmetrical diffuse hand numbness without any other sign or symptom of radiculomyelopathy. Although the MRI shows cord compression at the C5-C6 level from disc-osteophyte complex, his symptoms are not consistent with his MRI findings. Thus, he needs further workup, not a laminectomy at C5-C6.

5 / 10

Shoulder & Elbow - A 15-year-old female patient presents with a history of multiple anterior shoulder dislocations requiring reduction in the emergency department. Magnetic resonance imaging shows a Bankart lesion as well as a small Hill-Sachs lesion. When discussing operative options with the patient, which of the following should you tell her is an advantage of an arthroscopic Bankart repair versus an open Bankart repair?

Remediation:
a. There is no difference in recurrent dislocation rate between arthroscopic and open Bankart repairs.
b. There is no difference in return to activity between open and arthroscopic Bankart repairs.
c. Arthroscopy allows for small incisions and better cosmesis compared with open surgery.
d. There is no difference in postoperative pain between open and arthroscopic Bankart repairs.

6 / 10

Pediatrics - A 10-year-old boy presents with scoliosis, limited back range of motion, and asymmetric abdominal reflexes. A posteroanterior spine radiograph demonstrates an apex left main thoracic scoliosis measuring 35°. Which of the following is the next step in the patient's evaluation?

Remediation:
a.  A patient with an atypical scoliotic curve and abnormal reflexes should have additional imaging to evaluate for syringomyelia. Electromyography and nerve conduction studies will not show an abnormality such as syringomyelia.
b.  A patient with an atypical scoliotic curve and abnormal reflexes should be evaluated for syringomyelia with advanced imaging such as magnetic resonance imaging.
c.  While physical therapy may help the limited motion, the first step is for advanced imaging of the spine given the neurological findings and atypical curve.
d. A left thoracic curve in a patient with asymmetric abdominal reflexes should be evaluated for syringomyelia with advanced imaging.

7 / 10

Basic Science - Which of the following factors increases the fracture risk in a patient with osteoporosis?

Remediation:
a. Increased bone resorption affects trabecular bone, causing the trabeculae to become progressively thinner, eventually leading to the loss of trabecular connectivity. These changes in trabecular microarchitecture have been shown to rapidly compromise bone strength in areas where trabecular bone predominates, such as the vertebral bodies.
b. Increasing the cortical perimeter of a bone results in an exponential increase in resistance to bending and torsion without a marked increase in bone mass.
c.  Cortical porosity can serve as a site for fracture initiation, and also results in decreased bone mass, both of which can increase fracture risk.
d.  In addition to the degree of mineralization, the size and shape of the hydroxyapatite crystals also influence fracture risk. Increased bone strength seems to be associated with greater heterogeneity of mineral crystal size when compared with the presence of mostly large mineral crystals.

8 / 10

Hand and Wrist - A 67-year-old female patient presents with pain at the base of her thumb. She has had a diminished grip strength over the past several years and now has difficulty opening jars and turning door knobs. Imaging demonstrates Eaton grade III thumb basal joint osteoarthritis with approximately 40° of hyperextension at the metacarpophalangeal (MCP) joint. This deformity is not passively correctable. The patient is interested in operative reconstructive options. Given the deformity present, in addition to trapezial excision, an adjunct procedure that would best address this pathology is MCP joint:

Remediation:
a. Trapeziectomy is an effective treatment of thumb carpometacarpal (CMC) osteoarthritis failing nonoperative measures. Hyperextension laxity at the MCP joint should be recognized because missed MCP instability is a cause of recurrent pain and disability. Arthrodesis is the correct choice for 40° of hyperextension laxity in a passively uncorrectable joint.
b. Trapeziectomy is an effective treatment of thumb carpometacarpal (CMC) osteoarthritis failing nonoperative measures. Hyperextension laxity at the MCP joint should be recognized because missed MCP instability is a cause of recurrent pain and disability. Volar MCP joint capsulodesis is not appropriate for 40° of hyperextension laxity in a passively uncorrectable joint.
c.  Trapeziectomy with or without ligament reconstruction are options for treatment of thumb carpometacarpal (CMC) osteoarthritis failing nonoperative measures. Regardless, MCP instability must be addressed to prevent recurrence and pain.
d. Arthrodesis is the correct choice for 40° of hyperextension laxity in a passively uncorrectable joint. Arthrodesis should be performed in flexion and slight pronation because this is the most functional position for the thumb MCP joint and allows easy opposition.

9 / 10

Foot and Ankle  - Excessive iatrogenic shortening of the first metatarsal during hallux valgus surgery can lead to which of the following complications?

Remediation:
a. Shortening of the 1st metatarsal does not affect the sesamoid bones
b. Hallux rigidus is an arthritic condition that affects the first metatarsophalangeal joint and is not a recognized complication of iatrogenic first metatarsal shortening.
c. Excessive shortening of the first metatarsal can lead to transfer metatarsalgia due to overload on the lesser metatarsal heads.
d. Excessive shortening of the first metatarsal does not lead to medial column overload.

10 / 10

KNEE - A 45-year-old male patient presents with overall varus alignment of the right knee and grade 1 Ahlback changes within the medial compartment. He has no chondral pathology throughout the rest of the knee and has full range of motion. The varus malalignment is 12°. The patient has a body mass index of 29 kg/m2 and enjoys running and playing basketball. Which of the following would be the treatment of choice for this patient?

Remediation:
a. The patient does not have enough chondral damage to be indicated for OATS, and with a substantial varus femoral, if left uncorrected, the OATS would be expected to fail.
b. The patient is young and active with minimal arthritic changes; therefore, a medial opening wedge would correct the 12° of varus, provide reliable improvement in his symptoms, and would allow him to continue to run and play basketball.
c.  Arthroscopic debridement of the medial femoral chondral surface would not be the treatment of choice. With substantial varus deformity and medial-sided knee pain, simple debridement would not provide substantial relief of his symptoms.
d.  The patient does not meet the indications for a total knee arthroplasty. He has minimal arthritis.

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