Quiz of the Month – January 2023

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 - January 2022

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Trauma

A 22-year-old female patient sustained bilateral femoral fractures while skiing. She is brought to the emergency department and receives fluids and blood products. Her vital signs are currently blood pressure, 110/60 mm Hg; and heart rate, 133 beats/minute. Her base excess is -3. Which of the following is the best treatment for her orthopaedic injuries at this time?

Remediation:
A. Open reduction and internal fixation of both femoral fractures may be indicated once the patient has been successfully resuscitated and stabilized. At this point, definitive fixation would place the patient at risk for acute respiratory distress syndrome and multisystem organ failure.
B. Intramedullary nailing of both femoral fractures may be indicated once the patient has been successfully resuscitated and stabilized. At this point, definitive fixation would place the patient at risk for acute respiratory distress syndrome and multisystem organ failure.
C. The patient is hemodynamically unstable and would not be a candidate for definitive management of even one of her fractures at this time.
D. The patient has signs of hemodynamic instability and underperfusion. At this time, initiation of damage- control orthopaedics with external fixation of both femoral fractures to stabilize the fractures as much as possible is the treatment of choice.

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Sports

A 28-year-old male patient who is a professional hockey player injures his right middle finger metacarpophalangeal joint during a fight in a game. He is unable to initiate extension of this finger, but is able to hold the finger extended when it is placed in extension by his other hand. Radiographs are normal. You discuss operative fixation to enable an earlier return to play. Which of the following structures should be repaired?

Remediation:
A. The patient's injury is a ruptured radial sagittal band (boxer's knuckle), which is the structure that should be repaired.
B. The patient's injury is a ruptured radial sagittal band (boxer's knuckle), which is the structure that should be repaired.
C. The patient's injury is a ruptured radial sagittal band (boxer's knuckle), which is the structure that should be repaired. The extensor tendon is not involved in a boxer's knuckle.
D. The patient's injury is a ruptured radial sagittal band (boxer's knuckle), which is the structure that should be repaired. The radial lateral band is more distal than the radial sagittal band.

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Spine

A 48-year-old male patient presents to the emergency department with neck pain and an inability to move his legs following a bicycle accident. He was riding his bicycle, hit a bump, and fell over his handlebars.  Examination reveals abrasions on his face. His neurological examination reveals bilateral paralysis of the lower extremities. He has upper-extremity weakness and sensory loss at the level of C6. Rectal tone is decreased and without sensation. Cervical and thoracic spine magnetic resonance imaging show spondylotic disc disease, with disc herniation at C6-C7 causing severe spinal canal stenosis. Which of the following additional factors would indicate a good prognosis for neurological recovery?

Remediation:
A. This patient has acute incomplete spinal cord injury at the C6 level. The administration of corticosteroids after injury has limited evidence supporting neurological benefit. At best, it leads to improvement in one nerve root level, which may be beneficial in the CSP, but has no bearing on function for thoracic spinal cord injury.
B. Spinal shock is a physiological response to acute SCI, in which all reflexes below the level of injury are absent. It typically lasts <72 hours. Until this has resolved the final prognosis is uncertain.
C. Patients presenting with motor loss and sensory sparing are classified as Frankel B, or B on the American Spinal Injury Association (ASIA) impairment scale. However, these scales make no distinction between the types of sensory sparing (e.g. tactile, joint position sense and pain and temperature). A distinction has been made between the types of sensory sparing. Those with preserved pinprick have been shown to have a better chance of regaining a functional gait.
D. Outcomes of blunt trauma are more predictable and better than penetrating trauma, especially when the penetration was from a high velocity projectile, which produces cavitation injury

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Shoulder & Elbow

A 19-year-old male patient who is a military recruit presents with recurrent pain and feelings of instability in his shoulder. A magnetic resonance arthrogram reveals dye leakage inferiorly and a comma sign confirming a humeral avulsion of the glenohumeral ligament (HAGL).  Which of the following is the pathophysiology of an HAGL lesion?

Remediation:
A. Long head of the biceps instability can occur when there is failure of the transverse humeral ligament to maintain restraint. This can be in the form of a superior glenohumeral ligament tear, a subscapularis tear, or a combination.
B. This describes a classic soft-tissue Bankart lesion.
C. Failure can occur with or without an anterior inferior labral tear or bony avulsion of the anterior inferior glenoid.
D. This is the mechanism for internal impingement.

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Pediatrics

A 3-month-old girl with a unilateral Barlow positive left hip has been in a Pavlik harness for the past 1 month. Her mother is concerned that the left leg is not moving as much as the right leg. On examination, the infant is able to extend the right knee but not the left. Which of the following is the next most reasonable treatment recommendation?

Remediation:
A. Femoral nerve palsy is a known complication of Pavlik harness treatment and typically resolves with removal of the Pavlik harness. The nerve usually recovers fairly quickly, and the Pavlik harness can be reapplied at that time. Hyperflexion of the hip is thought to be the cause, and this should be avoided when the harness is reapplied.
B. Lack of knee extension with a child in a Pavlik harness is a classic sign of femoral nerve palsy. The harness should be removed immediately to allow the nerve to recover. Femoral nerve palsy is not associated with hip dysplasia itself.
C. Lack of knee extension with a child in a Pavlik harness is a classic sign of femoral nerve palsy. The harness should be removed immediately to allow the nerve to recover. The reduction status of the hip should not guide treatment as lower-extremity neuromotor function is more important than hip position.
D. Lack of knee extension with a child in a Pavlik harness is a classic sign of femoral nerve palsy. The harness should be removed immediately to allow the nerve to recover. Transition to a spica cast will not allow the nerve an optimal environment for recovery because hip flexion will be maintained.

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Basic Science

Cobalt-chromium alloy and stainless steel used in orthopaedic implants have approximately the same elastic modulus. In comparison, the magnitude of the elastic modulus of titanium alloy is approximately:

Remediation:
A. Titanium has an elastic modulus of approximately one-half of the other two alloys.
B. Cobalt-chromium and stainless steel have an elastic modulus of approximately 200 GPa. Titanium has an elastic modulus of approximately 110 GPa.
C. Titanium has an elastic modulus of approximately one-half of the other two alloys.
D. Titanium has an elastic modulus of approximately one-half of the other two alloys.

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Hand & Wrist

A 37-year-old male patient who is a construction worker presents after suffering a thumb injury during a fall 1 week ago. He has pain and bruising on the ulnar side of the thumb metacarpophalangeal (MCP) joint. There is greater than 40° of valgus laxity, both in extension and 30° of MCP joint flexion. There is no appreciable endpoint during stress testing. Plain radiographs show no fracture. Which of the following is the most appropriate next step in management?

Remediation:
A. With no endpoint during stress testing in full extension and 30° of flexion, both proper and accessory collateral ligaments appear to be torn. Repair of the thumb ulnar collateral ligament is the preferred treatment.
B. Transarticular pinning of the thumb MCP joint may be considered in cases of MCP dislocation or fracture-dislocation with more profound joint instability. There is no mention of joint dislocation needing closed reduction in this case.
C. Both proper and accessory collateral ligaments appear to be torn by examination. Acute thumb ulnar collateral ligament tears with significant instability should be operatively repaired.
D. Repair is the preferred treatment for acute thumb ulnar collateral ligament tears with significant laxity. Reconstruction is the treatment of choice in irreparable or chronic situations.

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Foot & Ankle

Which of the following intrinsic factors are thought to be associated with hallux valgus deformity?

Remediation:
A. A cavus foot deformity may contribute to pain in a number of different areas, including the lateral column of the foot. Pes cavus is not thought to be a cause of hallux valgus.
B. An elongated second metatarsal can contribute to lesser metatarsophalangeal joint instability and synovitis, with pain at the base of the 2nd toe. However, this is not thought to be a cause of hallux valgus.
C. An elevated distal metatarsal articular angle results in the articular surface of the first metatarsal head angulated into valgus which can contribute a hallux valgus deformity.
D. Hypermobility, rather than hypomobility, of the first tarsometatarsal joint is thought to contribute to varus angulation of the first metatarsal which can contribute to the development of hallux valgus.

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Knee

Which of the following are radiographic characteristics of inflammatory arthritis?

Remediation:
A. Subchondral sclerosis is generally seen in patients with advanced osteoarthritis rather than inflammatory arthritis.
B. Patients with inflammatory arthritis have marginal erosions. The marginal erosions are radiographic signs of the inflammatory tissues invading into the bone.  Osteoclasts are responsible for the bony erosions.
C. Inflammatory arthritis affects the entire joint equally and, therefore, typically results in symmetric joint-space narrowing.
D. Large periarticular osteophytes are associated with osteoarthritis. Inflammatory arthritis does not produce osteophytes.

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Hip

An 82-year-old female patient presents with a 3-month history of severe right groin pain. She has a medical history that is noteworthy for diabetes mellitus, hypertension, and stroke. She describes pain in the buttocks with ambulation, with radiation to the anterior aspect of the thigh and leg. She is able to ambulate, although with a mild limp. Her hip examination is normal, apart from iliopsoas weakness. Radiographs show mild osteoarthritis of the right hip. Which of the following is the appropriate next step?

Remediation:
A. This patient's symptom of buttock pain radiating to the anterior aspect of the thigh is most consistent with lumbar spine pathology; therefore, a lower extremity neurological examination is warranted.
B. Since this patient's symptoms are most likely due to lumbar spine pathology, hip MRI is not indicated.
C. Since this patient's symptoms are most likely due to lumbar spine pathology and she only has mild hip degenerative changes on imaging, THA is not indicated at this time.
D. This patient's symptoms are most likely due to lumbar spine pathology and her hip imaging shows degenerative changes, meaning hip arthroscopy is not indicated.

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