This quiz does not earn users CME credits. The questions must be answered within Clinical Classroom to earn CME credits
Quiz of the Month - June 2023
1 / 10
A 72-year-old male patient presents with an unstable intertrochanteric hip fracture. The patient's medical history includes osteoarthritis. When considering fixation constructs for this patient's injury, arthroplasty would be recommended to prevent which of the following complications associated with fixation using a cephalomedullary nail?
Remediation:A. The rate of deep venous thrombosis is the same regardless of the fixation construct used.B. Excessive shortening is a complication of a cephalomedullary nail.C. Increased blood loss is associated with arthroplasty.D. Mortality rate is lower with the use of a cephalomedullary nail.
2 / 10
A 20-year-old male patient who is a football player complains of severe lower back pain after a game. He denies any numbness or paresthesias. On examination, he has focal tenderness at L5, but there is no palpable step-off of the lumbar spine. He does exhibit lumbar hyperlordosis. There is pain with hyperextension that is relieved when he bends down to touch his toes. The pain in hyperextension is exacerbated when he is in a single-leg stance. Which of the following is the most likely diagnosis?
Remediation:A. An endplate fracture is a possibility, but given the examination findings of hyperlordosis and pain with hyperextension exacerbated with a single-leg stance, spondylolisthesis is a more likely diagnosis.B. A herniated lumbar disc would cause pain with bending forward. There would also be neurological symptoms.C. The hyperlordosis and pain with hyperextension exacerbated with single-leg stance are more indicative of spondylolisthesis than a sprain.D. Spondylolisthesis is evidenced by back pain, hyperextension in a single-leg stance, and hyperlordosis.
3 / 10
A 70-year-old female patient with severe lumbar stenosis undergoes an L4-S1 laminectomy. She does well and improves. However, at 6 months postoperatively, she starts to develop similar symptoms. Examination reveals a well-healed incision. Which of the following is the appropriate next step?
Remediation:A. PT will not determine the cause of her recurrent symptoms. The persistence of lumbar and nerve root pain after nerve root decompression surgery may be attributed to many causes, including (1) progression of the spondylotic disease in the presence of peridural fibrosis, (2) disc herniation, (3) persistence or recurrent stenosis of the spinal or nerve root canal, (4) arachnoiditis, and 5) vertebral instability. The workup often includes magnetic resonance imaging (MRI) with and without gadolinium to evaluate for nerve root compression and flexion-extension radiographs to evaluate for instability.B. Injections cannot be targeted without knowledge of the pathoanatomy. The persistence of lumbar and nerve root pain after nerve root decompression surgery may be attributed to many causes, including (1) progression of the spondylotic disease in the presence of peridural fibrosis, (2) disc herniation, (3) persistence or recurrent stenosis of the spinal or nerve root cana, (4) arachnoiditis, and (5) vertebral instability. The workup often includes magnetic resonance imaging (MRI) with and without gadolinium to evaluate for nerve root compression and flexion-extension radiographs to evaluate for instability.C. MRI allows for the determination of the pathoanatomy causing the recurrent stenosis symptoms. Contrast allows for the delineation between recurrent disc herniation (non-enhancing or rim-enhancing) and scar (diffusely enhancing).D. CT is inferior to magnetic resonance imaging (MRI) in the determination of neurological compression related to spinal stenosis. This option, especially with myelography, may be an alternative when MRI is not possible (i.e., if the patient has a pacemaker).
4 / 10
A 40-year-old male patient presents with right shoulder pain and dysfunction after a bicycle accident. The patient is right-hand dominant. On examination, there is deformity of the shoulder with a sagging girdle, ecchymosis, and deformity of the distal clavicle. Which of the following is the best radiographic view to identify a type IV acromioclavicular separation?
Remediation:A. This is a true anteroposterior view of the glenohumeral joint. It is best for identifying narrowing of the glenohumeral joint and superior migration of the humeral head.B. An axillary lateral view is best to be able to discern anteroposterior translation of the clavicle. The patient is placed in a supine position, and the arm is gently abducted 70°. The beam is shot from inferior to superior angled towards the axilla.C. A scapular Y view is best for identifying the shape of the acromion. The image is taken by aligning the medial border of the scapula and the anterior acromion in line with the beam. The beam is shot from the posterior.D. A serendipity view is best to identify dislocation of the sternoclavicular joint. The patient is placed supine and the beam is focused on the chest with a 40°cephalic tilt.
5 / 10
PediatricsA 12-year-old presents with generalized wrist pain and clinical deformity with a dorsoulnar bony prominence. Radiographs are shown. Which of the following operative options would address both issues?
Remediation:A. A distal radius osteotomy to restore typical alignment with ulnar shortening is the treatment of choice.B. While Vickers ligament is the tether, a 12-year-old girl is unlikely to have sufficient growth remaining to correct the deformity.C. An ulnar shortening osteotomy alone is unlikely to improve the patient's pain although the bony prominence will be mitigated.D. This is a salvage procedure that will excessively load the adjacent joints and limit motion in a patient who is this close to full growth. Wrist mechanics should be restored first before a salvage procedure is considered.
6 / 10
Healing of which of the following tendons involves intrinsic epitenon-derived fibroblast migration and infiltration of cells from the intrasynovial sheath, which can lead to the formation of adhesions?
Remediation:A. The patellar tendon is an extrasynovial tendon that heals via formation of fibrous tissue.B. Injuries to the rotator cuff tendons are intrasynovial and do not undergo spontaneous healing, whereas injury to the Achilles tendon is extrasynovial, where fibrous tissue formation can and does occur after injury.C. Injuries to the rotator cuff tendons are intrasynovial and do not undergo spontaneous healing, whereas injury to the Achilles tendon is extrasynovial, where fibrous tissue formation can and does occur after injury.D. Intrasynovial tendons, including flexors of the hand, typically heal via cells from the epitenon and endotenon as well as cells from the surrounding intrasynovial sheath.
7 / 10
A 30-year-old female patient has been diagnosed with a schwannoma on magnetic resonance imaging (MRI). Which of the following treatment options is recommended?
Remediation:A. Wide resection and reconstruction is the appropriate treatment for malignant peripheral nerve tumors, but a schwannoma can be excised while preserving normal neighboring fascicles.B. Interfascicular dissection of a schwannoma typically results in adequate resection of the tumor with preservation of neighboring fascicles and normal nerve function.C. Schwannomas, while benign, are generally symptomatic. Excision with preservation of normal neighboring fascicles is appropriate.D. Schwannomas, while benign, are generally symptomatic. Excision with preservation of normal neighboring fascicles is appropriate.
8 / 10
A 63-year-old female patient presents with tophaceous gout of the dorsal aspect of the left hand. The tophus is minimally tender and does not drain or ulcerate. She is able to use her hand normally. She is taking allopurinol, and her uric acid level is 5.8 mg/dL. She has not had an acute gout flare in 2 years. Which of the following is the best treatment option for the patient?
Remediation:A. This patient has a relatively asymptomatic gouty tophus with acceptable control of urate levels. Monitoring is appropriate.B. The American College of Rheumatology recommends maintaining the uric acid level at <6.0 mg/dL.C. An asymptomatic tophus that does not open and drain and is not in a critical area for function should be monitored and does not require debridement.D. The American College of Rheumatology recommends maintaining the uric acid level at <6.0 mg/dL. It is recommended to monitor kidney function routinely, but if she is stable on her current regimen and has no side effects, then she should continue her regimen.
9 / 10
At the time of revision surgery to address aseptic tibial loosening, you plan to use a press-fit tibial stem for component fixation, as shown. Which of the following is the appropriate technique for implanting this type of tibial stem?
Remediation:A. A press-fit stem does not use cement and, therefore, a cement mantle is not required.B. It is not possible to engage the metaphysis with a press-fit stem. A metaphyseal stem must be cemented.C. Press-fit uncemented stems need to obtain diaphyseal fixation. The technique is to ream until cortical chatter is achieved.D. This will possibly lead to fracture or inability to fully seat the tibial component.
10 / 10
HipWhich of the following structures, found 3 to 5 cm proximal to the greater trochanter, is most at risk during a direct lateral approach to the hip?
Remediation:A. The sciatic nerve is located over the posterior aspect of the hip and is most at risk during the posterior approachB. The sciatic nerve is located over the posterior aspect of the hip and is most at risk during the posterior approachC. The superior gluteal nerve, located 3 to 5 cm proximal to the greater trochanter is at risk during the direct lateral approach to the hip.D. The lateral femoral cutaneous nerve is at risk during the direct anterior approach to the hip.