Quiz of the Month - April 2024 - JBJS Clinical Classroom

The JBJS Quiz of the Month is a collection of 10 relevant questions from each orthopaedic subspecialty. The questions are drawn from JBJS Clinical Classroom, which houses over 4,500 questions and 3,100 learning resources. Take the Quiz to see how you score against your peers!

NOTE: This quiz does not earn users CME credits. The questions must be answered within Clinical Classroom to earn CME credits.

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Created on April 10, 2024

April 2024

1 / 10

Trauma
Which of the following is the most common type of Monteggia fracture pattern in adults?

A. Bado type 1

B. Bado type 2

C. Bado type 3

D. Bado type 4

Remediation:
A. Bado type 1 fractures are defined by an anterior angulation of the ulnar fracture with anterior dislocation of the radial head. This Monteggia lesion is the most common form in the pediatric population and is thought to result from a fall on an extended and hyperpronated arm. In adults, Bado type-2 injuries are most common.
B. Bado type 2 fractures are defined as posterior angulation of the ulnar fracture and posterior dislocation of the radial head. In adults, Bado type-2 injuries are most common.
C. Bado type 3 fractures are defined as proximal ulnar metaphysis fractures and lateral dislocations of the radial head. Bado type 2 fractures are the most common Monteggia injuries seen in adults.
D. Bado type 4 fractures are characterized by fractures of both the proximal aspect of the ulna and the radius. The radial head is also dislocated, typically anteriorly. Bado type-2 fractures are the most common Monteggia injuries seen in adults.

2 / 10

Sports Medicine
A 48-year-old female patient twisted her left knee while walking her dog 3 weeks ago. She had immediate medial-sided pain in the knee and was seen in her local emergency department; radiographs were obtained (shown). On examination, her left knee demonstrates a 1+ effusion. There is pain to palpation along the medial joint line, and she has pain with valgus stress but is stable. There are meniscal irritation signs. She lacks a few degrees of extension compared with the contralateral knee. Flexion is approximately 110°. There is no patellofemoral irritability. There is a negative Lachman test and a negative posterior drawer test. Which of the following do you recommend for her?

A. Magnetic resonance imaging (MRI) of the left knee

B. Aspiration and corticosteroid injection

C. Knee brace, physical therapy, and anti-inflammatory medication

D. Knee arthroscopy

Remediation:
A. The lack of full extension or locking of the knee raises concern for a displaced meniscus tear, so MRI is indicated to evaluate the meniscus.
B. Based on effusion and block to motion in absence of substantial osteoarthritis, further imaging is warranted.
C. Based on effusion and block to motion in absence of substantial osteoarthritis, further imaging is warranted.
D. Further imaging should be obtained before knee arthroscopy.

3 / 10

Spine
A 16-year-old male patient with adolescent idiopathic scoliosis (imaging shown) is scheduled for posterior thoracolumbar instrumented fusion. You plan to use tranexamic acid during the surgery because it has which of the following benefits?

A. Reduced pain

B. Reduced blood loss intraoperatively

C. Less need for allogeneic blood transfusions

D. Decreased postoperative hemoglobin levels

E. Reduced total length of hospital stay

Remediation:
A. Tranexamic acid has been shown to significantly reduce blood loss intraoperatively and the need for allogeneic blood transfusions. It has no effect on pain.
B. Tranexamic acid has been shown to significantly reduce blood loss intraoperatively and the need for allogeneic blood transfusions.
C. Tranexamic acid has been shown to significantly reduce blood loss intraoperatively and the need for allogeneic blood transfusions.
D. Tranexamic acid has been shown to significantly reduce blood loss intraoperatively and the need for allogeneic blood transfusions. It has no effect on postoperative hemoglobin levels.
E. Tranexamic acid has been shown to significantly reduce blood loss intraoperatively and the need for allogeneic blood transfusions. It has no effect on length of hospital stay.

4 / 10

Shoulder and Elbow
While performing olecranon debridement during an arthroscopic Outerbridge procedure, the ulnar nerve should be protected with a retractor placed through which of the following portals?

A. Anteromedial

B. Anterolateral

C. Direct posterior

D. Direct lateral

Remediation:
A. The ulnar nerve is at risk using the anteromedial portal if it is placed posterior to the intermuscular septum.
B. The ulnar nerve is on the medial side of the elbow
C. The retractor is placed in the posterior portal to protect the ulnar nerve, and the debridement is carried out using a posterolateral portal.
D. The ulnar nerve is on the medial side of the elbow.

5 / 10

Pediatrics
A 12-year-old boy has had knee pain and swelling off and on for the past several months. He is active in soccer and does not recall any injury to the knee except for some minor twist injuries that have resolved on their own. His parents brought plain radiographs and magnetic resonance images from another institution that show a stable osteochondritis dissecans lesion in the medial femoral condyle. Which of the following are the appropriate next steps in management?

A. Non-weightbearing for 3 months

B. Repeat the imaging studies if the prior images were obtained ≥6 months ago

C. Schedule the patient for an osteochondral allograft transfer surgery

D. Assess the mechanical axes alignment of the patient's knee

Remediation:
A. Nonoperative management begins with activity modification and limited weight bearing.
B. Repeat magnetic resonance imaging will demonstrate whether the lesion is healing or will guide treatment if there is additional edema and separation.
C. Nonoperative modalities should be tried first.
D. Malalignment can place undue pressure on the joint line and may need to be addressed operatively.

6 / 10

Basic Science and Pathology
A 35-year-old male patient presents to the emergency department following a motor vehicle collision. The patient has an Injury Severity Score (ISS) of 27 and undergoes orthopaedic surgery for his injuries. Which of the following interventions, if performed for this patient, increases his risk for developing acute respiratory distress syndrome (ARDS)?

A. Fiberoptic intubation

B. Massive blood transfusion

C. Early fixation of a long bone fracture

D. Intraoperative corticosteroid administration

Remediation:
A. Aspiration of gastric contents is associated with ARDS. Misplacement of the endotracheal tube is not likely with fiberoptic intubation, which theoretically decreases the risk of intubation-related complications such as aspiration.
B. Transfusion of blood products is an indirect lung-injury risk factor for ARDS.
C. Although some authors support delaying fracture fixation due to the risk of ARDS, there is also literature to support early long bone fixation.
D. Corticosteroid administration may help improve oxygenation early in the course of ARDS but is not a risk factor for ARDS development.

7 / 10

Hand and Wrist
A 28-year-old male patient presents after injuring his hand in a scooter collision. A radiograph is shown. Which of the following structures causes the most substantial shortening force in this injury?

A. Abductor pollicis longus

B. Adductor pollicis

C. Extensor pollicis longus

D. Flexor pollicis brevis

E. Volar oblique (beak) ligament

Remediation:
A. The radiographs demonstrate a Bennett fracture at the base of the thumb. The abductor pollicis longus is the most important shortening force. It also brings the base of the metacarpal radially.
B. The adductor brings the distal part of the metacarpal radially and supinates it a little. The abductor pollicis longus is the most substantial shortening force.
C. The extensor pollicis longus does act to shorten the thumb, but the abductor pollicis longus is the most substantial shortening force.
D. The flexor pollicis brevis is not typically a deforming force in a Bennett fracture. The abductor pollicis longus is the most substantial shortening force.
E. The beak ligament keeps the base fragment in place with the metacarpal's displacement of the metacarpal. The abductor pollicis longus is the most substantial shortening force.

8 / 10

Foot and Ankle
You have been following a 35-year-old female patient who is a recreational runner for peroneal tendinopathy in the setting of an overt cavovarus foot. She has undergone extensive nonoperative management including immobilization, physical therapy, and custom orthotics. Her pain and limitations persist, and she is ready to proceed with surgery. Your operative plan should address which of the following?

A. Peroneal pathology via peroneal tendoscopy

B. Peroneal pathology via open surgery

C. Cavovarus realignment

D. Cavovarus realignment as well as the peroneal pathology

Remediation:
A. Peroneal tendoscopy is useful for examining the tendons, performing debridement, and decompression of the groove. Tears are more difficult to address. Malalignment is not addressed with tendoscopy.
B. Peroneal tendon surgery alone may be met with recurrence.
C. The peroneal tendons should be addressed directly. Cavovarus realignment is not likely to result in treatment of the tendon pathology.
D. Operative intervention should address both the cavus and the tendon pathology. Coleman block testing will help to determine the treatment for the malalignment, specifically if the hindfoot varus is driven by forefoot cavus.

9 / 10

Knee
Which of the following factors are predictors of patient dissatisfaction following primary total knee arthroplasty (TKA)?

A. Pain with simple range of motion (ROM)

B. Desire to return to high-impact activities

C. Severe osteoarthritis

D. Mild to moderate osteoarthritis

Remediation:
A. Preoperative pain with simple ROM is a predictor for poor patient satisfaction following TKA.
B. Preoperative expectations of returning to high-impact activities is a predictor for poor patient satisfaction following TKA.
C. Severe osteoarthritis is not a predictor of postoperative patient satisfaction
D. Minimal osteoarthritis is a predictor for poor patient satisfaction following TKA.

10 / 10

HIP
The figure shows a half cup-cage construct that may be use to treat pelvic discontinuity. Which of the following describes the use and outcomes of this construct?

A. Long-term stability depends on the quality of screw fixation through the cage.

B. Removal of the ischial flange limits ischial dissection and may reduce the risk of sciatic nerve palsy.

C. Successful results have been reported in Paprosky type-2B and 3B defects with discontinuity.

D. The polyethylene liner is cemented in place after the cup-cage construct is assembled.

Remediation:
A. A study from 2017 by Martin et al. found that long-term survival of revision hip arthroplasty for pelvic discontinuity was related to the rigidity of the construct involving an ilioischial cage or cup-cage combination rather than the quality of screw fixation for the cage.
B. Removing the ischial flange may make implantation of the construct easier and puts the nerves less at risk.
C. Paprosky type-2B defects involve distortion of the superior acetabular rim with <3 cm of superior femoral head migration. Paprosky type-3B defects involve substantial superior dome destruction with >3 cm of superomedial femoral head migration. Both defects can benefit from a cup-cage construct.
D. This is the correct method of assembling a cup-cage construct, and cement must always be used to insert the polyethylene liner.

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