Quiz of the Month - February 2023 - JBJS Clinical Classroom

Created on February 06, 2023

QUIZ of the Month Title Image with Orthopaedic Icons

February 2023

1 / 10

Trauma

A 63-year-old female patient presents with right knee pain after a fall onto her right knee while walking. Radiographs and computed tomography demonstrate a patellar fracture with inferior pole comminution (5 fracture fragments) of 40% of her patella. Which of the following treatment strategies can provide a stable fixation construct?

A. Total patellectomy

B. K-wire placement followed by 18-gauge tension band placement

C. 4.0 mm cannulated screw placement with 18-gauge tension band placement

D. Inferior pole patellectomy with Krackow suture placement or suture fixation of the inferior pole

Remediation:
A. Total patellectomy is associated with decreased quadriceps strength due to loss of the patella as a fulcrum for extension of the knee.
B. Inferior pole comminution may limit the wire and cannulated screw purchase necessary for attempting tension band wiring of fractures in this patient.
C. Inferior pole comminution may limit the wire and cannulated screw purchase necessary for attempting tension band wiring of fractures in this patient.
D. Inferior pole patellectomy of 40% of the patella are successful in treating inferior pole comminution without altering the contact forces of the patella. Additionally, suture fixation is successful at fixation while limiting hardware irritation in comminuted inferior pole fractures.

2 / 10

Sports

An 18-year-old male patient who is a lacrosse player suffers a first-time shoulder dislocation early in his freshman college season and elects to undergo nonoperative treatment. He asks about the most effective protocol for rehabilitation and return to play. Which of the following is recommended?

A. 8 weeks of immobilization in a sling in external rotation followed by strength and motion therapy

B. 6 weeks of immobilization in a sling in internal rotation followed by strength and motion therapy

C. Immediate return to play with immobilization between games

D. Return to play when pain resolves and full range of motion and normal strength are attained

Remediation:
A. There is no role for prolonged immobilization in his rehabilitation. It can lead to stiffness and does not decrease the risk of recurrent injury.
B. There is no role for prolonged immobilization in his rehabilitation. It can lead to stiffness and does not decrease the risk of recurrent injury.
C. He should not return to play until he has pain-free range of motion and normal strength.
D. He should return to play when he no longer has pain and has regained full range of motion and strength.

3 / 10

Spine

A 50-year-old male patient is involved in a motor-vehicle collision and sustains a simple burst fracture of L2. The posterior ligamentous complex is intact. He is neurologically intact and his pain is adequately controlled. Which of the following is the best treatment option?

A. Early mobilization with or without the use of a thoracolumbar orthosis for 6 to 12 weeks

B. Percutaneous posterior spinal instrumentation without fusion

C. Posterior short-segment decompression and fusion at L1 to L3

D. L2 corpectomy with strut-grafting and posterior instrumentation

Remediation:
A. An L2 burst fracture with an intact posterior ligamentous complex (PLC) is a stable injury. This patient is also neurologically intact. Thus, nonoperative treatment with early mobilization is recommended. Bracing or casting has commonly been used as well, but the need to brace/cast stable burst fractures has been questioned by some more recently
B. This is a stable fracture that does not require surgery. More recently, some have advocated posterior instrumentation, particularly using minimally invasive techniques, without fusion (i.e., internal bracing) as opposed to traditional fusion techniques for treating unstable fractures.
C. An L2 burst fracture with an intact posterior ligamentous complex (PLC) is a stable injury. This patient is also neurologically intact. Thus, nonoperative treatment with early mobilization is recommended. If this was an unstable fracture, then short-segment posterior decompression and fusion would be a good option as long as there is sufficient residual anterior column support to "share the load."
D. This is a stable fracture that does not require surgery. If the patient had incomplete cord/conus/cauda equina neurological injury and/or severe comminution of the anterior column, an anterior or anterior/posterior operation would be a good option. It allows direct decompression and reconstruction of the anterior column.

4 / 10

Shoulder and Elbow

A 23-year-old male patient who is a swimmer presents with vague, deep shoulder pain for the past 2 months. He feels that the shoulder is stable but he feels a "pop" occasionally while swimming. On examination, he has anterior shoulder pain with palpation at the joint line and over the biceps. An O'Brien test is positive. His rotator cuff strength is 5/5 in all planes. The crank test elicits a clunk. He has had no treatment to this point. Which of the following is the best next step?

A. Computed tomography scan to rule out glenoid bone loss

B. Arthrogram magnetic resonance imaging to evaluate the superior labrum complex

C. Non-contrast magnetic resonance imaging to evaluate the biceps tendon

D. Oral nonsteroidal anti-inflammatory drugs and follow up in 6 weeks

Remediation:
A. While a computed tomography scan is a good tool to evaluate glenoid bone loss, this patient is experiencing soft-tissue symptoms that are best evaluated with magnetic resonance imaging.
B. A magnetic resonance imaging arthrogram is the test of choice for an intra-articular pathology.
C. A non-contrast magnetic resonance imaging has a low sensitivity for diagnosing a superior labrum anterior and posterior tear or biceps pathology.
D. While this can help with the pain, it will not address the mechanical shoulder symptoms that the patient is experiencing.

5 / 10

Pediatrics

An 11-year-old boy presents with intermittent left knee pain and swelling. He reports catching with knee flexion-extension. He remembers that he "popped the knee" when playing soccer a few days ago. After several days of rest, he tried to play soccer again but could not because of persistent painful swelling. On examination, the knee has a mild effusion, full passive range of motion, and knee discomfort at full flexion. There is lateral joint line tenderness. The knee is stable upon ligamentous examinations. Radiographs show no fracture but do show a flattened lateral distal femoral condyle. Which of the following would be the most appropriate next step?

A. Magnetic resonance imaging of the knee

B. Surgical arthroscopy of the knee

C. Prescribe a hinged knee brace locked in extension, and then follow up in 2 weeks

D. Aspirate the effusion and start physical therapy emphasizing active range of motion and vastus medialis oblique (VMO) strengthening

Remediation:
A. The case suggests a discoid meniscus, which can be confirmed with magnetic resonance imaging prior to operative treatment.
B. The case suggests a discoid meniscus, which can be confirmed with magnetic resonance imaging prior to operative treatment.
C. The case suggests a discoid meniscus, which can be confirmed with magnetic resonance imaging prior to operative treatment.
D. The case suggests a discoid meniscus, which can be confirmed with magnetic resonance imaging prior to operative treatment.

6 / 10

Basic Science

Fat embolism syndrome (FES) can occur in patients with single or multiple traumatic fractures. Which of the following best describes the mechanical and biochemical changes leading to the development of FES following a fracture?

A. Cytokines invade lung tissue, causing microvascular blood clots

B. Hematopoietic particles embolize to the lungs, causing mechanical blockage and local tissue necrosis

C. Acidic lipid particles embolize to the lungs, causing mechanical blockage and local inflammation

D. Lipids are released into the microvascular system of the lung during long bone reaming

Remediation:
A. The development of FES is mediated by inflammation, but this originates with the offending lipid particles and is not necessarily associated with microvascular damage.
B. While blood cells and non-lipid marrow elements are liberated at the time of a long bone fracture, these have not been implicated in the development of FES.
C. The pathophysiology of FES is both mechanical and inflammatory. Lipid particles liberated from the marrow space cause mechanical blockage in lung alveoli but are also acidic and inflammatory.
D. Lipid particles coming from the bone marrow cause mechanical and inflammatory injury to the alveoli. This can occur prior to fracture fixation, so in some cases is independent of reaming or instrumentation of the long bone canal.

7 / 10

Hand & Wrist

A 45-year-old male patient presents 1 week after experiencing acute hand pain while rock climbing. On examination, the volar side of his long finger is swollen, tender, and ecchymotic. His radiographs are negative. You suspect a tendon sheath pulley rupture. Which of the following findings is likely to confirm your diagnosis?

A. Locking of the digit in mid-flexion

B. Inability to fully flex the finger

C. Paradoxical distal interphalangeal extension

D. Rotational deformity with flexion

8 / 10

Knee

Which of the following best describes the comparison of the medial parapatellar approach with the subvastus approach for total knee arthroplasty?

A. Lower lateral release rates with the subvastus approach

B. Better range of motion at 1 year with the medial parapatellar approach

C. Better straight leg raise at 1 year with the medial parapatellar approach

D. Worse range of motion at 1 week with the subvastus approach

Remediation:
A. The subvastus approach shows lower rates of lateral release when compared to medial parapatellar arthrotomy.
B. There is no difference in the range of motion between the approaches at 1 year.
C. There is no difference in ability to perform a straight leg raise at 1 year between a medial parapatellar approach versus a subvastus approach. At 1 week, the subvastus approach had improved ability to perform a straight leg raise.
D. There is improved range of motion at 1 week following a subvastus arthrotomy versus a medial parapatellar approach.

9 / 10

Hip

Which of the following are differences between cemented and cementless fixation of the femoral component after total hip arthroplasty?

A. Cementless fixation has superior outcomes with regards to wear

B. Cemented fixation has superior outcomes and survivorship

C. Cementless fixation has a higher incidence of periprosthetic fracture

D. Cemented fixation has a higher incidence of periprosthetic fracture

Remediation:
A. Cementless and cemented fixation have been found to have equivalent outcomes with regards to wear
B. Cementless and cemented fixation have been found to have equivalent outcomes and survivorship overall, although cemented fixation may have better outcomes when used for femoral fixation of arthroplasty after femoral neck fractures in elderly patients.
C. Cementless fixation for total hip arthroplasty has been found to have a higher incidence of periprosthetic femoral fracture compared with cemented femoral implants.
D. Cementless fixation for total hip arthroplasty has been found to have a higher incidence of periprosthetic femoral fracture compared with cemented femoral implants.

10 / 10

Foot & Ankle

A 40-year-old female patient presents with increasing pain under her tibial sesamoid for the past 1 year. She has failed nonoperative treatment and is now requesting surgery. Radiographs demonstrate a fractured tibial sesamoid with dense sclerosis. Which of the following is the most appropriate treatment?

A. Dorsiflexion osteotomy of the 1st metatarsal

B. Vascularized bone-grafting and sesamoid open reduction and internal fixation

C. 1st metatarsophalangeal (MTP) joint arthrodesis

D. Tibial sesamoid excision

Remediation:
A. Dorsiflexion osteotomy is of benefit with sesamoid overload. However, it would not address the underlying sesamoid fracture and osteonecrosis.
B. This procedure is technically demanding and has not been shown to be of greater benefit than simple excision of the tibial sesamoid.
C. 1st MTP joint fusion is a salvage option, but tibial sesamoid excision will more directly address the tibial sesamoid pain and preserve function.
D. The sesamoid has a chronic fracture and has developed sclerotic changes that make fixation unlikely to succeed. Isolated tibial excision will provide pain relief, preserve function, and has a relatively low complication rate.

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