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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QUIZ of the Month Title Image with Orthopaedic Icons

June 2024

1 / 10

Trauma

You are called to assess a 40-year-old male patient who was a victim of a hit-and-run collision with a car. The car's bumper hit the lateral aspect of his left knee. You suspect he may have a knee dislocation. Which of the following should be included in the initial evaluation of the patient?

Remediation:
A. The initial evaluation of any patient with an extremity fracture includes assessment of the neurovascular status distal to the fracture to assess for possible vascular injury and compromise.
B. Assessing for open wounds is important to determine the need for and urgency of operative intervention.
C. The patient should be evaluated for any additional fractures or associated soft-tissue injuries.
D. Knee aspiration is not part of the initial examination of a trauma patient.
E. The patient has no injury to the head and had no loss of consciousness, so a head computed tomography scan is not indicated as part of the initial evaluation.

2 / 10

Sports Medicine

A 19-year-old male patient who is a football running back sustains a knee injury followed by an acute hemarthrosis. A plain radiograph of the knee is shown, demonstrating a displaced osteochondral fragment. Which of the following would be an appropriate next step in management?

Remediation:
A. The patient has a large loose body that should be removed, and the fracture should be treated with fixation.
B. Same as A
C. Same as A
D. Same as A

3 / 10

Spine

A 15-year-old female patient with adolescent idiopathic scoliosis (AIS) undergoes a posterior thoracic spine instrumented fusion. Imaging is shown. The operation was performed with a dedicated team of spinal anesthesiologists, nurses, and scrub technicians. Which of the following has been shown to be a benefit of using dedicated teams in the operative management of AIS?

spine

Remediation:
A. Shorter operative and total operating room time, reduced costs, less blood loss, and fewer blood transfusions are the benefits of using a dedicated team in the operative management of AIS.
B. Improvements in patient satisfaction are not a benefit of using a dedicated team in the operative management of AIS. Shorter operative and total operating room time, reduced costs, less blood loss, and fewer blood transfusions are the benefits of a dedicated team in the operative management of AIS.
C. Same as A
D. Same as A
E. Fewer neuromonitoring changes intraoperatively are not a benefit of using a dedicated team in the operative management of AIS. Shorter operative and total operating room time, reduced costs, less blood loss, and fewer blood transfusions are the benefits of using a dedicated team in the operative management of AIS.
F. Improvements in HRQoL outcome scores are not a benefit of using a dedicated team in the operative management of AIS. Shorter operative and total operating room time, reduced costs, less blood loss, and fewer blood transfusions are the benefits of using a dedicated team in the operative management of AIS.

4 / 10

Shoulder and Elbow

Following repair of a small-to-medium rotator cuff tear, which of the following best describes the differences in outcomes at 6 months between early mobilization and early immobilization?

Remediation:
A. An early range-of-motion protocol after repair of a small-to-medium rotator cuff tear has shown improved range of motion and lower VAS pain scores when compared with a sling immobilization protocol.
B. An early range-of-motion protocol after repair of a small-to-medium rotator cuff tear has shown better patient satisfaction when compared with a sling immobilization protocol.
C. There is no difference in retear rates at 6 months following repair of a small-to-medium rotator cuff tear with a sling immobilization protocol when compared with an early range-of-motion protocol.
D. Sling immobilization after repair of a small-to-medium rotator cuff tear has shown slightly higher visual analog scale (VAS) pain scores at 6 months when compared with an early range-of-motion protocol.

5 / 10

Pediatrics

An 8-month-old girl presents for follow-up of idiopathic right clubfoot that was treated with a Ponseti casting protocol. She was prescribed a foot abduction orthosis, but the brace appears clean and unused. On examination, she has recurrence of equinus and hindfoot varus. Which of the following treatment options would be appropriate at this time?

Remediation:
A. A short-leg cast is less effective than a long-leg cast. Ponseti principles recommend long-leg casting.
B. A tibialis anterior tendon transfer is not recommended until about age 2.5 years, when the lateral cuneiform has ossified.
C. While an extensile posteromedial release may be necessary for some clubfoot recurrences, it is not recommended for a first-time recurrence.
D. Recasting using the Ponseti technique is recommended given the lack of compliance with bracing.

6 / 10

Basic Science and Pathology

Which of the following accurately describes microRNA (miRNA) and its role in cancer?

Remediation:
A. miRNAs may act to inhibit tumor suppressor genes. In doing so, they can promote tumor growth.
B. miRNAs can activate proto-oncogenes and may act as an oncogene, promoting cell division and cancer formation.
C. miRNAs are associated with cancer and have been proposed to be causative.
D. miRNAs tend to be biologically stable and reproducible. As such, they may be used as reliable biomarkers for diagnosis.
E. miRNAs are known to activate proto-oncogenes, promoting a cancer phenotype.

7 / 10

Hand and Wrist

A 4-year-old boy presents with a type-IIb cleft hand. After discussion with the boy's parents, the decision is made to proceed with a 2-stage operative reconstruction. Which of the following components of the reconstruction should be performed in the first stage?

Remediation:
A. A first web-space deepening is not correct as the cleft must also be closed.
B. Cleft closure is performed first as the web-space deepening and thumb reconstruction will likely place incisions in the region where local flaps are needed for cleft closure, resulting in skin compromise.
C. A thumb is present in this case so index pollicization is not necessary.
D. A thumb is present in this case so a toe-to-thumb transfer is not necessary.

8 / 10

Foot and Ankle

A 59-year-old female patient with severe rheumatoid arthritis presents with progressive deformity in her foot and severe pain that limits her walking. She has failed nonoperative treatment and would like to consider surgery. Which of the following is the most appropriate option for her?

foot ankle

 

Remediation:
A. This is often referred to as a Hoffman-Clayton procedure and is most commonly used on a rheumatoid forefoot with recalcitrant arthritis and deformity, as seen in the image. The 1st MTP joint is fused for stability while the lesser metatarsal heads are resected (resection arthroplasty) to allow motion in the lateral foot.
B. With her degree of hallux overlap, the only option to maintain a stable 1st metatarsophalangeal joint is with a fusion. This also does not address the hammer toes.
C. This may be an option in a very low-demand elderly patient with pain under the 2nd and 3rd toes due to the overlapping hallux. It likely is not appropriate for this patient.
D. This will not address her forefoot deformities and is more commonly performed for a flat foot reconstruction.

9 / 10

Knee

A 33-year-old female patient presents with 10 years of anterior knee pain that is progressively worsening. She has pain with weightbearing activities, when climbing stairs, kneeling, and squatting. On examination, she has a mild knee effusion, normal knee alignment and patellar mobility, range of motion of 0° to 125°, and mild crepitus. Radiographs show preservation of the joint space. Despite several nonoperative interventions, including daily nonsteroidal anti-inflammatory drugs, occasional corticosteroid injections, and weight loss, she continues to have pain and limitations in her activities. Which of the additional following treatment modalities is most appropriate for this patient?

Remediation:
A. Bracing in the absence of a ligament injury or instability has not been shown to reliably improve anterior knee pain.
B. Evidence in the efficacy of glucosamine-chondroitin supplementation is currently lacking.
C. The history and examination are consistent with patellofemoral pain. Low-impact exercises, weight loss, and activity modifications more consistently relieve pain and improve function in patients with symptomatic anterior knee pain.
D. There is no robust evidence supporting the use of stem cell therapies in the management of anterior knee pain in a young patient.
E. A medial heel wedge is most effective at unloading the medial compartment of the knee. It has no effect on anterior knee pain.

10 / 10

Hip

A 54-year-old female patient with rheumatoid arthritis presents with long-standing right hip pain. Her imaging is shown. She says her rheumatologist has been prescribing hydrocodone-acetaminophen (10/325 mg) for her hip pain since “acetaminophen alone doesn’t work and naproxen upsets my stomach." She takes 4 to 6 of these pills per day for pain relief but is running low. She would like to discuss total hip arthroplasty (THA). Which of the following is the best approach to her opioid use?

hip

Remediaton:
A. Referral to a pain management specialist is the best way to optimize this patient prior to her procedure. A 2016 study of chronic opioid users with end-stage arthritis found that those who were successfully weaned prior to their procedures had better postoperative outcomes than those who were not. While patients may try to decrease their daily morphine equivalent intake on their own, a weaning program is best managed by a pain specialist.
B. Chronic opioid use has been associated with worse postoperative outcomes, but that in itself is not necessarily a reason to decline to perform a procedure for a patient with the appropriate indications for surgery who could benefit from undergoing THA.
C. While PCA infusions were common 5 to 10 years ago, multimodal pain regimens including acetaminophen, nonsteroidal anti-inflammatory drugs, anticonvulsants, and smaller doses of opioids are more commonly used now to minimize postoperative opioid addiction risk. Chronic opioid use is considered a modifiable risk factor and can be addressed with a preoperative weaning program under the direction of a pain management specialist.
D. Chronic opioid use is considered a modifiable risk factor that can be addressed with a preoperative weaning program under the direction of a pain management specialist. As an orthopaedic surgeon, you are under no obligation to write prescriptions for chronic opioids to treat arthritis, and according to the American Association of Orthopaedic Surgeons (AAOS) guidelines, opioids are not a recommended treatment for hip or knee arthritis.

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