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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

March 2024

1 / 10

Trauma

Which of the following best describes the etiology and treatment of femoral shaft fractures?

Remediation:
A. Most femoral shaft fractures are caused by high-energy trauma such as a motor-vehicle collision.
B. The "gold standard" for fixation of a midshaft femoral fracture is a reamed, locked femoral nail.
C. The incidence of ipsilateral femoral neck and shaft fractures is 3-9%. Preoperative x-ray and CT scan assessment of the femoral neck decreases the amount of undiagnosed femoral neck fracture. After femoral nailing, dynamic flouroscopic imaging of the femoral neck should be performed to rule out occult femoral neck fracture.
D. Rotational malalignment is the most common malreduction seen after intramedullary nailing of femoral shaft fractures.
E. Intramedullary nailing is the gold standard for diaphyseal femur fractures.

2 / 10

Sports Medicine

A 27-year-old female patient who is a tennis player injures her wrist in a fall. Magnetic resonance imaging demonstrates the injury (noted by an arrow on the image). Which of the following treatment options are appropriate at this time?

Remediation:
A. This is an acute avulsion of the triangular fibrocartilage complex. Either immobilization or acute repair would be appropriate treatment options.
B. Same as A
C. Same as A
D. Same as A

3 / 10

Spine

A 37-year-old male patient underwent a primary lumbar discectomy of a left paracentral L5-S1 disc herniation 3 years ago with complete resolution of his leg pain. Six weeks ago, he was carrying heavy boxes and experienced a recurrence of the same symptoms. After 4 weeks of physical therapy, magnetic resonance imaging demonstrates a recurrent left paracentral L5-S1 disc herniation. When discussing revision discectomy with the patient, you tell him that which of the following is more likely with revision discectomy?

Remediation:
A. A subanalysis of patients in the SPORT trial who underwent primary versus revision discectomy found there were no significant differences between the groups in operative time, blood loss, dural or nerve root injuries, or postoperative hematomas.
B. A subanalysis of patients in the SPORT trial who underwent primary versus revision discectomy found there were no significant differences between the groups in operative time, blood loss, dural or nerve root injuries, or postoperative hematomas.
C. A subanalysis of patients in the SPORT trial who underwent primary versus revision discectomy found there were no significant differences between the groups in operative time, blood loss, dural or nerve root injuries, or postoperative hematomas.
D. A subanalysis of patients in the SPORT trial who underwent primary versus revision discectomy found the revision group to have a significantly higher overall complication rate, longer length of hospital stay, and higher rates of wound infection.

4 / 10

Shoulder and Elbow

Which of the following are options for the management of the triceps during open reduction and internal fixation of the complex intra-articular distal humeral fracture that is shown?

Remediation:
A. While a triceps splitting approach can allow for visualization of the posterior aspect of the humerus, it does not give adequate visualization of the joint surface in the setting of severe comminution.
B. The extended Henry approach provides access to the volar aspect of the forearm which is not needed here.
C. This patient has substantial comminution of the joint surface which requires appropriate visualization to the joint surface with an olecranon osteotomy or a triceps tongue approach.
D. Same as C

5 / 10

Pediatrics

A 9-year-old girl presents with a history of repetitive lower-extremity fractures and frequent back pain. She has short stature for her age and is bow-legged. Radiographs of both lower extremities demonstrate poor ossification near widened physes and genu varum. She also has a history of premature loss of teeth. Which of the following laboratory test results would lead to a diagnosis of hypophosphatasia?

Remediation:
A. Decreased serum alkaline phosphatase levels with increased urine phosphoethanolamine and increased serum phosphate and calcium levels are diagnostic.
B. Same as A
C. Same as A
D. Same as A

6 / 10

Basic Science and Pathology

Microfracture, a clinical procedure used to treat articular cartilage lesions, results in the formation of a fibrocartilage repair tissue. Which of the following are features of fibrocartilage and render this tissue a poor replacement for articular/hyaline cartilage?

Remediation:
A. Fibrocartilage is the only type of cartilage that contains collagen types I and II collagen; type-I collagen does not have the ability to interact with proteoglycans, which provides the stability and strength to type-II collagen.
B. Fibrocartilage contains less aggrecan than hyaline cartilage, resulting in less water drawn into the extracellular matrix (ECM); therefore, the compressive modulus is lower.
C. Fibrocartilage contains less aggrecan than hyaline cartilage, resulting in less water drawn into the extracellular matrix (ECM); therefore, the tissue stiffness is lower.
D. Fibrocartilage contains type-I collagen, which does not have the ability to interact with proteoglycans like hyaline cartilage, which is predominantly composed of type-II collagen.
E. Fibrocartilage contains less aggrecan than hyaline cartilage, resulting in less water drawn into the extracellular matrix (ECM) and, therefore, an increase in hydraulic permeability.

7 / 10

Hand and Wrist

A 41-year-old male patient who is a shipping agent presents at the request of his worker's compensation attorney for a second opinion regarding a left wrist injury he sustained 5 weeks ago when he had a ground-level fall work while carrying several boxes. He does not recall a previous wrist injury and is upset that the insurance carrier is denying that he has an acute fracture. Lateral and oblique radiographs of his wrist and a single coronal view of his computed tomography scan obtained 1 week ago are shown. You counsel him that while his injury may have been aggravated by his fall, within a reasonable degree of medical probability his scaphoid fracture occurred prior to his recent injury. Your advice to the patient is based on which of the following radiographic findings?

Remediation:
A. Flexion deformity, rather than extension deformity, through the fracture site, the so-called "humpback deformity," is typical of scaphoid nonunions.
B. Sclerosis and beaking of the radial styloid is the first stage of scaphoid nonunion advanced collapse. The radial styloid bone spurring signifies the start of degenerative changes in the scaphoid fossa.
C. Cortication at the fracture site can be seen in established scaphoid nonunions.
D. Intraosseous cyst formation at the fracture site can be seen in established scaphoid nonunions and signifies bone resorption.

8 / 10

Foot and Ankle

A 45-year-old female patient presents for evaluation of her big toe pain. She has pain at the ends of range of motion of the hallux metatarsophalangeal (MTP) joint and tenderness over a dorsal osteophyte. An initial radiograph is shown. During a cheilectomy, it is found that she has minimal degenerative changes on the dorsal metatarsal head. After removal of the dorsal osteophyte, she has limited dorsiflexion but full plantar flexion of the metatarsophalangeal joint. Which of the following is the most appropriate next step intra-operatively?

Remediation:
A. A proximal phalanx dorsal closing-wedge (Moberg) osteotomy can be used to improve dorsiflexion at the expense of the loss of some plantar flexion.
B. A proximal phalanx lateral closing-wedge (Akin) osteotomy is used for correction of hallux valgus interphalangeus.
C. The patient has minimal degenerative changes, and the primary problem is lack of dorsiflexion, which would not be addressed by microfracture.
D. Patients with low-grade hallux rigidus with preserved plantar flexion can achieve good results by trading some plantar flexion for dorsiflexion with a proximal phalanx dorsal closing-wedge osteotomy.

9 / 10

Knee

A 37-year-old female patient presents with a 3-month history of left anterior knee pain. She reports that she was training for a half marathon and had to stop because of persistent knee pain. She has no history of a previous knee injury or symptoms. Her pain is worse with running but she does not have symptoms with her usual activities of daily living. Physical examination reveals a lateral tracking patella without apprehension. Radiographs reveal a lateral patellar tilt without any evidence of tibiofemoral disease. Which of the following is the most appropriate treatment recommendation for this patient?

Remediation:
A. Corticosteroid injections provide symptomatic relief but, in this instance, overuse during high-impact activity is the likely cause of her symptoms. As such, rest and activity modifications are most appropriate.
B. Operative intervention is usually a last resort. In addition, there is no evidence of patellar instability so operative intervention is not indicated.
C. Operative intervention is usually a last resort. While this patient has lateral tilt, she is not symptomatic with activities of daily living. Therefore, surgery would not be the most appropriate treatment at this time.
D. Rest, activity modification, and low-impact exercises are initially recommended in cases of symptomatic overuse.
E. Operative intervention is usually a last resort. Without evidence of patellar instability, proximal extensor mechanism realignment is not appropriate.

10 / 10

Hip

Which of the following medications prescribed for rheumatoid arthritis are not necessarily withheld prior to joint arthroplasty?

Remediation:
A. Recent guidelines for perioperative medication administration in patients with rheumatoid arthritis state that the current dose of methotrexate, leflunomide, hydroxychloroquine, and/or sulfasalazine may be continued without interruption for patients undergoing elective total hip or knee arthroplasty. Oral corticosteroids may be continued with the possible need for stress dosing perioperatively.
B. Same as A
C. Adalimumab is a tumor necrosis factor (TNF) alpha blocker. Guidelines recommend withholding all biologic agents prior to surgery in patients undergoing elective total hip or knee arthroplasty and planning the surgery at the end of the dosing cycle for that specific medication when possible.
D. Tafacitinib is a biologic enzyme inhibitor (janus kinase 1 and 3). Guidelines recommend withholding all biologic agents prior to surgery in patients undergoing elective total hip or knee arthroplasty and planning the surgery at the end of the dosing cycle for that specific medication when possible.
E. Infliximab is a tumor necrosis factor (TNF) alpha blocker. Guidelines recommend withholding all biologic agents prior to surgery in patients undergoing elective total hip or knee arthroplasty and planning the surgery at the end of the dosing cycle for that specific medication when possible.

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