Question1

WhichofthefollowingdrugsisadirectfactorXainhibitor?
Phenindione
Rivaroxaban
Aspirin
Clopidogrel
Dalteparin
References
http://en.wikipedia.org/wiki/Anticoagulant
AOnceDaily,Oral,DirectFactorXaInhibitor,Rivaroxaban(BAY59
7939),forThromboprophylaxisAfterTotalHipReplacement
BengtI.ErikssonetalCirculation.2006;114:23742381
Question2
Thefollowingstatementregarding1984modificationofGustiloand
Anderson'sclassificationofopenfracturesistrue:
TypeIIinjuriesareheavilycontaminated
TypeIIIBinjurieshaveadequatesofttissuecover
TypeIinjurieshaveawoundlessthan2cmlong
TypeIIIAinjurieshaveadequatesofttissuecoverdespiteextensive
lacerations
AllarterialinjuriesaregradedTypeIIICregardlesswhetherthearterial
injuryrequiresrepairornot.
References
TypeIIIwasreclassifiedintoA,BandCinthe1984modification.Gustilo,
RB.,MendozaRM.,WilliamsDN.ProblemsinthemanagementoftypeIII
openfractures:anewclassification.journaloftrauma24:742746,1984
JOrthopTrauma.1993;7(4):35760.
InterobserverreliabilityintheGustiloandAndersonclassificationofopen

fractures.
HornBD,RettigME
JAmAcadOrthopSurg.2010Jan;18(1):109.
Opentibialshaftfractures:I.Evaluationandinitialwoundmanagement.
MelvinJS,DombroskiDG,TorbertJT,KovachSJ,EsterhaiJL,MehtaS.
OpenfractureclassificationafterGustiloandAnderson
GradeI
Smallintooutwound(<1cm).Lowenergyinjury,nosofttissuecrushing
orstripping,nobonycomminution.
GradeII
Lacerationoverfracture(110cmwound).Lowenergyinjury,minimalsoft
tissue
crushingorstripping,nobonycomminution.
GradeIIIA
GradeIIIB
GradeIIIC
Highenergyinjury,bonycomminutionorsegmentalfracture,softtissue
crushing
strippingorseriouscontaminationbutadequatesofttissuecoverafter
debridement.
Highenergyinjury,bonycomminutionorsegmentalfracture,softtissue
crushing
strippingorseriouscontamination,inadequatesofttissuecoverafter
d6bridement
Anyopenfractureassociatedwithalocalvascularinjuryrequiringrepair.
theseverityofthewoundtoothercliniciansandthus
preventrepeatedandpotentiallycontaminating
woundexaminationsoutsideofasterileenvironment.
SURGICALCLASSIFICATION
Formalclassificationoftheopenfractureoccursafter
surgicaldebridement.Themostwidelyusedsystemis

thatattributedtoGustiloandAnderson.7,8Thisclassifies
theinjuryintothreetypes,withthehighenergy
injuriessubdividedintothreefurthergroups(Table2).
Thissystemhasstoodthetestoftimeandiswidely
understood.Theessentialelementsbeingthedifferentiation
betweenhighandlowenergyinjuriesandthe
conceptofadequacyofsofttissuecoverinthehighenergy
injuries.
Thesiteofthefracturehasanimportanteffecton
theinjurygrade,particularlywithregardtoquantity
oflocalmusclecoverandthevulnerabilityofthelocal
softtissuetoinjury.Afractureinthenormalfemur
hastobehighenergybecauseoftheintrinsicstrength
ofthebone;accordinglyallopenfemurfractures
mustbegradeIII,althoughthethickmusclecoverof
thethighusuallyprovidesadequatesofttissuecover.
Incomparison,thetibiaisuniquewithregardtoits
poorsofttissuecoverandparticularvulnerabilityto
injury.Accordingly,itisdifficulttohaveagradeIIIa
injurytothetibialdiaphysiswheremosthighenergy
diaphysealanddistaltibialfracturesaregradeIIIb
andrequirecomplexreconstructivesurgery.Themost
severeinjury(IIIc)istheopenfractureassociatedwith
avascularinjurythatrequiresrepair.Thesecanoccur
witheitherasevereorveryarelatively'minor'would.
Thehighgradingisbecauseoftheprimaryrisktothe
limbassociatedwiththearterialdisruptionandthe
susceptibilityofischaemicmuscletoinfection.
Asimilarclassificationsystemforclosedfractures
hasbeenproposedbyTscherne.4Thisalsodescribes
therangeofsofttissueinjuriesfromessentiallyno
significantinjurytomajorvasculardisruption,severe
musclerevitalizationorcompartmentsyndrome,all
withinaclosedskinenvelope,afullerclassification
systemconsideringbothinjurytypesisprovidedby
thecomprehensiveclassificationfromtheAO.9This
individuallyclassifiestheintegument,nerveandvascular
tissuesproducingamorecomprehensiveand
detailedsystem

Question3
Ofthefollowingconditions,whichiscausedbyapointmutationforthe
geneencodingfibroblastgrowthfactorreceptor3(FGFR3)?
EhlersDanlosSyndrome
Marfan'sSyndrome
Duchenne'sMuscularDystrophy
Achondroplasia
BeckerMuscularDystrophy
References
www.orthoteers.com
www.wheelessonline.com
Autosomaldominantdisorder.
Arisesduetoapointmutationforthegeneencodingafibroblastgrowth
factor(Fibroblastgrowthfactorreceptor3).
over80%ofallpersonswiththisdisorderareborntoparentswhoarenot
achondroplastic,&suchparentsrarelyhavesecondachondroplasticchild.
Itispresumedintheseinstancesthatdisorderisconsequenceofmutation
andmayberelatedtoamutationinafibroblastgrowthfactorgene.
Question4
WhichofthefollowingisNOTacommonriskfactorforthedevelopmentof
hypertrophicandkeloidscars?
Deepskinwounds
Darkpigmentedskin
Oldage
Woundtension

Delayedhealing
References
EssentialrevisionnotesfortheintercollegiateMRCS
C.ParchmentSmith
Aetiologyandmanagementofhypertrophicscarsandkeloids.
O'SullivanST,O'ShaughnessyM,O'ConnorTP.
AnnRCollSurgEngl.1996May;78(3(Pt1)):16875.
Hypertrophicscarsandkeloidscanbedescribedasvariationsoftypical
woundhealing.Inatypicalwound,anabolicandcatabolicprocessesachieve
equilibriumapproximately68weeksaftertheoriginalinjury.Atthisstage,
thestrengthofthewoundisapproximately3040%thatofhealthyskin.As
thescarmatures,thetensilestrengthofthescarimprovesasaresultof
progressivecrosslinkingofcollagenfibers.Atthispoint,thescarisusually
hyperemicanditmaybethickened,butittendstosubsidegraduallyover
monthsuntilaflat,white,pliable,possiblystretched,maturescarhas
developed.Whenanimbalanceoccursbetweentheanabolicandcatabolic
phasesofthehealingprocess,morecollagenisproducedthanisdegraded,
andthescargrowsinalldirections.Thescariselevatedabovetheskinand
remainshyperemic.Excessivefibroustissueisclassifiedaseitherakeloidor
ahypertrophicscar.

Question5
Whichofthefollowingdescribestherelationshipbetweenintensityofanx
raybeamandthedistancefromitssource?
Attenuationcoefficient
Bragg'slaw
Comptoneffect
Inversesquarelaw
Photoelectriceffect
References

ManojRamachandran,TheStanmoreguide:Pg51
Theintesityofanxrayisindirectlyrelatedtothesquareofthedistance
fromitssourcetheinversesquarelaw

Question6
Regardingobtainingconsentforanoperativeintervention,whichofthe
followingstatementsistrue?
Therefusalofacompetentpersonaged1617canneverbeoverriddenby
eitherapersonwithparentalresponsibilityoracourt.
Refusalbyacompetentchildandallpersonswithparentalresponsibilityfor
thechildcanbeoverruledbythecourtifthewelfareofthechildso
requires.
Aparentorrelativecangiveconsentonbehalfofanadultunabletogive
consentforhimorherself(anincapableadult).
Whenapatientgivesvalidconsenttoanintervention,ingeneralthatconsent
remainsvalidforaperiodoffourweeksafterwhichtimeitmustbere
obtained.
Consentmayonlybeobtainedbytheclinicianprovidingthetreatmentor
investigation
References
Referenceguidetoconsentforexaminationortreatment,March2001
http://www.gosh.nhs.uk/clinical_information/clinical_guidelines/cpg_guideli
ne_00151
Question7
AccordingtotheMusculoskeletalTumourSociety,excisionofatumour
throughthepseudocapsuleofatumour(thereactivezone)isdescribedas
whichofthefollowing?
Amputation
Intralesional
Marginal
Radical

Wide
References
SimFH,FrassicaDA:Softtissuetumours:Diagnosis,evaluationand
management.AAOS2:209,1994
SurgicalmarginsaregradedaccordingtoMSTSasfollows:
Intralesional:Planeofdissectionisthroughtumour.
Marginalmargin:Marginallineofresectionthroughreactivezoneof
tumour.
Widemargin:Entiretumourisremovedwithcuffofnormaltissue.
Radicalmargin:Entiretumourandcompartmentisremoved
Question8
Whichofthefollowingaccountsfor6580%ofthedrymassofflexor
tendons?
CollagentypeI
CollagentypeII
CollagentypeIII
CollagentypeIV
Elastin
References
CollagenOne:skin,tendon,vascular,ligature,organs,bone(main
componentofbone)
CollagenTwo:cartilage(maincomponentofcartilage)
CollagenThree:reticulate(maincomponentofreticularfibers)
CollagenFour:formsbasesofcellbasementmembrane
CurrentConceptsReview
TendonInjuryandTendinopathy:HealingandRepair
PankajSharma,NicolaMaffulli
TheJournalofBoneandJointSurgery(American).2005;87:187202
Question9

Mayfieldstagefourperilunateinjuryischaracterisedbywhichofthe
following
LunoTriquetralinjury
ScaphoLunateinjury
Lunatedislocation
LunoCapitateinjury
PisoTriquetralinjury
References
Green'sOperativeHandSurgery5thEdition,Page542543.
Mayfield'sClassisficationdescribesaconsecutivepatternofperilunatejoint
disrutption.
StageI:ScaphoLunate
StageII:LunoCapitate
StageIII:Lunotriquetral
StageIV:Lunatedislocation
Question10
Withreferencetospicacasttreatmentoffemoralshaftfracturesina5year
oldchild
25degreesofcoronalplanedeformityisacceptable.
Femoralshorteningof4cmisacceptableduetolaterovergrowth.
25degreesofsagittalplanedeformityisacceptable.
Themoreproximalthefracture,thelesserthehipflexionrequiredinthe
spica.
20degreesofrotationaldeformityisacceptable.
References
Acceptablealignmentdependsuponthechild'sagebutingeneral,nomore
than15degreesofdeformityinthecoronalplaneand25to30degreesinthe
sagittalplaneisacceptable.Shorteningshouldnotexceed2cm.
Thehipsshouldbeflexedto60to90degreestoalignthedistalfragment
withtheflexedproximalfragment.Thehigherthefracture,themorethehips
shouldbeflexed

Spicacasttreatmentisappropriateonlyforchildrenuptotheageof10years.
Fora11yearoldpatient,internal(plates,rods)orexternalfixationoptions
shouldbeconsidered
Tachdjian'sPediatricOrthopaedics.4thedition.2008.LowerExtremity
Injuries.Femur.pp263

Question11
ClottingstudiesonapatientwithhaemophiliaAaremostlikelytoshowthe
following
ProlongedAPTTandPT
ProlongedAPTTandnormalPT
ProlongedAPTTandreducedPT
NormalAPTTandprolongedPT
ReducedAPTTandprolongedPT
References
Prothrombintimeismeasureofextrinsicpathwayofcoagulationand
activatedpartialthromboplastintimeismeasureofintrinsicpathwayof
coagulation.HeamophilaAaccountsfor80%ofallheamophiliasandisdue
tofactorVIIIdeficiency.
ProlongedAPTTandPT:FactorV,Xdeficiency,DIC,Warfarin
ProlongedAPTTandnormalPT:Hemophilia,VonWillebrand'sdisease
NormalAPTTandprolongedPT:earlyliverfailure
www.gpnotebook.com
www.wheelesonline.com

Question12
InClassIIhypovolaemicshockthecharacteristicfindingwouldbe
SystolicBPfallsto100mmHgorless
Tachycardia>100/min
3040%bloodloss
Urineoutput<15mls/hour
Pulsepressureisincreased
References
AdvancedTraumaLifeSupportStudentCourseManual8thEdition
AclassIIhaemorrhagicshockresultsinabloodlossofaround7501500mls
(1530%ofbloodvolume).Inthiscategoryofshock,theHRisaround100
120,BPisnormal,Pulsepressureisdecreased,RRisaround2030,urine
outputisaround2030ml/hr,andthepatientismildlyanxious.
Question13
Apatientattendsforaroutine3monthpostoperativecheckfollowingatotal
hiparthroplastyperformedviaalateralapproach.Heisnotedtohavea
positivetrendelenburgsign.Thisismostlikelyduetodamagetowhich
nerve?
Inferiorglutealnerve
Superiorglutealnerve
Sciaticnerve
Nervetopiriformis
Obturatornerve
References
Miller,4thed.
Thisisasimplequestiontestingbothknowledgethattrendelenburgsignis
causedbyweakabductorsandthatthesemusclesaresuppliedbysup.gluteal
nerve

Arisesfromthelumbosacralplexus,arisesfromposteriorbranchesL4,L5,
S1
exitsthepelvisandenterstheglutealregiointhroughtheuppermarginofthe
greatersciaticnotch,justsuperiortothepiriformismuscle.Itcourseswith
superiorglutealarterybetweengluteusmediusandminimus,andsupplies
motorbranchestobothaswellasthetensorfascialata.
Twopatternsofneuralbranchingwereestablished.Thepointsoftermination
ofallbranchesformedanarcuatepatternalongthemiddleonethirdofthe
deepsurfaceofthegluteusmediusmuscle.Thesocalledsafeareaofthe
gluteusmediusmusclewasfoundtobeasmuchasfivecentimetersadjacent
tothegreatertrochanter.Ifthisdistanceisnotexceededbytheintramuscular
incision,therisktothesuperiorglutealnerveanditsbrancheswillbe
minimum.

Question14
Apatienthasneurogenicshock.Whichofthefollowingisthelikelyclinical
finding?
Cessationofneurogenicshockisheraldedbyreturnofbulbocavernosus
reflex
Systemichypotensionwithtachycardiafollowingspinalcordinjury
Systemichypotensionwithbradycardiafollowingspinalcordinjury
Cold,moistskin
Lossofparasympathetictone
References
http://emedicine.medscape.com/article/793582overview(goodoverview
article)
n.bWheelessTextbookhasconfusingterminology!

Neurogenicshockisatypeofshockcausedbythesuddenlossofthe
autonomicnervoussystemsignalstothesmoothmuscleinvesselwalls.It
usuallyoccursabovethelevelofT6(outflowbetweenC7&L1).
Traumacancauseaconcussionlikeinjurytospinalcordwhichleadstototal
sensoryandmotorpowerlossandlossofallreflexesforsomeperiod
followedbygradualrecoveryofreflexes.Thisstateisknownasspinalshock.
Itisclinicallyimportanttodistinguishhypovolaemic/spinal/neurogenic
shock.
1)Bulbocavernosusreflexreturnheraldstheendofspinalshock
2)Hypotensionwithtachycardiaishypovolaemicshock
3)Lossofsympathetictoneisfoundinneurogenicshock
4)Warm,dryskin(noperipheralvasoconstriction)

Question15
Afemoralvarusosteotomyincreaseswhichofthefollowing
Abductorleverarm
Adductorleverarm
Moreverticallineofactionoftheabductors
Noeffect
Weightbearingaxis
References
LovellandWinter'spediatricorthopaedics,Volume2ByWoodW.Lovell,
RobertB.Winter,RaymondT.Morrissy,StuartL.Weinstein
Page1072

Question16
A65yearoldmanhasasuspectedsepticarthritisofhiselbow.Whatarethe
bestlandmarksusedforaspiratinghisjoint?
Proximalandmedialtomedialepicondyleandtipofolecranon
Anterioranddistaltomedialepicondyle
Proximaltotipofolecranon
Betweenradialhead,lateralepicondyleandtipoftheolecranon
Anteriortolateralepicondyle
References
Wheeless(http://www.wheelessonline.com/ortho/aspiration_of_elbow_joint)
Discussion:
elbowcanbeenteredeitherulnarlyorradially,butradialapproachis
preferredinordertoavoidulnarnerveinjury;
radialnerveisliesanteriortotheelbowjoint,andmaybemovedeven
moreanteriorlybysupinatingtheforearm;
landmarksforaspirationoftheelbowjointaretheradialhead,lateral
epicondyle,andtipoftheolecranon(aconeustriangle);
priortoneedleinsertion,elbowflexedandpronatedtoprotecttheradial
nerve;
18gaugeneedleisthenplaceintothejointthruthesoftspot;
w/thisapproach,needlewillpenetrateonlytheanconeus&capsule
Question17
WhichofthefollowingdoesNOTleadtoathrombotictendency?
FactorVLeiden
Antithrombindeficiency
ProteinCandSdeficiency

Heparininducedthrombocytopenia
AntiProteinZdeficiency
References
AnesthAnalg.2010Nov16.
EtiologyandAssessmentofHypercoagulabilitywithLessonsfromHeparin
InducedThrombocytopenia.
SniecinskiRM,HurstingMJ,PaidasMJ,LevyJH.
ThrombRes.2008;121(6):72734.
ProteinZlevelsandantiproteinZantibodiesinpatientswitharterialand
venousthrombosis.
PardosGeaJ,OrdiRosJ,SerranoS,BaladaE,NicolauI,VilardellM.

Question18
WhichisthegoldstandardtestfordiagnosingpostoperativeDeepVein
Thrombosis(DVT)?
DuplexUltrasonography
125Ilabelledfibrinogen
DDimer
Venography
ImpedancePlethysmography

References
Duplex:goodforproximalthrombibutpoorforcalforpelvis,cheapandnon
invasivethereforemostcommon
Venography:goldstandard,usedinmostclinicaltrialsbutcostlyand
invasive
DDimer:verynonspecific,costlyandhighinpostoperativesetting
AAOSComprehensiveorthopaedicreviewpage155
Question19
Whichofthefollowingsuturematerialsisnonabsorbable?
Polyglactin
Polybutester
Polyglyconate
Polydioxanone
Polyglycolicacid
References
Basicplasticsurgerytechniquesandprinciples:Choosingtherightsuture
materialBayatA:studentBMJ2003;11:131174MayISSN09666494
Polybutester(Novofil)isanonabsorbablesuturewithmorecomplianceand
elasticitythanpolpropylene.Theothermaterialsmentionedare
biodegradablepolymers.
Absorbablenaturalsutures
Collagen
Plainsurgicalgut
Fastabsorbingsurgicalgut
Chromicsurgicalgut
Absorbablesyntheticsutures
Polyglactin910(Vicryl)
Polycaprolate(DexonII)
Poliglecaprone25(Monocryl)
Polysorb
Polydioxanone(PDSII)

Maxon
VLoc
Absorbablemonofilamentsutures
Caprosyn
Absorbablemultifilamentsutures
Nonabsorbablenaturalsutures
Surgicalsilk
Surgicalcotton
Surgicalsteel
Nonabsorbablesyntheticsutures
Nylon
Polyesterfiber(Mersilene/Surgidac[uncoated]andEthibond/Ticron
[coated])
PolybutesterSuture(Novafil)
CoatedPolybutesterSuture(Vascufil)
Polypropylene(Prolene)
SurgiproII

Question20
TheIdebergclassificationisusefulwhenplanningsurgicaltreatmentof
glenoidfractures.Ahorizontalfracturethroughtheglenoidandscapular
bodywithnoadditionalglenoidfracturecomprisesanIdebergtype:

I
II
III
IV
V
References
IdebergR.Fracturesofthescapulainvolvingtheglenoidfossa.In:
BatemanJE,WelshRP,eds.Surgeryoftheshoulder.Philadelphia:Decker,
1984:636.
IdebergClassification
TypeIAnterioravulsionfractures
TypeIITranverse,inferiorglenoid
TypeIIITranverse,superiorglenoid
TypeIVTransverse,throughbody
TypeVCombooftypesIIandIV
Question21
Thetypicalanteriorapproachtothecervicalspineusestheplanebetween
whichofthefollowingstructures?
Thecarotidartery(laterally)andjugularvein(medially)
Thecarotidsheath(laterally)andthetracheaandesophagus(medially)
Theinferiorthyroidartery(medially)andthecarotidsheath(laterally)
Thebrachialplexus(laterally)andthecarotidsheath(medially)
Thetrachea(laterally)andtheesophagus(medially)
References
Hoppenfeld&DeBoerSurgicalExposuresinOrthopaedics:TheAnatomic
Approach(PublishersLWW)
Thereare3layersoffasciawhichgoverntheanteriorapproachtotheneck.
Thefirstistheinvestinglayerofdeepfascia(themostsuperficial)which
envelopessternocleidomastoidandsurroundsthenecklikeacollar.Incise
thistoretractSCMlaterally.Afteryougothroughthistheninorderto

retractthecarotidsheathlaterallyyouneedtoincisethepretrachealfascia
whichiscontinouswiththecarotidsheath.Finallytheprevertebralfascia
overliesthecervicalspine.
Question22
WhichoneofthefollowingstatementsisFALSEabouttriggerthumbsin
childhood:
Ifpresentatbirth,30%resolvespontaneouslyinoneyear
Overtheageofoneyear,lessthan10%resolvespontaneously.
30%arebilateral.
SurgicalreleaseoftheA1pulleyisthetreatmentofchoiceinchildrenover
theageofoneyear.
Thereisastrongfamilialinheritancepattern.
References
Thereisnofamilialinheritancepattern.Restofthestatementsarecorrect.
Triggerdigitsontheotherhandareseenwithneurologicsyndromes
(Trisomy18)andmucopolysaccharidoses.
Transverseincisioninthedigitalcreaseistobepreferredforabetterscar.
LovellandWinter'sPediatricOrthopaedics,6thEdn2006.TheUpperLimb,
pp922985.
Wheelessonline
iftriggerthumbispresentatbirth,approximately30%ofchildrenwill
recoverspontaneouslyinoneyear;
12%ofthetriggerthumbsthatdevelopattheageofsixto30months
recoverinsixmonths;
iftriggerthumbdevelopsinachildoverthreeyearsofage,however,it
almostneverimprovesspontaneously;
achildnotseenuntilaftertheageoffourhasa50percentchanceof
developingapermanentflexioncontracture
Question23

ApatientishavingatransarticularC1/C2screwfixation.Whichstructureis
mostatrisk?
C2nerveroot
Hypoglossalnerve
Carotidartery
Vertebralartery
Vagusnerve
References
J.P.Stannard.Surgicaltreatmentoforthopaedictrauma.2007,pg122123
AnterolateralC1C2TransarticularFixationforAtlantoaxialArthrodesis:
Landmarks,WorkingArea,andAnglesofApproach.
Cavalcantietal
Neurosurgery2010Sept67(3)p.3842(thispaperhasagreatpicture)
ThevertebralarteryadoptsaserpentinecourseinrelationshiptotheC2
vertebra,makingitsusceptibletoinjuryduringthesurgicalproceduresinthe
region.Themultipleloopsofthearteryandabufferspacewithinthe
vertebralarterygrooveontheinferiorsurfaceofthesuperiorfacetoftheC2
vertebraandovertheposteriorarchofatlasprovidethearteryanextralength
andspace,probablyessentialtoavoidanystretchduringneckmovements.
Question24
Whichofthefollowingmechanisminducesthedirectionalmigrationof
osteoblastsduringboneformation?
Activehyperaemia
Angiogenesis
Chemotaxis
Increasedmicrovascularpermeability
Hydrostaticpressure
References
IGFIsecretedbyosteoblastsactsasapotentchemotacticfactorfor
osteoblasts.
2008Nov;43(5):86979.

NakasakiM,YoshiokaK,MiyamotoY,SasakiT,YoshikawaH,ItohK.
IGFIsecretedfromosteoblastsinthebonetissueisapotentchemotactic
factorthatmayplayamajorroleinrecruitmentofosteoblastsduringbone
formation.
Question25
ThefollowingsignsallcorrelatetoacruciateligamentinjuryEXCEPT
PositiveLachman'stest
Positivedialtestin90degreesflexion
Positivedialtestin30degreesflexion
Positivepivotshifttest
Positivequadricepsactivetest
References
Thepivotshifttest.ClinOrthopRelatRes.1976JulAug;(118):639.
Useofthequadricepsactivetesttodiagnoseposteriorcruciateligament
disruptionandmeasureposteriorlaxityoftheknee.JBoneJointSurgAm.
1988Mar;70(3):38691.
CampbellsoperativeOrthopaedics,11theditionvolII,partXIII,chapter
43kneeinjuries.

Question26
Whichofthefollowingstatementsregardingthroughkneeamputationis
true?
Itisprimarilyindicatedinadultsasthedistalfemurprovides70%ofthe
femoralstrength
Athroughkneeamputationismorefunctionallysuccessfulthanabelow
kneeamputation
Thepatellartendonissuturedtotheremnantsofthecruciatesinthe
intercondylarnotch
Thehamstringsareattachedtothekneejointcapsuletofacilitatehipflexion
TheITBisattachedtotheanteriorcapsuletoenhanceadductorfunctionin
singlelimbstance

References
CampbellsoperativeOrthopaedics,11theditionvolI,partIV,chapter11
lowerlimbamputations
Disarticulationofthekneeresultsinanexcellentendbearingstump.Newer
socketdesignsandprosthetickneemechanismsthatprovideswingphase
controlhaveeliminatedmanyoftheformercomplaintsconcerningthislevel
ofamputation.Althoughthebenefitofitsuseinchildrenandyoungadults
hasbeenproved,itsuseintheelderlyandespeciallyinpatientswith
ischemiahasbeenlimitedintheUnitedStates.Thisistruemainlybecause
thelongflapsrequiredinsteadcouldallowamorefunctional,short
transtibialamputationinmostinstances.Theselongflapsaresubjectto
necrosisinischemiclimbs.Astudyshowedthatkneedisarticulationisnotas
successfulinposttraumaticamputations,presumablybecauseofthelackof
viablemusculatureinthezoneofinjury.Nonetheless,kneedisarticulation
remainsafeasibleandevendesirablelevelofamputationforsomepatients.
ABKAistheamputationofchoiceinmostpatients.
Thehamstringscanbesuturedtoaidhipextension.
TheITBwouldaidhipabduction.

Question27
A32yearoldmanpresentswithapainfulrightknee.Plainradiographs
revealalyticlesioninthemetaphysisextendingtosubchondralboneinthe
distalfemurandinvolvingonethirdofthefemoraldiameter.CTscan
revealsnocorticalreactionaroundthelesion.Whichofthefollowingisthe
besttreatmentoption?
Chemotherapyalone
Intralesionalcurrettageandbonegrafting
Intralesionalsteroidinjection
Radiotherapyalone
Widelocalexcisionandkneereconstruction
References
GiantCelltumourofbone.Thelongtermresultsoftreatmentbycurrettage
andbonegraft.ZhenW,YaotianH,SongjianL,GeL,QingliangW.JBone
JointSurgBr2004Mar;86(2):2126
Chapter9OrthopaedicPathology,ReviewofOrthopaedics5thEdition,
MarkDMiller
ThetumourisaGCTacommonbenignbutlocallyaggressivetumour.Age
2050years.Anexpansilelyticlesion,involvingmetaphysisandepiphysis.
Usuallyfoundindistlafemur,proximaltibiaanddistlaradius.Treatmentis
byintralesionalexcisionandadjunctivemeasuresforstage1and2.Stage3
and4aretreatedwithenblocexcisionwithapproriatereconstruction.

Question28
Whichoneofthefollowingistruewithregardsprinciplesofobtaininga
biopsyforasuspectedtumour
Adequatehaemostasisisnotessential
Biopsysamplesnegativeforneoplasmneednotbesentforbacteriological
analysis
Frozensectionshouldnotbeperformedroutinelyonthesampletoensure
adequatetissuehasbeenobtained
Itispreferrabletobiospythroughmusclesratherthananintermusculartract
Thebiopsytractshouldnotbeexcised
References
Reviewoforthopaedics,Miller,5thedition2008,elsevierhealthpublishing,
ISBN9781416040934p500
Adequatehaemostasisisimportant,drainsareroutinelyused.
Negativebiopsysamplesshouldbesentforcultureandsenstivityifthereis
doubtaboutinfection.Frozensectionsshouldbesenttoensurediagnostic
tissuehasbeenobtained.Careshouldbetakentocontaminateaslittletissue
aspossible,deepincisionshouldgothroughasinglemusclecompartment
ratherthanthroughanintermuscularplane.Biopsytrackshouldbe
consideredasacontaminatedtractandexcised.

Question29
Therigidityorbendingstiffnessofaplateisproportionalto
Thethicknessoftheplate
Thethicknessoftheplatetothesecondpower
Thethicknessoftheplatetothethirdpower
Thelengthoftheplate
Thenumberofscrews
References
Thebendingstiffnessisproportionaltothesecondmomentarea,fora
rectanglethisisproportionaltothedistancefromtheneutralaxistothe
powerofthree.
Thereforedoublingtheplatethicknessincreasesitsbendingstiffness
eightfold.
Thetorsionalstiffnessinacylinderisproportionaltotheeffectiveradiusof
theobjecttothepower4.
ReviewofOrthopaedics,Miller
RamachandranBasicSciences

Question30
Intheprocessofwoundhealing,macrophages
Precedetheappearanceofneutrophils
Areactivatedbyinterleukin2
Synthesiseandsecretetumournecrosisfactor
Arederivedfrommegakaryocytes
Arenotinvolvedinhumoralimmunity
References
Therearefourphasestowoundhealing.Haemostasis,inflammation,
proliferationandremodelling
Plateletsaggregatetoallowhaemostasisandarefragmentsof
megakaryocytes
Neutrophilspredominateinitallyfollowedbyfibroblastsandmacrophages
(at2days)
Macrophagesareinvolvedinhumoralandcellmediatedimmunityand
secretegrowthfactorsandcytokines
IL2stimulatesTcellproliferation
Question31
A15yearoldboypresentswithbackpain.Plainradiographsshowvertebra
planaatL1.Whichisthemostlikelydiagnosis?
Discitis
Eosinophillicgranuloma

Osteoblastoma
Scheuermann'sdisease
Rickets
References
FlomanY,BarOnE,MoshieffR,MirovskyY,RobinGC,RamuN.
EosiniophillicGranulomaoftheSpine.JPediatrOrthopB1997Oct;6(4)
2605

Question32
WithregardstotheHerringclassificationofPerthes'disease,whichofthe
followingistrue:
Itisbasedonthedegreeofmedialpillarinvolvment.
Itisbasedontheextentofepiphysealinvolvementinthereossification
stage.
GroupBhipstendtodobetterinolderratherthanyoungerpatients.
Theclassificationisbasedontheappearanceinthefrogleglateral
radiographofthehips.
Lossof25%pillarheightwouldclassifythehipasgroupB.

References
Herringclassificationisbasedonthedegreeofflatteningofthelateralpillar
i.e.thelateralonethirdoftheupperfemoralepiphysisasseen(1)onanAP
pelvisview(2)inthefragmentationstage.
3groupsdescribed:
GroupA:Noflattening.
GroupB:Upto50%flattening.
GroupC:Morethan50%flattening.

Worsetheinvolvement,worsetheprognosis.ThusgroupChipsdoworse
thangroupBwhodoworsethanGroupA.
Inanygroup,olderthepatient,worsetheoutcome.Thisisduetothe
decreasingremodellingpotentialwithincreasingage.
ReviewofOrthopaedics,Miller,5thEdition,pg229230

Question33
Whichofthefollowingstructuresisresponsibleformedialdisplacementof
theneurovascularbundleinDupuytren'sdiseaseofringfinger?
Centralcord
Natatorycord
Grayson'sligament
Spiralcord
Pretendinousband
References
HaytonM.J.andGrayI.C.M.Dupuytren'scontracture:areview.Current
Orthopaedics2003;17:17
Aspiralcordoccurswhenfournormallyexistingstructures(pretendinous
band,spiralband,lateraldigitalsheet,andtheGraysonligament)become
diseased.Thespiralcordrunsdorsaltotheneurovascularbundleproximally
andvolartoitdistally.Whenthespiralcordiscontracted,theneurovascular
bundleisdrawntowardthemidlineofthefinger.Neurovascular
displacementisfoundmostcommonlyontheulnaraspectofthelittleand
ringfingers,andtediousdissectionisrequiredtopreventdigitalnerveinjury.
Question34

Inmalignancywithskeletalmetastases,whichofthefollowingstatementsis
NOTTRUE?
Serumcalciumisincreased
Serumphosphateisnormalorincreased
AlkalinePhosphataseisnormalorincreased
PTHisnormalorreduced
Urinarycalciumisreduced
References
Miller
Table115,p22ofMiller(5thed),2ndline:Maligwithbonymets.Serum
phosphateNorincreased.Urinarycalciumincreased
Medscape/Emedicine
Hypercalcaemiaofmalignancyisduetoeitherdirectactionoftumourcells
onboneorosteoclaststimulation(viaRANKL)byPTHrPproducedbythe
tumour.
ItalsoactsonthekidneytoincreasecalciumreabsorptionbythePCTas
wellasincreasingrenalphosphatesecretionbythekidney.Finallytheaction
ofPTHrP(likePTH)increasesconversionof25OHVitaminDto1,25OH
VitDwhichincreasesproductionofcalciumbindingproteinandtherefore
gutabsorption
Question35
ApatientwithfarlateraldiscprolapseatL4/L5islikelytopresentwith
Lossofanklereflex.
Alteredsensationonthedorsumofthefootinthefirstwebspace
WeaknessofExtensorHallucisLongus
Footdrop
WeaknessofFlexorHallucisLongus
References
MillerMD:ReviewofOrthopaedics.Sauders,2006.

FarlateraldiscprolapseatL4/5affectstheexitingL4nerveroot.A
paracentralprolapsewouldaffectthetraversingL5root.
AnklejerkS1
1stwebspaceofthefootinnervationL5
ExtensorhallucislongusL5
FlexorHallucislongusS1
Question36
AccordingtotheDenisthreecolumnclassification,whichofthefollowing
structureformspartoftheposteriorcolumnofthespine?
Posteriorintervertebraldisc
Posteriorvertebralbody
Posteriorligamentouscomplex
Posteriorlongitudinalligament
Annulusfibrosus
References
DenisF.Spinalinstabilityasdefinedbythethreecolumnconceptinacute
spinaltrauma.ClinOrthopRelResOct1984;(189):6576
Theanteriorcolumnconsistsof:anterior2/3ofvertebtralbody,anterior
annulus,anteriorlongitudinalligament.
Middlecolumn:posteriorwallofvertebralbody,posteriorannulus,posterior
longitudinalligament
Posteriorcolumn:Posteriorligamentouscomplexconnectingneuralarches
consistingoffacetcapsules,ligamentumflavum,interspinousligament&
supraspinousligament.
Failureoftwoormorecolumnsgenerallyresultsininstability.
Don'tgetconfusedbetweentheposteriorlongitudinalligamentouscomplex
andtheposteriorspinalligamentouscomplex.
Question37

Meyers&McKeevertypeIIIfracturesofthetibialspinearebestmanaged
by
Arthroscopic/openreductionandinternalfixation.
Closedreductionunderanaesthesiaandcasting.
Nonweightbearingwithcrutchesandregularobservation.
Partialweightbearingwithcrutchesandregularobservation.
Aspirationofkneeandcasting.
References
Tachdjian'sPediatricOrthopaedics.4thEdition,2008.LowerExtremity
Injuries;Knee:pp26532712.
TypeIIIfracturesarebesttreatedoperativelywithanarthroscopicoropen
techniqueusingsutureorascrew(thechoicedependinguponthesurgeon's
expertise).Thekneeisheldinfullextensionfor4weeks,followedby
strengtheningandrangeofmotionexercises.
Theintermeniscalligamentkeepsthefragmentfromsittingdowninitsbed
andneedstobefishedoutofthefracture.
Ifuntreatedorinadequatelytreated,typeIIIfracturescanresultinACL
deficiencysymptomsandsignsandcanactasamechanicalblocktofull
extension.

Question38
A64yearoldladyhaspresentedwithacloseddistalfemoralperiprosthetic
fractureaboveaclosedboxPCLsacrificingTKR.Shewaspreviouslyfit,
wellandindependentlymobile.Radiographsrevealnolooseningofthe
femoralcomponent.Whichofthefollowingwouldmostcommonlybeused
forthemanagementofthisfracture?
ConstrainedrevisionTKR
HingedrevisionTKR
Retrogradesupracondylarfemoralintramedullarynailing

Distalfemorallockingplateosteosynthesis
Circularframeexternalfixation
References
JAmAcadOrthopSurg,Vol12,No1,January/February2004,1220.
2004theAmericanAcademyofOrthopaedicSurgeons
TheJournalofBoneandJointSurgery(American)83:120(2001)
2001
InstructionalCourseLecture
PeriprostheticFracturesFollowingTotalKneeArthroplasty
DouglasA.Dennis,MD
TheJournalofArthroplasty
Volume20,Supplement2,June2005,Pages2732
PeriprostheticFracturesAfterTotalKneeArthroplasty
RaviTharaniMD,CassNakasoneMDandKellyG.VinceMD,
theLessInvasiveStabilizationSystem(LISS),hasbeenusedfor
supracondylarfracturesaboveTKAs.Althausenetalreviewedresultsfrom
differenttreatmentmethodsforsupracondylarfemurfracturesaboveTKA
andnotedadvantagestotheLISSplate,characterizedbythreadedscrew
holesintheplatethatmaintainthescrewssolidlyintheplate.Thisincreases
fracturestabilityespeciallyinosteoporoticbone.Thistechniqueis
specificallyhelpfulwherearetrogradenailcannotbepassedduetoaclosed
boxTKR.Asmallincisionispossibleasthescrewscanbeplaced
percutaneously.Thispotentiallyreducestheneedforbonegraft,riskof
infection,andbloodloss.Patientscanusuallybemobilizedsoonafter
surgerytoavoidcomplicationsofimmobilization.
Kregoretalhadfavorableresultsin13supracondylarfemurfracturesabove
TKAin11patientstreatedwithLISSplating.

Question39
Whatisthe%energyexpenditureabovebaselineduringambulation
followinganaveragetranstibialamputation?

10%
25%
45%
65%
75%
References
Miller,reviewoforthopaedics,5theditionchapter10,partII
Transtibial(belowknee)amputationAlongposteriormyocutaneousflapis
thepreferredmethodofcreatingasofttissueenvelope.Theoptimumbone
lengthisatleast12cmbelowthekneejointorlongerifadequate
gastrocnemiusorsoleusmusclecanbeusedtoconstructadurablesofttissue
envelope.Posteriormuscleshouldbesecuredtothebeveledanteriortibiaby
myodesis.Rigiddressingsarepreferredduringtheearlypostoperative
period,andearlyprostheticfittingmaybestarted521daysaftersurgeryif
theresiduallimbiscapableoftransferringloadandthepatienthasa
satisfactoryphysicalreserve.
AmputationLevel%EnergyAboveBaseline
Longtranstibial10
Averagetranstibial25
Shorttranstibial40
Bilateraltranstibial41
Transfemoral65
Wheelchair08
Question40
InwhichofthefollowingscenarioswouldthoracicbackpainNOTbea
commonfinding?
Thoracicspinalstenosis
Thoraciccompressionfracture
Thoracicdiscitis
Adolescentidiopathicthoracicscoliosis

Thoraciccostovertebralarthritis
References
Salesetal'Osteoarthritisofthecostovertebraljoints'JBJS(Br)2007;89
B:13369
IDIOPATHICadolescentscoliosisbyandlargedoesnotcausebackpain.In
factpresenceofbackpaininscoliosisshouldpromptfurtherinvestigationeg
MRItoexcludeanunderlyingdisorderbeforebeinglabelledasidiopathic.
Question41
Intheposterolateralcornerofknee,whichofthefollowingstructuresisnot
partofthecomplex?
Popliteustendon
Fabellofibularligament
Popliteofibularligament
Patellofemoralligament
LateralGastrocnemiustendon
References
Thepatellofemoralligamentisfoundonthemedialsideoftheknee.
Question42
Areporteddisadvantageofosteochondralallograftingis
Longeroperativetime
Longergraftincorporationperiod
Availabilityoflargerandincreasednumberofgrafts
Donorsitemorbidity
Potentiallylowerincidenceofarthrofibrosis
References

Suarez,LuisSierraMD;Richmond,JohnC.MD
Overviewofprocurement,processingandsterilisationofsofttissue
allograftsforsportsmedicine
SportsMedicineandArthroscopy.Volume15(3),September2007,pp106
113
Theclinicalandsurgicaladvantagesofallograftarewelldesribedandareas
follows:
availabilitytosurgeon,precisepreperationofgraftinanysizeandshape,
lackofdonorsitemorbidity,shorteroperativetimeandlackofclinically
significantimmunologicalreaction.Disadvantagesare:potentialfordisease
transmission,immunologicalreactionwithgraftrejection,cost,higher
incidenceofarthrofibrosis,limitedavailabilityanddemandingsurgical
technique.
Question43
Whichofthefollowingisthepredominantbloodsupplytotheanterior
cruciateligament
Poplitealartery
Superiormedialgenicularartery
Inferiorlateralgenicularartery
Middlegenicularartery
Superiorlateralgenicularartery
References
www.wheelessonline.com/ortho/anatomy_of_acl
Question44
Thenumberofseparateosteofascialcompartmentsinthehandare:
5
7
8

10
12
References
GreensTextbookofHands
Wheelersorthopaedics
10separateosteofascialcompartmentswhichtypicallycanbereleasedw/
carpaltunnelreleaseand1or2dorsalincisions;
dorsalinterossei(4compartments)
palmarinterossei(3compartments)
adductorpollicis
thenar
andhypothenar
Question45
Whichoneofthefollowingoptionsisanabsoluteindicationforamputation
inaGustilloIIIcopentibialfracture,accordingtoLange?
Coldischaemictimeexceeding6hours
Completeposteriortibialnervedisruption
Associatedpolytrauma
Severeipsilateralfoottrauma
Fracturewithmajorsofttissueandbonyreconstructionanticipated
References
KeeneGS,RobinsonAHN,BowditchMG,EdwardsDJ.Keytopicsin
orthopaedictraumasurgery.BIOSscientificpublisherslimited,1999;35
LangeRH,BachAW,HansenSTJr,JohansenKH.Opentibialfractures
withassociatedvascularinjuries:Prognosisforlimbsalvage.JTrauma
1985;25:2038.
Langeetal.,proposedadecisionmakingprotocolbasedonabsoluteand
relativeindications.Theoccurrenceofjustoneoftwoabsoluteindications
(completeposteriortibialnervedisruptioninadults;crushinjurieswith

longerthansixhoursofwarmischemiatime)warrantsprimaryamputation,
whileatleasttwoofthreerelativeindications(seriousassociated
polytrauma,severeipsilateralfoottraumaorprojectedlongcoursetofull
recovery)mustbepresenttoreachthatdecision
Question46
WhichisNOTarecognisedmethodoftreatingtibialnonunion
Exchangenailing
Dynamisation
Bisphosphonates
Pulsedelectromagneticstimulation
Openreductionandinternalfixationwithbonegraft
References
CourtBrown,etal.Exchangeintramedullarynailing.JBJS1995;77B:407
411
RockwoodandGreen's.FracturesinAdults

Question47
Leadbettersmanoeuvrefortheclosedreductionofintracapsularproximal
femoralfracturesinvolves:
Flexionandabduction,traction,externalrotation,adduction,extension.
Flexionandabduction,traction,internalrotation,adduction,extension.

Flexionandadduction,traction,internalrotation,abduction,extension.
Flexionandadduction,traction,externalrotation,abduction,extension.
Flexionandadduction,externalrotation,traction,internalrotation,
extension.
References
Leadbetter's1933and1938papers(BothJBJSAm)
Question48
A50yearoldmalepresentswithapainfulswellingofhisrightankle.MRI
demonstratesthatitisarisingfromthesofttissuesandbiopsyconfirmsthe
diagnosisofmalignancy.Thehistopathologicalreportismostlikelytoshow
whichofthefollowing?
Kaposisarcoma
Giantcelltumourofthesheath
MalignantFibrousHistiocytoma
SynovialSarcoma
Rhabdomyosarcoma
References
Softtissuetumorsandtumorlikelesionsofthefoot.Ananalysisofeighty
threecases.EJKirby,MJShereffandMMLewisJBoneJointSurgAm.
1989;71:621626.
Synovialsarcomaisthecommonestmalignancyinthefoot.GCTis
commonerbutisbenign

Question49
A45yearoldmanpresentswithanacutelypainfulkneeandiscorrectly
diagnosedwithCalciumPyrophosphateDehydrateDeposition(CPPD).
Whichoneofthefollowingistrue?

Surgicalwashoutisoftenrequired
Isdiagnosedbythepresenceofpositivelybirefringentcrystals
Doesnotcommonlyaffecttheknee
NSAIDSareineffective
Affects10xmorementhanwomen
References
O'Duffy,JD.Clinicalstudiesofacutepseudogoutattacks.Commentson
prevalence,predispositions,andtreatment.Arthritis&Rheumatism;1976.
Supplement.(19):349352.
male:female2:1inmoststudies.
NSAIDSusuallyeffectivepainreliefandsurgicalwashoutisnotusually
required.Imagingisusefulinconfirmingthediagnosis,butdoesnot
differentiatebetweengoutandpseudogout.Sometimesthereisevidenceof
chondrocalcinosisontheradiograph.
Positivebirefringenceisdiagnostic.
Question50
Withregardstohighpressureinjectioninjuries,whichsubstancewhen
injectedhasthehighestriskofrequiringamputation?
Oil
Paint
Grease
Fuel
Air

References

Wheelessonline
emedicine
Highpressuregreaseandpaintgunsaremostcommoncauseofinjury,&
siteofinjuryisoftenthepadodthethumborindexfinger;
severityofinjuryisoftenunderestimatedduetothesmallpunctateentrance
wound;
injectedsubstancepassesrapidlythruthesubcutaneoustissueandenters
theflexortendonsheath;
fromthereitpassesintooneormoreofthedeepspacesofthehand
incidence:paint:60%vsgrease:25%
patientprofile:
youngmale;
newjob;
nondominanthand(75%)
prognosticfactors:
materialinjected:
grease(fibrosis)
paint(necrosis):paintcausesanimmediatetissuenecrosisthatpersistsif
thetissuesarenotcompletelydebrided;
pressure:
<7,000psinonprognostic
>7,000psi100%amputation
Question51
Whatisthemostlikelycauseofpersistentlateralanklepainfollowinga
snowboardinginjurynotrespondingtoconservativetreatment?
Subtalardislocation
Peronealtendonsubluxation
Cuboidfracture
FractureofthelateralprocessofTalus
Fibularstressfracture
References
FracturesoftheTalus.Rockwood&Green'sFracturesintheAdult.6th
Edition.

Question52
Vertebraldiscinfectioninchildrenismostcommonlycausedbywhich
pathogen?
Staphylococcusepidermidis
Staphylococcusaureus
EscherichiaColi
Pseudomonasaeruginosa
Legionellapneumophilia
References
ReviewofOrthopaedics.MillerMDFifthedition:P491.
S.aureusismostcommonpathogeninchildrenusuallyviahaematogenous
spreadsincevertebralendplatesarestillopen.
Question53
A59yearoldmanhasa3yearhistoryofincreasedpaininhisrightfoot
withdeformity.Examinationrevealshindfootfixedvalgusof15degrees
withmidfootabduction.Hehastriednonsurgicaltreatmentwithoutrelief.
Whichofthefollowingwouldbethemostappropriatesurgical
management?
Medialslidingoscalcisosteotomy
Subtalararthrodesis
Talonaviculararthrodesis
SubtalararthrodesiswithFDLtransfer
Triplearthrodesis
References
CoreKnowledgeinOrthopaedics.FootandAnkle.
AfixedplanovalgusfootisaJohnsonandStromgrade3deformitywhich
requirestriplearthrodesis

Question54
WhichoneofthefollowingstatementsregardingAchondroplasiaisFALSE?
Itisthemostcommonformofdisproportionatedwarfism
ThegeneticmutationisintheFibroblastGrowthFactorReceptor3(FGFR3)
gene
Scoliosisisacommonfeature.
Itisstronglyrelatedtopaternalage
Narrowinterpediculardistancescanleadtodevelopmentofasignificant
spinalstenosis
References
OxfordTextbookofOrthopaedicsandTrauma
pg4748
Thoracolumbarkyphosisiscommonlyseen,andoftenresolvesatthetimeof
ambulation.Patientsoftendevelopexcessivelordosisduetostructural
abnormalitiesinthelumbarvertebrae.
Question55
Ayoungmalemanualworkerpresentswithsecondaryarthritisoftheindex
fingerPIPJofhisdominanthand.Withregardtoarthroplasty,whichofthe
followingistrue:
Siliconarthroplastyhasgoodlongtermresults
Poorflexionrangemayfollowuseofanundersizedsiliconarthroplasty
component
Pyrocarbonarthroplastyisnotassociatedwithsqueakingimplants
Arthrodesismaybebetterthanarthroplastyifhewishestoremaininwork

Apparentlooseningofapyrocarbonimplantonradiographsisalwaysdueto
trueimplantloosening
References
TheJournalofHandSurgery
Volume35,Issue12,December2010,Pages21072116

Question56
Apatient,whounderwentinsitupinningforSUFEandwasasymptomatic
immediatelyfollowingsurgerybuthassubsequentlydevelopedpain,
stiffnessandflexiondeformity.Whichofthefollowingisthemostlikely
diagnosis
AVN
Chondrolysis
Furtherslip
Normal
Pinpenetration
References
Althoughrare,chondrolysisisoneoftherecognisedcomplicationofSUFE.
Itusuallypresentsaspainandsignificantrestrictionofthejointmovement.
Tachdjian:PediatricorthopaedicsSecondEditionVol2,Pageno1066

Question57
Adisplacedfractureofthetalarneckwithdislocationofthebodyofthe
talus(anklejoint)butNOTthehead(talonavicularjoint)wouldbeclassified
as:
HawkinsI
HawkinsII
HawkinsIII
HawkinsIV
HawkinsV
References

KovalKJ,ZuckermanJD.Handbookoffractures.Chapter40p.437
Hawkinsclassificationisimportantasitcorrelateswellwiththeriskof
subsequenttalaravascularnecrosis.
Question58
InScapholunateadvancedcollapse(SLAC)wristwhichareaisclassically
NOTinvolved
ScaphocapitateJoint
RadialStyloid
Radiolunatejoint
RadioscaphoidJoint
CapitolunateJoint
References
Miller
scapholunateadvancedcollapse(SLAC)referstoaspecificpatternof
osteoarthritisandsubluxationwhichresultsfromuntreatedchronic
scapholunatedissociationorfromchronicscaphoidnonunion;
degenerativechangesoccurmostofteninareasofabnormalloading;
radialscaphoidjointisinvolvedinitially,followedbydegenerationinthe
unstablelunatocapitatejoint,ascapitatesubluxatesdorsallyonlunate;
Radiographs:
radioscaphoidjointisfirsttodevelopdegenerativechanges;
capitolunate&STTjoints,followinorderw/degenerativechanges;
capitatemigratesproximallyintospacecreatedbyscapholunate
dissociation;
radiolunatejointisusuallysparedbecauseofconcentricarticulationof
lunatew/insperoidlunatefossaofdistalradius;
lunate:
w/endstageSLACmidcarpaljointcollapsesundercompression&lunate
assuminganextendedordorsiflexedposition(DISIdeformity);

Question59
Regardingsubtalardislocation,whichoneofthefollowingstatementsistrue
Lateraldislocationismorecommon
Medialdislocationrequiresopenreductionmorefrequentlythanlateral
dislocation
Successfulclosedreductionoflateraldislocationcanbepreventedby
interposedtibialisposteriortendon.
Approximately10%oflateraldislocationsrequireopenreduction
Isusuallyunstableoncereduced
References
http://www.wheelessonline.com/ortho/sub_talar_dislocation
Lateraldislocationisalesscommontypeofsubtalardislocation(15%).It
occurswhencalcaneusisdisplacedlateraltotalus;Talarheadliesmedially,
andfootappearspronated;Navicularlieslateraltothetalarneck;lateral
dislocationsmaybecomplicatedbyinterposedposteriortibialtendon(or
sometimesFDL);approx20%oflateraldislocationsrequireopenreduction;
incisionoversinustarsi,andthreewksofNWBcasting,followedbyROM;
Medialdislocation,isthemostcommonsubtalardislocation(85%);foot&
calcaneusaredisplacedmedially;headofthetalusprominentdorsolaterally;
navicularliesmedialandsometimesdorsaltotalarhead&neck;footis
plantarflexedandissupinated;inversioncausesthisinjury;approxof10%
ofmedialdislocationsrequireopenreduction;capsuleoftalonaviclarjoint&
EDBblocksreduction,orinsomecasesthetalarheadmaybuttonholethru
theEDB;medialsubtalardislocationsaretreatedbylongitudinal
anteromedialincisionoverprominentheadandneckoftalus&minipulation
andreleaseofinterposedtissues;sincethejointisstableafterreductionthere

isnoneedforinternalfixation;afterreduction,ashortlegcastisappliedfor
3to4wks;

Question60
A40yearoldmanpresentstoyourarthroplastyclinicwithapainfulright
hip.Aplainradiographrevealsadysplasticacetabulumwithan80%
subluxedfemoralhead.Howshouldthedysplasiabeclassified?
HowieClassificationA2F3a
CroweGrade2
CroweGrade3
CroweGrade4
HowieClassificationA3bF3b
References
Reviewoforthopaedics.4thed.MillerM.D.
grade1:hipshavelessthan50%subluxation;
grade2:hipshavebetween50%to75%subluxation;
grade3:hipshavebetween75%to100%subluxation;
grade4:hipshavemorethan100%subluxation;
Howieclassification(HipInternational,2009)
Theacetabularclassificationcomprises:AI:Dysplasticacetabulum;AII:The
acetabulumassociatedwithalowfemoraldislocation;AIII:Thepost
surgicalacetabulum,with(AIIIa)orwithoutretainedmetalwork(AIIIb).The
femoralclassificationconsistsof:FI:Dysplasticfemurbutcontainedwithin
trueorlowacetabulum;FII:Thehighfemur;FIII:Postsurgicalfemur,again
withorwithoutmetalwork(FIIIaandFIIIb).

Question61

Whichofthehindfootjointshasthehighestincidenceofnonunion
followingatriplearthrodesis?
Calcaneocuboid
Talonavicular
Subtalar
Ankle
Calcaneonavicular

References
MizelMS,SobelM:DisordersoftheFootandAnkle.InMillerMD(ed):
ReviewofOrthopaedics,2ndEd.Philadelphia.W.B.Saunders,1996,pp223
243.
Isolatedtalonavicularfusionisassociatedwithahighnonunionrate.Thisis
thoughttobebecauseitsmovementiscloselylinkedtothatofthesubtalar
joint.Ifthesubtalarjointremainsmobileanexcessloadisplacedthrough
thetalonavicularjoint.Furthermorethenavicularhasapoorbloodsupply.
Question62
WhichofthefollowingisNOTarecognisedtechniqueforevaluating
posterolateralcornerinjuries?
Increasedexternalrotation
Posterolateraldrawertest
Reversepivotshifttest
Dialtestat15and60
Externalrotationrecurvatumtest
References
Sekiya&Milleretal.Aclinicallyrelevantassessmentofposteriorcruciate
ligamentandposterolateralcornerinjuries.JBoneJointSurgery(Am)2008;
90:16217.

MDMiller.ReviewofOrthopaedics.Fourthedition.2004.Saunders
Elsevier.Page218
Posterolateralcornerinjuriesarerarelyisolatedinjuriesandarecommonly
associatedwithotherligamentinjuries,especiallythePCL.Examinationfor
increasedexternalrotation,externalrotationrecurvatumtestand,
posterolateraldrawertestandreversepivotshifttestareimportant.TheDial
testshouldbeperformedatprone/supine(dialtest)30/90degreesknee
flexion,withERtorqueand10degreedifferencecomparedtocontralateral
legisapositivetest.

Question63
AdvancedTraumaLifeSupportrecommendationsstatethatadultpatients
withsecondorthirddegreeburnsshouldberesuscitatedwithRingers
Lactatesolutionaccordingtothefollowingformula:
1to2mlperkgbodyweightperpercentburninthefirst24hours
2to4mlperkgbodyweightperpercentburninthefirst24hours
8to10mlperkgbodyweightperpercentburninthefirst24hours
10to12mlperkgbodyweightperpercentburninthefirst24hours
Nospecificguidelinesforadults
References
ATLSStudentCourseManual
Fluidresuscitationrequirementsinburnspatientsarecalculatedusingthe
Parklandformulawhichadvocatesresuscitationwithcrystalloidoverthe
first24hourswith24mls/kilogramofbodyweightperpercentageburnof
TotalBodySurfaceArea(TBSA).Halfthevolumeisgiveninthefirst8
hourspostburn,withtheremainingvolumedeliveredover16hours.The
aimistoproduceaurineoutputinadultsof0.51.0mls/kg/hour.
Question64

Localanaestheticagentsarelesseffectiveinthepresenceofinfectiondueto
whichoneofthefollowingoptions
Ahigherionisedconcentrationoftheagent
Alowerionisedconcentrationoftheagent
AnalkalinepHinthetissuefluid
Localvasodilatation
Microorganismsingestingthelocalanaestheticagent
References
Onlythenonionisedformoflocalanaesthetics(LA)cantraversethe
neuronalmembrane,inordertoaccessthesodiumchannelsfrominsidethe
cell.Theacidicenvironment,causedbythepresenceofinfection,resultsina
higherconcentrationofionisedLA.Thisproducesrelativeinactivityofthe
LA.
Question65
Theessentialfluoroscopicviewsforpercutaneousscrewfixationofsacro
iliacjointwouldbe
PelvisAP,inlet,obturatoroutletandlateralsacral.
PelvisAP,iliacinlet,outletandlateralsacral.
PelvisAP,iliacinlet,obturatoroutletandlateralsacral.
PelvisAP,inlet,outletandlateralsacral.
PelvisAP,iliacinlet,obturatoroutletandteepee.
References
HilgertRE,FinnJ,EgbersHJ.Techniqueforpercutaneousiliosacralscrew
insertionwithconventionalCarmradiography.[ArticleinGerman].
Unfallchirurg.2005Nov;108(11):954,95660.
RockwoodandGreen'sFractureinAdults6threvedn(1Dec2005)
LippincottWilliams&Wilkins.EditorsRobertW.Bucholz,JamesD.
Heckman,CharlesM.CourtBrown,andPaulTornetta.Chapter41Fracture
ofthePelvicRing.pp15831664

Question66
ThefollowingaredistalrealignmentproceduresofthepatellaEXCEPT
ElmslieTrillatprocedure
Maquetprocedure
Insallprocedure
Fulkersonosteotomy
Hauserprocedure
References
www.wheelessonline.com/ortho/distal_realignment_for_patellar_subluxation
http://www.wheelessonline.com/ortho/insall_proximal_realignment_for_diso
rders_of_the_patella
FulkersonOsteotomy:
modificationoftheElmslieTrillatProcedure,butinvolvesanterior
displacementaswell;
mainindicationsarepersistentpainandmoderatearticulardegeneration;

allowsanteriorizationofupto15mm,whichshoulddecreaselateralfacet
contactpressure;
HauserProcedure:
discussedforhistoricalpurposesonly;
involvesmedializationofthetibialtubercleinordertodecreaseQangle;
duetotheanatomyoftheproximaltibia,translatingthetibialtubercle
medially,willalsotranslatethetubercleposteriorly;posteriortranslationof
thetibialtuberclewillhavetheeffectofincreasingpatellofemoralcontact
pressureswhichleadstoDJD;
MaquetProcedure:
discussedforhistoricalpurposesonly;involvesanteriortranslationofthe
tibialtuberclewhichhastheeffectofdecreasingpatellofemoralcontact
forces;patientsw/painduetoearlypatellofemoralarthrosismayexpectpain
relieffollowingtheMaquetProcedure;disadvantagesw/thisprocedure
includehighincidenceofskinnecrosis,andnoeffectontheQangle;
ElmslieTrillatProcedure:
medialtibialtubercletransferwhichhasnoposteriordisplacement;
doesnotinvolveanteriordisplacementofthetuberosity;
Insallprocedure:Proximalrealignmentwithstandardlateralretinacular
release.
Question67
InthesurgicaltreatmentofdeQuervain'sstenosingtenosynovitis,whichof
thefollowingtendonsshouldbedecompressed?
AbductorPollicisLongus
AdductorPollicis
ExtensorPollicisLongus
FlexorPollicisLongus
OpponensPollicis
References

Campbell'sTextbookofOperativeOrthopaedics,10thEd,PartXVIIIThe
Hand,page3772"StenosingTenosynovitis".
ItisnamedaftertheSwisssurgeonFritzdeQuervainwhofirstidentifiedit
in1895.
Thetwotendonsconcernedarethetendonsoftheextensorpollicisbrevis
andabductorpollicislongusmuscles.Thetendonsrun,asdoallofthe
tendonspassingthewrist,insynovialsheaths,whichcontainthemandallow
themtoexercisetheirfunctionwhateverthepositionofthewrist.Evaluation
ofhistologicalspecimensshowsathickeningandmyxoiddegeneration
consistentwithachronicdegenerativeprocessThepathologyisidenticalin
deQuervainseeninnewmothers.
DeQuervain'sismorecommoninwomen;thespeculativerationaleforthis
isthatwomenhaveagreaterangleofthestyloidprocessoftheradius.
Symptomsarepain,tenderness,andswellingoverthethumbsideofthe
wrist,anddifficultygripping.
Finkelstein'stestisusedtodiagnosedeQuervainsyndromeinpeoplewho
havewristpain.Toperformthetest,theexaminingphysiciangraspsthe
thumbandthehandisulnardeviatedsharply,asshownintheimage.Ifsharp
painoccursalongthedistalradiusDeQuervain'ssyndromeislikely.

Question68
Apatientpresentswithmidfootpainandswellingafterfallingdown
stairs.ThefollowingfindingonplainradiographdoesNOTimplyLisfranc
jointinjury:
Avulsionfractureofthesecondmetatarsalbase
Dorsaldisplacementofthefirstmetatarsalbase
Medialedgeofthesecondmetatarsalbasealignedwithmedialedgeof
middlecuneiform
Medialedgeoffourthmetatarsalbasealignedwithmedialedgeoflateral
cuneiform
Plantardisplacementofsecondmetatarsalbase

References
Rockwood&Green'sFracturesinAdults(3rdedition):Injuriesofthe
tarsometatarsaljoints,p.2145
Question69
Whenpositioningapatientwithanextracapsularfractureoftheneckof
femuronthefracturetable,whichoneofthefollowingwillmostaccurately
helpyouassesstherotationofthedistalfemur.
Therotationofthefootintheholdingdevice
Thepositionofthepatella
Theabductionangleoftheleg
Thegreatertrochanter
Theappearanceofthefemoralheadontheimageintensitier
References

Question70
Radiographicappearanceofhyperostosisresembling"moltenwax"running
downthecortexofboneischaracteristicof
Rickets
Melorheostosis
Osteopetrosis
Osteogenesisimperfecta
Fibrousdysplasia
References
PriniciplesofOrthopaedicPractice.RogerDee.Secondedition.P678

Question71
Duringfracturehealing,differentiationoftheprogenitorcellsdependson
localoxygentensionandstrainconditions.Basedonthistheory,whichone
ofthefollowingpromotesformationofwovenboneduringfracturehealing.
Highstrainandlowoxygentension
Lowstrainandhighoxygentension
Intermediatestrain
Lowoxygentension
Intermediatestrainandlowoxygentension
References
Miller,ReviewofOrthopaedics(5thedition)Page12

Question72
WhichofthefollowingoptionsisNOTassociatedwithrickets
Phosphatediabetes
Lackofdietaryoxalate
Organinsensitivitytoautogenous1,25dihydroxyvitaminDproduction
Freefattyacidsinintestinalsystem
Neurofibromatosis

References
pediatricorthopaedics
coreknowledgeinorthopaedics
johndormans
elsevier,mosby
VitaminDresistantricketsisalsocalledasphosphatediabetes.
Neurofibromatosiscancausetumorssecretingputativefactorsand
subsequentrenalosteodystrophy
Freefattyacidsinintestinalsystemcouldbeduetobiliarydiseasewith
interferencewithabsorptionoffatsolublevitaminD
Increaseindietaryoxalateandphytatescanchelatecalciumandlead
nutritionalrickets
Entericendorganinsensitivityto1,25dihydroxyvitaminDleadstoVitamin
Ddependentrickets,typeII

Question73
Massivebloodtransfusionimpliesatransfusionratioofpackedredblood
cell:freshfrozenplasma:platelet
3:2:1
5:1:1
1:1:1
6:2:1

3:1:1
References
Injury.2010Jan;41(1):359.
Massivetransfusionisarbitrarilydefiniedasthereplacementofapatient's
totalbloodvolumeinlessthan24hours,orastheacuteadministrationof
morethanhalfthepatient'sestimatedbloodvolumeperhour.
Question74
Regardingthesynovium,thefollowingstatementistrue
Itresemblesendothelium
Itislinedbystratifiedepithelium
TypeAsynovialcellsresemblemacrophages
Itisexquisitelysensitivetopain
Ithaspoorlymphaticdrainage
References
Synoviumhasgoodvascularandlymphaticsupply.Ithasgoodnervesupply
butitisnotverysensitivetopain.TypeBsynovialcellsresemble
fibroblasts.Synoviumhasnoepithelialcomponent.

Question75
Whichoneofthefollowingistruewithregardstothetechniqueof
combininglagscrewfixationwithtensionbandwiringofapatellafracture
Resultsinaconstructwithgreaterloadtofailurethaneitherlagscrew
fixationortensionbandwiringalone.

Resultsinaconstructwithlowerloadtofailurethaneitherlagscrewfixation
ortensionbandwiringalone.
Resultsinaconstructwithequalloadtofailurethaneitherlagscrewfixation
ortensionbandwiringalone.
Doesnotallowearlykneemobilisation
Shouldnotbeundertakenfortransversefractures
References
ReviewoforthopedicTrauma.MRBrinker
Question76
WhichofthefollowingoptionsisFALSEwithregardstoTuberculous
arthritis?
Juxtaarticularosteoporosis
Achronichistory
Higherconcentrationsofproteolyticenzymesinjointfluidascomparedto
pyogenicarthritis
Morelikelytoresultinfibrousankylosisthanpyogenicarthritis
Involvementofonlyonejoint
References
"Apley'sSystemofOrthopaedicsandFractures"LouisSolomon
DavidWarwick
SelvaduraiNayagam

Question77
Thefollowingistrueabouterrorsinclinicaltrials
TypeIerrorisincorrectlyacceptingthenullhypothesis

TypeIIerrorisincorrectlyrejectingthenullhypothesis
TypeIIIerrordoesnotexist
WecanprotectagainstatypeIIerrorwithstatisticalpoweranalysis
TypeIerrorcanbereducedbyincreasingthesignificancelevels
References
BasicOrthopaedicSciencesTheStanmoreGuide.
TypeIerroroccurswhenthenullhypothesisisincorrectlyrejected.
TypeIIerroroccurswhenthenullhypothesisisincorrectlyaccepted.
TypeIIIerroroccursrarelywhentheresearchercorrectlyrejectsthenull
hypothesisbutincorrectlyattributesthecause.
TypeIIerrorcanbereducedwithstatisticalpower
TypeIerrorcanbereducedbyreducingthesignificancelevels
Question78
WhichofthefollowingisNOTcorrectaboutPaget'sdisease?
Remodellingdiseasecausedbyexcessiveosteoclasticactivity
Commoninthefifthdecadeoflife
Commonsitesincludehandsandfeet
Cancausenervecompression
Bisphosphonatetherapyisthemainstayoftreatment
References
RosierRN,BukataSV.Bonemetabolismandmetabolicdonediseases.In:
OrthopaedicKnowledgeUpdate7.Rosemont,Ill:AmericanAcademyof
OrthopaedicSurgeons;2002:152154.

Question79

Regardingplatingoftibialshaftfractures,whichofthefollowingstatements
isINCORRECT
Infectionislesscommoninclosedfracturestreatedafteratwoweekdelay.
Delayedunionismorecommoninclosedfracturestreatedafteratwoweek
delay
Comminutedfracturesaremorelikelythantorsionalfracturestobe
complicatedbynonunion
Comminutedfracturesaremorelikelythantorsionalfracturestobe
complicatedbyinfection
Openfracturesaremorelikelythanclosedfracturestobecomplicatedby
nonunion
References
Campbells,Chapter51
Question80
TheAOprinciplesoffracturecareincludesallEXCEPT
Anatomicreductionofthefracturefragments
Stableinternalfixation
Nonweightbearinguntilradiologicalfractureunion
Preservationofbloodsupply
Earlyactivepainfreemobilisation
References
Brinker:ReviewofOrthopaedicTrauma

Question81
ECGchangesthatmaybeseeninPulmonaryEmbolismare:
Leftbundlebranchblock
LargeSwaveinleadI,alargeQwaveinleadIIIandaninvertedTwavein
leadIII
LargeSwaveinleadI,smallQwaveinleadIII
NormalSwaveinleadI,AbsentQwaveinleadIII,
Completeheartblock
References
TheS1Q3T3sign:
Manycallthispatterntherightheartstrainpattern,butthemore
appropriatetermis:acutecorpulmonale
TheS1Q3T3istheECGmanifestationofacutepressureandvolume
overloadoftherightventricle
AnSwaveinleadIsignifiesacompleteormoreoftenincompleteRBBB
InleadIII,lookforaQwave,slightSTelevation,andaninvertedTwave.
Thesefindingsaredueto
thepressureandvolumeoverloadovertherightventriclewhichcauses
repolarizationabnormalities.
TheS1Q3T3wasfirstdescribedbyMcGinnandWhiteinJAMAin1935.
Question82
InDevelopmentalDysplasiaoftheHip(DDH),whichofthefollowing
statementsistrueregardingtheOrtolani'stest?
ItisaprovocativetestforDDHthatattemptstosubluxatethefemoralhead.
Itisoftenpositiveinthewalkingchild.
Itconsistsofpushingdownthegreatertrochanterwhilesimultaneously
adductingthehip.
Itconsistsofliftingupthegreatertrochanterwhilesimultaneouslyabducting
thehip.
ItisalwayspositiveintheinfantwithDDH.

References
Tachdjian'sPediatricOrthopaedics.4thEdition.2008.Developmental
DysplasiaoftheHip:pp637770.
Barlow'sandOrtolani'stestsareusedtodiagnoseDDHinneonatesand
infants.
Barlow'sistheprovocativetestforthedislocatablehipandOrtolaniisthe
relocatingtestforthealready'out'hip.(RememberOrtolaniforOut!)
The'clunk'ofOrtolaniisasensationofrelocationoftheheadthatisseen
and/orfeltbutnotheard.Neverthelessthe'clicky'babyhipalwaysneedsto
befurtherinvestigatedviaultrasonography.
Question83
Themostcommonsequelaeofundiagnosedcompartmentsyndromeinthe
footis
Paresthesiainthetoes
Clawingofthetoes
Chronicallyswollenfoot
Absentpulses
Reflexsympatheticdystrophy
References
Millerorthopaedics

Question84
Prophylacticfixationisnecessaryinthemanagementofmetastaticbone
diseaseinwhichofthefollowingoptions:
Anosteoblasticlesionintheproximalhumerusinvolving50%ofcortex,
moderateamountofpain
Amixedlesionintheshaftofhumerus,involving50%ofthecortex,mild
amountofpain
Alyticlesionaffectingtheshaftoffemuraffecting30%ofthecortex,mild
pain
Amixedlesionaffectingtheshaftofradiusinvolving30%ofthecorttex,
mildpain
Alyticlesionintheneckoffemurinvolving50%ofthecortex,mildpain

References
http://www.wheelessonline.com/ortho/pathologic_fracture
MainsurgicaltreatmentforpathologicalfracturesisIMnailing.Adjuct
treatmentisnotusuallyneededunlessthereisaverylargedefectpresent.
AccordingtoMirels'classification,thefinaloptiongivesaMirelscoreof9,
evenassumingtheminimumscoreforpai,thisrequiresprophylactic
fixation.
Question85
Followingarethepossiblecausesofafalsenegativepivotshifttest
EXCEPT
Medialmeniscustear
Lateralmeniscaltear
Medialcollateralligamentrupture
Lateralcollateralligamentrupture
Iliotibialbandrupture

References
InsallJ.SurgeryoftheKnee3rdedition.
Magee.OrthopaedicClinicalExamination.
Question86
Whichofthefollowinginvestigationsbestdistinguishesosteoporosisfrom
osteomalacia?
IliacCrestBonebiopsy
SerumCalcium
SerumPhosphate
UrinaryCalcium
TetracyclinelabelledBoneBiopsy
References
BulloughPG,BansalM,DiCarloEF:Thetissuediagnosisofmetabolicbone
disease:Roleofhistomorphometry.OrthopClinNorthAm1990;21:6579.
Osteoporosistypicallypresentswithnormalserumcalcium,phosphorus,
alkalinephosphatase,vitaminD,andPTHlevels.Incontrast,osteomalaciais
characterisedbyhypophosphataemia,hypocalcaemia,increasedalkaline
phosphataselevels,lowlevelsofvitaminDmetabolites,andsecondary
hyperparathyroidism.
Urinarycalciumlevelsmaybenormalinosteoporosisbutarelowin
osteomalacia.Bothconditionsappearaslowbonemassonradiological
studiesandDXAscan.However,specificradiologicalfindingsuniqueto
osteomalaciaincludeLooserpseudofractures.
Abonebiopsyisthebestdifferentiatingtest.
Question87
Withregardstodiagnosisofsepticarthritis,thethresholdofwhitebloodcell
(WBC)concentrationandproportionofpolymorphs(PMN)inthejoint
aspirateis?

<200WBCsand25%PMNs
2002,000WBCsand50%PMNs
>50,000WBCsand50%PMNs
>80,000WBCsand75%PMNs
>200,000WBCsand50%PMNs
References
TheArthrosesMiller,reviewoforthopaedics,5theditionChapter1,
Section2/II
Jointfluidanalysis
1.Noninflammatoryarthritides200whitebloodcells(WBCs)with25%
polymorphonuclearneutrophils(PMNs);equalserumvaluesofglucoseand
protein;normalviscosity(high),strawcolor,firmmucinclot.
2.Inflammatoryarthritides200075,000WBCswithupto50%PMNs;
moderatelydecreasedglucose(25mg/dLlowerthanserumglucose);low
viscosity,yellowgreen,friablemucinclot.Synovialfluidcomplementis
decreasedinRAandnormalinankylosingspondylitis.
3.InfectiousarthritidesMorethan80,000WBCswithmorethan75%
PMNs,apositiveGramstain(alsopositivecultureslater),lowglucose(25
mg/dLlowerthanserumglucose),opaquefluid,increasedsynoviallactate.
Question88
Withregardstothegaitcycle,doublelimbstanceconsistsofapproximately
whattotalpercentageofonecycle(stride)
10%
12%
16%
20%
25%
References
Onegaitcycle(stride)isdefinedfrominitialcontact(heelstrike)ofoneheel
untilthenextheelstrikeoftheipsilateralheel.Itcanbedividedintoastance

phaseandaswingphase.Atthebeginningandendofthestancephasethere
isaperiodofdoublelimbsupport,eachconsistingofapproximately10%of
onetotalcycle(2x10%=20%).
MillerReviewofOrthopaedics5thedition,p553.

Question89
Withregardstotheanteriorapproach(SmithPeterson)tothehip,whichof
thefollowingstatementsistrue?
Thesuperficialdissectionisbetweengracilisandsartorius
Theinternervousplaneisbetweentheobturatornerveandthefemoralnerve
Themedialfemoralcircumflexarteryisacommonstructureatrisk
Theinternervousplaneisbetweenthefemoralnerveandthesuperiorgluteal
nerve
Thesuperficialdissectionisbetweenrectusfemorisandsartorius
References
Thisapproachtakesadvantageoftheinterneuralplanebetweenthesartorius
(femoralnerve)andtensorfasciaelatae(superiorglutealnerve).Itisuseful
foroperativeproceduressuchasopenreductionofthecongenitally
dislocatedhip.Thelateralfemoralcutaneousnerveisretractedanteriorly,
andtheascendingbranchofthelateralfemoralcircumflexartery(whichlies
superficialtotherectus)isligated.Fordeeperdissection,approachthe
intervalbetweenthegluteusmediusandrectusfemoris.Detachtheoriginof
bothheadsoftherectusfemoris.Reflectionoftheconjoinedrectustendon
toodistallycanriskinjurytothedescendingbranchofthelateralfemoral
circumflexartery.Retracttherectusmediallyandthegluteusmedius
laterally.Dissectanyattachmentsoftheiliopsoastotheinferiorcapsuleand
performacapsulotomy.Thereisarisktothelateralfemoralcutaneous
nerve,whichislocatedanteriorormedialtothesartoriusabout68cm
belowtheASIS.Thesuperficialcircumflexarterypenetratesthetensor
fasciaelataejustanteriortothelateralfemoralcutaneousnerve.Thefemoral
nerveandvesselscansometimesbeinjuredbyaggressivemedialretraction

ofthesartorius.
MillersreviewofOrthopaedics,5thed.,pp1767

Question90
TheSegondfractureisassociatedwithaninjurytotheanteriorcruciate
ligamentandisaresultofanavulsionofthe
obliquepoplitealligament
popliteustendon
lateralcollateralligament
lateralcapsule
arcuateligament
References
TheSegondfracture,oravulsionfractureofthelateralcapsule,is
pathognomonicofananteriorcruciateligamenttear.(Campbellsoperative
orthopaedics,VolIII)
OriginallydescribedbyDr.PaulSegond(French)in1879afteraseriesof
cadavericexperiments,theSegondfractureoccursinassociationwithtears
oftheanteriorcruciateligament(ACL)SegondP.Recherchescliniqueset
exprimentalessurlespanchementssanguinsdugenouparentorse.Progres
Med1879;7:297299,319321,340341.
Question91
Whatmusclesareresponsibleforthemostcommonresidualdeformityafter
antegradeintramedullarynailingforasubtrochantericfemoralfracture?
Hipabductorsandiliopsoasmuscle

HipInternalrotatorsandiliopsoasmuscle
Quadricepsandiliopsoasmuscle
Hamstringandiliopsoasmuscle
Quadricepsandhipadductors
References
1.FrenchBG,TornettaPIII.Useofaninterlockedcephalomedullarynail
forsubtrochantericfracturestabilization.ClinOrthop.1998;348:95100
2.RicciWM,BellabarbaC,LewisR.Angularmalalignmentafter
intramedullarynailingoffemoralshaftfractures.JOrthopTrauma.2001;
15(2):9095
Question92
A70yearoldmanisundergoingatotalkneereplacement.Thefemoral
componentisideallyplacedin3degreesofexternalrotation.Whichofthe
followingoptionsistherationaleforthis?
Tobalancetheextensiongapafterthebonecuts
Tobalancetheflexiongapafterthebonecuts
Toimprovepatellartracking
Topreventthejointlinebeingraised
Soasnottooverstufftheanteriorcompartmentoftheknee
References
Normally,theproximaltibiaisinslightvarus(3degrees).InTKR,thetibia
iscutat90degrees(i.e.,perpendiculartothemechanicalaxis).Inorderto
maintainasymmetricalflexiongap,thefemoralcomponentmustbe
externallyrotatedbythesameamounttocreateasymmetricalflexiongap.
Thisallowsforbalancedligamentsinflexion.
Itisacommonmisconceptionthattheexternalrotationistoimprovepatellar
tracking,thisissimplyabeneficialsideeffectofthecutsandbalancing.
Miller'sReviewofOrthopaedics(5thedition),pp3301
Question93

A48yearoldoverweightwomanpresentswitha2yearhistoryofpain
aroundherankle.Shedoesrecallfallingoverandinjuringherankle.On
clinicalexmaniationsheistenderbehindthemedialmalleolusandoverthe
sinustarsi.Sheisunabletoperformaunipedalheelraise.Subtalarjoint
movementsarepainfulandplainradiographsdemonstratedegenerative
changeinthemidtarsalandsubtalarjoints.Whichofthefollowingisthe
mostappropriatemanagement?
Pantalarfusion
Tibilaisposteriorrepair
Tibialisposteriorreconstruction
Diagnosticinjection
Talonavicularfusion
References
CoreKnowledgeinorthopaedics:Footandankle.CWDiGiovanniandJ
Greisberg,Elsevier2007.
Chapter:Adultacquiredflatfoot
Thisladyhashistoryandclinicalfindingssuggestingtibialisposterior
insufficiency.However,shehasgoneontodevelopsecondarydegenerative
changesandthusisunlikelytobenefitfromhindfootsparingprocedures
includingsofttissuereconstructionandcalcanealosteotomy.Adequate
treatmentofhersymptomswillrequireselectivefusionsbasedon
symptomaticrelieffromdiagnosticinjection.Thismaybeatriplefusion.
Question94
A12yearoldboywithnohistoryoftraumapresentswithlateralkneepain,
givingwayandaclunkingsensationonflexionandextensionoftheknee.
Whatisthemostlikelydiagnosis?
Osteochondritisdissecans
Discoidmeniscus
AnteriorCruciateLigamentrupture
Recurrentpatelladislocation
Blount'sdisease

References
ReviewofOrthopaedics,Miller5thedition,chapter4,section1/IV
NettersOrthopaedics,Greene
CurrentDiagnosisandTreatmentinOrthopaedics,Skinner
ApleysSystemofOrthopaedicsandFractures,Soloman
OrthoteersWebsite
Discoidmenisci(poppingkneesyndrome)Canbeclassifiedas(1)
incomplete,(2)complete,or(3)Wrisberg'svariant(Fig.414).Patientsmay
developmechanicalsymptoms,orpopping,withthekneeinextension.
Plainradiographsmaydemonstrateawidenedjointspace,squaringofthe
lateralfemoralcondyle,cuppingofthelateraltibialplateau,anda
hypoplasticlateralintercondylarspine.MRI(threeconsecutivesagittal
imagesdemonstratingacontiguouslateralmeniscus)canbehelpfulandmay
alsodemonstrateassociatedtears.Treatmentincludespartialmeniscectomy
(saucerization)fortears,meniscalrepairforperipheraldetachments
(Wrisberg'svariant),andsimpleobservationfordiscoidmenisciwithout
tears.
Question95
UsingtheWagnerClassificationofdiabeticfootulcers,whichanswerbest
describesaGrade3ulcer?
Gangreneoftheentirefoot.
Alocailised,superficialulcer.
Adeepulcertotendon,bone,ligamentorjoint.
Gangreneoftoesorforefoot.
Deepabscess,osteomyelitis.
References
MillerPg390,5thEditionDisordersoftheFootandAnkle
Question96
WhichofthefactorsbelowdoesNOTcontributetocatastrophicwearin
TKR

AflattibialPE
Akinematicdesignallowingamplefemoralrollback
CongruentPEmachining
IrradiationofPEinavacuum
Polyethylenethicknesslessthan8mm
References
MillerTable57

Question97
Thenerveoftheanteriorcompartmentofthelegis
Commonperoneal
Deepperoneal
Saphenous
Superficialperoneal
Sural
References
Last'sAnatomy.RegionalandApplied.Tenthedition.CSSinnatamby.The
deepperoneal(anteriortibial)nerve.Thecommonperonealdividesinto
superficialanddeepperonealnervesattheleveloftheneckoffibula.The
deepperonealenterstheanteriorcompartmentoftheleg.Itislateraltothe
anteriortibialvesselsintheupperthirds,anteriorinthemiddlethirdsand
againlateralinthelowerthirdoftheleg.Theiscalled'nervihesitans'asit
beginstocrosstheanteriortibialvesselsfromlateraltomedialside,
hesitates,andcomestolieontheirlateralsideagain.

Question98
A40yearoldjumpsfromthebackofalorrysustainingafracturetothe
medialtibialplateau.Thereisnoinvolvementofthelateralplateauasseen
onaCTscan.ThiscanbeclassifiedaccordingtoSchatzkerclassificationas
towhattypeofinjury?
1
2
3
4
5
References
SchatzkerJ,McBroomR,BruceD.Thetibialplateaufracture.TheToronto
experience19681975.ClinOrthopRelatRes.1979;(138):94104.
Question99
Thefollowingstatementsaboutbloodvesselsaroundthehipiscorrect
Theexternaliliacarterycanbeinjuredbyanterosuperiorquadrantacetabular
screw
Thelateralcircumflexfemoralarteryisusuallyadirectbranchoffemoral
artery
Profundafemorisisabranchoffemoralarterybeforeenteringfemoral
triangle
Medialcircumflexfemoralarterysuppliesleastbloodtothefemoralhead
SuperficialfemoralarterycontinuesonlateralsideofthighinHunter'scanal

References
Question100

ThefollowingaresymptomsandsignsofcaudaequinasyndromeEXCEPT
Numbnessintheperineum
Severebackpain
Anextensorplantarresponse.
Urinaryincontinence
Laxanalsphincter
References
2007CurrentMedicaldiagnosisandTreatment,StephenJ.Mcphee
OxfordtextbookofSurgery,2ndedition,vol.3,PeterJ.Morris,2000
ShortPracticeofSurgery,BaileyandLove's,24thEd,2004
Caudaequinawillexhibitssignsofalowermotorneuronelesion

Question101
Whichofthefollowingstatementregardingthoracicdischerniationsand
treatmentistrue?
Thoracicdischerniationismorecommonintheupperthanlowerthoracic
discs
Degenerativethoracicdiscsdisplaylessjointinstabilitytothatshownin
degeneratelumbardiscs
Thoracicdiscreplacementsurgeryalthoughnotcommonisawell
establishedprocedureintheUK
Afterthoracicdiscectomy,fusioniscommonlyperformedtoprovide
stability
Thoracicdischerniationsareusuallyasymptomaticasthecordtocanalratio
islow
References

NeurosurgClinNAm.1993Jan;4(1):7590.
Thoracicdischerniations.
DietzeDDJr,FesslerRG.
Thepresenceofribsstabilisethethoracicspineevenifthediscisremoved.
Thereforediscreplacementorfusionisrarelyrequired.Cordcompressionis
wellrecognisedasacomplicationofthoracicdiscsduetothehighcordto
canalratio.
Question102
ApatientishavingaSmithPetersenosteotomyofthespineforkyphosis.
Whichofthefollowingiscorrect?
Theprocedureshortenstheposteriorcolumn
Awedgeisremovedfromtheposteriorhalfofthevertebralbody
Anopeningwedgeosteotomyoftheanteriorvertebralbodyisperformed
Ananteriorfusionisneverrequired
Thisprocedurecannotbeperformedatmultiplelevels
References
CorrectiveOsteotomiesinSpineSurgery
J.BrianGill,MD,MBA;AndrewLevin;TimBurd;MichaelLongley
JBoneJointSurgAm.2008;90:25092520
Thisisatechniqueforshorteningtheposteriorcolumntherebycorrecting
forward(positive)saggitalplanedeformity.Yougetabout10degreesper
level.Thereferenceaboveisagoodrecentreviewofallthecommonlyused
osteotomytechniques.
Question103
Thecirculatingbloodvolumeofan8yearoldchildisapproximately
70ml/Kg
80ml/kg
90ml/kg
100ml/kg

150ml/kg
References
ATLSmanual,7thEd.2004
Question104
Inwhichofthefollowingdoesendochondralossificationoccur?
Callusformationduringfracturehealing
Heterotopicboneformation
Embryoniclongbonedevelopment
Calcifyingcartilagetumors
Alloftheabove
References
BrinkerMR.Basicscience:Bone.In:MillerMD,ed.Reviewof
Orthopaedics.3rded.Philadelphia,Pa:WBSaunders;2000:912.

Question105
Thefollowingstatementsregardingtraumaticspondylolisthesisoftheaxis
(C2)aretrueEXCEPT
TheLevineandEdward'sclassificationsystemisbasedonlyonthelateral
radiograph
Neurologicalinvolvementisuncommon
Tendstocompresstheneuralcanal
Type1fracturesareusuallysecondarytohyperextensionandaxialloading
TypeIIandIIIfracturesareunstableanddisrupttheC2/3motionsegment.

References
ManagementoftraumaticspondylolisthesisoftheaxisJBJSAm67A:217
226,1985
*Classification
oTypeI
+Noangulation
+Upto3mmofanteriortranslation
+Stable
oTypeII
+Angulation>10degrees
+Anteriortranslation>3mm
oTypeIII
+Veryunstable
+Severeangulation/displacement
+DislocationofoneorbothC2C3facets
*Treatment
*TypeI:Hardcollarfor8weeks
*TypeII:SOMIbraceafterclosedfor8weeks
*TypeIII:
oClosedReductionofdislocatedfacetsmaynotbepossible
oMayneedORIFwithfusion
Associatedwithneurologyinonly510%

Question106
WhatisthemostcommoncauseforrevisionofareversedTotalShoulder
Replacement?
Deepinfection
Looseningofglenoidcomponent
Looseningofhumeralcomponent
Lossofrangeofmotion
Periprostheticfracture

References
BjrgTildeSFevang,SteinALie,LeifIHavelin,ArneSkredderstuen,and
OveFurnes.Riskfactorsforrevisionaftershoulderarthroplasty
1,825shoulderarthroplastiesfromtheNorwegianArthroplastyRegister.
ActaOrthop.2009February26;80(1):8391.
Question107
Thesafeinsertionofacetabularscrewsintotalhiparthroplastyis:
Anteroinferior
Anterosuperior
Posteroinferior
Posterosuperior
Posterolateral
References

Question108
Whatisthemostlikelysynovialresponsetometalonmetalvolumetricwear
debris?
Fibroblastactivation
Lymphocyteactivation
Macrophageactivation
Mastcellactivation

Metalallergy
References

Question109
TheArteryofAdamkiewiczisanimportantvesselinspinalsurgery.
A:Anterior(longitudinal)spinalartery
B:Lumbarvessels

C:Rightposteriorintercostalartery
D:Aorta
E:Thoracicintercostalvessels
F:Bothanteriorandposteriorintercostalarteries
G:Leftposteriorintercostalartery
H:Anteriorsegmentalmedullaryartery
I:Anteriorcordsyndrome
J:T6T8
K:T9T10
L:L3L4
1:Thearteryisusuallyfoundbetweenwhichlevels?
Correctanswer:
K
Youranswer:
K
2:WhatisthetypicaloriginvesselofthearteryofAdamkiewicz?
Correctanswer:
G
Youranswer:
D
3:WhatistheprimaryanastomosisofthearteryofAdamkiewiczwhich
suppliesthespinalcord?
Correctanswer:
A
Youranswer:
F
References
GraysAnatomyTheAnatomicalBasisofClincalPractice.39thEdition.
AofAcomesofftheleftposteriorintercostalarterywhichinturnbranches
fromtheaorta.
TheAdamkiewiczarteryislocatedbetweenT8andL3,atT9orT10in50%,
andcomingfromtheleftsidein75%ofcases.
Spinalcordischaemiaisrareaftersegmentalvesselligation.Spinal
angiographyallowsdeterminingthetopographyoftheAdamkiewiczartery
safelysotheapproachcanbealteredasnecessary.
Question110

Whichofthefollowingcytokinesandgrowthfactorsareimportantinwound
healing?
A:Endothelin1
B:Intracellularsignalregulatedkinase
C:Transforminggrowthfactorbeta1
D:Matrixmetalloproteinase
E:Transforminggrowthfactorbeta3
F:Extracellularsignalregulatedkinase
G:Connectivetissuegrowthfactor
H:Transforminggrowthfactorbeta2
I:Activinreceptorlikekinase
J:Transforminggrowthfactorbetareceptor
1:Whichmajorgrowthfactorisreleasedbydamagedplateletsinasurgical
wound?
Correctanswer:
C
Youranswer:
E
2:Topicalapplicationofwhichgrowthfactorenhanceswoundhealing?
Correctanswer:
C
Youranswer:
H
3:Whichgrowthfactorcancausefibroblastproliferationinwoundhealing?
Correctanswer:
G
Youranswer:
G
References
BRKlass,AOGrobbelaar,KJRolfe.Transforminggrowthfactor1
signalling,woundhealingandrepair:amultifunctionalcytokinewithclinical
implicationsforwoundrepair,adelicatebalance.PostgradMedJ2009;85:9
14.
Scarringfromsurgicalincisions,traumaticwounds,burnsorinfection
presentsamajorclinicalproblem.Itisestimatedthat100millionpatientsa
yearinthedevelopedworldacquireascar,withasignificantproportionof
thesescarsbeingclassifiedaspathological.Theupregulationorabnormal
signallingofthemultifunctionalcytokinetransforminggrowthfactor1
(TGF1)hasbeenconsideredtobethemainculpritintheformationofscar

tissuebecauseofitsabilitytoinducefibroblaststosynthesiseandcontract
theextracellularmatrix(ECM)andinduceitsdownstreammediator,
connectivetissuegrowthfactor(CTGF;alsoknownasCCN2)and
endothelin1(ET1).
Thereactiontoinjuryisaninherentresponseresultinginrestorationof
tissueintegrity.Woundhealingisoftendescribedasaseriesofevents,
wheresolublemediatorsfromonecellsetoffaseriesofeventsinanother
cell,resultingingenetranscriptionandproteintranslation,culminatinginthe
mainphasesofwoundhealing.Briefly,damagedvesselsallowthe
productionofafibrinclot,preventingfurtherbloodlossandallowinga
provisionalmatrixforcellmigration.Variousgrowthfactorsandcytokines
arereleasedfromdamagedplateletsincludingTGF1.TGF1isknownto
causeitsowngenetranscription,resultinginapositivefeedbackloop(fig3),
andhasbeenshowntobeconsistentlypresentthroughouttheadultwound
healingprocess.TGF1attractsneutrophils,macrophagesandfibroblasts
intothewound.Reepithelialisationoccurs,withkeratinocytesmoving
acrossthegranulationtissue.Oncethekeratinocyteshaveestablisheda
barrier,contactinhibitionmakesthemswitchphenotype,andthey
differentiateintostratifiedsquamouskeratinisingepidermis.
TheTGFfamilyofcytokinesisanimportantfamilyofcytokinesassociated
withanumberofphysiologicalprocesses.AberrantexpressionofTGF1has
beenshowntobeassociatedwithanumberofdiseasesincludingfibrosisor
scarring.ThisreviewwilldiscusshowTGF1affectsgeneexpression
throughitsintracellularsignallingpathways,therolethatTGF1playsin
bothwoundhealingandscarring,andthepossibleclinicalimplicationsand
potentialfuturetreatmentstopreventorreducescarringorfibrosis.

Question111
Withreferencetothebiomechanicsofkneepleaseselectthemost
appropriateanswers.
A:AnteriorCruciateLigament(ACL)
B:PosteriorCruciateLigament(PCL)
C:PopliteofibularLigament
D:Iliotibialband
E:PoplitealObliqueLigaments(POL)
F:SuperficialMedialCollateralLigament(MCL)
G:DeepMedialCollateralLigament(MCL)
H:LateralCollateralLigament(LCL)
I:Menisci
J:Posteriorcapsule
1:Theprimaryrestrainttointernalrotation
Correctanswer:
A
Youranswer:
A
2:Thesecondaryrestrainttoposteriortranslation
Correctanswer:
H
Youranswer:
H
3:Primaryrestrainttovalgusstressatallangles
Correctanswer:
F
Youranswer:
F
4:Providesabout24%ofthefunctionasasecondaryrestrainttoanterior
translation
Correctanswer:
D
Youranswer:
D
References

BasicOrthopaedicSciencesTheStanmoreGuide.editedbyManoj
Ramachandran.2007

Question112
ManagementofCalcanealFracturesstillposeamajordilemaforthetrauma
surgeon.Selectthecorrectanswersrelatedtocalcaneumfractures.
A:2540degrees
B:95100degrees
C:EssexLopresti
D:Harris
E:Broden'sview
F:4060degrees
G:FroglegView
H:120140degrees
I:Neer's
J:AO
K:Sander's
1:WhatisBohler'sangleinanormalcalcaneum?
Correctanswer:
A
Youranswer:
A
2:Whatradiographicviewisusedtoimagethebodyandthesustenaculum
oftheCalcaneus?
Correctanswer:
D
Youranswer:
D
3:Aclassificationthatusesthelateralradiographtoassessarticular
involvementandjointdepression?
Correctanswer:
C
Youranswer:
C
References

RockwoodandGreen'sfracturesinadults.6thEdition.
CampbellsoperativeOrthopaedics,11theditionvolIV,partXIX,chapter
86
Studiesinfracturepatterns,softtissuemanagement,andoutcomesof
calcanealfractureshavegivenaclearunderstandingofwhichinjuriesare
likelytobenefitfromearlysurgicalinterventionandwhicharelikelytohave
highratesofcomplicationsandpooroutcomes.Regardlessofthetreatment,
calcanealfracturesareassociatedwithnumerouscomplicationsandpoor
outcomeswithsignificantlongtermqualityoflifeissues.
Calcanealfracturescanbeextraarticular(notinvolvingthesubtalarjoint)or
intraarticular(involvingthesubtalarjoint).
Radiographicevaluationofthefractureshouldincludefiveviews.Alateral
radiographisusedtoassessheightloss(lossofBhlerangle)androtationof
theposteriorfacet.Theaxial(orHarris)viewismadetoassessvarus
positionofthetuberosityandwidthoftheheel,whichisoftenamajorcause
ofmorbidityforpatientsparticularywithregardstofindingcomfortable
footwear.Anteroposteriorandobliqueviewsofthefootaremadetoassess
theanteriorprocessandcalcaneocuboidinvolvement.AsingleBrodnview,
obtainedbyinternallyrotatingtheleg40degreeswiththeankleinneutral,
thenanglingthebeam10to15degreescephalad,ismadetoevaluate
congruencyoftheposteriorfacet.Forsurgeonsexperiencedinthecareof
thesefractures,threeradiographsmaybesufficient,butmostoftenCTscans
areobtainedtoevaluatetheinjurycompletely.Thescansshouldbeordered
intwoplanesthesemicoronalplane,orientedperpendiculartothenormal
positionoftheposteriorfacetofthecalcaneus,andtheaxialplane,oriented
paralleltothesoleofthefoot.
Sanderscalssificationisnowcommonlyusedtodecideandplansurgical
management,butitisbasedontheCTimagesonly.Inparticularthelocation
andcomminutionofposteriorfacetoncoronalCTscan.

Question113
Selectwhichtumourmostcloselymatchesthedescriptionbelow:
A:Osteosarcoma
B:Enchondroma
C:Ewing'ssarcoma
D:Periostealchondroma
E:Osteochondroma
F:Chondroblastoma
G:Aneurysmalbonecyst
H:Simplebonecyst
I:Giantcelltumour
J:Chondrosarcoma
1:Amalignanttumorofboneinwhichneoplasticosteoidisproducedbya
proliferatingspindlecellstroma.
Correctanswer:
A
Youranswer:
J
2:Adevelopmentaldysplasiaofperipheralgrowthplatewhichformsa
cartilagecappedprojectionofbonefoundnearmetaphysesoflongbones.
Correctanswer:
E
Youranswer:
E
3:Abenignandasymptomaticcartilaginoustumorofbonewhichmost
oftenoccursinadolescentsoryoungadults.
Correctanswer:
B

Youranswer:
B
4:Thistumourisassociatedwithatranslocationbetweenchromosomes11
and22
Correctanswer:
C
Youranswer:
C
References
Campbellsoperativeorthopaedics,11thed,Vol1.p793810.
Osteosarcoma:spindlecellneoplasmsthatproduceosteoidarearbitrarily
classifiedasosteosarcoma.The"classic"osteosarcomaisthemostcommon
andusuallyoccursaboutthekneeinchildrenandyoungadults.
Osteochondromaisabeningsurfacelesionariseingfromsecondaryaberrant
cartilage(fromperichondrialring)onthesurfaceofbone.
Chondromasarebenigncartilagelesions,iftheyarelocalizedtothe
medularrycavity,theyarecalledenchondromas.

Question114
Theinternervousplanebetweenwhichpairofnervesisexploitedbythe
followingsurgicalapproaches?
A:AxillaryandSuprascapular
B:MusculocutaneousandUlnar
C:MedianandRadial
D:MedialPectoralandLateralPectoral
E:AxillaryandLateralPectoral
F:PosteriorInterosseousandRadial
G:UlnarandRadial
H:MusculocutaneousandRadial
I:AxillaryandRadial
J:MedianandUlnar
1:Henryapproachtotheforearm
Correctanswer:
C
Youranswer:
B
2:Anteriorapproachtotheshoulder
Correctanswer:
E

Youranswer:
A
3:Anteriorapproachtothemidshaftofhumerus
Correctanswer:
H
Youranswer:
C
References

Question115
Choosetheappropriateantibiotictomatchthegivencharacteristics.
A:Cefuroxime
B:Ceftriaxone
C:Cephradine
D:Clindamycin
E:Gentamycin
F:AmphotericinB
G:Ciprofloxacin
H:Chloramphenicol
1:Athirdgenerationcephalosporin.
Correctanswer:
B
Youranswer:
A
2:Achieveshighconcentrationinbone(nearlyequalsserumconcentration
afterIVadministration).
Correctanswer:

D
Youranswer:
D
3:Antibacterialthatisunsuitableforusewithcementpowderasitbecomes
inactivatedduringcementpolymerisation.
Correctanswer:
H
Youranswer:
D
4:Usedinthetreatmentofcandidaosteomyelitis.
Correctanswer:
F
Youranswer:
F
References
ReviewofOrthopaedics.Miller.4thedition.

Question116
Choosethebestsurgicaltreatmentoptionforthegivenfracture
A:CannulatedHipscrews
B:Dynamichipscrew
C:TotalHipReplacement
D:CementedHemiarthroplasty
E:IntramedullaryHipscrew
F:Nonoperativemanagement
G:InternalFixation
H:BipolarHemiarthroplasty
I:UncementedHemiarthroplasty
1:An85yearoldlady,poorlymobilewithadisplacedintracapsularfracture
neckoffemur.
Correctanswer:
D

Youranswer:
H
2:A75yearoldactivegentlemanwithathreepartpertrochantericfracture
neckoffemur.
Correctanswer:
B
Youranswer:
E
3:A60yearoldgentlemanwithRheumatoidarthritisandadisplaced
intracapsularfractureneckoffemur.
Correctanswer:
C
Youranswer:
C
References
NICEguidelinesontreatmentohHipfractures

Question117
Whichismostlikelyvesseltobeinjuredduringthefollowingprocedures?
A:Perforatingbranchesofprofundafemorisartery
B:SuperficialFemoralartery
C:Profundafemorisartery
D:Transversebranchoflateralcircumflexartery
E:Ascendingbranchofthemedialcircumflexartery
F:Superiorglutealartery
G:Inferiorglutealartery
H:Superficialcircumflexiliacartery
I:Pudendalartery
J:Externaliliacartery

1:Lateralapproachtothefemurforadynamichipscrewfollowingaclosed
reductionofanintertrochantericfracture.
Correctanswer:
A
Youranswer:
G
2:Insertionofastraightfemoralintramedullarynailforasubtrochanteric
fracture.
Correctanswer:
E
Youranswer:
E
3:Initialapproachforatrochantericentrycephalomedullarynail
Correctanswer:
F
Youranswer:
F
References
Cambell'soperativeorthopaedics,Hoppenfeld'sSurgicalexposuresin
orthopaedics,MoeinetalInjury2005,EksiogluetalCORR2003,Ozsoy
JBJSAm2007

Question118
Atwhichlevelinthephysisdothefollowingpathologicalprocessesoccur
A:Primaryspongiosa
B:Secondaryspongiosa
C:Zoneofprovisionalcalcification
D:Proliferativezone
E:Reservezone
F:Degenerativezone
G:Maturationzone

H:Secondarybonyepiphysis
1:Rickets
Correctanswer:
C
Youranswer:
C
2:Acutehaematogenousosteomyelitis
Correctanswer:
A
Youranswer:
A
3:Achondroplasia
Correctanswer:
D
Youranswer:
D
4:Osteogenesisimperfecta
Correctanswer:
B
Youranswer:
F
References
ReviewofOthopaedics5theditionMDMiller
Figure113onpage12listszones,histology,function,exemplarydiseases
anddefects.

Question119
IndigitalflexortendonsheathInfection
A:Eikenellacorrodens
B:Index,middleandringfingers
C:Pasteurellamultocida
D:Paronassign

E:Thumb,indexandlittlefingers
F:DicksonWrightssign
G:Kanavelssign
H:Thumb,ringandlittlefingers
I:Staphylococcusaureus
J:Felonssign
1:Thedigitsmostcommonlyinvolvedare
Correctanswer:
B
Youranswer:
B
2:Themostcommoncausativeagentfollowingahumanbiteis
Correctanswer:
I
Youranswer:
I
3:Thenamegiventothefourcardinalsigns(flexedpositionoffinger,
symetricalenlargementofthewholefinger,excessivetendernessoverthe
courseofthesheathandexcruciatingpainwithpassivefingerextension)is
Correctanswer:
G
Youranswer:
G
References
1) Index,MiddleandRingfimngerflexorsheathsaremostcommonly
involved.
2)Themostcommonbacterialagentiss.aureus.Ahighindexof
suspicionofPasteurellamultocidashouldbemadeiftheinfection
developswithin24hrsofacatbite.Eikenellacorrodensisseenwith
higherincidencefollowinghumanbitewounds,buts.aureusisstillthe
mostcommonorganism.
3)DescribedbyAllenBKanavelin1912.Paronasspaceisasub
tendinousspaceofthewristPusinFPLsheathcanascendinthe
radialbursaandruptureintothisspace.Afelonisaclosedspace
infectionofthefingertippulp.DicksonWrightwasoneofthefirstto
suggestpostoperativesheathirrigationbackin1943.

Question120
Tumoursaroundthekneeintheyoungadult.Selectthemostappropriate
firstlinetreatmentmodalityofeachofthefollowingconditions
A:Abovekneeamputation
B:Intraarticularchemotherapy
C:Marginalresection
D:Neoadjuventchemotherapy
E:Radicalresection
F:Radiotherapy
G:Widelocalexcisionwithendoprostheticreplacement
H:Widelocalexcisionwithjointpreservation
I:Intralesionalprocedure
1:EnnekingIIaOsteosarcomaofdistalfemoralmetaphysis
Correctanswer:
D
Youranswer:
D
2:LocalisedNodularPVNS
Correctanswer:
C
Youranswer:
E
3:LargeDistalfemoralAneurysmalBoneCyst
Correctanswer:
I
Youranswer:
I
References
Reviewoforthopaedics,fifthedition.MarkDMiller.Saunders.
OsteosarcomasareprimarilytreatedwithNeoadjuventchemotherapyasthis
isthemostimportanttreatmentmodalityforimprovingsurvival.Thisis
thoughttoreducethepresenceofearlypulmonarymicrometastasis.
NodularPVNScanberesectedlocallyunlessithasbreachedthejoint
capsule.Thereishoweverahighrecurrencerateandreresectionsareoften
combinedwithadjuventradiotherapy.
AneurysmalbonecystsandGiantCellTumourscanbetreatedwith
curettageandimpactionbonegraftingaformofintralesionalresection.

Question121
Regardingthebiomechanicalbehaviourofthefollowingmatchthe
appropriateanswerstothestatements
A:10fold
B:8fold
C:16fold
D:4fold
E:2fold
F:0.5fold
G:20fold
H:1fold
I:5fold
J:3fold
1:Foragivenmaterial,doublingtheplatethicknessincreasesitsrigidity
Correctanswer:
B
Youranswer:
B
2:Foragivenmaterial,doublingtheradiusofasolidnailincreasesits
rigidity
Correctanswer:
C
Youranswer:
C
3:Foragiventhicknessofplate,howmanytimesisatitaniumplaterigidin
comparisontoastainlesssteelplate(approximately)
Correctanswer:
F
Youranswer:
F

References
BasicOrthopaedicSciencesTheStanmoreGuide
Doublingthethicknessofaplate(rectangularconstruct)resultsinan
increasedSMAandconsequentlyincreasedrigiditybythethirdpowerofthe
multiplyingfactorwhichinthiscaseis2raisedtothepowerof3=8.
DoublingthethicknessofarodresultsinanincreasedPMAand
consequentlyincreasedrigiditybythefourthpoweri.e.2raisedtothepower
of4=16.
RigidityisdefinedasSMAmultipliedbytheYoungsmodulus.Youngs
modulusofsteelisroughlyhalfthatofstainlesssteel.Henceforagiven
platethickness,titaniumplatesarehalfasrigidasstainlesssteel.

Question122
Thefollowingistrueconcerningeachofthebelowlistedapproachestothe
hipjoint:
A:Isanextensileapproach
B:Utilisestheintervalbetweentensorfascialataandgluteusmedius
C:Deepdissectionisbetweenadductormagnusandadductorbrevis
D:Usestheintervalbetweensartoriusandthefemoralsheath
E:Wouldrequirerepairoftheinguinalligament
F:Splitsmuscleinnervatedbytheinferiorglutealnerve
G:Isrecognisedtoputthesuperiorglutealnerveatincreasedriskofinjury
H:Isrecognisedtoputthelateralcircumflexfemoralvesselatanincreased
riskofinjury
I:Allowsthepossibilityofincreasingmuscletensionwithoutalteringcentre
ofrotation,necklengthoroffset
1:Thetranstrochantericapproach
Correctanswer:
I
Youranswer:
I
2:Theanteriorapproach(SmithPeterson)
Correctanswer:
A
Youranswer:
B
3:Themedialapproach(Ludloff)
Correctanswer:
C
Youranswer:
C
4:Theposteriorapproach
Correctanswer:

F
Youranswer:
A

References
SurgicalexposureinOrthopaedics.TheAnatomicApproach,Stanley
HoppenfeldandPietdeBoer.ThirdEdition.LippincottWilliamsand
Wilkins.page365452
SirJohnCharnleypioneeredtheuseofthetranstrochantericinthe1950s.
Thisapproachallowsanextensileexposure,advancementofthetrochanter,
andpropersofttissuetensioning.Itaidsthecorrectorientationofprosthetic
implantsandallowsthepossibilityofincreasingmuscletensionwithout
alteringcentreofrotation,necklengthoroffset.
TheSmithPatersonappraochisanextensileapproachandexploitstheIN
planebetweenthesartoriusandtensorfascialatatopenetratetheouterlayer
ofthejointmusculature.
Themedialapproach(Ludloff)utilizesthedeepplaneofdissectionbetween
theadductorbrevisandadductormagnus.Thesuperficialdissectiondoesnot
exploitandINplane,sincebothadductorlongusandmagnusareinnervated
bytheanteriordivisionoftheobturatornerve.

Question123
Withregardstofingerreplantation
A:Almostanypartinachild,multipledigits,amputationofthumb
B:Almostanypartinachild,amputationatmultiplelevelsofdigits,
amputationproximaltoFDS
C:Almostanypartinachild,amputationdistaltoDIPJ,crushormangled
parts
D:Bone,extensortendon,flexortendon,arteries,nerves,veinsandskin
E:Bone,veins,nerves,skin,flexortendon,arteriesandextensortendon
F:Bone,skin,vein,artery,extensortendon,flexortendon,nerves
G:Thumb,long,ring,smallandindexfinger
H:Index,small,ring,longandthumb
I:Index,long,ring,smallandthumb
1:Thefavourableindicationsforreplantationoffingerare
Correctanswer:
A
Youranswer:
A
2:Theidealoperativesequenceofreplantationinachievingahigher
viabilityratewouldbe
Correctanswer:
D
Youranswer:
D

3:Thepriorityfordigitreplantationinmultipledigitamputationmustbein
theorderof
Correctanswer:
G
Youranswer:
G
References
Tamai,S:Twentsyearsexperienceoflimbreplantationreviewof293upper
limbreplants.JHandSurgery(Am)7:549555,1982
UrbaniakJR,RothJH<NunleyJAetalTheresultsofreplantationafter
amputationofasinglefinger.JBJS(Am)67:611619,1985
1)Thefavourableindicatonsforreplantationoffingerareanypartinachild,
thumbandmultipledigitsandNOTmultiplelevel
2)TheidealsequenceofreplantationisBonefirstthenextensortendon
followedbyflxortendon,arteries,nerves,veinsandfinallyskin
Question124
Withregardstobonydevelopment,whichanswerismostappropriateforthe
followingstatements?
A:Triradatecartilage
B:Superiorfemoralphysis
C:Greatertrochantericphysis
D:Lessertrochantericphysis
E:Ischialphysis
F:Femoralheadossificationcentre
G:Greatertrochanterossificationcentre
H:Lessertrochanterossificationcentre
I:Ischialtuberosityossificationcentre
J:Pubisossificationcentre
1:Whichstructureappearsaroundtheageof612months?
Correctanswer:
F
Youranswer:
F
2:Whichstructureappearsaroundpuberty?

Correctanswer:
I
Youranswer:
D
3:Whichstructureappearsaround5yearsofage?
Correctanswer:
G
Youranswer:
J
4:Whichstructurefusesbetween20and22yearsofage?
Correctanswer:
E
Youranswer:
J
References
Graysanatomy
Question125
Withregardstothecruciateandcollateralligamentsoftheknee,which
structureneedstobedamagedtoresultin
A:SuperficialMCL
B:AnteriorCruciateLigament
C:PosteriorCruciateLigament
D:DeepPartofMCL
E:LateralCollateralligament
F:PopliteusTendon
G:MedialMeniscus
H:Lateralmeniscus
I:LateralMeniscofemoralLigament
J:GastronemiusTendon
1:Lossofrollglidemechanism
Correctanswer:
B
Youranswer:
A
2:PositiveValgusstresstest
Correctanswer:
A

Youranswer:
A
3:LossofscrewhomemechanismandincreasedtibialexternalRotation
Correctanswer:
F
Youranswer:
F

References
GoldblattJP,RichmondJC.Anatomyandbiomechanicsoftheknee.
OperativetechniquesinSportsMedicine,2003;11(3):172186.
MartelliS,PinskerovaV.Theshapesofthetibialandfemoralarticular
surfacesinrelationtotibiofemoralmovement.
FreemanMAR,PinskerovaV.Themovementofthenormaltibiofemoral
joint.JBiomech,2005;38:197208.
SuperficialpartofMCListhemoreimportantcontributortostability.
Cuttingthesuperficialpartresultsinjointwidening.
Apartfromanteriortranslationoftibia,ACLdeficiencyalsoresultsinlossof
rollglidemechanismatthejoint.Rollingpredominatesininitialflexion,
followedbysuddenposteriorshiftofcontactpoint(thisisthebasisforthe
Pivotshifttest).Popliteushasimportantroleinscrewhomemechanism.
SectioningofPopliteusresultsinmarkedincreaseintibialERin90degrees
flexion.

Question126
Forthefollowingclinicalscenariosselectthemostappropriatespinal
procedure
A:Vertebroplasty
B:Corpectomy
C:Instrumentedfusion
D:Spinalstabilisation
E:GrowthRods
F:Interbodyfusion
G:Harringtonrods
H:360degreefusion
I:Pediclesubtractionosteotomy(PSO)
J:Braceapplicationandnonoperativemanagement

1:Painfulosteoporoticvertebralcompressionfracture.STIRimagesonthe
MRIscanshowacleftwithfluidatthesiteofthefracture.
Correctanswer:
A
2:Maybeusedtocorrectasignificantkyphoticdeformity
Correctanswer:
I
Youranswer:
I
3:Aprocedurethatinvolvesremovalofavertebralbodyoftenwith
subsequentcagereconstruction.
Correctanswer:
B
Youranswer:
B
4:TreatmentforaflexibleadolescentidiopathicscoliosiscurvewithaCobb
angleof40degreesinapremenarchalgirl.
Correctanswer:
C
Youranswer:
C

References
KallmesDF,ComstockBA,HeagertyPJ,etal.(August2009)."A
randomizedtrialofvertebroplastyforosteoporoticspinalfractures".N.Engl.
J.Med.361(6):56979
CurveProgessioninIdiopathicScoliosis
Weinsteinetal
JBJS(Am)1983Vol65(4)447455
1)Vertebroplastyorkyphoplastymaybeusedtotreatosteoporoticfractures.
IfyoucanseefluidinacleftatthefracturesiteonaSTIRsequencethenit
suggeststhattreatmentwillbesuccessful.
2)PSOormutliplePonteosteotomiesareusedtocorrectsaggitalbalance
whicharesignificanteg30degrees

3)Curvesgreaterthan40degreesinapremenarchalgirlarelikelyto
progress
Question127
Whendesigningastudywhichfactorneedstobeconsideredif
A:Poweranalysis
B:Nullhypothesis
C:Parametrictest
D:TypeIIerror
E:TypeIerror
F:Linearregression
G:Independentvariables
H:Matching
I:Randomisation
1:Youaretryingtocalculatethesamplesizeneeded
Correctanswer:
A
Youranswer:
A
2:Youareestimatingtherateoffalsepositiveresults
Correctanswer:
E
Youranswer:
E
3:Youarecomparingtwocontinousvariables
Correctanswer:
F
Youranswer:
F
References
Apoweranalysisisamethodofdeterminingthenumberofpatientsrequired
inastudytohaveareasonablechanceofshowingadifferenceifoneexists.
Thenullhypothesisisanassumptionthatanydifferenceseenispurelyby
chance.Studiesaredesignedtoeitherproveordisprovethisassumption.
Aparametrictestassumesdataissampledfromaparticularformof

distributionsuchasanormaldistribution.Nonparametrictestsmakeno
suchassumption
Errorsarisewhenacceptingorrejectingthenullhypothesis.
AtypeI(alpha)erroroccurswhenadifferenceisfoundbutinrealitythereis
notadifference.AtypeII(beta)erroroccurswhennodifferenceisfound
butadifferencedoesexist.
LinearregressionCorrelationisatermusedtodescribetherelationship
betweentwoparameters.Linearregressioniswhentherelationshipcanbe
plottedonastraightlinesuchaswithparametricdata.Regressioncanalso
becurvedorlogistic.
Forvariablestobeindependent,thereneedstobenochancethatasubject
couldappearinbothgroupsbeingcompared.AnunpairedTtestwouldbe
usedtocompareindependentvariablesprovidedtheyfollowanormal
distribution.
Matchingisaprocessofidentifyingsubjectsindifferentgroupsthathave
certainsimilarcharacteristics(eg.Age,sex,comorbidities)
Randomisationensuresthatallprognosticvariables,knownandunknown,
willbedistributedevenlyamongthetreatmentgroups.Randomisationcan
besimple(eg.Computergeneratedtables),stratified,orblock.
BasicOrthopaedicSciences.TheStanmoreGuide.RamachandranM.
HodderArnold.
Question128
Thefollowingpathologiesareassociatedwithwhichoftheseclinical
conditions?
A:CerebralPalsy
B:Rett'ssyndrome
C:Poliomyelitis
D:GuillainBarresyndrome
E:CharcotMarieToothDisease
F:Freidrich'sAtaxia
G:SpinalMuscularAtrophy
H:Duchenne'sDystrophy

I:Becker'sDystrophy
J:WerdnigHoffmannDisease
1:Geneticallydetermineddemyelinationand/oraxonaldegenerationin
peripheralnerves
Correctanswer:
E
Youranswer:
E
2:PeriventricularLeukomalacia
Correctanswer:
A
Youranswer:
I
3:Autoimmunemediateddemyelinationand/oraxonaldestructionin
peripheralnerves
Correctanswer:
D
Youranswer:
D
References
Tachdjian'sPediatricOrthopaedics.4thEdition,2008.Vol2,Neuromuscular
Disorders:pp16751674.
CMThasbeenclassicallydividedintodemyelinatingandaxonalforms.But
researchindicatesthatdemyelinationrenderstheaxonsusceptibleto
degenerationandhenecthe2picturescancoexist.
Periventricularleukomalaciaandintraandperiventricularhaemorrhagesare
frequentMRIfinidingsinCerebralpalsy.Theformerresultsfroman
ischemicinsulttothearterialwatershedareaclosetotheventricularwalls.
GBSyndromeisnowthecommonestcauseofacuteflaccidparalysisin
childreninthewest.Itischaracterisedbysymmetricmotorandsensory
paresisofthelimbsandattimesthetrunk.Thediseaseisautoimmuneand
directedagainstperipheralnervoussystemmyelin,axonorboth.Itis
triggeredbyaprecedingbacterialorviralinfection.
Question129

Concerninglumbarintervertebraldiscs
A:TypeIIICollagen
B:TypeVICollagen
C:TypeIICollagen
D:TypeIVCollagen
E:TypeXCollagen
F:TypeICollagen
G:TypeXICollagen
H:TypeIXCollagen
1:Whichtypeofcollagenismostprevalentinthenucleuspulposusaffected
byagerelatedchange?
Correctanswer:
F
Youranswer:
A
2:Whichtypeofcollagenismostprevalentinthenucleuspulposusofthe
normaldisc?
Correctanswer:
C
Youranswer:
C
3:Whichtypeofcollagenisinvolvedinthecrosslinkingofaggregatesin
theintervertebraldisc?
Correctanswer:
H
Youranswer:
H

References
1.HadjipavlouAG,TzermiadianosMN,BogdukN,ZindrickMR.The
pathophysiologyofdiscdegeneration:acriticalreview.JBoneJointSurgBr
2008;9010:126170.
1.ThecollagencontentofthenucleusincreasesandchangesfromtypeIIto
typeICollagenrenderingthenucleusmorefibrousduringtheageing

process[1].Theconcentrationofcellsandproteoglycanshoweverdecrease
withinthediscwithage.
2.TypeIXcollagencrosslinksaggregateswhichareheldtogetherbytypeII
collagen.

Question130

Withregardstobonetumourschoosethemostappropriateresponseforeach
ofthefollowing
A:Osteosarcoma
B:Chondrosarcoma
C:Enchondroma
D:Ewingssarcoma
E:Osteoidosteoma
F:Unicameralbonecyst
G:Nonossifyingfibroma
H:Giantcelltumour
I:Chondroblastoma
J:Metastaticbonetumour
1:AssociatedwithPagetdisease
Correctanswer:
A
Youranswer:
A
2:Lyticlesioninadultsthatcanextendtosubchondralarea,narrowzoneof
transition
Correctanswer:
H
Youranswer:
H
3:Mirel'sscore
Correctanswer:
J
Youranswer:
J
4:Canbetreatedbyradiofrequencyablation
Correctanswer:
E
Youranswer:
E
References
Apley's
Miller
RamachandranBasicSciencs
Question131

Matchthefollowingbiomechanicaltermsforstressstrainbehaviourof
ligamentstotheirdescription
A:Plasticdeformation
B:Toein
C:Fracture
D:Dips
E:Elasticdeformation
F:Creep
G:Hysteresis
H:Stressrelaxation
I:Compressivefailure
J:Ligamentremodelling
1:Thefirstregioninthestressstraincurveofligamentwhichshowsanon
linearrelationship
Correctanswer:
B
Youranswer:
B
2:Thisbehaviourisappliedintheapplicationofplastercastsfordeformity
correction
Correctanswer:
F
Youranswer:
F
3:Smallforcedisruptionssometimesobservedattheendofthelinear
regionofthestressstraincurve
Correctanswer:
D
Youranswer:
H
References
BasicOrthopaedicSciencesTheStanmoreGuide
Thetoeinregionisduetothestraighteningofthecrimpedfibres.Thedips
thatareseentowardstheendofthelinearportionofthecurvearecausedby
earlysequentialfailureofafewgreatlystretchedfibrebundles.
Thethreemainfeaturesoftheviscoelasticmaterialarestressrelaxation,
creepandhysteresis.

Stressrelaxationisdescribedasdecreaseinstresswhensubjectedtoa
constantstrainovertime.
Creepisdescribedasincreaseindeformation(strain)whenaconstantloadis
appliedovertime.
Hysteresisisdescribednetinternalenergylossduringloadingandunloading
ofthestressstraincurve.
Question132
Withregardtonervesatriskduringsurgicalapproachestothehip
A:Pudendalnerve
B:Nervetoobturatorinternus
C:Superiorglutealnerve
D:Inferiorglutealnerve
E:Sciaticnerve
F:Posteriorfemoralcutaneousnerve
G:Lateralfemoralcutaneousnerve
H:Nervetoquadratusfemoris
I:Theclunealnerves
J:Theanteriorandposteriordivisionsoftheobturatornerve
1:Whichnervemaybeinjuredduringthemedialapproach?
Correctanswer:
J
Youranswer:
J
2:Whichnervemaybeinjuredduringtheanteriorapproach?
Correctanswer:
G
Youranswer:
G
3:Whichnervemaybeinjuredduringthelateralapproach?
Correctanswer:
C
Youranswer:
C
References
HoppenfeldS,deBoerP.Surgicalexposuresinorthopaedicstheanatomic
approach.3rded.LippincottWilliamsandWilkins2003

Theanatomyofthemedialapproachistheanatomyoftheadductor
compartmentofthethigh.Theobturatornerveisderivedfromtheanterior
divisionoftheL2L4nerve,anddividesintheobturatornotchintoanterior
andposteriordivisions.Thenerveliesontheanteriorsurfaceoftheadductor
brevis.Theposteriordivisionoftheobturatornerverunsdiallyonthe
surfaceoftheadductormagnus.
Theanteriorapproachinternervousplaneliesbetweenthesartoriusandthe
tensorfascialata.Thelateralfemoralcutaneousnervepasseseitherover,
behindorthroughthesartoriusmuscle.
Thelateralapproachallowsexposureofthehipjointforjointreplacement.
Thesuperiorglutealnerverunsbetweenthegluteasmediusandminimus3
5cmabovethegreatertrochanterandcanbedamagedwithproximal
dissection.

Question133
Whichofthefollowingoptionsbestdescribesthesefractureconfigurations?
A:Myerson'stypeA
B:EssexLoprestilesion
C:Sanderstype3.
D:Supinationadductioninjury.
E:Myerson'stypeB.
F:GartlandtypeII.
G:SupinationExternalrotationinjury.
H:MilchtypeI.
I:KilfoyletypeIII.
J:MilchtypeII.
1:Transverseavulsionfractureofthelateralmalleolusbelowthe
syndesmosiswithaverticalfractureofthemedialmalleolus.
Correctanswer:
D
Youranswer:
D
2:Lateralordorsoplantardisplacementofallfivemetatarsalswithor
withoutfractureofthebaseofsecondmetatarsal.
Correctanswer:
A
Youranswer:
B
3:Thefracturelinetraversesthecapitellarossificationcentre,intothe
capitellartrochleargroove.
Correctanswer:
H
Youranswer:
H
References

Campbell'sOperativeOrthopaedics10thEdition
LaugeHansen,N.:Ankelbrud.I.Genetiskdiagnoseogreposition.
Dissertation,Copenhagen,Munksgaard,1942
LaugeHansen,N.Ligamentousanklefractures.Diagnosisandtreatment.
ActaChir.Scand.97:544,1949
MyersonMS,FisherRT,BurgessAR,KenzoraJE.Fracturedislocationsof
thetarsometatarsaljoints:endresultscorrelatedwithpathologyand
treatment.Foot&Ankle.1986Apr;6(5):22542
Fracturesofthemedialepicondyleandepicondyleoftheelbowinchildren.
KilfoyleR.CORR1965July;41:4350
Fracturesandfracturedislocationsofthehumeralcondyles.MilchH.1964
Sept;4(5):592607.
Intaarticularfracturesofthecalcaneus:Presentstateoftheart.SandersR.
JOT1992June;6(2):252265.
Managementofsupracondylarfracturesofthehumerusinchildren.Gartland
JJ.SurgGynecol.Obstet.1959Aug;109(2):14554.
Fracturesoftheradialheadwithdistalradioulnardislocation.EssexLopresti
P.JBJS(Br)1951;33:244250.
TheLaugeHansenclassificationofanklefracturesconsistsof4different
typesbasedonthepositionofthefootandthedirectionofdislocatingforce
momentumcausingthefracture.SupinationExternalrotationisthe
commonesttypeofinjuryseenwithanobliquefractureofthedistalfibulaat
thelevelofthesyndesmosiswithorwithoutafractureofthemedial
malleolus.PronationAbduction,PronationExternalrotationandSupination
Adductionaretheremainingthreetypes,thelatterconsistingofatransverse
fractureofthedistalfibulainferiortothesyndesmosiscombinedwitha
verticalshearfractureofthemedialmaleolus.
QuenuandKuss(1909)describedhomolateral,isolatedanddivergent
patternsofLisfrancinjury.Thiswasmodifiedin1982byHardcastletoTotal
incongruity,partialincongruityanddivergent.Myerson(1986)further
modifiedthisclassificationintotypeA(totalincongruityeitherlateralor
dorsoplantar),TypeB1(Partialincongruitymedialdislocation)andB2
(Partialincongruitylateraldislocation)andC1(divergentpartial
displacement)andC2(divergenttotaldisplacement)
Milchdescribedlateralcondylefracturesofthedistalhumerusinchildren.In
type1fracturesthefracturelinecoursesmedialtraversingthecapitellar
ossificationcentreintothecapitellartrochleargroove.Thisistherarer,more
stableconfiguration.Type2fracturesaremorecommonandthefractureline
extendsintotheareaofthetrochleaandproducesinherentinstabilityofthe
elbow.

Sandersclassificationdescribescalcanealfractures,Gartlandclassified
supracondylarfracturesandKilfoyledescribedmedialcondylefracturesin
children.
TheEssexLoprestilesionisaradialheadfractureinassociationwitha
dislocationofthedistalradioulnarjointandinterosseusmembrane
disruption.

Question134
Regardingsurgicalapproachforanteriorreleaseandposteriorcorrectionin
scoliosis
A:Anteriorspinalartery
B:Vertebralartery
C:Segmentalvessels
D:LongThoracicNerve
E:Latissimusdorsi
F:Serratusanterior
G:Serratusposterior
H:Multifidus
I:Convexity
J:Concavity
1:Whatstructureisatriskduringdeepexposureofvertebraeforanterior
release?
Correctanswer:
C
Youranswer:
A
2:Oneofthemusclesintheofthedeeplayerofback
Correctanswer:
H
Youranswer:
F
3:Shouldtheanteriorapproachtoascoliosisbeontotheconcavityor
convexityofthecurve?
Correctanswer:
I
Youranswer:

I
References
HoppenfeldandDeBoerSurgicalApproachesinOrthopaedics
Segmentalvesselslieoverthevertebralbodiesandareatriskduring
dissectionthroughoverlyingfasciawhilstgainingaccesstothediscs.
Multifidusisadeepbackmusclealthough,invivo,itisoftendifficultto
distinguishclearly.
Anteriorapproachshouldbetotheconvexityofacurveinordertoallow
maximumaccesstodiscspaces.

Question135
Withregardstotestingofneuromuscularconditionsinchildren,
A:MRIscan
B:Alphafetoprotein
C:AlanineTransaminase
D:Tyrosinase
E:Computerizedgaitanalysis
F:EMG
G:Creatinekinase
H:Aldolase
I:Troponins
J:SomatosensoryEvokedPotentials(SSEP)
1:ThishelpsinthediagnosisofCerebralPalsy.
Correctanswer:
A
Youranswer:
A
2:Itsserumlevelcanbe20to200timesabovenormalinDuchenne's
musculardystrophy.
Correctanswer:
G
Youranswer:
D
3:Thisisanotherenzymeraisedinmusculardystrophy.
Correctanswer:
H

Youranswer:
H
References
Tachdjian'sPediatricOrthopaedics.4thEdition,2008.Disordersofthe
Brain:pp12751397.
Tachdjian'sPediatricOrthopaedics.4thEdition,2008.MuscleDiseases:pp
16211674.

Question136
Foreachoftheclinicalscenarioschoosethemostlikelypathogen
A:StaphylococcusAureus
B:StaphylococcusEpidermidis
C:StreptococcusPyogenase
D:StreptococcusPneumoniae
E:NieseriaGonorrhoea
F:MycobacteriumTuberculosis
G:TreponemaPallidum
H:PseudomonasAeruginosa
I:SalmonellaTyphi
J:EscherichiaColi
1:A25yearoldmanpresentswiththoracolumbarpain.AnMRIsuggests
discitisatL1.
Correctanswer:
A
Youranswer:
A
2:A45yearoldladypresentswithadischargingwound2weeksfollowing
aposteriorlumbarinterbodyfusion.UrinedipsticksuggestsaUTI
Correctanswer:
J
Youranswer:

J
3:A40yearoldladywith3monthsofthoracicbackpain.Examination
revealsgeneralisedlymphadenopathyandalumpontheleft9thribatthe
anterioraxillaryline.Urinedipshowedplentyofwhitecellsbutnogrowth
oncultures.
Correctanswer:
F
Youranswer:
F
References
http://emedicine.medscape.com/article/1263845overview(goodoverview)
SpinalInfectionsGovenderJBJS(Br)2005Vol87B,Issue11,14541458
1.StaphylococcusAureusisthecommonestpathogeninvolvedindiscitis
2.EscherichiacoliandProteusspeciesaremorecommoninpatientswith
UTIs.
3.Thechronicity,collarstudabscess(lumpontherib)andthesterilepyuria
suggestTB
n.b.InIVdrugabusers,KlebsiellaandPseudomonasarecommonlyseenbut
notasfrequentlyasS.Aureuswhichisstillthecommonestcauseofdiscitis.

Question137
Withregardsarthroscopyoftheshoulder,choosethemostappropriate
response
A:Cephalicvein
B:Subclavianartery
C:Posteriorcircumflexartery
D:Longthoracicnerve
E:Thoracoacromialartery
F:Axillarynerve
G:Suprascapularnerve
H:Supraclavicularnerve
I:Musculocutaneousnerve
J:Supraclavicularartery
1:Whatstructurecanbedamagedwhenthetrocarispushedmediallyonthe
neckofscapuladuringarthroscopicBankartcapsulorraphy?
Correctanswer:

G
Youranswer:
G
2:Whatnerveisatriskwhenusingalateralportalforsubacromial
decompression?
Correctanswer:
F
Youranswer:
F
3:Briskbleedingduringarthroscopicsubacromialdecompressionismost
likelyfromwhichvessel?
Correctanswer:
E
Youranswer:
E
4:Anteriorportalplacementcanleadtoinjurytothisvascularstructure
Correctanswer:
A
Youranswer:
J

References
Campbellsoperativeorthopaedics,11thedition,mosbyelservierpages
29232993
Anatomicrisksofshoulderarthroscopyportals:anatomiccadavericstudyof
12portals.
MeyerM,GraveleauN,HardyP,LandreauP.2007May;23(5):52936.

Question138
WithregardstoVitaminDsynthesis
A:PTH
B:Calcitonin
C:Kidney
D:Skin
E:Bone
F:Liver
G:Osteoprotegerin
H:25hydroxyvitaminD31alphahydroxylase

I:VitaminD25hydroxylase
J:P450mixedfunctionoxidase
1:Hydroxylationofcholecalciferoloccursinthisorgan
Correctanswer:
F
Youranswer:
F
2:Hormonethatregulates1,25dihydroxyvitaminDsynthesis.
Correctanswer:
A
Youranswer:
B
3:EnzymethatconvertsvitaminDintocalcidiol.
Correctanswer:
I
Youranswer:
I

References
AAOSOrthopaedicBasicScience
Intheskin,7dehydrocholesterol,aderivativeofcholesterol,isphotolyzed
byultravioletlightintoprevitaminD3.PrevitaminD3spontaneously
isomerizestovitaminD3(cholecalciferol).Whetheritismadeintheskinor
ingested,cholecalciferolishydroxylatedinthelivertoform25

hydroxycholecalciferol(calcidiolor25(OH)D).Thisreactioniscatalyzedby
themicrosomalenzymevitaminD25hydroxylase,whichisproducedby
hepatocytes.Oncemade,theproductisreleasedintotheplasma,whereitis
boundtoanaglobulin,vitaminDbindingprotein.Calcidiolistransportedto
theproximaltubulesofthekidneys,whereitishydroxylatedtoform
calcitriol(aka1,25dihydroxycholecalciferolandabbreviatedto
1,25(OH)2D).ThisproductisapotentligandofthevitaminDreceptor
(VDR),whichmediatesmostofthephysiologicalactionsofthevitamin.The
conversionofcalcidioltocalcitrioliscatalyzedbytheenzyme25
hydroxyvitaminD31alphahydroxylase,thelevelsofwhichareincreased
byparathyroidhormone(andadditionallybylowcalciumorphosphate).

Question139
Withreferencetocalciummetabolism

A:Hypocalcaemia
B:Tscoreis>2.5SDbelowthemean
C:Raisedalkalinephosphatase,raisedparathyroidhormoneandlowurinary
calcium
D:Hypercalcaemia
E:Tscoreis<2.5SDbelowthemean
F:Zscoreis>2.5SDbelowthemean
G:Raisedalkalinephosphatase,lowparathyroidhormoneandlowurinary
calcium
H:Raisedalkalinephosphatase,raisedparathyroidhormoneandhigh
urinarycalcium
I:Zscoreisbetween1and2.5SDbelowthemean
J:Increasedphosphatelevels
1:Isacauseofmusculartetany
Correctanswer:
A
Youranswer:
A
2:Osteoporosiscanbedefinedby
Correctanswer:
B
Youranswer:
E
3:Nutritionalricketscanbeidentifiedbythefollowingbloodtests
Correctanswer:
C
Youranswer:
C
References
WHOclassificationofnormalbonemineraldensityiswithin1standard
deviationofthemean.OsteopeniaisconsideredwhentheBMDis12.5SD
belowthemeanandosteoporosisisconsideredwhenBMDis>2.5SD
belowthemean.
Urinarycalciumisusedtodifferentiatebetweenprimary
hyperparathyroidismandnutritionalrickets.Innutritionalrickets,urinary
calciumislowwhileintheotheritishigh.