Online 2011 Orthopaedic Self-Assessment Examination by Dr.Dhahirortho
1
1
,Online2011
Online 2011Orthopaedic
OrthopaedicSelf-Assessment
Self-AssessmentExamination
Examinationby
by Dr.Dhahirortho
Dr.Dhahirortho
Question 1
Which of the following methods of treating a vertically oriented (eg, Pauwels III)
femoral neck fracture is mechanically optimal?
1- Two parallel fully threaded screws
2- Three parallel partially threaded screws
3- Three parallel fully threaded screws
4- Four parallel partially threaded screws
5- Sliding hip screw and side plate
DISCUSSION: Vertical fractures have a higher rate of displacement and nonunion because
of shearing forces across the fracture. Biomechanical and clinical studies indicate that for
the vertically oriented fracture of the femoral neck, the most stable fixation construct is a
sliding hip screw and side plate. Antirotation screws may be used as well. Nonsurgical
management carries a high risk of early displacement because of shear forces. Three
screws are loaded as a cantilever and have less resistance to displacement compared
with a fixed-angle device with a side plate. Fully threaded screws will not allow any
compression and have the same drawbacks as partially threaded screws. The addition of
a fourth screw has not been shown to be of benefit. The Preferred Response # 1 is 5.
Question 2 Figures 2a and 2b are the MR arthrograms of a 19-year-old college baseball
pitcher who injured his throwing elbow during a game 5 days ago when he felt a pop.
Immediately after the throw he reported significant discomfort with pitching and noted
that he could not achieve his normal velocity or accuracy in location with his
subsequent pitches. On further questioning, he admits to increasing medial elbow pain
over the last few seasons with pitching. Examination reveals medial elbow swelling and
somewhat diffuse tenderness to palpation medially. Valgus stress at 30 degrees of
flexion and resisted wrist flexion produced discomfort. He notes some tingling in his
fourth and fifth fingers but Tinel's test posterior to the medial epicondyle is
unremarkable. Radiographs of the elbow show no fracture. Because the patient wishes
to return to competitive throwing, what is the next step in management?
1- Ulnar nerve transposition
2- Ulnar collateral ligament reconstruction
3- Long arm cast for a medial epicondyle fracture
4- Open reduction and internal fixation of the medial epicondyle
32
3
,Online 2011 Orthopaedic Self-Assessment Examination by Dr.Dhahirortho
5- Elbow arthroscopy and excision of a posteromedial olecranon osteophyte
4
4
, Online 2011 Orthopaedic Self-Assessment Examination by Dr.Dhahirortho
DISCUSSION: This high level throwing athlete has a full-thickness injury to the ulnar
collateral ligament and is most likely to be able to return to competitive throwing with an
ulnar collateral ligament reconstruction. There is no radiographic evidence of a medial
epicondyle fracture. The clinical presentation and lack of a posteromedial olecranon
osteophyte makes valgus extension overload unlikely, and therefore, makes arthroscopic
osteophyte excision a suboptimal choice. Whereas ulnar nerve pathology can coexist with
an ulnar collateral ligament injury, isolated ulnar nerve transposition without addressing
the ligament injury is not warranted in this patient. Initial nonsurgical management with
activity modification and physical therapy is appropriate for partial-thickness injury to the
ulnar collateral ligament in a non-throwing athlete, and in athletes whose sporting
activity places them at low risk. The Preferred Response to Question # 2 is 2.
Question 3 Figures 3a and 3b are the radiographs of an active 59-year-old woman who
has had a 5-year history of right great toe pain. Nonsurgical management, consisting of
shoe modifications, an orthotic with a Morton's extension, injections, and medications,
has failed to provide relief. The range of motion is 30 degrees of dorsiflexion to 10
degrees of plantar flexion with pain at each end point, but not through the midrange of
motion. What is the most appropriate management?
1- Cheilectomy
2- Keller resection arthroplasty
3- Silastic implant arthroplasty with titanium grommets
4- Arthrodesis of the first metatarsophalangeal joint
5- Total metatarsophalangeal joint arthroplasty
5
5
1
1
,Online2011
Online 2011Orthopaedic
OrthopaedicSelf-Assessment
Self-AssessmentExamination
Examinationby
by Dr.Dhahirortho
Dr.Dhahirortho
Question 1
Which of the following methods of treating a vertically oriented (eg, Pauwels III)
femoral neck fracture is mechanically optimal?
1- Two parallel fully threaded screws
2- Three parallel partially threaded screws
3- Three parallel fully threaded screws
4- Four parallel partially threaded screws
5- Sliding hip screw and side plate
DISCUSSION: Vertical fractures have a higher rate of displacement and nonunion because
of shearing forces across the fracture. Biomechanical and clinical studies indicate that for
the vertically oriented fracture of the femoral neck, the most stable fixation construct is a
sliding hip screw and side plate. Antirotation screws may be used as well. Nonsurgical
management carries a high risk of early displacement because of shear forces. Three
screws are loaded as a cantilever and have less resistance to displacement compared
with a fixed-angle device with a side plate. Fully threaded screws will not allow any
compression and have the same drawbacks as partially threaded screws. The addition of
a fourth screw has not been shown to be of benefit. The Preferred Response # 1 is 5.
Question 2 Figures 2a and 2b are the MR arthrograms of a 19-year-old college baseball
pitcher who injured his throwing elbow during a game 5 days ago when he felt a pop.
Immediately after the throw he reported significant discomfort with pitching and noted
that he could not achieve his normal velocity or accuracy in location with his
subsequent pitches. On further questioning, he admits to increasing medial elbow pain
over the last few seasons with pitching. Examination reveals medial elbow swelling and
somewhat diffuse tenderness to palpation medially. Valgus stress at 30 degrees of
flexion and resisted wrist flexion produced discomfort. He notes some tingling in his
fourth and fifth fingers but Tinel's test posterior to the medial epicondyle is
unremarkable. Radiographs of the elbow show no fracture. Because the patient wishes
to return to competitive throwing, what is the next step in management?
1- Ulnar nerve transposition
2- Ulnar collateral ligament reconstruction
3- Long arm cast for a medial epicondyle fracture
4- Open reduction and internal fixation of the medial epicondyle
32
3
,Online 2011 Orthopaedic Self-Assessment Examination by Dr.Dhahirortho
5- Elbow arthroscopy and excision of a posteromedial olecranon osteophyte
4
4
, Online 2011 Orthopaedic Self-Assessment Examination by Dr.Dhahirortho
DISCUSSION: This high level throwing athlete has a full-thickness injury to the ulnar
collateral ligament and is most likely to be able to return to competitive throwing with an
ulnar collateral ligament reconstruction. There is no radiographic evidence of a medial
epicondyle fracture. The clinical presentation and lack of a posteromedial olecranon
osteophyte makes valgus extension overload unlikely, and therefore, makes arthroscopic
osteophyte excision a suboptimal choice. Whereas ulnar nerve pathology can coexist with
an ulnar collateral ligament injury, isolated ulnar nerve transposition without addressing
the ligament injury is not warranted in this patient. Initial nonsurgical management with
activity modification and physical therapy is appropriate for partial-thickness injury to the
ulnar collateral ligament in a non-throwing athlete, and in athletes whose sporting
activity places them at low risk. The Preferred Response to Question # 2 is 2.
Question 3 Figures 3a and 3b are the radiographs of an active 59-year-old woman who
has had a 5-year history of right great toe pain. Nonsurgical management, consisting of
shoe modifications, an orthotic with a Morton's extension, injections, and medications,
has failed to provide relief. The range of motion is 30 degrees of dorsiflexion to 10
degrees of plantar flexion with pain at each end point, but not through the midrange of
motion. What is the most appropriate management?
1- Cheilectomy
2- Keller resection arthroplasty
3- Silastic implant arthroplasty with titanium grommets
4- Arthrodesis of the first metatarsophalangeal joint
5- Total metatarsophalangeal joint arthroplasty
5
5
